CD304 + adipose tissue-derived mesenchymal stem cell abundance in autologous fat grafts highly correlates with improvement of localized pain syndromes

ABSTRACT

Surgery, burns or surgery-free accident are leading causes of scars with altered tissue consistency, a reduced degree of motion and pain. Autologous fat grafting can dramatically improve tissue consistency and elasticity but less frequently results in the reduction of pain. Therefore, we analyzed different cell populations present within the adipose tissue to be engrafted and correlated them with the reduction of pain after surgery. Here, we identify a population of CD3 - CD4 - CD304 + cells present in grafted adipose tissue, whose abundance highly correlates with pain improvement shortly after surgery ( r2 = 0.7243****) as well as persistently over time (3 months later: r2 = 0.6277****, 1 year later: r2 = 0.5346***, and 4 years later: r2 = 0.5223***). These cells are characterized by the absence of the hematopoietic marker CD45, whereas they express CD90 and CD34, which characterize mesenchymal stem cells (MSCs); the concomitant presence of CD10 and CD73 in the plasma membrane supports a function of these cells in pain reduction. We deduce that the enrichment of this adipose tissue-derived MSC subset could enhance the therapeutic properties of adipose grafts and ameliorate localized pain syndromes.

Rejuvenation in Men Facial Aging: A Combined Approach

Facelift surgery, also known as rhytidectomy, is a popular cosmetic procedure aimed at reversing the signs of facial aging. While facelift surgery is more commonly performed in women, an increasing number of men are seeking this procedure to maintain a youthful appearance. The long recovery period conflicts the overall primary outcome anticipated by men undergoing rhytidectomy, i.e., appear younger, youthful, and ready to reaffirm their value in the working environment. Anterior direct neck lift, blepharoplasty (upper and lower eyelid blepharoplasty), and lipofilling are three techniques that have been shown to be effective in improving facial rejuvenation outcomes in elderly male patients. However, there is little to no evidence of the safety and efficacy of these techniques when used in combination. By combining these techniques, we hypothesized that we could achieve outcomes comparable to traditional facelift surgery, but with a lower risk of complications and a shorter recovery time. We conducted a retrospective case series study of 18 male patients who underwent facial rejuvenation surgery using the combination of anterior direct neck lift, blepharoplasty (upper and lower eyelid blepharoplasty), and lipofilling at our institution between 2018 and 2021. All 18 patients completed the study, with an average follow-up of 12 months. No major complications were observed, and all patients reported a high level of satisfaction with their outcomes.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Case report: a step-by-step body contouring approach in a case of young patient with CLOVES syndrome

CLOVES syndrome is a rare overgrowth disorder caused by gene mutations. This case study describes a 28-year-old woman with CLOVES syndrome who underwent multiple surgeries to achieve a positive outcome while preserving lymphovascular structures. The report underscores the importance of a multidisciplinary approach and tailored surgical interventions for managing CLOVES.

Literature Review: Venous Thromboembolism Prophylaxis in Plastic Surgery

Venous thromboembolism (VTE) is a postoperative complication experienced in all branches of surgery, including plastic surgery. Its occurrence can be lowered with adequate prophylaxis in the light of the patient's risk category and the type of surgery that will be performed. Nevertheless, thromboembolic prophylaxis is not routinely administered in plastic surgery. The prevention of VTE has gained significant attention in the past 5 years due to increased knowledge about the disease process and the alarming incidence rates. This literature review is specifically aimed at carrying out a synopsis of VTE prophylaxis trials conducted on plastic surgery patients. Antithrombotic agents have generally been avoided by plastic surgeons due to the increased risk of bleeding or hematomas; however, the prevalence of clinically important bleeding has not been found to increase with their use, as it emerges from numerous studies. VTE events can lead to increased morbidity and mortality rates, as well as a rise in healthcare costs. As it emerges from multiple studies, as a preventive measure against VTE, it is strongly advised to use mechanical prophylaxis along with low-molecular-weight heparin as the primary treatment option for plastic surgery patients who are at a greater risk. Up to date though, this practice is not commonly embraced by physicians. Preventing VTE is crucial, and measures to do so are necessary. However, there is no clear evidence to support the use of anticoagulation for plastic surgery patients, and some surgeons are hesitant to use it due to potential bleeding in extensive dissection areas.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Implant-Based Breast Reconstruction: Impact of Body Mass Index on Postoperative Complications and Aesthetic Results: A 5-Year, Single-Center Study

BACKGROUND

Increasing adoption of implant-based breast reconstruction (IBR) has raised expectations regarding postoperative outcomes and aesthetic results. BMI has been extensively explored as a predictor of complications. This study is the first to examine complication rates in underweight subjects, and compares these rates among underweight, normal weight, overweight, and obese patients.

