Davide Forcellini

Autologous fat graft in scar treatment.

Introduction Regenerative medicine is an emerging and rapidly evolving field of research and therapy, thanks to new discoveries on stem cells. Adipose tissue is a connective tissue which contains a reserve of mesenchymal stem cells. Clinical improvements in trophic characteristics of teguments after autologous fat graft are well described in literature. In this paper, we present our observation after 6 years of autologous fat graft experience in scar remodeling. Materials and Methods All patients recruited had retractile and painful scars compromising the normal daily activity/mobility of the joint involved. We performed surgical procedure with Coleman technique. In 20 patients, we performed a clinical assessment using Patient and Observer Scar Assessment Scale (POSAS) and Durometer measurements. Results In all treated scars, a qualitative improvement was shown both from an aesthetic and functional point of view. Most importantly, reduction or complete resolution of pain and increases in scar elasticity were objectively assessable in all cases. In patients studied using Durometer and POSAS score, areas treated with autologous fat graft showed statistically significant reduction in hardness measurements in comparison with areas infiltrated with saline solution. POSAS scores showed a statistically significant reduction of a great deal of POSAS parameters as a result of an improvement of both clinical evaluation and patient perception. Conclusions Injection of processed autologous fat seems to be a promising and effective therapeutic approach for scars with different origin such as burns and other trauma scars, and post-surgery and radiotherapy outcomes. In general, we can affirm that treated areas regain characteristics similar to normal skin, which are clinically objectivable, leading not only to aesthetic but also functional results.

Matching Biological Mesh and Negative Pressure Wound Therapy in Reconstructing an Open Abdomen Defect

Reconstruction of open abdominal defects is a clinical problem which general and plastic surgeons have to address in cooperation. We report the case of a 66-year-old man who presented an abdominal dehiscence after multiple laparotomies for a sigmoid-rectal adenocarcinoma that infiltrated into the abdominal wall, subsequently complicated by peritonitis and enteric fistula. A cutaneous dehiscence and an incontinent abdominal wall resulted after the last surgery. The abdominal wall was reconstructed using a biological porcine cross-linked mesh Permacol (Covidien Inc., Norwalk, CT). Negative Pressure Wound Therapy (NPWT), instead, was used on the mesh in order to reduce wound dimensions, promote granulation tissue formation, and obtain secondary closure of cutaneous dehiscence which was finally achieved with a split-thickness skin graft. Biological mesh behaved like a scaffold for the granulation tissue that was stimulated by the negative pressure. The biological mesh was rapidly integrated in the abdominal wall restoring abdominal wall continence, while the small dehiscence, still present in the central area, was subsequently covered with a split-thickness skin graft. The combination of these different procedures led us to solve this complicated case obtaining complete wound closure after less than 2 months.

Breast Fistula Repair after Autologous Fat Graft: A Case Report

We report the case of a 55-year-old female patient who attended our clinic for the presence of a scar retraction in the upper pole of the left breast as a complication of breast augmentation. In the scar area, we observed an orifice that probing revealed to be a fistula. The patient was referred to surgical intervention under general anesthesia to obtain scar contracture release using autologous fat graft; one month after autologous fat injection, following healing of the fistula, the patient underwent a second surgical procedure to replace the left breast implant. Unexpectedly, two weeks after the surgical procedure, complete healing of the breast fistula within the scar area was observed; this observation was confirmed during the second surgical step for left breast implant repositioning, when we observed the absence of the fistula orifice in the breast implant cavity. Upon clinical examination at 1-year followup, tissue integrity was preserved. The patients satisfaction was excellent. We have observed a possible additional effect of fat graft.

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 con-chal grafting can produce aesthetic and functional results that rival the most sophisticated flap reconstructions of the lateral ala.

