Insights on DRGs, guideline compliance and economic sustainability. The case of mastectomy with immediate breast reconstruction

Background

Immediate breast reconstruction is recommended for eligible patients undergoing mastectomy, raising the issue of economic sustainability of both mastectomy and breast reconstruction performed within the same hospitalization, as opposed to two surgical procedures in two different hospitalizations.

Study design

A retrospective analysis was conducted to compare economic sustainability of mastectomies with or without immediate breast reconstruction.

Methods

Economic data on hospitalizations for mastectomy in a Teaching Hospital between 1 January 2019 and 31 March 2021 were analyzed to assess their sustainability.

Results

338 admissions were selected (63.9% with immediate breast reconstruction (CI 99%: 57.2% to 70.6%). Compared to mastectomy alone, mastectomy with immediate breast reconstruction had higher cost of € 2,245 (p < 0.001), with operating rooms and devices as main cost drivers. Current reimbursements rates (which are the same for mastectomy alone and for mastectomy with immediate breast reconstruction) led to an average loss of € 1,719 for each mastectomy with immediate breast reconstruction.

Conclusion

Current DRGs reimbursement rates for hospital admissions for breast cancer surgery do not guarantee immediate breast reconstruction's economic sustainability. DRGs system should be revised, or other solutions as bundled payment should be implemented in the light of the costs of innovation in healthcare, considering mastectomy and breast reconstruction steps in a path of linked actions aimed at improving patients' health.

Impact of microvascular free flap reconstruction in oral cavity cancer: our experience in 130 cases

The aim of this study was to investigate the oncological outcomes in patients affected by oral carcinoma treated with radical compartmental surgery followed by microvascular flap reconstruction. We conducted a retrospective analysis on a cohort of 130 patients. All patients underwent ablative tumour resection (compartmental surgery) followed by immediate reconstruction with free flaps and adjuvant chemoradiotherapy, when necessary according to our tumour board and international guidelines. Disease-specific survival (DSS) curves were obtained using the Kaplan-Meier method. Log-rank test and generalised Wilcoxon test were used to investigate the most important prognostic factors on 5-year DSS. A Cox proportional hazards model was constructed to provide hazard ratios or relative risks for individual variables. 88.5% of patients were affected by SCC. There were 46 (35.4%) women and 84 (64.6%) men in the sample with a mean age of 58.5 years. At the end of the follow-up period, 36 (27.7%) patients died, only 3 of which for other causes. The 5-year DSS rate was 67.8% (S.E. 4.9%). In univariate Kaplan-Meier analysis and in multivariate Cox regression model, seven variables were found to have a significant relationship with DSS: T (p = 0.026) and N (p = 0.0001) status, clinical stage (according to the UICC TNM Sixth Edition) (p = 0.007), margins of resection (p = 0.001), extracapsular spread (p = 0.005), recurrence of disease (p = 0.00002) and treatment modality (evaluated as surgery alone or surgery + RT/CHT) (p = 0.004). Our results confirmed findings already reported in the literature, and allowed us to conclude that compartmental surgery combined with free flap reconstruction can increase survival in oral cancer patients.

Radiation dose intensification in pre-operative chemo-radiotherapy for locally advanced rectal cancer

BACKGROUND

To assess the role of radiation dose intensification with simultaneous integrated boost guided by 18-FDG-PET/CT in pre-operative chemo-radiotherapy (ChT-RT) for locally advanced rectal cancer.

METHODS

A prospective study was approved by the Internal Review Board. Inclusion criteria were: age >18 years old, World Health Organization performance status of 0-1, locally advanced histologically proven adenocarcinoma of the rectum within 10 cm of the anal verge, signed specific informed consent. High-dose volumes were defined including the hyper-metabolic areas of 18-FDG-PET/CT of primary tumor and the corresponding mesorectum and/or pelvic nodes with at least a standardized uptake values (SUV) of 5. A dose of 60 Gy/30 fractions was delivered. A total dose of 54 Gy/30 fractions was delivered to prophylactic areas. Capecitabine was administered concomitantly with RT for a dose of 825 mg/mq twice daily for 5 days/every week.

