The use of external ultrasound combined with superficial subdermal liposuction.

Superficial subdermal liposuction (SSL) was presented by the authors as an evolution in traditional liposuction in 1989. It allows one to treat the superficial fat to obtain better skin retraction during every liposuction procedure. The use of ultrasound (US) in liposuction began 10 years ago as the direct application of this energy to the adipose tissue using a probe to obtain the selective destruction of fat, followed by its aspiration. This technique gave rise to many complications and thus many concerns. The external delivery of US has been proposed to overcome some of the drawbacks associated with this procedure. The authors investigate the role of external ultrasound (EU) used in conjunction with SSL. When comparing EU and SSL with SSL alone, pretreatment with EU results in less bleeding during liposuction, aspirated fat that is clearer and more oily, and less bruising and swelling during the early postoperative period. EU is an ideal complementary procedure to SSL because the crumbling of the fat induced by US permits a more uniform aspiration of the subdermal fat layer, making skin retraction more even and effective.

External ultrasound used in conjunction with superficial subdermal liposuction: a safe and effective technique.

The authors present their experience with the external ultrasound (EU) used in conjunction with superficial subdermal liposuction (SSL) to achieve better results in a safe, predictable, and reproducible way, and discuss the safety of liposuction and the related methods of anesthesiology.

Technical refinements in the surgical treatment of gynecomastia.

The authors present their experience with liposuction of breast fat followed by sharp excision of the breast gland, when needed. Liposuction is performed, introducing a short uterine curette through a hemicircular periareolar incision. The suction is carried out as close as possible to the glandular tissue and all around the areola in a fan shape until the boundaries of the mammary region are reached in all directions to allow better skin redraping. Because the fat layers are encased in the fibrous septi of the superficial fascial system, suction of the fat lobules allows shrinkage of the septi and also enables skin retraction in patients with marked gynecomastia and considerable skin redundancy. Moreover, because liposuction causes an increase of coagulative factors in the treated area, it plays an important role in spontaneous hemostasis. In fact, the hypercoagulative state of the fat treated by liposuction implies minimal bleeding in additional surgery. The removal of the residual mammary gland is very easy, hemostasis is usually not needed, and drains are usually not used.

Breast shape malformations.

Breast shape malformations are deformities of the breast contour involving the inferior breast pole. They range from minor forms such as a high submammary fold to major forms such as the tubular breast. The malformation implies an altered relationship between the mammary parenchyma and the superficial fascial system (SFS). The surgical correction consists of the releasing of the gland from all the connections with the surrounding tissues. In some cases, once the glandular tissue is freed from the constricting SFS, the parenchyma spreads revealing a sufficient volume to obtain a normal breast. If hypoplasia of the breast or inferior quadrant hypoplasia is present, the use of an implant is mandatory.

Rationale of subdermal superficial liposuction related to the anatomy of subcutaneous fat and the superficial fascial system.

The liposuction technique has changed greatly over the years. In 1989, the authors presented subdermal superficial liposuction which treats the superficial fat layer and yields better skin retraction. With this technique the surgeon can treat thin adipose layers to obtain better results in more cases than the traditional liposuction technique. The technique can be used in cases with difficult skin adjustment and in secondary cases when "deep only" liposuction has been performed and there were residual adiposities. Subdermal superficial liposuction evolved so that one could obtain good skin retraction by performing massive liposuction of all the fat layers. The authors named this technique MALL (Massive All Layer Liposuction). The technique is applied in body areas where the fat layer is very thick and stretches the skin because of its volume and weight such as in the abdomen, posterior arms, and internal surface of the upper third of the thighs. MALL liposuction drastically reduces the indications for abdominoplasty and inner thigh and arm dermolipectomies. Knowledge of the anatomy of the subcutaneous fat and the superficial fascial system allows one to explain the subdermal superficial liposuction from an anatomical point of view, to perform a more rational and effective procedure, and to differentiate the technique depending on the area of the body.

MALL liposuction: the natural evolution of subdermal superficial liposuction.

Subdermal superficial liposuction, first presented by the authors at the ISAPS Congress at Zurich in 1989, is performed with thin three-hole Mercedes cannulas (diameter ranges from 1.8 to 2 mm) to treat small and secondary adiposities and to allow better skin retraction. Suction of the subdermal layer of fat reduces the thickness and consistency of the superficial fat and enhances the possibility of skin retraction. In cases where there is a large adiposity of the abdomen, arms, or inner thighs, there is a conspicuous volume of fat whose weight tends to overstretch and to carry the overlying skin downward. In these cases we need to reduce the large fat volume to permit effective skin retraction. Therefore, we apply the principles of traditional liposuction with those of subdermal superficial liposuction to aspirate large amounts of fat from all the adipose layers. We call this technique Massive All Layer Liposuction (MALL). The amount of skin shrinkage after this "defatting" procedure is remarkable and the clinical results are very good. The MALL technique can be applied to other areas as well. In our experience this new liposuction technique has dramatically reduced the indications of abdominoplasties and dermolipectomies of inner thighs and arms.