OBJECTIVES

The aim of this study was to investigate the influence of BMI on postoperative complications and aesthetic results in IBR following mastectomy.

METHODS

Retrospective analysis encompassed patients undergoing mastectomy with subsequent IBR, performed by a collaborative team of breast and plastic surgeons. Demographics, treatment specifics, and outcomes were evaluated by univariate and multivariate regression models. Significance was determined at P < .05.

RESULTS

In total, 1046 IBRs were performed in 921 patients, of whom 63 had a BMI <18.5 kg/m2, 572 were normal weight, 215 were overweight, and 71 were obese. Significantly higher complication rates were observed in both obese and overweight patients compared with normal-weight patients (P < .001). Each unit increase in BMI correlated to 7% increased odds of overall complications and 13% increased odds of reconstructive failure. Underweight individuals had higher capsular contracture rates than normal-weight patients, 14.3% vs 3.65%, respectively (P = .001). In addition, aesthetic complications rates in underweight patients were higher than in normal-weight patients, 36.4% vs 25.7%, respectively (P < .05).

CONCLUSIONS

This study confirmed BMI to be a strong predictor of postoperative complications and aesthetic outcomes, and demonstrates that low BMI has a significant impact on the incidence of capsular contracture and aesthetic complications.

LEVEL OF EVIDENCE: 3

Surgical Tips for Aesthetic Lower Lid Blepharoplasty: Prevention of Round Eye

In the present study, we highlight surgical tips based on our experience in lower eyelid blepharoplasty. These have been shown to be crucial in the prevention of several complications, specifically lateral lower-lid displacement.

Methods

A series of bilateral lower-lid blepharoplasties were performed on 280 patients at Humanitas-Research-Hospital (Milan, Italy) between January 2016 and January 2020. Patients with a history of lower-lid blepharoplasty and patients requiring canthopexy/canthoplasty were excluded. Needing to singularly evaluate and correct several lower-eyelid structures to obtain a harmonic result, we preoperatively assessed the amount of skin excess, the eyelid margin malposition relative to the globe, and the presence/absence of herniated fat-pads. Pre- and postoperative standard photographs were collected. Patients were evaluated by measuring scleral show, snap-back test, and distraction test. Blinded-fashioned photograph analysis was performed by independent plastic and oculoplastic surgeons who did not execute the procedures. A visual analogue scale was administered to all patients to assess satisfaction.

Results

In total, 280 patients underwent successful lower blepharoplasty, with satisfactory results of scleral show, snap-back test, and distraction test. Of the 280 patients, four presented postoperative complications. At 10-month follow-up visit, we achieved a mean patient visual analogue scale satisfaction score of 8.4. Postoperative surgeon's photographs mean score was 4.5.

Conclusions

Without the use of muscle flaps, our technique averts tarsal ligament misposition, preserves orbicularis-muscle innervation, and limits thermal spread, assuring excellent stability of results and high patient and surgeon satisfaction. Cosmetic outcome in terms of symmetry, appearance, and lower lid line definition revealed high satisfaction with the result over time, with a remarkably low complication rate.

Comment on "Reverse Expansion Following Nipple Sparing Mastectomy: A Natural, Safe and Effective Autologous Technique for Breast Reconstruction"

Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Smartphone Dynamic Infrared Thermography for Harvesting AICAP Flap in a Large Breast-conservative Surgery

Flaps based on perforators of the intercostal arteries have been described for the reconstruction of defects resulting from partial mastectomies. Dynamic infrared thermography (DIRT) identifies hot spots that accurately correspond to and evaluate perforator vessels toward the skin. The new generation of portable thermal cameras has become smaller, less expensive, more sensitive, and compatible with common smartphones. One option is the FLIR ONE system (FLIR Systems, Inc., Wilsonville, OR), a smartphone-compatible thermal camera. Despite its lower resolution, compared with the larger infrared camera models, it represents a viable option for thermal skin mapping, and its compact nature allows for easy portable use. The purpose of this article is to report a case of a preoperative study with smartphone DIRT used in the preparation of an anterior intercostal artery perforator-based flap for breast reconstruction after a wide resection at the level of the right infer-internal breast region, including a skin excision. Our study documents how smartphone DIRT is a rapid, sensitive, easily accessible and cost-effective diagnostic method for the topographical identification of intercostal artery perforators. It can be used as a rescue method at any stage of the intervention if it differs from the preoperative planning. It also confirms the proven usefulness of this flap for the reconstruction of partial defects in the breast and thoracic region.

Quantitative Analysis of the Histological Features of Tuberous Breast

INTRODUCTION

Tuberous breast deformity (TB) is a condition mostly characterized by breast stenosis, areolar widening and glandular asymmetry. The most accredited hypothesis describes an abnormal thickening of the fascia corporis that might influence an alteration in the glandular development, limiting the horizontal growth of breast parenchyma. Alterations in the extracellular matrix components (ECM) might be involved in the abnormal breast development.