RESULTS

Between September 2011 and July 2015 fortypatients were recruited. At the time of the analysis, median follow up was 20 months (range 5-51). The median interval from the end of ChT-RT to surgery was 9 weeks (range 8-12). Thirty-seven patients (92.5 %) were submitted to sphincter preservation. Tumor Regression Grade (Mandard scale) was recorded as follows: grade 1 in 7 (17.5 %), grade 2 in 17 (42.5 %), grade 3 in 15 (37.5 %) and grade 4 in 1 (2.5 %). Post-surgical circumferential resection margin was negative in all patients. A tumor downstaging was reported in 62.5 % (95 % CI: 0.78-0.47). A nodes downstaging was registered in 85 % (95 % CI: 0.55-0.25). 18-FDG-PET/CT was not able to predict pCR. No correlation was found between pre-treatment SUV-max values and pCR. A metabolic tumor volume >127 cc was related to ypT ≥2 (p 0.01). Patients with TRG >2 had higher tumor lesion glycolysis values (p 0.05).

CONCLUSION

Preliminary results did not confirm some advantages in terms of primary tumor downstaging/downsizing compared to conventional schedules reported in historical series. The role of 18-FDG-PET/CT in neoadjuvant rectal cancer management needs to be confirmed in further investigations. Long terms results are necessary.

The role of oxidized regenerate cellulose to prevent cosmetic defects in oncoplastic breast surgery

BACKGROUND

Breast conserving surgery (BCS) combined with postoperative radiotherapy has become the gold standard of locoregional treatment for the majority of patients with early-stage breast cancer, offering equivalent survival and improved body image and lifestyle scores as compared to mastectomy. In an attempt to optimize the oncologic safety and cosmetic results of BCS, oncoplastic procedures (OPP) have been introduced in recent years combining the best principles of surgical oncology with those of plastic surgery. However, even with the use of OPP, cosmetic outcomes may result unsatisfying when a large volume of parenchyma has to be removed, particularly in small-medium size breasts.

AIM

The aim of this article is to report our preliminary results with the use of oxidized regenerate cellulose (ORC) (Tabotamp fibrillar, Johnson & Johnson; Ethicon, USA) as an agent to prevent cosmetic defects in patients undergoing OPP for breast cancer and to analyze the technical refinements that can enhance its efficacy in optimizing cosmetic defects.

METHODS

Different OPP are selected based on the location and size of the tumor as well as volume and shape of the breast. After excision of the tumor, glandular flaps are created by dissection of the residual parenchyma from the pectoralis and serratus muscles and from the skin. After careful haemostasis, five layers of ORC are positioned on the pectoralis major in the residual cavity and covered by advancement of the glandular flaps. Two additional layers of ORC are positioned above the flaps and covered by cutaneous-subcutaenous flaps.

RESULTS

The use of ORC after OPP has shown promising preliminary results, indicating a good tolerability and positive effects on cosmesis.

CONCLUSIONS

This simple and reliable surgical technique may allow not only to reduce the rate of post-operative bleeding and infection at the surgical site but also to improve cosmetic results.

Oral cavity defect reconstruction using anterolateral thigh free flaps

BACKGROUND

It is estimated that about 92,000 new cases of oral cavity and pharyngeal cancer occurred in Europe in 2008. During the past 30 years in the USA and Western Europe, the prognosis for oral cancer has clearly improved thanks to the possibility of reconstruction with microvascular free flaps, resulting in broader and safer resections. The anterolateral thigh flap is now being increasingly employed for this goal. The aim of the present work is to evaluate the anterolateral thigh free flap in the reconstruction of oral cavity defects.

