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Bouwman FCM, Verhoeven BH, Klein WM, Schultze Kool LJ, de Blaauw I. Congenital Vascular Malformations in Children: From Historical Perspective to a Multidisciplinary Approach in the Modern Era-A Comprehensive Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:567. [PMID: 38790562 PMCID: PMC11119901 DOI: 10.3390/children11050567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024]
Abstract
Congenital vascular malformations (CVMs) are the result of an aberrant development during embryogenesis. Although these lesions are present at birth, they are not always visible yet. Once symptomatic, patients suffer from pain, bleeding, ulcers, infections or lymphatic leakage, depending on the subtype of vessels involved. Treatment includes conservative management, surgery, sclerotherapy, embolization and pharmacological therapy. The clinical presentation varies widely and treatment can be challenging due to the rarity of the disease and potential difficulties of treatment. This review gives an overview of the historical developments in diagnosis and classification and exposes the key elements of innovations in the past decades on the identification of genetic mutations and personalized treatment. These advances in the field and a multidisciplinary approach are highly valuable in the optimization of clinical care aimed at both curing or stabilizing the CVM and pursuing physical and psychosocial wellbeing.
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Affiliation(s)
- Frédérique C. M. Bouwman
- Department of Pediatric Surgery, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (F.C.M.B.); (B.H.V.)
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.M.K.); (L.J.S.K.)
- Hecovan Center of Expertise for Hemangiomas and Vascular Malformations Nijmegen, VASCERN VASCA European Reference Center, Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Bas H. Verhoeven
- Department of Pediatric Surgery, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (F.C.M.B.); (B.H.V.)
- Hecovan Center of Expertise for Hemangiomas and Vascular Malformations Nijmegen, VASCERN VASCA European Reference Center, Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Willemijn M. Klein
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.M.K.); (L.J.S.K.)
- Hecovan Center of Expertise for Hemangiomas and Vascular Malformations Nijmegen, VASCERN VASCA European Reference Center, Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Leo J. Schultze Kool
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.M.K.); (L.J.S.K.)
- Hecovan Center of Expertise for Hemangiomas and Vascular Malformations Nijmegen, VASCERN VASCA European Reference Center, Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Ivo de Blaauw
- Department of Pediatric Surgery, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (F.C.M.B.); (B.H.V.)
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Han T, Jiang S, Xiong J, Cui J, Shen W. 3D printing personalized guide plate in the management of recurrent intramuscular venous malformations: A single center experience. Phlebology 2023; 38:307-314. [DOI: 10.1177/02683555231162300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Objective This study aimed to investigate the feasibility and effectiveness of 3D printing personalized guide plate in the management of recurrent intramuscular venous malformations (IVM). Methods Fifteen patients with recurrent IVM were retrospectively assessed. 3D-slicer software was used to extract and reconstruct the imaging data from CT and/or MRI to highlight the morphology, size, and puncture depth of the lesion. With the guidance of personalized plate, complete excision of the IVM was adopted along the pre-marked (methylene blue, MB) margin. Results Personalized guide plate matched involved extremity well, and MB-puncture approach was consistent with preoperative design. All IVMs were removed radically in one single session. Complete pain relief was obtained in all cases postoperatively. Conclusion The application of 3D printing guide plate can be safe, effective, and reliable to confirming the precise margin of IVM, renders a promising technique with a high practical value in resection of recurrent lesion.
