Abdominoplasty after massive weight loss. Safety preservation fascia technique and clinical outcomes in a large single series-comparative study.

Introduction: Weight loss after bariatric surgery causes very important modifications to the patient's silhouette. Abdominal fat and skin excess reduction are associated with several complications. The most frequent are seroma and hematoma whereas major complications, such as pulmonary embolism, are less frequent. This study aimed to describe our technical procedure for abdominoplasty in patients with massive weight loss after bariatric surgery. Methods: In total, 196 patients were included. All patients who underwent abdominoplasty classic (group A) and abdominoplasty with the preservation and lift of Scarpa fascia (group B) and with umbilical transposition between May 2018 and May 2021 were included. Patients with concomitant correction of ventral hernia were excluded. Demographic and operative data were analyzed according to comorbidities and postoperative complications. Results: There were 160 (81.6%) women. The mean age was 43.6 years; the mean weight was 86.7 kg; and the mean BMI was 28.6 kg/m2. Five patients (2.5%) presented postoperative seroma. Four patients (2%) presented partial dehiscence/skin necrosis one of them requiring a revision. Finally, 26 patients presented a postoperative complication, with an overall incidence of 12.6%. The average postoperative hospital stay was 3.6. The rates of seroma were significantly higher in men, patients with a BMI > 30 kg/m2, and aged >50 years. Conclusion: Preserving Scarpa Fascia during surgical post-bariatric patient procedures reduces the seroma formation and the scar complication and reduces the tension of the inguinal-pubic region with correction of our deformation after weight loss. Improves reducing the drain and reducing seroma incidence suction and hospital stay.

A Retrospective Case Series in Fournier's Disease: And Its Emergency Management et Grafting Technique for Penis Coverage.

Fournier's gangrene is a necrotizing soft tissue infection of the genital, perineal, and perirectal areas. A primary isolated involvement of the penis is rare, but it can be affected in some circumstances. The purpose of this case series is to present the findings of our thirteen years' experience in the reconstruction of the penis in Fournier's gangrene and our full-thickness grafting technique to cover the penis rod. We retrospectively reviewed patient data who underwent a penis reconstruction following Fournier's gangrene in 2018. The data was analyzed to report the estimated percentage of complications, of patients with primary or secondary gangrene of the penis, the number of reinterventions, and finally the percentage of deaths or recovery. 23 patients underwent reconstruction with our technique of full-thickness skin graft. In all cases, the skin graft was harvested from the upper arm with an arrow shape mark. No further penile revision surgery was required, and neither patient complained about retraction, nor traction, or pain during erection. The donor site healed without any complications. We believe that the coverage of the penis using our grafting technique is safe, easily reproducible, and demonstrates excellent esthetic and functional results.

Breast Reconstruction by Exclusive Lipofilling after Total Mastectomy for Breast Cancer: Description of the Technique and Evaluation of Quality of Life.

BACKGROUND: The objective of this work was to describe the technique of exclusive lipofilling in breast reconstruction after total mastectomy, to evaluate the satisfaction and quality of life of the patients, and to explore current literature on the subject. METHODS: We conducted a retrospective observational multicentric study from January 2013 to April 2020. The modalities of surgery, esthetic result, and patient satisfaction were evaluated with the breast reconstruction module of BREAST-Q. RESULTS: Complete data were available for 37 patients. The mean number of sessions was 2.2 (standard deviation 1.1), spread over an average of 6.8 months (SD 6.9). The average total volume of fat transferred was 566.4 mL. The complication rate was 18.9%. No severe complication was observed (Clavien-Dindo 3/4). Two patients were diagnosed with recurrence, in a metastatic mode (5.4%). The average satisfaction rate was 68.4% (SD 24.8) for psychosocial well-being and 64.5% (SD 24.1) for sexual well-being. The satisfaction rate was 60.2% (SD 20.9) for the image of the reconstructed breast and 82.7% (SD 21.9) for locoregional comfort. CONCLUSIONS: Breast reconstruction by exclusive lipofilling after total mastectomy provides satisfactory quality of life scores. The simplicity of the surgical technique and equipment required, and the high satisfaction rate confirm that lipofilling should be included in the panel of choice of breast reconstruction techniques.