PATIENTS

The aim of our case control study is to use histological specimens to analyze qualitative and quantitative differences in collagen fibers, elastic fibers and vessel densities in TB and normal breasts of 20 patients using a software for digital pathology.

RESULTS

The quantitative findings showed increasing concentrations of collagen fibers and decreasing elastic fibers in TB, compared to normal breasts. No difference was seen in vessel density among the two groups. The qualitative findings highlighted differences in the distribution of the ECM among the TB specimens. Collagen fibers showed a packed appearance rather a scattered distribution, while elastic fibers visibly presented a reduction and a focal distribution of their concentration.

CONCLUSIONS

The study proposes a correlation between abnormalities in ECM concentrations and TB, resulting in a higher degree of fibrosis and in the characteristic stenotic and less elastic morphology of the deformity.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Effect of Adjuvant Radiotherapy on One- and Two-Stage Prosthetic Breast Reconstruction and on Autologous Reconstruction: A Multicenter Italian Study among 18 Senonetwork Breast Centres

Purpose

In modern breast cancer treatment, a growing role has been observed for breast reconstruction together with an increase in clinical indications for postmastectomy radiotherapy (PMRT). Choosing the optimum type of reconstructive technique is a clinical challenge. We therefore conducted a national multicenter study to analyze the impact of PMRT on breast reconstruction.

Methods

We conducted a retrospective case-control multicenter study on women undergoing breast reconstruction. Data were collected from 18 Italian Breast Centres and stored in a cumulative database which included the following: autologous reconstruction, direct-to-implant (DTI), and tissue expander/immediate (TE/I). For all patients, we described complications and surgical endpoints to complications such as reconstruction failure, explant, change in type of reconstruction, and reintervention.

Results

From 2001 to April 2020, 3116 patients were evaluated. The risk for any complication was significantly increased in patients receiving PMRT (aOR, 1.73; 95% CI, 1.33-2.24; p < 0.001). PMRT was associated with a significant increase in the risk of capsular contracture in the DTI and TE/I groups (aOR, 2.24; 95% CI, 1.57-3.20; p < 0.001). Comparing type of procedures, the risk of failure (aOR, 1.82; 95% CI, 1.06-3.12, p=0.030), explant (aOR, 3.34; 95% CI, 3.85-7.83, p < 0.001), and severe complications (aOR, 2.54; 95% CI, 1.88-3.43, p < 0.001) were significantly higher in the group undergoing DTI reconstruction as compared to TE/I reconstruction.

Conclusion

Our study confirms that autologous reconstruction is the procedure least impacted by PMRT, while DTI appears to be the most impacted by PMRT, when compared with TE/I which shows a lower rate of explant and reconstruction failure. The trial is registered with NCT04783818, and the date of registration is 1 March, 2021, retrospectively registered.

Immediate direct-to-implant breast reconstruction: A single center comparison between different procedures

Background

The increased incidence of conservative mastectomy operations (nipple- and skin- sparing) has increased the frequency of immediate breast reconstructions (IBR). In order to guarantee patients the best possible aesthetic outcome, the least chance of complications and moreover, the least postoperative pain, the technique with prepectoral prosthetic pocket was recently reconsidered with the use of ADM. This is the first study using Fortiva® in prepectoral breast reconstruction, and it compares the outcomes of three different patient populations (undergoing retromuscular, prepectoral and prepectoral reconstruction with ADM). The authors suggest that prepectoral breast reconstruction with ADM may bring benefits compared to the current standard technique (retromuscular) as well as compared to the prepectoral reconstruction without ADM.

Methods

Retrospective data analysis of patients who underwent mastectomy followed by immediate breast reconstruction with silicone implants (DTI), performed by a team of breast surgeons and plastic surgeons. Logistic factor regressions were performed in order to investigate the effects of the three different intervention techniques on the incidence of complications. Fisher's exact test was used to analyze the differences in the occurrence of each complication. Mann Whitney test was used to compare the averages of referred pain. A p value &lt;0.05 was considered significant.

Results

A total of 67 patients underwent DTI reconstruction, of which 43 with retromuscular prosthesis, 13 prepectoral and 11 prepectoral with ADM. We found a significantly lower incidence of surgical complications with ADM, exclusively in comparison with retromuscular reconstruction (p = 0.028). It emerges prepectoral reconstruction with ADM involves significantly less visibility of the implant than both the prepectoral surgery without ADM (p = 0.013) and the retromuscular technique (p = 0.029). Finally, postoperative pain referred at twelfth month is significantly less relevant in the group with prepectoral prosthesis and ADM, both in the group with retromuscular (p &lt; 0.001) and prepectoral without ADM (p = 0.001).

