Aldo Bertani

WOUND MANAGEMENT WITH N-CARBOXYBUTYL CHITOSAN

In patients undergoing plastic surgery, donor sites were treated with soft pads of freeze-dried N-carboxybutyl chitosan to promote ordered tissue regeneration. Compared to control donor sites, better histoarchitectural order, better vascularization and the absence of inflammatory cells were observed at the dermal level, whilst fewer aspects of proliferation of the malpighian layer were reported at the epidermal level. Accordingly, N-carboxybutyl chitosan leads to formation of regularly organized cutaneous tissue and reduces anomalous healing.

Comparative study of breast implant rupture using mammography, sonography, and magnetic resonance imaging: correlation with surgical findings.

Abstract:  Purpose of this study was to evaluate the accuracy of mammography, ultrasonography, and magnetic resonance imaging (MRI), in the detection of breast implant rupture and to make a correlation with findings at explantation. The study population consisted of 63 women with 82 implants, undergoing surgical explantation. Implant rupture status was blindly determined obtaining diagnosis of rupture, possible rupture, or intact implant. Strictly predetermined rupture criteria were applied and compared with findings at surgery, which were considered the gold standard. False‐positives and false‐negatives were retrospectively evaluated to identify pitfalls in the investigation. All associations between imaging signs and surgical findings were evaluated by using chi‐square test. The respective sensitivity and specificity of investigations are reported. Our experience suggests that MRI is the more accurate method for identification of breast implant rupture, even if it should be performed following the diagnostic algorithm proposed.

Nerve regeneration through a combined autologous conduit (vein plus acellular muscle grafts)

The authors describe nerve regeneration obtained by using a combined autologous conduit, consisting of a vein plus acellular muscle grafts. The right sciatic nerve of seven Sprague Dawley rats was transected for a length of 2 cm and the gap was filled with 2 cm long femoral vein conduit in which two autologous acellular muscle grafts had been previously inserted. Clinical and electrophysiologic tests were carried out twelve weeks after the surgical procedure. The nerve was then removed and a morphological study, including histologic examination, immunohistochemistry and quantitative analysis, was performed. The left sciatic nerve was also removed and used as a control. Regeneration was observed in the middle and distal parts of the conduit in 5 rats. Nerve conduction velocity ranged between 0 and 14.9 ms(-1). In the distal part the nerves were enclosed by a perineurium thicker than their normal counterpart and in which groups of small axons were surrounded by thin myelin sheaths. Quantitative analysis showed that the operated nerve presented a wide variation of the area of the fascicle and the density of the fibres per area, while the diameter of the axons and myelinated fibres showed only small variation, independent of the size of the fascicle. In conclusion, by using this technique, the authors succeeded in obtaining regeneration of a well formed nerve fascicle.

Paraffin oil injection in the body: An obsolete and destructive procedure

Injection of foreign materials, such as paraffin oil, is an old and obsolete procedure. The authors describe previous uses for this procedure that had been used since the 19th century and the treatment of patients affected by such a disease.

Local rh-VEGF administration enhances skin flap survival more than other types of rh-VEGF administration: a clinical, morphological and immunohistochemical study.

Abstract:  The aim of the present study was to evaluate experimentally whether administration of recombinant (rh) vascular endothelial growth factor (VEGF) can protect skin flaps from necrosis and to study the optimum mode of rh‐VEGF administration. We used rats to study the effects of local or systemic administration of rh‐VEGF on skin flap during surgery; we also tested preoperative systemic administration of rh‐VEGF to assess whether it may prepare the tissue to respond to the hypoxic injury better than previously tested methods. The animals were 30 male Sprague‐Dawley rats. Group I rats received multiple systemic injections of rh‐VEGF in the tail artery prior to flap dissection. Group II rats were injected with rh‐VEGF in the clamped left epigastric artery during flap dissection; in this group, the left flaps thus received rh‐VEGF locally (via incubation for 10 min during hypoxia) and the right flaps systemically, after blood flow restoration. Group III received saline solution instead of VEGF in the same way as group II. Skin samples from the distal portion of the flaps were collected on day 7 for morphological and immunohistochemical analysis. The flaps exhibiting the least necrosis were those treated with local rh‐VEGF, followed by those treated with systemic rh‐VEGF. The flaps that received rh‐VEGF locally showed a strong VEGF expression on keratinocytes and endothelial cells, the greatest amount of mature and newly formed vessels and strong survivin expression in endothelial cells. Local rh‐VEGF administration should thus be considered as an effective therapeutic option to enhance the survival of a tissue at risk for perfusion.

