Dr. Valerio Pagliuca

Surgery in Graves' disease: our experience. Giorn It Chir XLIX – 1995. Avenia N. – Puma F. – Galeotti M. – Santoprete S. – Urbani M. – Casadei S. – Ricci F. – Daddi N. – Pagliuca V. – Ottavi P.;

• Cervical-mediastinal goiters: clinical-therapeutic considerations on 100 operated cases. Giorn It Chir XLIX – 1995. Avenia N. – Puma F. – Cerroni M. – Galeotti M. – Urbani M. – Santoprete S. – Casadei S. – Daddi N. – Pagliuca V. – Ottavi P.;
• Microsurgical treatment of varicocele recurrences. Giorn It Chir Vol. 52 – 1998. Pacifici A. – Contine A. – Sarno U. – Trapassi S. – Servili S. – Pagliuca V. – Dominici C.

• Thyroid pathology of surgical interest with short hospital stay. II Permanent updating conference of the Italian Polyspecialist Society of Young Surgeons (SPIGC) – Chieti 17-18/05/1996. Avenia N. – Alberti D. – Ragusa M. – Ricci F. – Fonsi GB – Daddi N. – Pagliuca V. – Ottavi P. – Calzolari F.;

• Use of the diode laser in cutaneous vascular pathologies; IV° National Estense Conference of Video-Plastic Surgery – Ferrara 8-9-10/06/2000; Pacifici A. – Coccaro A. – Calabrese A. – Becchetti A. – Pagliuca Vlr.;
• Our current experience in the constitution of the penis in gyno-android transsexualism; Transits: Paths and meanings of gender identity; Bologna 24/06 1/07/2000; Pacifici A. – Dominici C. – Cordellini M. – Mazzeo C.- Pagliuca V.
• Use of the erbium laser: our experience. 50th National Congress of the Italian Society of Plastic, Reconstructive and Aesthetic Surgery (SICPRE), Rome 14-16/09/2001;Pacifici A. – Pagliuca Vlr. – Sarno U. – Coccaro A. – Dominici C.;
• Hair removal with pulsed light: our experience. Vth National Congress of Aesthetic Medicine; Milan 10-11-12/10/2003; Pacifici A. – Pagliuca V.; Dominici MM – Dominici C.;

• Laser resurfacing: indications, technique and results. 48th National Congress of the Italian Society of Plastic, Reconstructive and Aesthetic Surgery (SICPRE), Gubbio (PG), 25-30/09/1999; Pagliuca Vlr. – Pagliuca Vnt. – Sarno U. – Barile A. – Petricig P.;
• Considerations and results in the use of the erbium laser; 3rd National Congress of Aesthetic Medicine; Milan 12-13-14/10/2001; Pagliuca V.; Pacifici A. – Sarno U. – Coccaro A.;
• Use of pulsed light in the treatment of hypertrichosis; Full immersion course on: laser and pulsed light in cosmetic surgery – Perugia, 11-12/06/2004; Pagliuca V.;
• Lasers and biomedical technologies in vascular lesions; Spoleto (PG), 3-4/10/2008; Pagliuca V.
• Member of the scientific conference committee: Botulinum Toxin; Perugia 23-24/04/2003;
• Laser and Pulsed Light in Aesthetic Surgery: where we are in Italy; Perugia 11-12/06/2004;
• Lasers and Biomedical Technologies in Plastic Surgery; Spoleto (PG) 3-4/10/2008.

From 02/05/2008 to 03/31/2010 he held the position of Medical Director of the Specialist Clinic - Terni Laser Center located in Terni – Via Montegrappa 51/d, authorized by the Umbria Region at no. 494 of 02/05/2008.
Since 03/21/2011 he has held the position of Medical Director of the Specialist Clinic - Libero Fisiomed located in Terni - Via del centenario 23, authorized by the Umbria Region at no. 757 of 11/02/2011.
Since May 2009 he has been registered in the Register under number 888 as an Office Technical Consultant at the Court of Terni.