Conclusions

This study demonstrates that immediate prepectoral breast reconstruction with ADM is a safe and reliable technique, able to exceed some type of limits imposed by prepectoral reconstruction. Moreover, it provides benefits if compared to the current standard technique. In the future, this technique could also be added to it, after a proper selection of patients in pre- and intraoperative time.

Review of Tuberous Breast Deformity: Developments over the Last 20 Years

Tuberous breast (TB) deformity is a condition characterized by alterations in breast morphology and tissue structure with high prevalence in the general population. The literature provides sparse descriptions of TB, as not many investigations on the condition have been conducted. The aim of this review was to analyze and provide a holistic overview on the morphological characteristics of the TB.

Methods

A review of current literature was performed using the PubMed database from 2001 to 2021. The key words used for the review included "tuberous breast," "constricted breast," and "stenotic breast." We included articles that analyzed the anatomic and histologic characteristics of TB.

Results

From 213 articles, only 42 met the inclusion criteria. A total of 171 articles were excluded, as they were letters, not related to the condition, or were written in a foreign language. The studies in this review drew on hypothesis on the embryological origin of TB and analyzed the composition of TB tissues, consisting in a constricting fibrous ring, made of longitudinally arranged collagen and elastic fibers. Furthermore, the review reports the different anatomical and surgical classifications, as well as the various surgical corrective procedures developed throughout history up to 2021.

Conclusion

The review describes all etiological, epidemiologic, anatomical, histological, and surgical characteristics of tuberous breast.

Safety of autologous fat grafting in breast cancer: a multicenter Italian study among 17 senonetwork breast units autologous fat grafting safety: a multicenter Italian retrospective study

BACKGROUND

Autologous fat grafting (AFG), defined as the re-implant to the breast of fat tissue from different body areas, has been firstly applied to esthetic plastic surgery and then has moved to reconstructive surgery, mainly used for scar correction and opposite breast altering. Nevertheless, due to the potentially unsafe stem-like properties of adipocytes at the tumoral bed level, no clear evidence of the procedure's oncological safety has been clearly documented at present.

PATIENTS AND METHODS

We retrospectively collected data of early breast cancer (BC) patients from 17 Italian Breast Units and assessed differences in terms of locoregional recurrence rate (LRR) and locoregional recurrence-free survival (LRFS) between patients who underwent AFG and patients who did not. Differences were analyzed in the entire cohort of invasive tumors and in different subgroups, according to prognostic biological subtypes.

RESULTS

With a median follow-up time of 60 months, LRR was 5.3% (n = 71) in the matched population, 3.9% (n = 18) in the AFG group, and 6.1% (n = 53) in the non-AFG group, suggesting non-inferiority of AFG (p = 0.084). Building Kaplan-Meier curves confirmed non-inferiority of the AFG procedure for LRFS (aHR 0.73, 95% CI 0.41-1.30, p = 0.291). The same effect, in terms of LRFS, was also documented among different biological subtypes (luminal-like group, aHR 0.76, 95% CI 0.34-1.68, p = 0.493; HER2 enriched-like, aHR 0.89, 95% CI 0.19-4.22, p = 0.882; and TNBC, aHR 0.61, 95% CI 0.12-2.98, p = 0.543).

CONCLUSIONS

Our study confirms in a very large, multicenter cohort of early BC patients that, aside the well-known benefits on the esthetic result, AFG do not interfere negatively with cancer prognosis.

Superior Pedicle Breast Reduction with Prefiguration of Final Shape: A 10-year Retrospective Study

Breast reduction, also defined as reduction mammaplasty, is one of the most common procedures performed in aesthetic surgery. Multiple techniques have been proposed throughout the years and several classification systems have been adopted according to: type of incision, pedicle blood supply (cutaneous, glandular, dermoglandular), extent of undermining, excision area, simultaneous or separate tissue excision (fat/gland, skin, or both), and combination of the aforementioned. In the present article, we share our 10 years' experience with reduction mammaplasty and we describe our personal technique, a modified superior pedicle breast reduction.

METHODS

We performed a retrospective analysis on 823 consecutive patients undergoing either aesthetic or functional reduction mammaplasty at Humanitas Research Hospital between 2009 and 2018. For each patient, we evaluated the mean resection volume and complication rate. We also assessed patients' satisfaction (VAS scale) and aesthetic outcome (assessed by independent surgeons, scale from 1 to 5).

RESULTS

The average patient age was 48, ranging from 17 to 77 years. The average operative time was 77 minutes, ranging from 62 to 123 minutes. After a thorough follow-up of these patients, we can conclude that our technique has a low complication rate, patients' satisfaction is excellent, and the result is stable over time in terms of shape and symmetry (the mean VAS score was 8.1). Postoperative surgeon's photographs evaluation scores were 4.5 ± 0.5. Average resected volume was 860gr.

