Emanuele Cigna

RECONSTRUCTION OF A NATURAL-LOOKING UMBILICUS

Based on the assumption that the umbilicus is a wound that has healed by second intention, we describe a method of reconstruction. The procedure consists of complete resection of the umbilical scar and its reconstruction by a linear incision at the site of the new umbilicus and inversion of the skin hedges, which are sutured to the linea alba leaving a 1 cm space between the skin borders to cause secondary wound healing. This procedure provides a natural-looking umbilicus. It is easy and quick to do, and can be used for reconstruction after abdominoplasty, excision of a naevus, or when the umbilicus has been removed during a previous xiphopubic incision.

Metatypical basal cell carcinoma: a clinical review

BackgroundMetatypical cell carcinoma can be considered as a new entity of skin cancer, being an intermediate typology between basal cell carcinomas and squamous cell carcinomas. The behaviour of the metatypical cell carcinoma lies between these two varieties of skin cancer. It is difficult to perform a differential diagnosis based on morphological and clinical features – therefore it is only possible by accurate histology.MethodsThe authors have retrospectively analysed clinical records of 240 patients who were affected by metatypical skin cancer and who were treated by surgery, radiotherapy and chemotherapy.ResultsMTC affected more males than females (62.5% vs 37.5%) than males. The most affected site was the cervicofacial area, 71.7%; then the trunk, 10%; the limbs, 9.6%; the scalp 3.7%; and other regions 5%. A recurrence occurred in 24 cases (10%), mainly in head and neck area.ConclusionIn this manuscript, the authors have emphasised the importance of conducting a differential diagnosis, and the importance of the specific treatment for metatypical skin cancer, even though more clinical studies and long-term follow-ups are required before establishing specific guidelines.

Detection of melanoma cells in sentinel lymph nodes by reverse transcriptase-polymerase chain reaction: prognostic significance.

Background: Recently reverse transcriptase-polymerase chain reaction (RT-PCR) has been proposed as a new sensitive method for the detection of submicroscopic melanoma nodal metastases. Sentinel lymph node (SLN) status is considered the most important prognostic factor for melanoma patients. Thus, in recent years, melanoma research has been focused on identifying new molecular markers of micrometastases.Methods: In this study, 129 SLNs were collected and analyzed by RT-PCR for tyrosinase and melanoma inhibitory activity (MIA) messenger RNA (mRNA) expression. Results from PCR analysis were then compared with those obtained by hematoxylin and eosin and immunohistochemistry and related to progression of disease.Results: MIA gene expression was positive by RT-PCR in 27% of the tyrosinase-positive SLNs. When the correlation between tyrosinase and/or MIA mRNA expression and disease-free survival was evaluated by the Kaplan-Meier exact test, there was a statistically significant correlation between simultaneous tyrosinase and MIA gene expression in SLNs and progression of disease.Conclusions: RT-PCR analysis for both MIA and tyrosinase mRNA may identify a subset of melanoma patients with a worse prognosis whom the routine methods, such as histology and immunohistochemistry, fail to identify because of the poor sensitivity of these methods.

CD133 and ABCB5 as stem cell markers on sentinel lymph node from melanoma patients

In the last years the nature of initiating melanoma cells has been discussed and the melanoma stem cell theory has been proposed as and alternative and/or supplemental view of newborning melanoma cells. It has been described that melanoma cells derived from metastatic melanoma specimens as well as melanoma cell lines are able to grow in an embryonic stem cell-based media and these melanoma stem-like cells possess capacity of self-renewal and high tumorigenicity. In 2005 the first evidence of a stem-cell like population existence in human melanoma has been provided. CD133 or prominin-1 is one of most studied marker of staminality expressed by melanoma cells; specifically, the down regulation of CD133 leads to a reduced cell capacity to metastatize. Nevertheless, there is disagreement concerning the constant presence of CD133þ cells in primary and metastatic melanomas. ABCB5, the third member of the human P-gp family, is a rhodamine and doxorubicin efflux transporter, identified as a novel drug transporter involved in drugresistance in human malignant melanoma. ABCB5 was found to be specifically expressed on CD133þ tumor

Extracorporeal shock wave therapy for the management of burn scars

Background Hypertrophic and contracture scars are common problems after burn injuries and cause functional and cosmetic deformities. A wide variety of treatments has been advocated for postburn pathologic scars regression. Unfortunately, the reported efficacy has been variable. Objectives To investigate the use of extracorporeal shock wave therapy (ESWT), which mainly targets the fibroblasts in scar tissue, as an effective modality for scar treatment in burn patients. Materials and Methods An experimental study with ESWT was performed in 16 patients with postburn scars contractures, hypertrophic scars, or keloids twice a week for 6 weeks. Digital photographs were obtained and visual analogue scales were completed before and after treatment. Results Already after the first session, scars appeared more pliable, and color mismatch was less evident. At the end of the study period, all treated scars obtained a more acceptable appearance. Conclusions Extracorporeal shock wave therapy is a feasible and cost‐effective treatment in the management of postburn pathologic scars.