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Affiliation(s)
- Tao Han
- Department of Burns and Plastic Surgery, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Shupei Jiang
- Department of Burns and Plastic Surgery, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Jiageng Xiong
- Department of Burns and Plastic Surgery, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Jie Cui
- Department of Burns and Plastic Surgery, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Weimin Shen
- Department of Burns and Plastic Surgery, Children’s Hospital of Nanjing Medical University, Nanjing, China
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Liu H, Hu L, Yang X, Xu Z, Gu H, Chen H, Lin X. Dabigatran etexilate is efficacious in consumptive coagulopathy and pain associated with venous malformations. J Vasc Surg Venous Lymphat Disord 2023; 11:397-403.e1. [PMID: 36328137 DOI: 10.1016/j.jvsv.2022.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/11/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Consumptive coagulopathy treatment and pain management are crucial for patients with venous malformations (VMs). Dabigatran etexilate, a non-vitamin K antagonist oral anticoagulant, has known advantages compared with low-molecular-weight heparin and vitamin K antagonists, including oral administration, a more consistent pharmacokinetics/pharmacodynamics profile, a better safety profile, and no need for coagulation surveillance. In the present study, we tested the efficacy and safety of dabigatran etexilate for consumptive coagulopathy treatment and pain management for patients with VMs. METHODS To investigate the efficacy and safety of dabigatran etexilate in treating localized intravascular coagulation (LIC) associated with VM, we retrospectively collected data for 19 outpatients with VM and LIC, who had been treated with dabigatran etexilate from September 2019 to June 2021. The patients provided oral informed consent and underwent biologic blood testing, routine examinations, and determination of coagulation function before and after treatment. The dosage of dabigatran etexilate was 110 mg twice daily for adults and 55 mg twice daily for children. RESULTS All 19 patients had benefited from dabigatran etexilate treatment with coagulation improvement and pain relief. Pain had improved in all 16 evaluable patients. The fibrinogen and D-dimer levels had improved in 18 of 19 patients. The fibrin degradation product level had improved in 10 of 14 patients. None of patients reported lesion regression, appearance changes, or improvement in mobility. No significant differences were found in the D-dimer, fibrinogen, and fibrin degradation product levels between the short-term (<10 days) and long-term (≥10 days) use of the medication. Dabigatran etexilate was well tolerated by all patients. No bleeding event had occurred during follow-up. CONCLUSIONS The results of our study have confirmed the efficacy and safety of dabigatran etexilate in treating pain and LIC in patients with VMs. Dabigatran etexilate is a suitable choice preoperatively to modify coagulation function and pain in patients with VMs.
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Affiliation(s)
- Hongyuan Liu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Li Hu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xi Yang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zian Xu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hao Gu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hui Chen
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaoxi Lin
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Department of Laser and Aesthetic Medicine, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Pessanha I, Delgado-Miguel C, Alves H, Triana P, Lopéz-Gutierrez JC. Venous malformations: what do phleboliths tell us in the pediatric population? Pediatr Surg Int 2022; 38:1501-1506. [PMID: 35852593 DOI: 10.1007/s00383-022-05181-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Phleboliths are often observed within Venous malformations (VM) and frequently indicated as cause of morbidity. The aim of this study is to investigate independent risk factors for phleboliths in a pediatric population and to determine if its presence influences clinical management. METHODS We retrospectively review data from patients diagnosed with VM in a vascular anomalies center during a 5-year period. Associations between phleboliths and potential risk factors were assessed. A multivariable analysis, was performed to assess the influence of phleboliths in the need for surgery. RESULTS We included 88 patients with a mean age of 10 years. Phleboliths were found in 33.0%. In univariate analysis, there were no significant differences between the two groups regarding age or gender, location, dimension or depth of the VM, pain and laboratory parameters. Multivariable analysis could not detect any independent risk factor for phleboliths. In contrast, multivariable logistic analysis revealed that when phleboliths were present, the need for surgical extirpation was more likely (p = 0.031). CONCLUSIONS This study showed that patients who have phleboliths within their VM seem to require surgery more frequently. This constitutes an entirely innovative thought that could raise awareness to a lower threshold for surgery in this group of patients.
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Affiliation(s)
- Inês Pessanha
- Department of Paediatric Surgery, Paediatric Hospital, Centro Hospitalar E Universitário de Coimbra, R. Dr. Afonso Romão, 3000-602, Coimbra, Portugal.