MATERIALS AND METHODS

Between July 2004 and February 2009, we harvested 73 free flaps for the reconstruction of soft tissue defects in the oral cavity of 70 patients at our institution. The oncological and functional results in these 70 patients were evaluated, particularly in those patients reconstructed with anterolateral thigh (ALT) free flap. We also evaluated the quality of life using the FACT-H&N questionnaire.

RESULTS

We observed no significant differences in functional and oncological results between patients reconstructed by ALT and patients reconstructed with other flaps. Swallowing may be more difficult in patients who undergo adjuvant irradiation.

CONCLUSIONS

In our opinion, the very low morbidity at the donor site, great versatility, and very long pedicle make the ALT free flap the first choice for reconstructing soft tissue defects in the oral cavity (particularly mobile tongue).

Conservative and radical oncoplastic approches in the surgical treatment of breast cancer

In the attempt to optimise the balance between the risk of local recurrence and the cosmetic outcomes in breast surgery, new surgical procedures, so-called oncoplastic techniques, have been introduced in recent years. The term oncoplastic surgery refers to surgery on the basis of oncological principles during which the techniques of plastic surgery are used, mostly for reconstructive and cosmetic reasons. The advantage of the oncoplastic surgery for breast cancer is the possibility of performing a wider excision of the tumour with a good cosmetic result. Oncoplastic surgery is a broad concept that can be used for several different combinations of oncological surgery and plastic surgery: excision of the tumour by reduction mammoplasty, tumour excision followed by remodelling mammoplasty, mastectomy with immediate reconstruction of the breast and partial mastectomy with reconstruction. Careful patient selection and preoperative planning are key components for the success of any oncoplastic operation for breast cancer. Accurate preoperative evaluation of the clinical and biological features of the tumour as well as of the morphological aspects of the breast allow the surgeon to make a decision if a conservative or radical approach is preferable and select the most effective oncoplastic surgical technique. In this review we summarise the indications, advantages and limitations of several oncoplastic procedures.

A particular solution in the treatment of primitive neoplasms of the distal third of the tibia. Presentation of a clinical case and review of the literature

Primitive malignant neoplasms affecting the distal third of the tibia are altogether rare, and their treatment is considerably controversial. The authors describe the diagnostic procedure and a particular surgical strategy of limb salvage in a case of malignant fibrous histiocytoma located at the distal third of the tibia, in particular pointing out the difficulties in restoring the continuity of the skeletal tissues and of the muscle, and with a review of the relevant literature.

Myocardial SPECT: what do we gain from attenuation correction (and when)?

AIM

This study aimed at assessing the impact of attenuation correction performed by means of a new hardware device (Beacon(tm)) in the assessment of coronary artery disease with myocardial SPECT and, afterwards, at identifying what specific risk class of patients would mostly benefit from the technique.

METHODS

The first 500 consecutive patients, referred to our facility for coronary artery disease (CAD) assessment, were included in this study. Myocardial SPECT was performed after i.v. of 740 MBq of (99m)Tc Tetrofosmin (Myoview, Amersham Health) both after stress and at rest. Studies were acquired by means of a 3 head system (IRIX, Philips Medical System) equipped with the Beacontm option to correct for non-uniform attenuation. Out of the whole population studied, 130 patients underwent coronary angiography (CAG), 108 of which were proven to be affected by significant CAD, defined as a >50% coronary vessel lumen reduction. Attenuation corrected (AC) as well as non-attenuation corrected studies (NAC) were reconstructed, blindly read and qualified as: normal; borderline normal; borderline abnormal and definitely abnormal.

