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The implantation of breast prostheses for both aesthetic and reconstructive purposes has been growing exponentially in the last 20 years. Safety and prosthesis lifespan are majorly debated issues in relation to the correlated long-term complications. Mainly the periprosthetic capsule that develops around the implant is often the cause of complications and particularly for macrotextured silicone breast implants. Some reports have tried to elucidate the mechanism by which macrotextured silicone implants undergo damage and cause double capsule formation. In this study, we investigated the morphological characteristics of double capsule of macrotextured implants surgically removed from patients. With the use of microscopy techniques, this work analyzed the newly formed tissue observed in the interaction between synthetic and biological surfaces.

Prosthetic reconstruction failures can usually be reconstructed again using flaps. But in case of contraindications or when the patient accepts no additional scars, no common reconstructive alternative is available. Free fat grafts offer a new option even if several technical problems need to be faced. Two cases of failed implant reconstruction after radiotherapy were reconstructed using lipofilling only, achieving a quite pleasant aesthetic result. Fat graft transplantation can be a reliable and safe option for breast reconstruction in selected patients. A wide discussion about free fat grafts is presented with respect to technical details and variables; a survey of the risks reported in literature is also provided, included the peculiarities of lipofilling in neoplastic patients and in irradiated areas.

Background: A reduced nipple projection is the main reason for scarce satisfaction in nipple-areola complex reconstruction [9, 6] and many techniques have been proposed to sustain the reconstructed nipple. Method: 90 nipples in 70 patients were reconstructed either using a little wedge from labia minora (LMW) (70) or with nipple sharing (NS) (20). Two months after reconstruction, each reconstructed nipple was injected with DermaLive®. A second and a third injection were performed two and five months later. The injected volume was trimmed depending on the desired projection. Nipple projection was measured at the moment of implant, before and after each injection and six and twelve months after the last injection. Results: nipple projection was fully satisfactory in all cases and it was comparable to the contralateral nipple. Average nipple projection at six months was 5.8 mm in LMW patients, and 3.8 mm in NS ones (p

Pseudoxanthoma elasticum (PXE) is a rare hereditary disorder of elastin fibers, characterized by yellowish coalescent papules in flexural surfaces with abnormally lax and corrugated skin. It can be associated to systemic manifestations mostly regarding eyes and vessels. Aesthetic surgery of cutaneous hyperlaxity was described in the international literature only in few cases, mostly as neck lift. A 40-year-old woman presented with cutaneous signs of PXE, demanding brachioplasty. Results after a nine-month followup are quite satisfying, and no signs of local recurrence or scar alterations are present.

Breast reconstruction is fully justified only from an aesthetical perspective. A reconstructed breast, therefore, should be as aesthetically natural and similar to the contralateral one as possible, even if this means reproducing some little defects. The breast's profile (projection, ptosis, sulcus location, and superficial unevenness), symmetry, areola, and nipple are the characterizing aesthetic factors. The authors present their experience in prosthetic breast reconstruction seen with an aesthetic eye and an artistic touch, illustrating personal tips and technical adjustments: use of anatomical prostheses, pectoralis muscle treatment, sulcus stabilization or reconstruction, superficial irregularities correction, and nipple-areola complex reconstruction. Results are evaluated by both the surgeon and the patient using a score system, validating the method.

The tuberous breast syndrome is the result of a complex series of defects with various degrees of expression. However, much confusion has been generated in the literature by the use of often inadequate terminology, which is partly the cause of multiplicity of managements being proposed that mainly aim to correct the major defect and not the entire syndrome. The surgical approach adopted by our group stems from the improvement of classic techniques, consisting essentially of a combination of periareolar mastopexis, additive mastoplasty, and gland base enlargement by cross incision. Our results were fully satisfying both aesthetically and functionally. We achieved a correct shape, resolved ptosys and reduced areolas with no double-fold effect, and attained good symmetry in more complex unilateral cases.