CONCLUSION

The proposed technique is safe, fast, and simple with a relatively short learning curve, making it didactic and intuitive for young surgeons.

AUtologous fat graft in foot calcaneal postsurgical chronic ulcer

INTRODUCTION

Post-traumatic injury of talus's posterior area and ankle joint with consequent scar formation is often complicated by an unhealing trophic ulcer. Aim of this paper is to evaluate the autologous fat graft effectiveness in treating Achilles tendon area wounds.

MATERIAL AND METHODS

From October 2011 to March 2014 we treated with fat graft a total of 7 patients with post-surgical painful chronic ulcer of calcaneal area. Mean age was 38.6 years (range 22-64 years). One patient was a professional football player who was presenting a post-injury ulcer not respondant to advanced dressings.

RESULTS

Wound rehepitelization was observed in all cases treated within one month and fat grafting resolved pain related to the wound. All patient returned to their daily normal activities. In all cases treated we observed an increased softness of perilesional post-surgical scars. Our professional football player came back able to perform an usual training 5 days post-operation obtaining complete rehepitelization within 3 weeks.

DISCUSSION

Our surgical approach showed a therapeutic effect that relies on biological properties of adipose tissue; those properties are clear in both procedures of chronic ulcer's rehepitelization stimulation and perilesional tissue's enhancement obtaining pain control. The procedure is safe, with low rate of complication.

Optimising aesthetic outcome after nipple-areola complex-sparing mastectomy and immediate one-stage prosthetic reconstruction: A simple surgical trick to fix nipple-areola complex position

Background:

Nipple-areola complex (NAC) sparing mastectomy (NSM) is mostly indicated in patients with small-/medium-sized and non-ptotic breasts, while skin-reducing mastectomy is used in patients with medium or large breasts with severe ptosis. NAC location on the reconstructed breast is one of the major factors in determining the final aesthetic result and patients’ satisfaction. An optimum result obtained at the end of surgical procedure may be altered and compromised by skin redistribution and consequently NAC depositioning during the post-operative period in patients with medium-sized breasts and a moderate degree of ptosis.

Aims:

In the present study, we propose a simple surgical trick to fix the NAC in the desired position with a long-lasting result.

Methods:

We selected 35 patients undergoing NAC sparing mastectomy for breast cancer and immediate one-stage prosthetic reconstruction and we performed a single suture to fix NAC in the desired position before closing the skin envelope. We evaluated NAC complex position stability overtime comparing pre-operative standard photographs with early (3 weeks after surgery) and late (1 year after surgery).

Results:

In all patients, we were able to place the NAC complex on the desired position, and the result was stable at 1 year follow-up. The aesthetic outcome was satisfactory in all patients with no change in the complication rate.

Conclusions:

This simple surgical trick has been shown to be safe and effective in optimising the aesthetic outcome in a patient undergoing NAC sparing mastectomy and immediate one-stage prosthetic reconstruction. Level IV: evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Functional fat injection under local anesthesia to treat severe postsurgical dysphagia, case report

BACKGROUND

In this study, we present the first application of functional fat injection performed under local anesthesia in the treatment of severe dysphagia secondary to head and neck cancer surgery.

METHODS

Functional fat injection was performed using a transcervical approach. Control of injection depth and site was performed through a transnasal flexible endoscope. The effect of surgery was evaluated through videofluoroscopy (VFS), Fiberendoscopic Evaluation of Swallowing (FEES), Functional Oral Intake Scale (FOIS), and Eating Assessment Tool-10 (EAT-10).

RESULTS

Before the functional fat injection, the patient was dependent on permanent tube feeding; the VFS and FEES revealed a severe impairment of swallowing abilities. The EAT-10 scored 26. Twelve months after surgery, the patient was on oral diet, the VFS demonstrated mild to moderate dysphagia, the FEES demonstrated aspiration only with liquids and the EAT-10 improved.

CONCLUSION

Functional fat injection under local anesthesia could be useful in the treatment of chronic dysphagia in selected patients.

Fat Graft in Composite Breast Augmentation with Round Implants: A New Concept for Breast Reshaping

BACKGROUND

Breast augmentation surgery with implants is one of the most common aesthetic surgical procedures. Round and anatomical textured implants are employed very often, and fat grafting has proven to be a very useful complementary procedure in breast augmentation. Many authors report a more natural result with anatomical compared to round implants. Nevertheless, anatomical implants can be associated with complications such as implant rotation with subsequent shape distortion. In this article, we propose a combination of high-profile round implants and fat grafting to obtain a natural result analyzing its impact on the aesthetic outcome and patient satisfaction.