RESULTS

In the group of 130 patients who underwent CAG, sensitivity for CAD detection did not vary significantly (96% and 93%, for NAC and AC studies, respectively, p=ns) whereas specificity increased from 73% (NAC studies) to 91% (AC studies), p<0.01. Normalcy rate, assessed in a small subgroup (n=21) with a <5% likelihood for CAD, was found to be 80% for NAC studies vs 93% for AC studies (p<0.05). As regards synthetic clinical judgements, when we grouped normal and probably normal readings into a single ''normal'' category and, conversely, probably abnormal and definitely abnormal into a single ''pathological'' category, we see that after attenuation correction studies reported as ''pathological'' are reclassified as ''normal'' in 17.8% of the cases (25.2% in males and 6.9% in females, p<0.05). The opposite is seen in only 1.6% of the cases (1.3% in males and 4.4% in females). According to established criteria, 155 patients were classified at low risk for CAD (<15%), 115 at intermediate risk (from >15% to <50%) and 230 at high risk (>50%). The intermediate risk class showed the greatest impact: ''normal'' findings increased from 52% to 72%, thus reducing the rate of ''pathological'' reports from 48% to 28%.

CONCLUSIONS

This study shows that, while sensitivity for CAD is not affected by attenuation correction, specificity increases significantly, as well as normalcy rate. Out of the whole population studied, the main finding was that attenuation correction increases the rate of normal reports, more frequently in males than in females, and that studies carried out in patients at intermediate risk for CAD are more likely to be affected.

Soft tissue sarcomas: research of prognostic factors and therapeutics scheme

The Soft Tissue Sarcomas shows consisting mortality that grazes 50%. Commonly the histologic type, the largeness of the tumor and the degree of malignity, are considered prognostic factors influencing the survival of patients affected from such tumor. The aim of our study is to characterize the new prognostic factors influencing the local recidives and metastatic dissemination. We have analysed 17 possible clinical and histologic prognostic factors in 80 patients affected of soft tissue sarcomas. The results have dimonstrated that: the compartimentality and the cellular differentiation seem to be more influent to the insurgence of local recidives and metastasis; while the low malignity degree, the wide surgical margins and the histopatological characters of benignity can influense positively the survival.

The effect of twisting on microanastomotic patency of arteries and veins in a rat model

The authors examined the effect of twisting on the patency of microvascular anastomoses 3 days after surgery. A total of 69 male Wistar rats were divided randomly into four groups. The femoral arteries and veins were dissected for a standard distance. A total of 69 microarteriorrhaphies and 68 microvenorrhaphies were performed at 0 deg and with twist of the vessel ends of 90, 180, and 270 deg. Three-day patency rates for arterial microanastomoses were 100% with a 0-deg twist, 80.9% with a 90-deg twist, 68.4% with a 180-deg twist, and 64.2% with a 270-deg twist. Three-day patency rates for venous microanastomoses were 100% with a 0-deg twist, 85% with a 90-deg twist, 28.5% with a 180-deg twist, and 25% with a 270-deg twist (p = 0.047 for arteries, p = 0.001 for veins). These data are statistically significant. Moreover, assuming the risk of thrombosis to be 1 for microanastomosis without twisting, the odds ratio for the risk of vessel thrombosis for 270-deg twisting (the maximal examined degree of arterial and venous twist in the current study) is 10.08 for arterial anastomosis and 226.85 for venous anastomosis.

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.

Combined radiological and surgical treatment of arteriovenous malformations of the head and neck

Arteriovenous malformations (AVMs) are high-flow lesions. More than 50% of all AVMs are located in the head and neck region. They represent a therapeutic challenge because of their hemodynamic characteristics and their modality of growth. AVMs have a tendency to recur and often require radical resection, making surgical ablation and reconstruction difficult. AVMs require angiography not only for diagnostic purposes but as an initial therapeutic step in the form of embolization. Surgical ablation, which follows a few days after embolization, is facilitated by the reduction in vascularity and shrinkage of the lesion, both of which are afforded by the embolization. These benefits allow for less blood loss at the time of ablation, and less extensive resection. The authors report their experience with 16 patients with extracranial AVMs of the head and neck examined over the last decade.