| | | | - Hélio Alves
- Department of Biomedicine, Unit of Anatomy, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Paloma Triana
- Department of Plastic Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
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Clinical characteristics associated with pain in patients with peripheral vascular malformations. J Vasc Surg 2021; 75:1054-1062.e1. [PMID: 34606955 DOI: 10.1016/j.jvs.2021.08.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/29/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Vascular malformations (VM) can negatively impact the patient's quality of life (QoL). Pain is a common problem in these patients. The aim of this study was to investigate risk factors associated with pain and to assess how pain affects QoL. METHODS This prospective cross-sectional study was conducted in a tertiary vascular anomaly expertise center. Between June and December 2020, all patients from our local database (334 adults and 189 children) with peripheral VMs were invited to complete the Outcome Measures for VAscular MAlformations questionnaire to evaluate the presence, frequency, and intensity of pain. Additionally, patients were asked to complete several Patient-Reported Outcome Measurement Information System scales to evaluate their QoL. Risk factors associated with pain were identified in bivariate analysis and multivariable logistic regression. QoL domains were compared between patients who experienced pain and patients who did not. RESULTS A total of 164 patients completed the questionnaire about pain and 133 patients completed all QoL questionnaires. Approximately one-half of the patients (52%) reported pain in the past four weeks and 57% of these patients reported pain daily or several times a week. Female sex (P = .009), lesions located in the upper extremity (P < .001) or lower extremity (P < .001), and intramuscular/intraosseous lesions (P = .004) were independently associated with the presence of pain. The following QoL domains were diminished in patients who experienced pain in comparison with patients who did not: pain interference (P < .001), physical functioning (P < .001), and social participation (P < .001) in adults, and pain interference (P = .001), mobility (P = .001), and anxiety (P = .024) in children. CONCLUSIONS Pain is a frequently reported complaint in patients with VMs and is present in approximately one-half of the patients. Patients with lesions located in the upper or lower extremity, intramuscular/intraosseous lesions, and female patients are more likely to experience pain. The presence of pain negatively impacted patients' QoL. Although VM are a benign condition and expectative management is frequently applied, our study shows that pain is a serious concern and needs to be actively assessed. Pain is a sign of various etiologies and should be examined to properly treat the pain.
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Hu L, Chen H, Yang X, Sun Y, Liu H, Gu H, Liu M, Lin X. Operative management of equinus associated with lower limb venous malformations. Phlebology 2021; 37:125-133. [PMID: 34541959 DOI: 10.1177/02683555211047286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Functional impairment is a common complaint in patients with venous malformations. Equinus can occur when the venous malformation involves the lower limb, a challenging condition with only a few studies to guide treatment choices. This study was aimed to investigate the operative management of equinus associated with lower limb venous malformations. METHOD Between August 2015 and September 2017, a total of 12 patients presented with equinus associated with lower limb venous malformations and underwent surgical correction. Preoperative and postoperative clinical symptoms, physical examination and orthopaedic evaluation were retrospectively reviewed. 8 patients who experienced pain underwent percutaneous sclerotherapy prior to the operation. Surgical management included gastrocnemius intramuscular aponeurotic recession, Z-lengthening of the Achilles tendon, Hoke technique and Taylor Spatial Frame external fixation. RESULTS There were eight female and four male patients with a mean age of 14.3 ± 5.9 years. The mean follow-up period was 34.8 ± 9 months. The range of motion of ankle dorsiflexion (with knee extended) improved for each patient (mean, 25.4 degrees; standard deviation, 8.5 degrees). No neurovascular complications were observed. CONCLUSION Operative correction of equinus associated with lower limb venous malformations is safe and effective. Selective preoperative sclerotherapy is necessary for optimal outcomes.
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Affiliation(s)
- Li Hu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hui Chen
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xi Yang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Sun
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongyuan Liu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hao Gu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ming Liu
- Department of Orthopedics, Shanghai Ninth People's Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Orthopedics, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiaoxi Lin
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Budge EJ, Khalil Allam MA, Mechie I, Scully M, Agu O, Lim CS. Venous malformations: Coagulopathy control and treatment methods. Phlebology 2020; 36:361-374. [PMID: 33283636 DOI: 10.1177/0268355520972918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Venous malformations (VMs) are ectatic channels which arise as a result of vascular dysmorphogenesis, commonly caused by activating mutations in the endothelial tyrosine kinase receptor (TIE2)/phosphatidylinositol 3-kinase (PI3Kinase) pathway. With a prevalence of 1% in the general population, and a diverse clinical presentation depending on site, size and tissue involvement, their treatment requires a personalised and multidisciplinary approach. Larger lesions are complicated by local intravascular coagulopathy (LIC) causing haemorrhagic and/or thrombotic complications which can progress to disseminated intravascular coagulopathy (DIC). METHODS We performed a literature review using a PubMed® search and identified 15 articles to include. References of these texts were examined to further expand the literature review.Principle findings: Several treatment options have been explored, including compression, sclerotherapy, laser therapy, cryoablation and surgery in addition to the management of LIC with low-molecular-weight-heparin (LMWH) and other anticoagulants. Targeted molecular therapies acting on the phosphatidylinositol 3-kinase (PI3Kinase)/Protein Kinase B (AKT)/mammalian target of rapamycin (mTOR) pathway are newly emerging. CONCLUSION Despite a wealth of literature, larger, multi-centric, randomised and prospective trails are required to offer further clarification on the therapeutic management of coagulopathy control and to provide symptomatic benefit to patients with VMs. There should be efforts to provide long term follow up and to use standardised risk stratification tools and quality of life (QOL) questionnaires to aid comparison of agents and treatment protocols.