Coincidental or Causal? Concurrence of Colorectal Carcinoma with Primary Breast Cancer.

Multiple primary malignant neoplasms (MPMN) represent the occurrence of a second malignancy in the same patient within 6 months after the detection of first primary (synchronous) tumor, or > 6 months after primary detection (metachronous). We present a case of a patient treated for carcinoma of the breast who developed a metachronous primary malignancy in the colorectal tract. These tumors were histologically different with distinct immune-histochemical parameters. The association between breast and colon cancer is well documented in the literature with several studies reporting the coexistence of common extrinsic and genetic predisposing factors. Although rare, MPMN are becoming more common due to the increased number of elderly cancer survivors, improved diagnosis and enhanced awareness. The association between colorectal and breast cancer should not be dismissed merely as metastasis since there is good precedent for the co-occurrence of these primary tumors.

Large cell anaplastic lymphoma associated with breast implant: a rare case report presentation and discussion of possible management.

Anaplastic large cell lymphomas (ALCL) are a rare type of primary breast lymphoma. The association between breast implants and ALCL was first described in 1997. Breast implant associated (BIA)-ALCL arises from the inflammatory T cells surrounding the fibrous capsule, and most tumors are in situ. Here we present the case of a 60-year-old woman with ALCL following bilateral silicone breast prosthesis implantation for aesthetic reason. The patient presented at our observation 7 years following the first surgery reporting a sport trauma in the right thoracic region with breast enlargement and tenderness, complaining breast pain at the palpation of the right breast. Imaging study showed a right fluid collection surrounding the affected breast implant. For this reason, the patient underwent bilateral complete capsulectomy (surgical specimen histologically analyzed and resulted negative for ALCL) and implantation of new breast silicone prosthesis. In 10 months, a progressive relapse of the symptoms with a right peri-implant fluid collection restauration was documented and bilateral surgical removal of breast prostheses with right peri-implant capsular biopsy were performed. The histological analysis of the peri-implant capsule laid for ALCL cellules and a new radical surgical excision of bilateral periprothesic capsule was performed followed by adjuvant radiotherapy for a skin relapse of the disease with a subsequent complete remission. No further relapse was observed afterwards. This clinical case raised a series of diagnostic and therapeutic issues highlighting similarities with previous BIA-ALCL reports, but also some peculiarities that deserve to be further investigated and described in order to make an early recognition of the disease for the proper management and treatment of the patient. Due to the rarity of these tumors, rapidly diagnosing a BIA-ALCL case, not neglecting other associated symptoms or signs, is essential to ensure timely and safe treatment.

Algorithm of rational approach to reconstruction in Fournier's disease.

BACKGROUND: Fournier's gangrene is a rare form of necrotizing fasciitis that affects the genital area up to the perineal region and sometimes the abdominal wall. OBJECTIVES: Our article aims to show that in the treatment of extensive forms of Fournier's gangrene, correct use of flap and skin grafts and a quick reconstruction of the exposed tissues avoid scarring retraction of the testicles and deformation of the penis. MATERIALS AND METHODS: We retrospectively reviewed the clinical and photographic data of Fournier's gangrene cases treated at our Institute. The data were evaluated to obtain an estimate of the results of the reconstructive technique used, in terms of percentage of occurred healings and eventual complications. RESULTS: A total of 34 patients underwent surgery for Fournier's gangrene. In nine cases (26.5%), we had minor complications: in four patients, suffering from diabetes and obesity, a retard in attachment of graft occurred, while in five patients with perianal problems there was a delay in healing due to the onset of local infection. CONCLUSION: The reconstruction approach described here may reduce surgical times. In Fournier's gangrene, the exposed tissues must be reconstructed as quickly as possible.

Peri-areolar double-pedicle technique in the treatment of iatrogenic gynecomastia.