METHODS

In this study, we report our personal approach on 31 consecutive patients undergoing primary aesthetic breast augmentation with high-profile round implants and fat grafting. We describe our personal technique of breast augmentation via the periareolar approach and fat grafting. We evaluated short- and medium-term aesthetic outcomes and patient satisfaction using a 10-point VAS scale.

RESULTS

We achieved in all cases high patient satisfaction and good aesthetic outcomes with a "natural" breast shape and a "smoothened" upper pole with low complication rates. The technique is safe, simple, fast, and it leads to high levels of patient satisfaction.

CONCLUSIONS

Our observations show that the combination of high-profile round implants and fat grafting in aesthetic breast augmentation can improve the aesthetic outcome and patient satisfaction as with anatomical implants eliminating the risk of implant rotation.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Autologous fat graft in irradiated orbit postenucleation for retinoblastoma

Autologous fat grafting has been extensively and successfully adopted in a number of pathologic conditions in regenerative surgery especially on irradiated fields in order to improve pain symptoms and tissue trophism promoting scar release. In the present study, we report our experience with autologous fat grafting for the treatment of postirradiation fibrosis and pain on three consecutive patients undergoing orbital enucleation for locally advanced retinoblastoma (RB) and subsequent radiotherapy. We selected three consecutive patients who underwent orbital enucleation for locally advanced RB and subsequent local radiotherapy showing severe reduction in orbital volume and eyelid length and retraction due to fibrosis, spontaneous local pain exacerbated after digital pressure with no possibility to place an ocular implant. They underwent autologous fat grafting in the orbital cavity and results were evaluated by clinical examination at 5 and 14 days, and 1, 3, 6 months, and 1 year after surgery. A significant release of scar retraction, reduction of fibrosis and orbital rim contraction together with an important improvement of pain symptoms was observed in all patients. The local changes observed enabled an ease placement of an ocular prosthetic implant (implant). No local or systemic complication occurred. Fat grafting is a promising treatment for patients showing radiotherapy related complication in the orbital area and it should be adopted by all oculoplastic surgeon in order to improve pain syndrome creating the ideal local conditions for the placement of an ocular prosthetic implant.

Stenotic Breast Malformation and Its Reconstructive Surgical Correction: A New Concept From Minor Deformity to Tuberous Breast

BACKGROUND

Several classification systems have been reported to define the spectrum of tuberous breast deformity, and a range of surgical techniques has been described. In this paper, we proposed a new classification including tuberous breast and minor deformity based on stenosis type, glandular trophism and ptosis adapting surgical planning to different breast types.

METHODS

A total of 246 patients meeting our definition for stenotic breasts asking for surgery were analyzed in this study. We considered eight different types of stenotic breasts analyzing anatomical presentations, and we then proposed eight key-point maneuvers, finalized to the correction of different breast deformities and their possible association according to the stenotic breast type. Results have been evaluated by a group of three surgeons and by patients. In addition, we evaluated the complication incidence in terms of re-intervention rate.

RESULTS

Following our classification eight different groups were distinguished. For each one we reported the prevalence and the surgical procedure adopted. Results evaluated by the surgeon group reported a mean aesthetic outcome of 8.2 (range 5-10), whereas patients reported a mean value of 7.9 (range 6-10). During a follow-up period with a mean of 16 months we observed a 4.9% re-intervention rate.

CONCLUSIONS

We believe this new classification to be very complete in evaluating breast shape, including most of the breast evaluable features. Our results confirmed the suitability of the approach for appropriate preoperative planning, thus improving the global surgical outcome.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Therapeutic effect of hyaluronic acid in reducing nasal mucosa recovery time after septoplasty

Mucociliary clearance represents a host defense mechanism of airways that can be compromised by various pathologic conditions, such as nasal septal deviation. Although septoplasty can resolve obstruction, it impairs mucociliary clearance in the immediate postoperative period. Clinical studies have demonstrated how hyaluronic acid can interfere with this function. Our study aims to provide evidence of a therapeutic effect of hyaluronic acid on nasal mucosa recovery after septoplasy. Sixty-five patients underwent septoplasty. On postoperative day 1, patients were randomized to a control arm that was treated with mupirocin ointment or an experimental arm that received additional treatment with sodium hyaluronate solution. Pre- and postoperatively, anterior rhinoscopy was performed to analyze mucosal status, and mucociliary clearance was measured by using the saccharin transit time (STT) method. The t test was used for independent groups. During the preoperative evaluation, we observed a significant difference in STT between the convex and concave side in both groups. Fifteen days after surgery, we observed a significant difference preoperatively to postoperatively for both the convex and the concave side (p < 0.02 and p < 0.008, respectively). One month after surgery, we observed a reduction of STT when comparing preoperative control group values and, after 1 month, postoperative values in both sides (p < 0.015 and p < 0.005, convex and concave side, respectively). Our results show a significant reduction of the STT for both nasal sides as soon as 15 days after septoplasty in patients randomized to additional treatment. Our experience provides further evidence for the therapeutic effect of hyaluronic acid in accelerating nasal mucosa recovery after septoplasty.