Periareolar Approach in Oncoplastic Breast Conservative Surgery

Breast cancer represents the most frequent cancer in female population. Nowadays breast conservative surgery (BCS) is an accepted option for breast malignancies, and its indications has been extended thanks to the advent of oncoplastic surgery, reducing both mastectomy and re‐excision rate, avoiding at the same time breast deformities. From January 2008 to November 2011, 84 women underwent BCS with periareolar approach for oncoplastic volume replacement. We divided patients into four groups analyzing breast size and resection volume (Group 1: small‐moderate sized breast with resection <20%; Group 2: small‐moderate sized breast with resection >20%; Group 3: big sized breast with resection <20%; Group 4: big sized breast with resection >20%). We evaluated patients’ satisfaction regarding final esthetic outcome using the specific module “Satisfaction with outcome” of the Breast‐Q questionnaire 1 year after surgery. The mean age was 52.1 years, and the mean follow‐up was 11.2 months. During the follow‐up, 12 patients have been lost. We obtained high satisfaction mean value with Breast‐Q questionnaire in each group: 75.8 in group 1, 63.4 in group 2, 81.1 in group 3, 69.7 in group 4. Periareolar approach as oncoplastic volume replacement technique is useful in correction of breast deformity after BCS: it is a versatile technique that can be easily adapted for any breast tumor location and for wide glandular resection.

Gynecomastia and Tuberous Breast: Assessment and Surgical Approach

We read with great interest the article published by Cannistra et al. [1] about gynecomastia with severe ptosis and its treatment. We would like to point out that some forms of gynecomastia do not match properly the existing classifications [2–4]. Tuberous breast deformity can be associated with gynecomastia, with the same features as the corresponding condition in females. We suggest considering this a separate entity in male patients and we propose a specific surgical procedure. From January 2005 to January 2008 we treated six patients with gynecomastia and tuberous breasts using our technique. We combined traditional liposuction by the tumescent technique, standard maneuvers to reduce skin and gland excess, and gland redraping. About 50 ml of saline solution and 10 ml mepivacaine 2% with epinephrine 1:100,000 was injected via a 2-mm incision in the inferoexternal quadrant. Liposuction using a 2-mm blunt cannula was performed beneath the entire mammary region. A concentric circle entirely around the areola was deepithelized. A semicircular, infra-areolar incision of the dermis was made, leaving a superior dermal pedicle to the nipple-areola complex. A cone-shaped mass of breast tissue beneath the areola was resected. As with female tuberous breasts, the constricted base was released with electrocautery and radial incisions of the residual breast fibrous tissue beneath the areola were made. After hemostasis, a suction drain was placed laterally. An intradermal purse-string peripheral suture allowed areolar repositioning. Compressive elastic dressing was used to prevent seroma or hematoma. Elastic garments were kept on for 2 weeks postoperatively. At 1-year follow-up the cosmetic appearance was excellent in all patients (Fig. 1). Appropriate diagnosis is essential for treatment. Our studies on tuberous breasts in female patients suggest that

Metabolic Implications of Surgical Fat Removal: Increase of Adiponectin Plasma Levels After Reduction Mammaplasty and Abdominoplasty.

AbstractRecent studies tried to identify new indicators of risk in the development of insulin resistance, cardiovascular disease, and metabolic syndrome; recently, breast size has been proposed as a new measure of risk for type 2 diabetes mellitus in women. To understand the role of breast adipose tissue and subcutaneous adipose tissue in lipidic and glucose metabolism, we decided to evaluate the variation on levels of adiponectin in plasma and other well-known metabolic markers before and after surgical fat reduction.We formed 2 groups: breast reduction group (M−) and abdominoplasty group (ADD). For all patients enrolled in the study, we recorded anthropometric measurements 1 hour before surgery (that we considered as time zero). At time zero, we always performed a blood sample to observe the assay of glucose, total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, CRP, TNF-&agr;, IL-1, IL-6, and adiponectin. The dosage of the above parameters was repeated 40 days after the surgical intervention with the aim of assessing whether they showed a statistically significant change after surgery.Adiponectin levels increased significantly in both groups of patients after surgery: in patients undergoing reduction mammaplasty and abdominoplasty, the mean increase was equal to 1.68 (P = 0.007) and 4.28 (P = 0.019), respectively. The variation in increase was not statistically different between the 2 groups (P = 0.254).Moreover, in the M− group, we observed that HDL levels increased and glycemia decreased significantly.Our study shows that reduction mammaplasty is a surgical procedure associated with a significant improvement in adiponectin level, HDL cholesterol level, and a significant decrease in glycemia level.The effective correlation between the role of breast adipose tissue and appearance of disease is still to be determined.