OBJECTIVES: To describe the surgical approach to the treatment of iatrogenic gynecomastia via peri-areolar incision. METHODS: In this study, we describe our experience in the surgical management of iatrogenic hormonal gynecomastia with our technique described for idiopathic gynecomastia. We treated 70 patients with gynecomastia at a plastic surgery unit between 2000 and 2016. Ten of these patients had a painful hypertrophic mammary gland with grade III gynecomastia secondary to hormone therapy after prostate cancer. RESULTS: The presence of a very discreet scar around the areola often has very interesting aesthetic results. Areolar tissue sensation was completely preserved in 40% of patients. No short-term complications were observed; in follow-up, only one case of keloid scars was noted on a patient with dark skin, and only one case of areolar necrosis on a patient with critical breast ptosis. CONCLUSION: This technique is feasible. It restores almost normal anatomy structure with minimal scarring and preserves good regional neurovascular supply, with only 60% altered areolar sensation.

Treatment of hidradenitis suppurativa: Surgery and yeast (Saccharomyces cerevisiae)-exclusion diet. Results after 6 years.

BACKGROUND: Hidradenitis suppurativa is a complex disorder, the pathogenesis of which is still unsolved. The known association between hidradenitis suppurativa and Crohn's disease, an autoimmune disease diagnosed with the presence of Anti-Saccharomyces cerevisiae antibodies of the IgG family, suggests that a much more complex mechanism than a simple infectious disorder is involved. The goal of this study is to report patients' characteristics and the outcome of 6 years of a yeast (Saccharomyces cerevisiae)-exclusion diet and surgery in the treatment of hidradenitis suppurativa. METHOD: We analyzed 185 patients with hidradenitis suppurativa with a self-evaluative questionnaire. Thirty-seven patients were treated in our center following our protocol. The other 148 were members of a support group for patients with hidradenitis suppurativa treated by other centers. RESULTS: In 80% of patients who had the onset of hidradenitis suppurativa before the age of 30, the female to male ratio was 3.34:1, 74% were active smokers, and 5% also had Crohn's disease. In the diet group, 70% had an improvement of hidradenitis suppurativa symptomatology, 81% of whom in less than 6 months. Also, 87% of patients demonstrated an immediate recurrence of skin lesions less than a week after consuming a food containing the yeast. Immunologic testing showed intolerance to yeast, wheat, and cow's milk in 20%, 29%, and 23% of patients, respectively. CONCLUSION: The analysis confirmed the stabilization and regression of hidradenitis suppurativa with our diet, presumably by decreasing the local and systemic inflammation, leading to a less invasive operative treatment. These new findings seem to link hidradenitis suppurativa to food intolerance and gut dysbiosis.

Facial skin rejuvenation by autologous dermal microfat transfer in photoaged patients: Clinical evaluation and skin surface digital profilometry analysis.

Cumulative long-term exposure to solar ultraviolet radiation promotes premature skin aging characterized by wrinkle formation and reduced skin elasticity. In this study, we assessed whether microfat transfer could improve dermal and subcutaneous tissue thickness loss associated with photoaging. Twenty-one patients affected by facial photoaging (photodamage grade II-IV; age range 35-62 years; 19 females, 2 males; all of Caucasian origin) were treated using minimally invasive autologous dermal white fat transfer harvested with a recently designed microcannula. The results were determined by clinical assessment and patient self-evaluation and quantified by the Antera 3D® dermal digital device for noninvasive, objective, reliable, and accurate assessment of facial skin texture, color, and wrinkle characteristics. Compared with the pretreatment condition, the increment in soft tissue volume and improvement in skin quality and texture were assessed by a dermatologist after treatment. In addition, instrumental evaluation by digital skin profilometry of the treated areas revealed a 41% reduction in average wrinkle depth (7.29 ± 1.04 × 10-2 mm pretreatment vs. 4.31 ± 1.16 × 10-2 mm at 90 days posttreatment; p < 0.001), improved skin texture, more homogeneous and uniform skin color, and declined facial hemoglobin and melanin concentrations. The majority of patients (above 90%) reported improvements in self-perception. No significant complications were reported throughout the study. In conclusion, by using digital profilometry analysis as an objective and innovative tool to determine the outcome of treatment, we demonstrated that autologous microfat transfer is a safe and well-tolerated procedure with measurable beneficial effects on facial skin aging.