BLEPHAROPLASTY
Blepharoplasty surgery is a procedure that allows the removal of excess fat and, often, also excess skin, from the lower and upper eyelids. Blepharoplasty can correct both the sagging of the upper eyelids and the eyelid bags. The eyelid surgery is performed on a day hospital basis under local anesthesia with light sedation. Normally an incision is made along the natural fold of the eyelids, in the skin fold of the upper eyelid and in the area immediately below the eyelashes for the lower eyelid. The incision can extend up to the “crow's feet” or expression lines around the outer contour of the eyes. Through these incisions it is possible to separate the skin from the underlying fat and muscles, to remove excess fat, also removing, if necessary, the skin and muscle that have lost their initial tension. At the end of the operation, some very thin stitches are applied. After blepharoplasty it is normal for the eyelids to swell and for bruising of varying degrees to occur. These phenomena may be more marked on one side than the other and this is not a cause for concern. To limit edema and bruising, which often tend to spread downwards, it is useful to apply ice compresses to the eyelids. These phenomena will tend to disappear within approximately 7-10 days. To contain edema, it is preferable to keep the head higher than the body, even during sleep. For this purpose, it is sufficient to assume a supine position during sleep with the head raised at 45° from the horizontal plane. After 5-6 days you can wash your head by tilting it backwards. For 6 weeks after the operation it is necessary to avoid exposure to the sun with the face, avoid intense sporting activity, in particular swimming and diving.

RHINOSEPTOPLASTY
Rhinoseptoplasty is an operation that allows you to reduce or improve the size of the nose, to shape the profile of its tip or pyramid, to narrow the nostrils or to modify the angle between the nose and the upper lip, but also to relieve breathing problems. Rhinoseptoplasty requires a hospital stay of approximately 1 day and is generally performed under general anesthesia. The operation involves incisions that are preferably inside the nostrils; the skin is separated from its bone and cartilaginous structure, which is remodeled according to the desired profile. At the end of the operation, a small cast shower is applied, which helps to preserve the new profile, as well as nasal swabs which are removed after approximately 24 hours; the cast will be removed after 7 days. The swelling under the eyes may increase in the two days following the operation, it will then descend to the cheeks due to gravity and then resolve in approximately 7-10 days. If you use eyeglasses, these can be placed on the cast for the first week, then they can be suspended on the forehead with a plaster the first month after the operation. Don't blow your nose for a week; open your mouth if you need to sneeze. Do not bend your head forward below the level of your heart for 2 weeks to avoid bleeding. For any nosebleeds, simply lie down and relax, apply a swab soaked in hydrogen peroxide to the bleeding nostril, and place ice-cold compresses on your nose and eyes. Encrustations that form in the nostrils can be gently removed with a cotton swab soaked in hydrogen peroxide. After about 1 week you can wash your head by tilting it backwards. For 6 weeks after the operation it is necessary to avoid exposure to the sun with the face, avoid intense sporting activity, in particular swimming and diving.

ADDITIVE BREAST PLASTIC
Breast augmentation is a surgical operation aimed at increasing the size of underdeveloped breasts and improving their shape. The main reasons that lead a patient to undergo this procedure lie in the desire to increase the volume and rebalance any asymmetries. Breast implants are silicone shells filled with a more or less fluid gel of the same substance. The most commonly used prostheses are polyurethane or textured.
The incision can be made in the inframammary fold, around the areola (inferior or superior hemiperiareolar) or in the axillary cavity. The inframammary route is probably the most physiological, as it completely respects the gland; through the incision, the breast tissues are raised to create a pocket which can be located in a retro-glandular or sub-muscular position, therefore below the pectoralis major muscle. Sub-muscular insertion reduces the potential risk of capsular contracture, however you have less control over possible dislocation of the prosthesis. The periareolar route allows a good view of the operating field and certainly leaves a less visible scar than that of the inframammary fold. Hypersensitivity, hyposensitivity or insensitivity phenomena may occur in the areas surrounding the incision, which generally disappear over time. There is no scientific evidence to demonstrate the existence of a cause-effect relationship between breast implants and breast cancer, however the procedures for performing a mammogram must be modified. After the operation, a corset must be worn (day and night for a month), which helps to keep the prosthesis inside the appropriate pocket and to improve the new infra-mammary line. The stitches will be removed after approximately 10 days; the swelling will disappear only after a period ranging from 4 to 6 weeks. It is preferable not to perform physical exercises for 15 days and to resume intense sporting activity after approximately 6 weeks