Outcomes of immediate tissue expander breast reconstruction followed by reconstruction of choice in the setting of postmastectomy radiation therapy.

A common sequence for performing staged tissue expander breast reconstruction is to immediately insert a tissue expander, complete expansion before radiotherapy, and then perform the definitive reconstruction after radiotherapy is complete. This study evaluates the outcomes of this treatment regimen in 237 patients over a 10-year period at Northwestern Memorial Hospital. Overall, 62% of the patients successfully completed tissue expander/ implant reconstruction, 22.3% experienced major complications leading to explantations or conversions to flap, and 13.5% completed tissue expander/ elective autologous reconstruction. Of the patientswho underwent second-stage tissue expander to implant exchange, 87.5% successfully completed reconstruction without experiencing complications leading to explantation or conversion to autologous reconstruction. Thus, this study indicates that immediate tissue expander followed by reconstruction of choice breast reconstruction in the setting of postmastectomy radiation therapy can be successfully performed in most of the patients.

Innovations in the Treatment of Male Chest Deformity After Weight Loss: The Authors' Technique

Gynecomastia may result in psychological problems because the presence of a “feminized” chest changes the male body contour, altering the masculine ideal of virility. Currently, surgical techniques described for the correction of gynecomastia are for some patients associated with aesthetically unacceptable scars, sometimes less tolerated than the chest deformity itself. The case of a 20-year-old man who underwent the authors’ male chest body-contouring technique with minimal visible scars is described.

Treatment outcomes for keloid scar management in the pediatric burn population.

We read with attention the article entitled ‘‘Treatment outcomes for keloid scar management in the paediatric burn population’’ written by Patel et al. (Burns 2012; 38(5):767–71) [1]. In this article the Authors made a comparison between keloid scars treated with excision and skin grafting and keloid treated with steroid and surgery. Data demonstrate that steroid and surgery do not decrease the numbers of recurrence compared with excision and grafting. We noticed in this interesting article that the authors do not mention autologous fat graft as alternative in after burn keloid treatment and we would like to add our topics about keloid remodeling and treatment by lipostructure. Autologous fat grafting, as described by Coleman, found new applications and is now extending to unexpected fields, including regenerative surgery and related research opening up many avenues in aesthetic and reconstructive surgery. A large literature has demonstrated that this tissue contains an extracellular matrix (e.g., collagens, laminin, fibronectin, growth factors) and cellular components (adipocytes and many other factors). It has clearly documented the presence of adipose-derived stem cells and many types of growth factors in the adipose derived stromal vascular fraction which is the principal responsible of the regenerative effect on the hyperplasic tissue with the consequent remodelling of the scar. We were among the first to experience and treat with autologous fat graft a large number of patients affected by hypertrophic scars and burn keloids [2–6]. Adipose tissue creates an important angiogenic effect because of the non vascularised graft. The graft promote an ipossic environment and the consequent angiostimulation on the receiving site as co-factor in eutrophism of the keloid and wound healing beyond promoting the survival of the graft. Following these considerations, we have started a case– control study in which we treated patients with keloid and hypertrophic scars using autologous fat graft and the results obtained show a considerable improvement of skin texture, elasticity, thickness, and clinical reduction of pain in treated areas. We started our experience in this technique treating hypertrophic scars and keloid; we extended the application of autologous fat graft on patient affected by ulcer and scleroderma and recently we applied this kind of graft in the treatment of post mastectomy pain syndrome and Arnold’s syndrome with optimal results. Our results suggest that lipofilling can improve scar quality and change the possibilities on keloid treatment. We speculate that this improvement depends on tissue regeneration promoted by adipose tissue-derived stem cells. In particular in hypertrophic scars, histologic examination shows patterns of new collagen deposition, local hypervascularity, and dermal hyperplasia in the context of new tissue, with high correspondence to the original. The satisfactory results along with the not too invasive approach are the essential requisites for routine clinical applications on keloid scar even in pediatric burn population.