Reconstruction of the Abdominal Wall in Anatomical Plans. Pre- and Postoperative Keys in Repairing "Cold" Incisional Hernias.

BACKGROUND AND AIMS: The clinical results of the vertical "vest-over-pants" Mayo repair were evaluated, and the risk factors for incisional hernia recurrence were studied. The purpose of this study is to point out the importance of reducing pre and post operative risk factors in the incisional hernia repair process in order to achieve a physiologically normal abdominal wall. METHODS: Twenty patients diagnosed with incisional hernia underwent an abdominal reconstruction procedure using the Mayo (Paletot) technique at Bichat Claude Bernard Hospital between 2005 and 2015. All procedures were performed by a single surgeon and all patients were pre-operatively prepared, identifying all coexisting conditions and treating them accordingly before undergoing surgery. RESULTS: All patients underwent at least one surgical operation before the hernia repair procedure and a quarter had experienced at least three, prior to this one. Nine patients had a body mass index of >30 kg/m2. Additional risk factors and comorbidities included obesity in 45%, diabetes mellitus in 10%, smoking in 55%, and high blood pressure in 40%. Hernia defect width was from 3 cm (25% F) to 15 cm (5% M) of which nine patients (45%) had a 10 cm defect. Most of the patients had an average hospitalization of 7 days. The patients were carefully monitored and were called on periodic consultations after 3, 6, and 12 months from the moment of the procedure. Patient feedback regarding hernia recurrence and complaints about the scar were noted. Physical examination is essential in determining the hernia recurrence therefore the scar was examined for any abnormalities that may have occurred, which was defined as any palpable or detected fascial defect located within seven centimeters of the hernia repair. Post-operative complications: seroma formation, wound hematoma, superficial and deep wound infection, recurrences and chronic pain were followed and no complications were registered during the follow-up period. CONCLUSIONS: Reducing the risk factors to a minimum prior to surgery will increase the success of the incisional hernia repair and generate a positive impact on the patient's quality of life. The lofty goal of significant weight loss prior to elective hernia has shown to be the key factor in using the Mayo technique for incisional hernia repair. This study demonstrates that the Mayo repair technique is a suitable and trustworthy alternative for repairing incisional hernias with very good results. It's costs are minimal and it can be easily reproduced, even by less experienced surgeons.

Harvest of superficial layers of fat with a microcannula and isolation of adipose tissue-derived stromal and vascular cells.

BACKGROUND: Adipose tissue is a source of stromal and vascular cells suitable for regenerative medical applications. Cell recovery depends on several factors, including the characteristics of the cannula used to harvest tissue. OBJECTIVES: The authors assess whether aspiration of superficial layers of adipose tissue performed with a microcannula, rather than a standard cannula, allows for improved isolation of stromal and vascular cells, and they evaluate the angiogenic potential of the isolated cells in vitro and in vivo. METHODS: Adipose-derived stromal and stem cells (ADSC) were collected from the lipoaspirate of the abdomen and hip regions of 6 healthy female donors. For adipose tissue harvest, several options were compared: (1) a rounded-tip cannula with a length of 170 mm, a diameter of 3 mm, and a single elliptic suction port on the side near its distal end (port diameter: 3 × 9 mm) or (2) a rounded-tip infiltration cannula with a length of 170 mm, a diameter of 2 mm, and 5 round ports placed spirally along the sides of the distal cannula shaft (each port diameter: 1 mm) (Shipper Medical Technologies Corporation, Centennial, Colorado). Isolated cells were characterized for (1) expression of the endothelial specific marker CD31 by immunohistochemical and cytofluorimetric analyses and (2) tubular-like structure formation using a 3-dimensional angiogenesis assay on Matrigel. Human ADSC were transduced to express firefly luciferase as a marker suitable for bioluminescent tracking and transplantation studies into immunosuppressed mice were performed. RESULTS: ADSC yield was determined to be significantly higher in samples collected with the microcannula (P = .04). Moreover, isolated cells acquired typical endothelial-like morphology in vitro, formed capillary-like structures, and expressed the distinctive endothelial cell marker CD31. Cells implanted into immunosuppressed mice persisted for several weeks in areas undergoing neovascularization. CONCLUSIONS: These results suggest that aspiration of adipose tissue with a microcannula can be a minimally invasive method to obtain clinically relevant numbers of stromal and vascular cells useful for autologous transplant procedures and for promoting tissue regeneration and neovascularization.