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Affiliation(s)
- Eleanor J Budge
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK
| | | | - Imogen Mechie
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Marie Scully
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK.,Research Department of Surgical Biotechnology, Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, UK
| | - Obi Agu
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK.,Research Department of Surgical Biotechnology, Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, UK
| | - Chung Sim Lim
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK.,Research Department of Surgical Biotechnology, Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, UK
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Paolacci S, Mattassi RE, Marceddu G, Manara E, Zulian A, Guerri G, De Antoni L, Arduino C, Cavalca D, Bertelli M. Somatic Variant Analysis Identifies Targets for Tailored Therapies in Patients with Vascular Malformations. J Clin Med 2020; 9:jcm9113387. [PMID: 33105631 PMCID: PMC7690376 DOI: 10.3390/jcm9113387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/07/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022] Open
Abstract
Vascular malformations include various disorders characterized by morphological, structural and/or functional alterations of blood and lymph vessels. Most are sporadic, due to somatic mutations. Here, we report a cohort of patients with sporadic and/or unifocal vascular malformations, in whom we carried out next generation sequencing analysis of a panel of genes associated with vascular malformations. The 115 patients analyzed were from different clinical centres. In 37 patients (32%), we found pathogenic mutations: most of these were gain-of-function mutations in PIK3CA (18%, 21/115) and TEK (13/115, 11%). We also found mutations in GNAQ, CCM2 and PTEN. Identifying pathogenic variants in patients with vascular malformations can help improve management, particularly in cases with activating mutations that cause an increase in cell proliferation. Personalized pharmacological treatment, if possible, is now considered preferable to surgery and can help prevent recurrences, i.e., long-term complications of residual malformation or regrowth of tumors. For instance, rapamycin is currently being investigated for the treatment of various vascular malformations associated with hyperactivation of the phosphoinositide 3-kinase/Akt/mammalian target of rapamycin (PI3K/Akt/mTOR) pathway.
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Affiliation(s)
- Stefano Paolacci
- MAGI’S LAB, Via delle Maioliche, 57/D, 38068 Rovereto, TN, Italy; (A.Z.); (G.G.); (M.B.)
- Correspondence: ; Tel.: +39-046-442-0795
| | - Raul Ettore Mattassi
- Center for Vascular Malformations “Stefan Belov”, Clinical Institute Humanitas “Mater Domini”, Via Gerenzano, 2, 21053 Castellanza, VA, Italy;
| | - Giuseppe Marceddu
- MAGI EUREGIO, Via Maso della Pieve, 60/A, 39100 Bolzano, Italy; (G.M.); (E.M.); (L.D.A.)
| | - Elena Manara
- MAGI EUREGIO, Via Maso della Pieve, 60/A, 39100 Bolzano, Italy; (G.M.); (E.M.); (L.D.A.)
| | - Alessandra Zulian
- MAGI’S LAB, Via delle Maioliche, 57/D, 38068 Rovereto, TN, Italy; (A.Z.); (G.G.); (M.B.)
| | - Giulia Guerri
- MAGI’S LAB, Via delle Maioliche, 57/D, 38068 Rovereto, TN, Italy; (A.Z.); (G.G.); (M.B.)
| | - Luca De Antoni
- MAGI EUREGIO, Via Maso della Pieve, 60/A, 39100 Bolzano, Italy; (G.M.); (E.M.); (L.D.A.)
| | - Carlo Arduino
- Medical Genetics Unit, City of Health and Science, Corso Bramante, 88, 10126 Turin, Italy;
| | - Daniela Cavalca
- Laser Surgery Operating Unit, Plastic Surgery Department, San Rocco Clinical Institute, Via dei Sabbioni, 24, 25050 Ome, BS, Italy;
| | - Matteo Bertelli
- MAGI’S LAB, Via delle Maioliche, 57/D, 38068 Rovereto, TN, Italy; (A.Z.); (G.G.); (M.B.)
- MAGI EUREGIO, Via Maso della Pieve, 60/A, 39100 Bolzano, Italy; (G.M.); (E.M.); (L.D.A.)
- EBTNA–LAB, Via delle Maioliche, 57/G, 38068 Rovereto, TN, Italy
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