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Actually, surgical correction is the accepted standard of treatment. Many different techniques have been described and proposed and fall into three main groups:. In our opinion, the main issue is to achieve a pleasant chest wall shape, limiting scar extension, especially in the areolar area. The technique, first described in and called the pull-through technique , combines liposuction and parenchymal excision. Ten years after its publication, we reviewed our series, to obtain an accurate assessment based on a larger patient population and a longer follow-up.

The surgical procedure is always performed under general anesthesia.

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Markings are done with the patient in an upright position and include:. A hypotonic solution and local anesthetic with epinephrine , is used for subcutaneous infiltration. This step is now performed in a different way than before: the solution is injected through the two skin incisions using a 2-mm multi-hole smooth cannula. Twenty minutes after the solution has been injected, liposuction is performed. This is a wide and accurate liposuction with different aims:.

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Fat tissue removal and contour reshaping are performed routinely in liposuction of the pectoral region. Isolation of the glandular tissue, however, is a specific step of this technique: the aim is to separate glandular tissue from its cutaneous and fascial attachments, in order to facilitate its following extraction in small pieces through the short skin incisions. The two layers must be meticulously created keeping in mind that the goal of the procedure is to detach glandular tissue almost completely both from the inferior plane and the superficial one. Once the parenchyma has been freed from its lower and superficial attachments, it can be mobilized: at this point of the procedure, the parenchyma mimics an octopus with its head corresponding to the areola.

At the end of liposuction, the residual glandular tissue, located mostly in the subareolar area, can be pinched in order to localize and evaluate its shape and amount. The parenchyma to be excised is pinched between the thumb and the index, then it is clamped using a surgical forceps passed through the skin incisions Fig.

The mammary parenchyma is clamped using a forceps and pulled out through the small liposuction incision. The instrument is then pulled out through the skin incision used for liposuction, the glandular tissue is exposed, and the parenchyma is excised using a scalpel or the electrocautery Fig. The piecemeal resection requires accurate inspection and palpatory check in order to minimize bleeding and avoid excessive removal with consequent skin irregularities.

All the pieces of removed mammary tissue are collected and sent, as separated specimens from the right and left breast, for histological examination. Intraoperative picture showing the glandular tissue pulled through the incision in the inframammary fold. After glandular tissue removal has been completed, consistency and uniformity of the mammary area are checked by pinching the skin: additional liposuction, using a thin cannula can eventually be performed to smooth out contour irregularities, especially at the margins of the pectoral area and along the anterior axillary pillar.

Skin incisions are sutured in layers, and stitches are removed on the eighth postoperative day. A compressive dressing is applied at the end of surgery and removed at the time of stitches' removal; after that, an elastic garment has to be worn until the end of the first postoperative month. Since the technique was also applied in gender-confirming surgery to masculinize the chest wall in female-to-male transsexuals.

These specific patients were selected according to breast volume and ptosis: in cases of small or medium-sized breasts with mild or no ptosis [type I, IIa Fig. Sixty patients underwent chest wall remodeling using this procedure: they all underwent hysterectomy and ovarectomy at the same sitting. Patients operated so far can be divided as follows Figs.

The stitches were removed on the eighth postoperative day. In all the cases, a significant reduction of breast volume with glandular tissue removal was achieved and skin retraction led to a good male-looking chest. The same results were recorded in the group of female patients undergoing gender-confirming surgery. All the patients were satisfied with the result, and none had functional impairment of the arms. Excessive gland removal or excessive liposuction can lead to irregularities of the skin surface. This undesirable event is very obnoxious for the patient and sometimes very difficult to correct.

Skin irregularities were corrected by further superficial liposuction and or lipofilling performed under local anesthesia. These complications, both due to excessive superficial liposuction or undermining, occurred in the earlier series and were corrected by fat injection and scar revision. Many different techniques have been proposed and described to remove breast tissue in male patients with gynecomastia.

The choice should be guided by the severity of the deformity in terms of breast volume and skin redundancy. The ideal procedure should masculinize chest contours while respecting the areolar complex and minimizing surgical trauma. Albeit malignancy and breast cancer in male patients reported only in 0.

Compared to surgical procedures that use a periareolar approach [ 4 ], the technique we employ offers many important advantages, both esthetic and functional:. Areolar deformities are only possible as consequence of excessive tissue removal just below the areola. With introduction, notes, and iconographic apparatus. Valentina Ricci. Venice: Marsilio Editore, New Haven: Yale U P, Anno X. La Mostra della Rivoluzione fascista del genesi — sviluppo — contesto culturale-storico — ricezione. With an afterword by Claudio Fogu.

Piste — Piccola biblioteca di storia 4.

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Contributors include Jeffrey T. Filippo Tommaso Marinetti, Teatro. Milan: Oscar Mondadori, Revolutionary Tides. Authored, ed. Iris and B. Gerald Cantor Center for the Visual Arts, Co-edited and introduced with Matthew Tiews. Multimedia, multiauthor volume. Schnapp, and others. Korean translation under contract with Stanford U Press.

Introduction by Luiz Costa-Lima. Collection of essays, translated into Portuguese.

The Falling (The Morrelini Chronicles, #2) by Allen Renfro

Italiamerica , ed. Schnapp, vol. SPEED limits. Skira, Milan An open access edition of the book is available here.

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