New perspectives in the treatment of hidradenitis suppurativa: surgery and brewer's yeast-exclusion diet.

BACKGROUND: Hidradenitis suppurativa (HS), or acne inversa, is a chronic inflammatory skin disease characterized by abscesses, fistulating sinus tracts, and scarring. The exact pathogenesis of this disease remains unclear. We present our experience with HS and a possible cause of the disease and offer a surgical and clinical treatment that allows for disease resolution. METHODS: We studied 12 patients who presented with axillary and perineal fistulas and underwent surgical excision (repaired by skin grafts or healing by secondary intention) or localized treatments followed by diet modification. All patients were found to have a specific immunology IgG reaction to brewer's yeast and wheat and were put on a controlled brewer's yeast-free diet for 12 months and followed monthly. RESULTS: The diet demonstrated immediate stabilization of their clinical symptoms, and the skin lesions regressed over the 12-month treatment period. Similarly, all the patients demonstrated an immediate recurrence of skin lesions following accidental or voluntary consumption of beer or other foods containing brewer's yeast or wheat. The patients also demonstrated a return of their quality of life and activities, including the reestablishment of sexual activity in the patients with inguinal and perigenital lesions. CONCLUSION: The results of the investigation suggested that the patients had severe reactions to brewer's yeast. Surgery followed by the elimination of the foods containing or made with the yeast resulted in a rapid stabilization of the dermatologic manifestation and a slow, but complete, regression of the skin lesions within a year. Despite the small number of patients in our study, our study could provide the basis for extensive and multicentric studies in order to better investigate this disabling and rare disease.

Surgical treatment of gynecomastia with severe ptosis: periareolar incision and dermal double areolar pedicle technique.

BACKGROUND: Gynecomastia is a morphostructural impairment of the mammary region in men caused by parenchymal hypertrophy or a cutaneous distortion of breast skin covering or both. The clinical classification introduced by Simon et al. in 1973 ranks gynecomastia in three degrees. Each subtype can be treated with a specific technique. This article describes an alternative surgical procedure for treating gynecomastia with severe ptosis(type III and type IIIb of Simon's classification). METHODS: Fifty-eight patients were treated for gynecomastia in our Plastic Surgery Unit from 1996 to 2004. The cutaneous excess of periareolar skin is evaluated by a pinching test. A circular periareolar mark is traced corresponding to the cutaneous excess that has to be removed.Initially, liposuction of adipous tissue on the periphery of the mammary region is performed through two cutaneous 3-mm incisions at the 3 o'clock and 9 o'clock positions around the areola. After this, the liposuction incisions are enlarged from 10 o'clock to 8 o'clock and from 2 o'clockto 4 o'clock to create access for the mastectomy. This dissection creates a double dermal areolar pedicle. The new areolar position is fixed with a Benelli round block suture. RESULTS: A resolution of the morphologic deformity without evident scars after hair growth and a correction of the breast deformity has been observed in the 6-month follow-ups conducted for all the patients. CONCLUSION: We observed that the vascular-nervous net under the areola at 12 o'clock and 6 o'clock is very important, more so than the lateral pedicle, and the conservation of a double vascular-nervous pedicle reduces significantly the risk of areolar necrosis, especially in cases of gynecomastia type III and in cases where there is a high degree of breast malformation such as the tuberous breast.

Thigh and buttock lift after massive weight loss.