Radiotherapy is a fundamental therapeutic resource in a large majority of neoplastic diseases. But adverse reactions and complications can severely damage the irradiated tissues. Adverse effects can be distinguished into early (within few weeks to 90 days from treatment) and late ones (months to years from exposure). Late adverse effects are primarily the result of radiation-dependent reduction of stem cells or progenitors (Brush, 2007; Rodemann & Blaese, 2007). Fibrosis, teleangiectasias and atrophy are the most common late effects for skin and subcutaneous tissues and those most frequently observed in irradiated breast cancer patients. The mean concentrations of collagen are two times higher in irradiated skin than in non-irradiated skin thus leading to fibrosis (Autio et al, 1998; Riekki et al, 2002). There seems to be a genetic predisposition for fibrosis and teleangiectasias as a response to radiotherapy. Fibrosis risk is also associated with an inflammatory response, whereas telangiectasia is linked to endothelial cell damage. Atrophy is related to an acute response, but no genetic predisposing factors have yet been identified. (Quarmby et al, 2003; Andreassen et al, 2005; Giotopoulos et al, 2007). The reconstructive properties of adipose tissue are also significantly altered (Poglio et al, 2009) as the stromal microenvironment is unable to self-repair the injury suffered. Depletion of the stromal compartment leads to a loss of the precursor reservoir, thus compromising its ability to maintain tissue homeostasis. In response to ionizing radiation, fibroblasts and macrophages remain in an activated state, continuously generating growth factors and free radicals (Barcellos-Hoff et al, 2005) which are the main reasons for fibrosis. Radiations also severely harm the homeostatic network connecting parenchymal, mesenchymal, and vascular cells within tissues and normal interactions between cells are therefore altered (Barcellos-Hoff et al, 2005; Bentzen, 2006). Late adverse effects of radiotherapy in breast reconstructions can consequently cause flap failure, implant exposure, and capsular contracture in prosthetic breast reconstructions. The final aesthetic results can also be compromised due to liponecrosis.

Background: When prosthetic reconstruction fails, and in the case of absolute contraindications to flaps use, no common reconstructive option is available. Methods: A large irradiated breast was reconstructed using only fat grafts (9 sessions) after prosthetic reconstruction failure (exposure of implant) due to absolute contraindications to general anesthesia and unavailability of large flaps. During the first four sessions small volumes were implanted in the extremely rigid and retracted tissues with regenerative purposes. Larger volumes were implanted during the last five sessions to improve volume and shape. Results: A pleasant aesthetic result was achieved. Tissue regeneration with good vascular support was evident at ultrasonography and magnetic resonance. Histologic and ultrastructural examination of the new tissue showed normal adipose tissue with cell and vasculostromal maturation aspects. No degenerative or inflammatory aspects were present. Conclusion: Fat graft transplantation can be a reliable and safe option for breast reconstruction in selected patients.

Technological developments based on the use of autologous white adipose tissue (WAT) attracted attention to minor fat depots as possible sources of adipose tissue. In plastic surgery, the trochanteric fatty pad is one of the most used WAT depots for its location and organoleptic characteristics that make it particularly suitable for reconstructive procedures. Despite its wide use in clinic, the structure of this depot has never been studied in detail and it is not known if structural differences exist among trochanteric fat and other subcutaneous WAT depots. The present study was performed on trochanteric fat pad with the aim to clarify the morphology of its adipocytes, stroma and microcirculation, with particular reference to the stem niches. Histological and ultrastructural studies showed that the main peculiar feature of the trochanteric fat concerns its stromal component, which appears less dense than in the other subcutaneous WATs studied. The intra-parenchymal collagen stroma is poor and the extracellular compartment shows large spaces, filled with electron-light material, in which isolated collagen bundles are present. The adipocytes are wrapped in weak and easily detachable collagen baskets. These connective sheaths are very thin compared to the sheaths in other subcutaneous WAT depots. The capillaries are covered by large, long and thin elements surrounded by an external lamina; these perivascular cells are poor in organelles and mainly contain poly-ribosomes. In conclusion, when compared to other WAT deposits, the trochanteric fatty pad shows structural peculiarities in its stroma and microcirculation suggesting a high regenerative potential. Resistance, dissociability, microvascular weft and high regenerative potential make the trochanteric fatty pad a privileged source for harvesting in autologous WAT-based regenerative procedures.

Background: Standard mastopexy techniques generally involve dermal interruption with a possible reduction of the neurovascular supply to the nipple-areolar complex. The dermal layer is usually back-folded to sustain the breast, leading to deep changes in breast structure, with possible consequences in imaging and raising concerns for cancer prevention and staging. Methods: The technique presented here is based on the Pitanguy’s inverted T disepithelization pattern. Five to seven 2-mm-long dermal incisions are placed along a line 3-4 mm above the sulcus. The fascia is pinched through these accesses and sutured to the deep derma and the breast cone is reconfectioned by infolding the dermal layer and the gland. Between 2001 and 2005, 54 patients with isolated breast grade 2 or 3 ptosis were treated using this technique. The results were evaluated both at three months and two years after surgery. The patients were also asked to answer a questionnaire about the nipple-areolar complex sensitivity and its effects on social life. Results: Aesthetic results were good in all cases, with no significant difference between the two controls. nipple-areolar complex sensitivity alterations three months after surgery were minimal (19%) or null (81%) with no significant effect on social life and even better two years after surgery. No serious technique-related complication or “bottoming out” occurred. Conclusions: The technique presented here achieves a good and stable correction of ptosis with a good stabilization of the inframammary fold and minimal effects on nipple-areolar complex sensitivity and trophism. Transdermal sulcus blockage prevents inframammary fold migration and “bottoming out”.