Analysis of infiltrating epitheliomas of the nose examined from 1986 to 1995

OBJECTIVE

Epitheliomas of the nose are frequently highly aggressive lesions with wide cutaneous-subcutaneous growth or an infiltrative growth pattern, especially when located at the columellar base, the alar base, and toward the inner chantal region. The aim of this study was to review this lesion with respect to location, recurrence, and treatment.

METHOD

The authors present a retrospective study of 193 infiltrating epitheliomas of the nose examined between 1986 and 1995, including primary and recurrent cases. The authors term "clinically infiltrating epithelioma" any epithelioma whose growth implies the infiltration of the osteocartilaginous framework.

RESULTS

The analysis of this case series, based on the histotype and the site of the epitheliomas, confirms that most of the primary histologically infiltrating basal cell carcinomas (BCCs) and of the recurrent BCCs are located at the alar base. The analysis of recurrences shows an aggressive local behaviour (multiple recurrences in the same site, change of the histologic pattern toward a more malignant one, etc.) suggesting that many of them were submitted to an insufficient physical or surgical treatment in the past.

CONCLUSIONS

A radical surgical approach at the first signs of the primary lesion is mandatory in cases of nasal epithelioma.

Bleeding patterns in recent postmenopausal outpatients with uterine myomas: comparison between two regimens of HRT

OBJECTIVES

To evaluate and to compare the bleeding patterns obtained with two regimens of hormone replacement therapy given to early postmenopausal women with asymptomatic uterine leiomyomas.

METHODS

In this randomised prospective 1-year study 50 early postmenopausal women with one to four asymptomatic uterine leiomyomas were enrolled into two study-groups to take two regimens of hormone replacement therapy for 12 28-day cycles: (A) Tibolone, 2.5 mg/day; (B) conjugated equine estrogens (CEE), 0.625 mg/day plus medroxyprogesterone acetate (MPA), 5 mg/day. The bleeding patterns and the changes in uterine volume of the 47 outpatients who completed the study were evaluated and compared.

RESULTS

Amenorrhea incidence was higher in group A (75.0% of the cycles) than in group B (65.6% of the cycles), while irregular bleeding and irregular spotting incidences were higher in group B (29.7 and 4.7% of the cycles, respectively) compared to group A (22.6 and 2.4% of the cycles, respectively). The mean bleeding and spotting lengths were not statistically different between patients in group A and those in group B. Finally, at the end of the study period transvaginal ultrasonography showed no significant change in leiomyoma size.

CONCLUSIONS

The results demonstrate that, in early postmenopausal patients with asymptomatic uterine leiomyomas, Tibolone treatment seems to be preferable compared to CEE-MPA continuous combined treatment in relation to the lesser occurrence of irregular bleeding. Furthermore, neither Tibolone nor CEE-MPA therapy, at the doses used here, promote fibroid growth.

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.

Malignant tumors of the orbital region. Analysis of cases examined from 1986 to 1995

OBJECTIVE

To present a retrospective study of 154 orbital tumors examined from 1986 to 1995.

METHODS

We analyzed the clinical behavior and the degree of local malignity also in relationship with the particular anatomical characteristics of this site.

RESULTS

In this are, it is not rare finding tumors with a scarce cutaneous extension but a deep involvement including the bone, or of recurrences after a previous insufficient treatment with an aggressive clinical course.

CONCLUSION

The principles for the surgical approach are: exeresis as radical as possible, one-stage operation for tumoral resection and reconstruction, bringing of trophic tissue able to sustain any complementary treatment, easy and fast execution, and short clinical course.