BACKGROUND: Surgical and medical treatment of obesity involves a significant loss of weight (30-90 kg) during a short time (12-24 months). The technical procedures for treatment of skin excess on the thigh create scars on the posterior buttock fold and the inguinal fold. Since 1999, the authors have used a heart-shaped incision for buttock thigh lifts. METHODS: The authors have treated these regions with a two-step intervention. First, abdominal lipectomy and lipoaspiration of the internal and external face of the thigh are performed. Then after 6 months, the buttock thigh lift is performed using a heart-shaped incision traced previously in an anterior direction from the perianal region on the inguinal fold and spread the iliac crest to the intergluteal fold posteriorly. The skin dissection is performed on the scarpa aponeurosis so as not to damage the lymphatic system. RESULTS: In their experience with 15 patients, the authors had no infectious complications, or lymphorrea. The operative time was generally 3(1/2) h. The patients did not require blood transfusions and were on sick leave for 3 to 4 weeks. CONCLUSION: The surgical procedure that we propose reduces the complications and the surgical time with a good result.

Brachioplasty after massive weight loss: a simple algorithm for surgical plane.

After massive weight loss, patients experience a severe skin laxity of the arms with or without associated fat deposits. More than 20 years elapsed after the first aesthetic brachioplasty in 1954 before this problem was addressed with significant technical innovation. The current brachioplasty techniques are somewhat unpredictable and commonly associated with significant untoward results and complications including misplaced, widened, or hypertrophic scars as well as contour deformities resulting from overcorrection centrally and underresection. The authors define preoperative marking that permits reduction of overcorrection problems and makes the surgical technique easy for young surgeons. They have performed this procedure for 6 years with satisfactory results.

Orbitofacial cleft number 5: radiographic, anatomical, and histologic study of a 24-week-old fetus.

BACKGROUND: Orbitofacial clefts are caused by a congenital absence of midfacial tissues between the eye and the upper lip just medial to the corner of the mouth. As a whole, facial clefts occur with an incidence of 1.43 to 4.85 per 100,000 births. The exact incidence of these unusual orbital facial clefts is unknown. Only a few clinical cases and their treatment have been reported in the world literature, and no anatomical or histologic study has been presented. METHODS: The authors present a detailed anatomical and histologic study in a 24-week-old fetus with a right-side no. 5 orbitofacial cleft (according to Tessier's classification). RESULTS: During the anatomical dissection, it was observed that in the trigeminal Gasser ganglion on the right side there was no infraorbital branch of this nerve. Both the foramen rotundum and the infraorbital groove, where the nerve exits, were hypotrophic. CONCLUSION: After embryologic analysis of their observation, the authors propose that the orbitofacial no. 5 cleft should be considered as a tissular disruption of the face secondary to damage of the terminal branches of the maxillary nerve.

Torsoplasty after important weight loss.

Weight loss exceeding 40 kg frequently causes excess skin on the lateral and posterior chest wall. Other authors have suggested surgical dissection of the excess skin using horizontal incision or, alternatively, using a vertical incision positioned in the axillary region. This procedure is incomplete and does not correct the skin ptosis in the subaxillary lateral chest wall. The current authors propose a surgical technique that permits resection of excess skin and lifts the torso on the back, positioning the scars on the anterior axillary pillar and around the breast. This treatment is performed for the patient after significant weight loss. The scar normally is hidden behind the anterior axillary pillar on the axillary fold.

[Scrotal reconstruction by inguinal flap after Fournier's gangrene]. / La reconstruction du scrotum après gangrène de Fournier par lambeau inguinal.

OBJECTIVES: The authors propose the use of a pedicle inguinal flap for reconstruction of the scrotal region after wide tissue resection following gangrene of the perineum. MATERIAL AND METHODS: Between 1998 and 2002, the authors treated 14 patients by surgical debridement following Fournier's perineo-perianal cellulitis. The authors used a pedicle inguinal flap in two patients with complete resection of the scrotal sac. RESULTS: Clinical examination at 3 years showed a good functional and aesthetic result. The trophicity and sensitivity of the neo-scrotum and testes were normal. CONCLUSIONS: The inguinal flap proposed by that authors allows cover of the scrotal region with relatively thick, sensitive tissue with limited scarring and functional sequelae.