Current Trends in Breast Reduction

Results of our study describe the long term effects of reduction mammaplasty. Many women with excessively small or large breasts have an altered personal self-image and often suffer from low self-esteem and other psychological stresses. This procedure is designed to reduce and reshape large breasts, and since the size, shape, and symmetry of a woman’s breasts can have a profound effect on hermental and physical well-being it is important to observe the patient’s long-term outcome. Currently, breast reduction surgery is safe, effective and beneficial to the patient. In Croatia, reduction mammoplasty is often excluded from the general health care plan. The distinction between »reconstructive« versus »cosmetic« breast surgery is very well defined by the American Society of Plastic Surgeons Board of Directors. Unfortunately, the Croatian Health Society has yet to standardize such a distinction. There is an imperative need for evidence-based selection criteria. We retrospectively analyzed data of 59 female patients suffering from symptomatic macromastia who underwent reduction mammaplasty over a 16 year period (1995 until 2011). Our aim was to compare and contrast the various techniques available for reduction mammaplasty and to determine, based on patient outcome and satisfaction, which technique is most suited for each patient. The results of our study generally reinforce the observation that reduction mammaplasty significantly provides improvements in health status, long-term quality of life, postsurgical breast appearance and significantly decrease physical symptoms of pain. A number of 59 consecutive cases were initially treated with the four different breast reduction techniques: inverted-T scat or Wisa pattern breast reduction, vertical reduction mammaplasty, simplified vertical reduction mammaplasty, inferior pedicle and free nipple graft techniques. The average clinical follow-up period was 6-months, and included 48 patients. The statistical analysis of the postoperative patient complications revealed a significant positive relationship in regards to smoking. The majority of these complications were wound related, with no significant relationship between patient complications and variables such as age, BMI, ASA score, resection weight of breast parenchyma, nipple elevation, duration of surgery, and type of pedicle. The higher number of complication correlated with a lower volume of parenchyma resection (rho=–0.321). Overall satisfaction with the new breast size (79%), appearance of the postoperative scars (87%), overall cosmetic outcome score (91%), overall outcome (100%), psychosocial outcome (46%), sexual outcome (85%), physical outcome (88%), satisfaction with preoperative information data (92%), and finally satisfaction with overall care process (96%) was calculated. As expected, the physical symptoms disappeared or were minimized in 88% of patients. Each method of breast reduction has its advantages and disadvantages. The surgeon should evaluate each patient’s desires on the basis of her physical presentation. Breast reduction surgery increases the overall personal and social health; not only for the patient, but for their family and friends as well. It is an imperative that every surgeon is aware of this, in order to provide the highest level of care and quality to their patients

Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs

Necrotizing fasciitis (NF) is an uncommon soft tissue infection, usually caused by toxin-producing virulent bacteria. It is characterized by widespread fascial necrosis primarily caused by Streptococcus hemolyticus. Shortly after the onset of the disease, patients become colonized with their own aerobic and anaerobic microflora from the gastrointestinal and/or urogenital tracts. Early diagnosis with aggressive multidisciplinary treatment is mandatory. We describe three clinical cases with NF. The first is a 69 years old man with diabetes mellitus type II, who presented with NF on the posterior chest wall, shoulder and arm. He was admitted to the intensive care unit (ICU) with a clinical picture of severe sepsis. Outpatient treatment and early surgical debridement of the affected zones (inside 3 hours after admittance) and critical care therapy were performed. The second case is of a 63 years old paraplegic man with diabetes mellitus type I. Pressure sores and perineal abscesses progressed to Fournier's gangrene of the perineum and scrotum. He had NF of the anterior abdominal wall and the right thigh. Outpatient treatment and early surgical debridement of the affected zones (inside 6 hour after admittance) and critical care therapy were performed. The third patient was a 56 year old man who had NF of the anterior abdominal wall, flank and retroperitoneal space. He had an operation of the direct inguinal hernia, which was complicated with a bowel perforation and secondary peritonitis. After establishing the diagnosis of NF of the abdominal wall and retroperitoneal space (RS), he was transferred to the ICU. There he first received intensive care therapy, after which emergency surgical debridement of the abdominal wall, left colectomy, and extensive debridement of the RS were done (72 hours after operation of inquinal hernia). On average, 4 serial debridements were performed in each patient. The median of serial debridement in all three cases was four times. Other intensive care therapy with a combination of antibiotics and adjuvant hyperbaric oxygen therapy (HBOT) was applied during the treatment. After stabilization of soft tissue wounds and the formation of fresh granulation tissue, soft tissue defect were reconstructed using simple to complex reconstructive methods