The Prevalence of Tuberous/Constricted Breast Deformity in Population and in Breast Augmentation and Reduction Mammaplasty Patients

BACKGROUND

The exact prevalence of tuberous breast deformity (TBD) has not been properly investigated and still remains undetermined. We report our data about TBD prevalence with the aim of demonstrating its high prevalence.

MATERIALS AND METHODS

A retrospective analysis was performed on preoperative photographs of 1600 Caucasian female patients admitted to our department from January 2009 to July 2014 for augmentation or reduction mammaplasty and other breast clinical conditions. The main features of TBD included a contracted skin envelope, a reduction in breast parenchyma of the lower medial and lateral quadrants, a constricted breast base, abnormal elevation of the inframammary fold, herniation of the breast into the areola with a constricted breast base, and nipple areola complex herniation with a normal breast base. Patients were classified into three groups: breast augmentation group (AUG group), breast reduction group (RED group), and general population group (POP group).

RESULTS

Four hundred patients were analyzed for each group (AUG and RED group); 194 patients (48.5 %) and 189 cases (47.3 %), respectively, demonstrated at least one tuberous breast deformity; in 800 patients of the POP group, we found 221 patients (27.6 %) with at least one tuberous breast deformity.

CONCLUSIONS

Retrospective analysis reveals a high prevalence of TBD in the general population and in particular in women seeking breast augmentation or breast reduction (about 50 %). TBD is characterized by a wide range of clinical features with a spectrum of degrees. Preoperative evaluation is crucial to achieve an optimum outcome and patient satisfaction.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Autologous fat grafting in the treatment of fibrotic perioral changes in patients with systemic sclerosis

Autologous fat tissue grafting (AFTG) has been successfully used in the treatment of different sclerotic conditions, including localized scleroderma. Patients with advanced systemic sclerosis (SSc)-related perioral thickening and mouth opening limitation are candidates for this therapeutic approach. AFTG of the lips was performed to improve mouth opening in patients with SSc. We enrolled in the study 20 female patients with diffuse SSc (median age 35 ± 15 years and 11 ± 10 years of disease duration). Two-milliliter fractions of autologous fat drawn from trochanteric or periumbilical areas were injected in eight different sites around the mouth. Baseline and after-treatment mouth opening changes were assessed by measuring interincisal distance and oral perimeter, while skin hardness was tested by digital durometer. Pre- and posttreatment modifications of microvascular architecture were assessed by counting capillaries in the inferior lip videocapillaroscopy (VC) images and by scoring the microvascular density (MVD) in anti-CD34/CD31 immunohistochemical (IH) stained perioral skin biopsy sections. Similarly, histological sections were examined to evaluate dermoepidermic junction (DEJ) modifications. Three months after treatment, both the interincisal distance and oral perimeter significantly increased (p < 0.001). At the same time, a significant skin neovascularization became evident, both considering the VC images (p < 0.001) and MVD scores in IH sections (p < 0.0001). Finally, some skin histological aspects also improved, as shown by the significant changes in DEJ flattening scores (p < 0.0001). The present study suggests that, in patients with SSc, AFTG can improve mouth opening and function, induce a neovascularization, and partially restore the skin structure.

Upper lid blepharoplasty, eyebrow ptosis, and lateral hooding

BACKGROUND

Upper blepharoplasty is a common aesthetic surgical procedure. Different surgical techniques and markings have been described, some of which may incorporate browpexy or browlifting. Considering the upper periorbital area as an aesthetic unit, various techniques of browpexy and browlifting have been taken into consideration.

OBJECTIVES

The authors describe their technique for upper blepharoplasty, which includes an extended cutaneous excision that permits good correction of lateral hooding, reducing the need for browpexy or browlifting. Indications and surgical outcomes are also presented.

METHODS

The authors retrospectively reviewed the records of 552 consecutive patients who underwent upper blepharoplasty according to the authors' technique between January and December 2008. The patients received local anesthesia. Cutaneous excision extended beyond the eyelid to include the lower lateral portion of the eyebrow area.

RESULTS

Optimal functional correction was achieved in all cases, and the majority of patients were pleased with their aesthetic result. No significant complications occurred; 4 minor complications were noted and are described fully in the text.

CONCLUSIONS

The authors' modification of the usual technique of blepharoplasty results in excellent correction, both functional and aesthetic, of the periocular area, particularly the lateral portion. The technique is safe, and patient satisfaction is high.