Morphological study of the capsular organization around tissue expanders coated with N-carboxybutyl chitosan

Expanders coated with N-carboxybutyl chitosan were inserted into surgical wounds in the dorsal skin of rabbits and the formation of capsular tissue was studied by scanning electron microscopy and transmission electron microscopy. N-carboxybutyl chitosan, in the course of the capsular organization, favours and potentiates the correct proliferation and organization of the tissue, rather than sustaining reactive processes leading to scar formation. N-carboxybutyl chitosan stimulates physiologically the tissue repair process and favours angiogenesis, whilst depressing fibrogenesis to a certain extent. Applications are envisaged in the treatment of wounds and in plastic surgery.

Carcinoma of the Male Breast: An Underestimated Killer

&NA; Male breast carcinoma represents only 1 percent of all breast cancers. Despite the rarity of this neoplasia, the malignancy is often very aggressive, mostly because of delayed diagnosis. Consequently, large excisions are usually needed, and subsequent reconstruction is performed by means of fasciocutaneous or myocutaneous local or distant flaps, depending on the stage of the neoplasia. The signs, symptoms, prognosis, and reconstructive methods of such an unusual form of breast cancer are discussed in this article. (Plast. Reconstr. Surg. 102: 696, 1998.)

A simple and reliable method of nipple reconstruction using a spiral flap made of residual scar tissue.

Nipple reconstruction represents the final and probably the most important stage of breast reconstruction. Although several techniques have been proposed over the years to restore nipple integrity, the main problem remains the degree of shrinkage in nipple projection after reconstruction. The decrease in projection depends on the method used, even if it has been proved that every method has a degree of decrease that ranges from 50 to 70 percent. We propose a new, simple, and reliable method of nipple reconstruction in which the residual scar of mastectomy, and eventually a very small amount of healthy skin, is used in to reconstruct a neonipple. After making the preoperative measurements to center the nipple symmetrically to the opposite side, elevation of a laterally based flap is performed. The elevated skin is then twisted on its main axis, with its cutaneous part outside, and sutured in a spiral way. After that, a specific stent and dressing are applied to avoid, as much as possible, the shrinkage tendency of the neonipple. With this simple technique, we obtained fine results with a minimal residual scar. Description of the surgical technique is described in detail below.

The free latissimus dorsi flap revisited: a primary option for coverage of wide recurrent lumbosacral defects.

&NA; In comparison with other regions of the trunk, defects located in the lumbosacral region are infrequent. However, these particular lesions sometimes present difficulties in reconstruction, arising from the quality of the surrounding tissue and the width of the defects. In this area, the skin adheres strongly to subcutaneous tissue and is difficult to mobilize. Attempts to perform local or regional flaps for covering defects of this area often end in necrosis of the flaps, with subsequent risk of infection and unstable wounds. The consequence is larger defects and the need for a wide, tension‐free coverage, which can be performed after a wide debridement. The authors report on 10 patients presenting with wide, recurrent (and in some cases, infected) defects of the lumbosacral region, after already having undergone several reconstructive local or regional operations. In all cases, the authors harvested a free latissimus dorsi flap, lengthening the pedicle by means of an arteriovenous suralis loop connected to the thoracodorsal vessels (lumbar defect) or the femoral vessels (sacral defect). The procedure, already described in the past by others, has been revisited by the authors’ group and used as the technique of choice in selected cases, that is, in the presence of wide, recurrent, and infected lesions; radiation; and scarring injuries. The authors thus obtained stable coverage with well‐vascularized tissue and were able to save the patients any further operations. The authors suggest, therefore, that this procedure can be used in cases of wide and recurrent defects where other conventional procedures have failed. Advantages, disadvantages, and technical features of the method used are discussed in this article. (Plast. Reconstr. Surg. 109: 1960, 2002.)

An explosion in the mouth caused by a firework

Explosion and gunshot mouth injuries represent a challenging problem with regard to restoring optimal oral function. These wounds exhibit a spectrum of complexity and mostly include extensive soft tissue trauma complicated by burns, foreign bodies, fractures and concomitant traumas. To gain maximal restoration of oral function, the use of reconstructive techniques, together with microsurgical techniques, such as grafting of nerves, vessels and soft tissue, as an acute free flap to cover a large defect, are immediately necessary. We report the case of a young Caucasian patient who destroyed the middle and lower thirds of the face when a firecracker blasted in his mouth. His clinical history is unusual in terms of the modality of injury, i.e. a Russian roulette game, and the lesions suffered, in the reconstruction of which we used both surgical and microsurgical techniques.