Careful preoperative planning of aortic valve surgery – impact of echocardiography and CT parameters

Objective: We can observe an increase in incidence and prevalence of patients with aortic valve stenosis in the general population. The gold standard in aortic valve therapy is aortic valve replacement. Preoperative planning is essential for good outcomes, as the severity of stenosis and calcifications can sometimes be extremely progressive and even involve the aortic root and ascending aorta. There is not enough research on comparation of CT scan analysis of aortic valve stenosis and echocardiography which is the golden standard of disease diagnosis.1-3 Patients and Methods: We have analyzed 88 patients [age: 70.01±9.066 (mean±SD); female: n=45, 51.1%]. Among the patients, 12 had bicuspid aortic valve leaflet structure while the rest of the patients (n=76, 86.4%) exhibited TAV stenosis. Degree of aortic stenosis was assessed according to mean pressure gradient (MPG), peak pressure gradient (PPG), aortic valve area (AVA) indexed aortic valve area (AVAi) and maximum speed through aortic valve (Vmax). These were compared with calcium score (AVCS) calculated from CT scan. All of these patients were observed in the operating room during surgery and valves analyzed after explantation. All of the patients underwent aortic valve replacement. Results: Average AVCS values (median + IQ range) were 3306.3 (1995.4 – 4820.6) [female: 2215 (1463.35 – 3372.85); male: 4093.5 (3133.3 – 5274.4). Average AVCS values for BAV patients were 3063.5 (3323.125 – 4868.9) and 3106.55 (1965.375) – 4780.125) for TAV patients. There were significant correlations between AVCS and AVAi (Spearman’s ρ=−0.24, P=0.025), PPG (ρ= 0.38, P< 0.001), MPG (ρ= 0.36, P= 0.001) V max (ρ= 0.37, P < 0.001) and gender (ρ= 0.485, P < 0.001) while AVA values showed no significant correlation with AVCS (ρ= -0.066, P = 0.540). Overall survival was similar not depending of severity of calcifications and stenosis, however clamp time and surgery time were longer for patients with severely calcified valves which means calcium scoring as a parameter should also be taken in consideration during preoperative planning. Conclusion: Careful preoperative planning is essential for good outcome of surgery, here we have proven the connection between echocardiography parameters of aortic stenosis and calcium score calculated by CT scan

Our experience with aortic valve repair with a remodeling technique, extraaortic ring implantation and root replacement

Objective: Aortic valve replacement (AVR) is still the most commonly used therapeutic option for patients suffering from AR. Aortic valve repair (AVRep) is an attractive alternative method, since it avoids the risks of prosthesis-related complications.1-3 We would like to present our experience with the Yacoub root remodeling, valve sparing technique with the extraaortic expansible ring. Patients and Methods: Between November 2014 and July 2019, a total of 79 patients (52.6±13.3 years; 15.2% female, EuroScore II of 3.15%±2) underwent AVRep, 12 due to isolated cusp malcoaptation and 67 associated with aortic root dilatation. Reconstruction was done with the Coroneo Extraaortic Ring (27 (25-31)), and the Gelweave graft (28 (26-32)). 44 patients had a tricuspid valve, 33 patients had a bicuspid valve, and 2 patients had an unicuspid valve. Concomitant procedures included Mvrep and TVrep in 4 patients, CABG in two patents. Aortic arch was replaced in two patients, two patients underwent hemiarch replacement, and two patients had aortic arch replacement with stented conduit and placement of stent in descending thoracic aorta (EVITA stent graft Jotec GmbH). Echocardiography was used to determine AR severity grade preoperatively, during immediate post-operative period (within 7 days from operation) and at early follow-up. Results: In postoperative follow-up no patients died. Freedom from reoperation was 88% (10/79) and there were 2 patients reoperated due to early postoperative regurgitation, one patient was reoperated due to AI after two years, and one was operated due to pseudoaneurysm formation after 2.5 years. A significant decrease in LV end-diastolic diameter was observed (LVEDD) (60mm preoperatively, 53 mm postoperatively) with further decrease at early follow-up. At follow up none of the patients had major AR (AR0=61, AR1+=14, AR2+=4). Conclusions: We have proved that AVRep is a good alternative for patients with aortic insufficiency and leads to LV reverse remodeling with comparable results in terms of LVEDD and LVEF immediately post-operatively and at early follow up. It is feasible to use this technique in tricuspid, bicuspid, as well as unicuspid valves with excellent results