LEVEL OF EVIDENCE

4.

Reconstruction of a full-thickness alar wound using an auricular conchal composite graft

Nasogastric intubation has become a frequently used method for alleviating gastrointestinal symptoms. Necrosis from alar pressure during prolonged nasogastric and nasotracheal intubation is common, and can result in considerable deformity if it is unrecognized. The reconstruction of full-thickness alar wounds often requires multiple challenging surgical procedures. Difficult full-thickness alar defects often require nasal mucosal replacement for lining, cartilage batten graft support for the preservation of nasal function, and skin coverage for the restoration of an aesthetically correct appearance. Free composite conchal grafting can offer a single-staged, one-step repair of difficult full-thickness alar wounds that are no larger than 1.5 cm in size. A thorough explanation of the graft design and execution is presented, as well as a case report and literature review. Free composite conchal grafting can produce aesthetic and functional results that rival the most sophisticated flap reconstructions of the lateral ala.

Tuberous breast: Morphological study and overview of a borderline entity

BACKGROUND

Tuberous breasts are widely known and described. Several surgical strategies have been proposed; however, few studies explain the origin or structural alterations of this deformity. No histological studies have been performed. The present article describes a morphological and histological study of breast tissue specimens.

METHODS

Mammary specimens of 22 female and five male patients with tuberous breasts were histologically analyzed and compared with six specimens harvested from normal female breasts and from three cases of true 'normal' gynecomastia.

RESULTS

A high prevalence of one histological subtype was observed, with the presence of collagen fibres among few fibroblasts. Histochemical analysis highlighted alterations of the arrangement and of the quantity of collagen involving breast structures.

CONCLUSIONS

Results of the present study suggest that collagen deposition alterations can better explain breast parenchyma modifications. Histological features of male subjects support this theory. Additionally, the observation of two cases in male homozygous twins suggests the role of genetic influences.

Phase 2 cross-over multicenter trial on the efficacy and safety of topical cyanoacrylates compared with topical silicone gel in the prevention of pathologic scars

BACKGROUND

Many clinical studies on scar therapy are reported in the literature, but only silicone gel sheeting and corticosteroid injections are supported by accurate prospective controlled studies. This prospective multicenter cross-over phase 2 study tested the effectiveness of a topical cyanoacrylate compared with silicone gel in improving postsurgical scars

METHODS

Patients presenting with symmetric breast scars after augmentation or reduction mammaplasty were enrolled in the study. From the same day as stitch removal, the cyanoacrylate was applied on one side every 3 to 5 days and the silicone gel on the other side twice a day for 3 months. Assessments of patients and external observers using a visual analog scale were recorded at scheduled visits during 1 year, and scars were photographed. Objective evaluations included measurements of scar width, length, and elevation. The statistical significance of objective parameter modifications was analyzed using the Wilcoxon test

RESULTS

Positive effects of both tested products were observed during the scar maturation process, and final scars of good quality were achieved without any major adverse effect. The topical cyanoacrylate proved to be more efficacious in preventing scar widening, and this result was statistically significant

CONCLUSIONS

The tested topical cyanoacrylate had a positive effect on the scar maturation process at least comparable with that of topical silicone gel.

Lower blepharoplasty with direct excision of skin excess: a five-year experience

BACKGROUND

Many patients present for aesthetic treatment of their lower eyelid region. Although traditional lower blepharopasty can successfully correct prominent lower eyelid bags, tissue excesses in the lower periorbital region (such as crepe-like skin and festoons) can cause distress for patients both aesthetically and physically, as they may cause discomfort. The skin that can be removed from this area (below the eyelashes) with a traditional incision is limited since tension on the lower eyelid must be avoided.

OBJECTIVE

The authors report the results of their five-year experience performing lower blepharoplasty with a direct skin excision in the lower periorbital region.

METHODS

Fifty-five patients were treated with the authors' method of blepharoplasty between Ferbruary 2004 and February 2009. After precise preoperative marking, each patient was placed under local anesthesia and the excess of tissue in the lower periorbital region was removed. When necessary, removal of fat bags was performed. When the tissue in excess was significant, this kind of direct incision allowed the removal of more skin than the traditional method, without tension on the lower eyelid.

RESULTS

No major complications-or even temporary scleral show-was observed in any of the patients in this series. In addition, no patients complained of any exaggerated visibility of postoperative scarring. The high rate of patient satisfaction with this procedure has led the authors to apply this type of incision with increasing frequency in their blepharoplasty patients.

CONCLUSIONS

The authors' direct incision technique for lower blepharoplasty, when selected with the appropriate indications, can provide a successful and safe alternative to traditional methods. Options for treatment of the lower lid are few since the area is a very challenging one to treat and the authors believe that this additional alternative will be helpful to both surgeons and patients alike.