Background This study investigated the effects of lipofilling on both the functional and the aesthetic aspects of breast reconstruction. Methods Sixty-one consecutive patients with irradiated reconstructed breasts (62 breasts) were offered free fat transfer to enhance the results and correct the defects. Twenty patients were enrolled (active branch) and underwent multiple sessions of lipofilling, while the others were considered controls. The fat was harvested by syringe and processed by saline washing only (no centrifugation). Three months after the last session the functional outcome was evaluated using the LENT-SOMA scoring system and the aesthetic outcome was evaluated using a visual 5-point scale. Results A significant improvement in all the LENT-SOMA scores after free fat grafting was observed; the scores after treatment were all significantly lower than those before it and were also significantly lower than those of untreated breasts. These results also were confirmed by comparing homogeneous subgroups of breasts with similar LENT-SOMA ranks before treatment. Similarly, the cosmetic outcomes were significantly enhanced after serial lipofilling. The four cases in the active branch with severe flap thinning resolved with no implant exposure (mean follow-up = 17.6 months), while implant exposure occurred in the two cases with the same problem in the control group. In one case, a Baker 3-4 capsular contracture was downgraded to Baker 1 after only one session of lipofilling. No complications occurred in the treated cases. Conclusion Free fat transfer is a safe and reliable technique in improving the outcomes of irradiated reconstructed breasts with implants.

The flexibility of lower cohesivity silicone prostheses is the main reason for wrinkling, rippling and evidence of implant edges. The soft cohesive silicone implants promise to minimize such effects with minimal softness reduction. Forty consecutive patients received soft cohesive prostheses (INAMED Style 110 ST) and were studied prospectively. A historical group, made up by the 40 consecutive patients who received lower cohesivity silicone implants (INAMED Style 110) in the immediately preceding months, was used as a control. Wrinkling, prosthetic edge perceptibility and capsular contracture degree were assessed six months after surgery. The tissue coverage thickness was measured using ultrasonography. The patients were then asked to evaluate the breast softness by means of an anonymous questionnaire, where they also expressed their overall satisfaction by means of the five-steps linear analogical scales. The wrinkling prevalence was 9.2% in the soft cohesive group vs. 55% in the lower cohesivity one (p

Prominauris, the most common malformative defect of the external ear, is dependent on a combination of elementary defects mainly affecting the antihelix and the concha. Transection versus cartilage weakening results in antihelix treatment are discussed. In this study, 104 ears with antihelical defects were treated in 63 consecutive patients: the 33 patients (53 ears) in group A, received a transection-based treatment, whereas the 30 patients (51 ears) in group B, underwent cartilage weakening and suture. All the patients were treated using a posterior access. The aesthetic results were evaluated by an independent well-trained plastic surgeon. No differences were found in correction degree and stability between the two methods, but cartilage weakening techniques provided a smoother and more natural curvature Cartilage weakening techniques can lead to better aesthetic results, primarily because of a softer and more natural ear curvature.

CONTEXT: The most revolutionary concept in rhytidectomy is the role of Sub Muscular Aponeurotic System (SMAS), even if many alternative approaches have been proposed. The main aim of face lift is to bring back the time, preventing the "lifted-face" appearance. SETTINGS AND DESIGN: The authors present their personal experience with different levels of undermining, i.e. subperiosteal forehead lift, subcutaneous midface lift with SMAS plication and platysmal suspension, and discuss the anatomical and biomechanical elements of rhytidectomy. RESULTS: Optimal aesthetic results were achieved by repositioning the neck, face and forehead tissues in a global and harmonious fashion, without distorting face characteristics and disguising surgery trails as much as possible. CONCLUSIONS: Different levels of undermining can give good and stable aesthetic results minimizing the risks and preventing face distortion.

A new submuscular-subglandular technique to correct teardrop-shaped breasts using round prostheses is presented. In this technique the prostheses are only partially covered by muscle. The muscle is also divided to enhance the projection at the nipple level without the need for anatomical prostheses. A series of 911 implanted prostheses is presented and the results are discussed with regard to both visual and tactile aspects, as well as the dynamic appearance. The complication rates are surprisingly comparable to those of totally submuscular implant techniques. This perhaps suggests that the coverage provided by the divided muscle is sufficient to minimize the contact between the implant and the gland, often considered the primary cause of the higher capsular contracture rates found in techniques using subglandular locations.