Subperiosteal lateral browlift and its relationship to upper blepharoplasty.

Skin redundancy of the upper eyelid is often associated with a variable degree of ptosis of the lateral third of the eyebrow, which increases the extent of the defect. Correcting this condition implies a combination of a temporal lift with a standard upper blepharoplasty. In the temporal lift it is possible to perform an easy subaponeurotic and subperiosteal dissection of the soft tissues of the temporal area through an incision behind the hairline with pleasing and long-lasting results. The brow ptosis is corrected without noticeable scars and with inconspicuous damage to scalp follicles of the temporal region.

Polyurethane-covered mammary implants: a 12-year experience.

Polyurethane-covered mammary implants are the implants of choice in aesthetic and reconstructive mammary surgery. These implants give very good results in regard to breast contour and consistency, and have a very low complication rate. We present our 12-year experience using polyurethane-covered prostheses. We place the implant mostly in the subglandular or subcutaneous site, and their capsular contracture rate is extremely low (3.3%). Based on our experience, we also review the other complications and side effects occurring with polyurethane prostheses and discuss them in detail.

Subdermal liposuction.

Liposuction is a widely used technique today and indications are that it is becoming even more popular due to new technical refinements. The use of cannulae with a smaller diameter allows suction of the fat immediately under the dermis. The cannula we use to perform this new kind of fat suction is straight and has an external diameter of less than 2 mm. This cannula, the so-called Mercedes cannula, has a bullet tip and a three-hole head. Moreover, the holes are not round but are slit-shaped and oriented in the same plane at 120 degrees. This cannula is specifically designed to produce less trauma. The cannula with one downward-facing orifice is not suitable for suction of the subdermal layer and an upward-facing orifice would be too traumatic. The advantage of this new technique, apart from the possibility of treating patients with very slight adiposity, is to allow an effective skin retraction. When a large amount of fat has already been aspirated, residual deformities can occur. These skin irregularities represent the lack of an effective cutaneous retraction mostly due to the permanence of the subdermal fat. In fact, the presence of a thick subdermal adipose layer decreases the possibility of skin retraction. Therefore, indications for liposuction of the subdermal fat are mainly the slight adiposities and the remnant deformities of a previous liposuction operation. Moreover, this technique is applied to every lipoplasty whenever better skin retraction is needed.

Experience and technical refinements in the "donut" mastopexy with augmentation mammaplasty.

Minor ptosis and pseudoptosis of the breast may be corrected by a "donut" mastopexy. This technique offers the opportunity to reach a good aesthetic result with minimal scarring. A prosthesis is inserted at the time of the mastopexy and the skin is reduced in an elliptical way to achieve a good balance between the breast volume and the skin envelope.

Preoperative breast marking in reduction mammaplasty.

A simple method of preoperative marking for reduction mammaplasty is described. This method may be used in macromastias when the technique chosen implies a postoperative scar with the shape of an inverted T. The marking sequence follows standard steps, but the drawing is always different because it is a consequence of the shape of the breast. This marking method reduces the chance of making mistakes due to excessive personal evaluations or to the use of standard drawing patterns that may be not suitable for all breast shapes.

Cleft lip: aesthetic results following a different skin incision.

In a revision of the cleft lip cases repaired in the past 20 years using the most common techniques, the most significant observation that has emerged is the alteration of lip anatomy due to the abnormal dislocation of tissue masses and scar direction. These may have negative consequences on the final development of the lip. In an effort to avoid some of these inconveniences the authors propose a very flexible technique that recalls Pfeiffer's concepts, consisting of a vertical line of incision interrupted at various points so as to obtain angles of different degrees. The method has been named the W-technique with variably sized angles.

[Therapeutic indications for immature angioma in the early infancy]. / Indicazioni terapeutiche nell'angioma immaturo della prima infanzia

Angiomas are classified briefly and their main features are described. Attention is then directed to the most frequent type: immature angioma. Its main feature is a parenchymatous or soft-elastic consistency; this is important for diagnosis. Little swelling is noted during crying, laughing and with the patient in an inclined position. These angiomas are typical of early infancy and usually regress spontaneously with visible sequelae, as in 70% of the reported series. Treatment should thus be avoided, since it is often useless and may even be damaging. Exceptions include cases where further growth is noted during monthly or bimonthly controls, or where clinically ascertainable cavernomas are formed. Reference is made to the possibility of treatment with triamcinolone, though this is viewed more as a test of the possibility of regression.