REDUCTION BREASTPLASTY
Reduction mammoplasty is an operation aimed at those patients who have excessive breast volume compared to the proportions of the body, heavy and pendulous breasts with the nipples and breast areolas facing downwards, significant volumetric asymmetries, related physical disorders and psychological discomfort. The operation is performed under general anesthesia and requires a hospital stay of 1 or 2 days. The specific individual characteristics and preferences/expectations of the patient lead the surgeon to choose the technique to adopt to obtain breast reduction. The two main techniques involve the preparation of a lower pedicle flap or an upper pedicle flap. After removing excess breast tissue, fat and skin, the nipple and areola are relocated to the desired level. The areola, normally dilated in voluminous breasts, is reduced; generally the areola-nipple complex is not detached from the underlying tissues, allowing the patient to maintain the sensitivity of the region, also preserving the possibility of breastfeeding. Generally, drainage tubes are placed to avoid the accumulation of serum and, at the end of the operation, an elastic bandage is applied. After 1 or 2 days the drains and compression bandage will be removed, then a post-operative corset will be worn for a few weeks. The stitches are removed in successive stages ranging from approximately 7 to 21 days. It is possible to feel some numbness in the nipple and areola area, which will however be temporary. To resume normal work and social activity it is necessary to wait approximately 15-20 days; for intense physical exercise you need to wait at least 6 weeks.

ABDOMINOPLASTY
Abdominoplasty is a surgical procedure aimed at removing excess skin and fatty tissue from the abdominal region and strengthening the muscles of the abdominal wall. The operation produces a permanent scar of variable dimensions, positioned in an area where it can be completely covered by clothing. The operation is performed under general anesthesia and requires a hospital stay of approximately 2 days. An incision is made in the area immediately above the pubic area, the length of which will depend on the amount of skin to be removed. The prepared skin flap is tightened and the excess part eliminated, while the abdominal muscles are put back into tension by bringing them back together on the midline. A second incision will allow the previously isolated navel to be repositioned. Generally, drainage tubes are placed to avoid the accumulation of serum and, at the end of the operation, an elastic bandage is applied. After 1 or 2 days the drains will be removed and a compressive dressing will be kept on for about 2 weeks. During the post-operative period, the use of an elastic sheath is mandatory for approximately 6 weeks. In the days immediately following the operation it is advisable to refrain from making particular physical efforts; you need to wait 15-20 days before resuming usual physical activity and at least 6 weeks before practicing intense sporting activity. The stitches will be progressively removed over a period of approximately 7 to 21 days.

LASER LIPOLYSIS
Localized accumulations of adipose tissue, resistant to diet and exercise, can be definitively eliminated through liposuction, an undercover body contouring technique. Liposuction can be performed on any area, but the areas where it is most frequently practiced are the hips, thighs, knees, abdomen, submental region. The amount of fat that can be removed is limited and determined based on the characteristics of the individual patient. After surgery, minimal skin scars inevitably remain, located in correspondence with the natural skin folds and therefore destined to become practically invisible. Laser lipolysis is a laser-assisted liposculpture treatment, so minimally invasive and minimally traumatic that it is requested by an increasingly wider target of patients than those interested in traditional methods of classic liposculpture. Laserlipolysis represents an innovative technique, specifically designed to remove excess adipose tissue through the selective interaction between the laser beam and adipocytes. The result is the denaturation and rupture of the fat cell membranes and the leakage of their contents. At the same time, the small blood vessels are closed by photocoagulation so as to reduce blood loss. Finally, by working in the superficial layers it is possible to perform photostimulation of the dermal collagen from the inside with a retraction effect on the skin tissue. The laser light is conveyed through microcannulas with a diameter of 1 mm. The high power of the laser light breaks the membranes of the adipose cells, encouraging the release of the cellular contents, an oily solution of low viscosity which allows on the one hand the easy modeling of the body and, on the other, its easy removal even with microcannulas. low pressure or syringes. Laserlipolysis can however be associated with traditional liposuction techniques, especially in the case of large volumes. The resulting advantages are a good reduction in skin flaccidity caused by the emptying of fat and greater regularity and homogeneity of the skin surface. The procedure is performed on an outpatient basis or in day surgery and under local anesthesia with modest sedation.

FRACTIONAL LASER AND MICRO LASER PEEL
A new technology has recently been introduced: fractional laser ablation. This innovation has allowed small islands of skin to be left at a microscopic level within the treated tissue, from which healing occurs much more rapidly. Compared to traditional ablative skin resurfacing, the course is decidedly shorter. A wide range of solutions can be treated with the fractional erbium laser: deep and superficial wrinkles, scars from trauma, acne and chickenpox, senile and sun pigmentation. The procedure consists of subjecting the patient to topical anesthesia with anesthetic cream, associated with truncal anesthesia; the administration of laser energy creates thousands of microscopic channels in the skin, interspersed with areas of healthy, untreated skin. In the treated areas there is a stimulation to produce new collagen, while the areas of untreated skin are toned due to the physiological healing process. After treatment, a burning sensation is felt, which generally subsides within about an hour. Complete healing occurs within 3-4 days. Subjects predisposed to Herpes viral infections must follow a prophylaxis protocol with, for example, aciclovir 400 mg tablets; one tablet should be taken every 12 hours, from 2 days before surgery until two days after. In patients with obvious signs of photoaging, the new Micro Laser Peel technique is specifically indicated; It consists of a controlled and precise ablation of the superficial layers of the skin. This operation is halfway between a microdermabrasion and a full skin resurfacing, removing 20 to 50 microns of epidermis. From the day after the treatment, flaking progressively appears, followed by the repair process which takes place within 4-5 days.