Plasma catecholamines in pre- and in postmenopausal women with mild to moderate essential hypertension

The sympathetic nervous system (SNS) is thought to play an important role in the pathogenesis of essential hypertension and many studies have established a relationship between plasma levels of norepinephrine (NE) and epinephrine (E) and sympathetic nervous activity (SNA). Furthermore, it has been suggested that climacteric women are more exposed to psychosocial stress which can produce a transient rise in blood pressure (BP) and, with time, determine a hypertensive state. Plasma NE and E levels were measured at rest and after physiological stimulation (head-up tilt test) in 20 hypertensive (BP: 146 +/- 13/101 +/- 4 mm Hg) and in 20 normotensive women (BP: 132 +/- 7/85 +/- 4 mm Hg). Women in each of these two groups were further subdivided according to their climacteric status (10 premenopausal and 10 postmenopausal women). No difference in NE values at rest was found between groups and subgroups. During head-up tilt test, Ln NE plasma values increased in normotensive and hypertensive groups; the rise was significantly higher in hypertensive than in normotensive women (P < 0.01). In climacteric subgroups, Ln NE appeared markedly increased above resting levels in pre- and postmenopausal hypertensive women when their position was changed from supine to upright (P < 0.01). Since high plasma NE levels after stimulation (head-up tilt) are associated with sympathetic overactivity, we conclude that SNA is involved in the pathogenesis of essential hypertension in climacteric women.

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.

Effects of various prostaglandin synthesis inhibitors on the tone of the lower oesophageal sphincter in man

The role of endogenous prostaglandins in the modulation of lower oesophageal sphincter (LES) function has been assessed by giving three structurally unrelated cyclooxygenase inhibitors and monitoring their acute effects on LES tonus and platelet thromboxane (TX) B2 production in 20 healthy volunteers. In a double-blind, placebo-controlled, cross-over study, IV injection of soluble salts of acetylsalicylic acid and indomethacin elicited a transient increase in LES tonus of approximately 50% over baseline. A similar pattern was observed after the rectal administration of indomethacin. In contrast, indoprofen had no measurable effect on LES tones, despite comparable inhibition of platelet cyclooxygenase activity. This may have been due to the markedly different tissue distribution of the drug. The results suggest that endogenous prostaglandins physiologically exert an inhibitory influence on LES function.

Treatment of angiomas with sclerosing injection of hydroxypolyethoxydodecan

The authors discuss the indications for hydroxypolyethoxydodecan in the sclerosing treatment of angiomas, with particular reference to cavernous, venous, and evolutive angiomas (ie, immature angiomas that fail to involute by eight to ten months). Moreover, the sclerosing agent may be employed, in connection with embolization and subsequent surgery, in arteriovenous angiomas with a relevant cutaneous-subcutaneous development. The authors have successfully used the "interstitial" sclerosing technique, according to Andrews' method. This technique involves interstitial injections to obtain the sclerosis of the thin threads of fibrous tissue stroma between the blood vessels. The sclerosing therapy may cause the complete regression of "low flow" angiomas or, at least, a partial reduction that simplifies the ensuing surgical excision. In the case of partial regression of the angioma obtained with the sclerosing therapy, the surgery of the remaining angioma causes a lesser degree of bleeding (especially in areas that do not particularly lend themselves to surgical exploration, ie, the oral cavity); an increased reliability in the radicality of the intervention (due also to the reduced size of the lesion); and better results from an aesthetic-functional point of view.

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.

Immature angiomas: the importance of the Doppler exam in diagnosis and prognosis

Immature angiomas are vascular hamartomatous malformations but clearly different from all other vascular, capillary, venous, arteriovenous, and lymphatic malformations, which, normally present at birth and established from a cellular viewpoint, grow because of the effect of hemodynamic stimuli and present no tendency toward spontaneous regression. The difference between immature angiomas and other hemangiomas has been demonstrated by investigations into cell dynamics. To facilitate a differentiated diagnosis and prognosis, the hemodynamics of the angiomas were studied with the Doppler flowmeter. The use of noninvasive techniques, such as those introduced by the Doppler flowmeter, permit a technical alternative and/or integration, giving results of equal relevance and importance, as well as the advantages of a more accessible and less expensive methodology.