INFILTRATION OF HYALURONIC ACID
Hyaluronic acid is today the most widespread substance among injectable implants used for the treatment of wrinkles, furrows, small depressed areas and for the temporary increase in volume of lips, cheekbones and other areas of the face. The injection is made with a very thin needle into the thickness of the dermis. The aim of the infiltration with hyaluronic acid is to fill and correct the deepest wrinkles of the face. The method involves the use of a hyaluronic acid preparation which is infiltrated immediately below the wrinkles to be treated. It is a natural product, 100% reabsorbable, an essential constituent of the human body, it does not cause allergic reactions, nor are any complications related to its use described. Once injected, hyaluronic acid is gradually reabsorbed by the body. The duration of this process varies from individual to individual. The possible pain of the treatment varies based on individual sensitivity, but also depends on the site where the hyaluronic acid is injected. The lips, for example, are particularly sensitive and it is therefore advisable to apply an anesthetic cream before treatment, or perform truncal anesthesia. Other areas, such as the nasolabial folds, can be treated without any anesthesia or by applying anesthetic cream. The result depends on the starting situation, as in all medical and surgical aesthetic treatments; therefore it is very important that the doctor and patient analyze the possibilities and limits of the possible intervention. A person with marked nasolabial wrinkles cannot expect these to disappear with just one vial of hyaluronic acid: multiple sessions will be necessary to achieve the desired result. If the folds are less marked, the result will be more evident even with the infiltration of just one vial of hyaluronic acid. Even for the increase in volume of the lips everything depends on the starting situation; in patients with very thin lips, who wish to significantly increase both their volume and projection, it would be advisable to initially perform a treatment that is not particularly aggressive, possibly performing a "touch-up" 1-2 weeks later. Instead, a person who wishes to highlight the contour of the lips and slightly increase their volume will probably be satisfied after just one session. This operation is performed in an outpatient clinic, with or without local anesthesia; in most cases, normal work and social activities can be resumed immediately. The duration is limited in time, ranging from 3 to 12 months. There are normally no significant skin reactions immediately after treatment. Sometimes, the patient may notice redness and feel a slight burning sensation and edema, which in most cases disappear within a few hours.

BOTULINUM TOXIN INFILTRATIONS
Botulinum toxin is a class "C" medicinal specialty. It is a drug, obtained from a bacterium, Clostridium Botulinum, which has been authorized for marketing by the Ministry of Health starting from 1 April 2004. The toxin is marketed in freeze-dried and vacuum-packed form, for whose use requires its activation, obtained using physiological solution in variable quantities in relation to the use and the results you want to obtain. Botulinum toxin causes the disappearance of expression wrinkles as it is able to cause relaxation of the underlying muscles, which with their contraction cause the appearance of the wrinkles themselves. Generally it is used to treat wrinkles that appear in the upper third of the face, particularly in the glabella, forehead and "crow's feet". This distension is obtained through a mechanism of flaccid paralysis, caused by the inhibition of the release, at the level of the motor endplate (the connection area between nerve and muscle), of a chemical mediator fundamental for the transmission of the nervous impulse. In this way the nervous impulse is not transmitted and the muscle does not contract, thus also causing the overlying skin to relax and the wrinkles to disappear. Its effect, which becomes evident after about a week, lasts on average 4-6 months and, in any case, the treatment should not be repeated before 3 months. Mild swelling and transient redness may occur immediately after treatment. The effect of botulinum toxin is not immediate and takes about 1 week to be fully visible. In the hours following treatment, it is recommended not to practice intense sports. You should not rub or massage the treated area for 24 hours after treatment. The results will be visible within a few days, but for about fifteen days, the effects on the face may be variable before stabilizing. The effects will usually have disappeared after a variable period of 3-6 months. Any complications known so far are in particular a descent of the eyelid or eyebrow, difficulty swallowing, and facial expression disorders. Eventually, these disorders usually persist for a few weeks.