Deltopectoral flap revisited: Role of the extended flap in reconstruction of the head and neck

The extended deltopectoral flap is still the best choice in selected cases. During the period 1987-2004, 34 patients required reconstruction of the head and neck using this flap. Twenty-nine had had one or more failed attempts at microsurgical reconstruction after excision of cancer. Five were treated primarily. The flap was divided at least three weeks after the primary operation. All 34 survived, and there were no donor site complications. Twenty-seven patients had an uncomplicated outcome, but the remaining seven required later closure or skin grafting, usually under local anaesthesia, for complications. The extended deltopectoral flap has been used successfully to provide stable coverage of defects in the head and neck and should remain in the armamentarium of reconstructive microsurgeons.

Microsurgical teaching: Our experience

Today, microsurgery plays a fundamental role in plastic surgery, expanding surgical possibilities for cancer, trauma and aesthetic-related surgery. However, throughout the years, teaching and training systems for microsurgery have not evolved in the same manner as its operative techniques. The use of rats has been, and still is, the standard model for microsurgery training. However, stringent laws for animals used in experiments, combined with the rising costs of this model, have instigated the need to find alternative methods. To overcome this dilemma, we have developed a three-step approach to optimise microsurgery training, particularly when there is no access to animal laboratories.

Breastfeeding After Reduction Mammaplasty Using Different Techniques

BackgroundThis study reviewed mammary glandular function and breastfeeding after reduction mammaplasty performed via four different surgical techniques. Patients who underwent this procedure were asked to answer questions concerning the birth of a child, natural breastfeeding, and the reasons why natural breastfeeding was not performed or was interrupted.MethodsBetween 1992 and 2001, 368 reduction mammaplasties were performed in the Department of Plastic Surgery at the “La Sapienza” University of Rome. After reduction mammaplasty, 105 patients had a child and were enrolled in the study. Breastfeeding data were compared with data from hospital records at the time of surgery in terms of patient age, reduction mammaplasty technique, sensitivity of the nipple–areola complex after the operation, and proportion of the gland removed.ResultsMaternal breastfeeding was considered to have occurred if it lasted more than 3 weeks and was not accompanied by any nutritional supplements. Babies were breastfed by 60.7% of the patients who underwent a superior pedicle reduction mammaplasty, by 43.5% of those who underwent an inferior pedicle reduction mammaplasty, by 48% of those who underwent a medial pedicle reduction mammaplasty, and by 55.1% of those who underwent a lateral pedicle reduction mammaplasty.ConclusionsThe findings demonstrate that conservative reduction mammaplasty techniques supported by medical and paramedical staff permit subsequent breastfeeding. In particular, the best outcomes resulted from superior pedicle reduction mammaplasty. Skilled execution of the surgical technique is mandatory to guarantee adequate vascularization and sensitivity of the nipple–areola complex and to spare as many of the glandular ducts and lobules as possible.

Island lateral plantar artery perforator flap for reconstruction of weight-bearing plantar areas.

Reconstruction of the foot often presents difficulties, particularly in weight-bearing areas (WBA). The peculiarities of WBA tissues are rarely found in other regions of the body. The case examined, presents a 72-year-old diabetic patient, with lower-limb arteriopathy, and sensitive and motor neuropathy, with an ulcer in the weight-bearing area of the foot, close to the V metatarsal bone. The plantar defect was reconstructed by using an island V-Y 6cm×3cm flap, based on the lateral plantar artery perforators. The postoperative course was smooth and the flap survived completely. The lateral plantar artery perforator flap is minimally invasive and provides a valid alternative for the repair of glabrous plantar defects.

Fibronectin and laminin expression in sentinel lymph nodes of patients with malignant melanoma

SIR, Malignant melanoma (MM) has shown an alarming increase in incidence over the last few decades; currently it represents roughly 5% of skin cancers and 1% of all malignant tumours, with an annual increase in incidence and mortality of 2–3% during the last 30 years. Sentinel lymph node (SLN) biopsy has greatly improved the staging and prognostic evaluation of primary cutaneous MM; in particular, the Reverse Transcriptase–Polymerase Chain Reaction (RT-PCR), which is able to detect melanoma cells expressing tyrosinase mRNA, offers an additional technique to the histopathological examination. The remodelling of cell adhesion molecules during the process of tumour progression is known to play a key functional role in cancer progression and metastasis. To date, although there have been several attempts to identify molecular markers among cell adhesion molecules in melanoma lesions and in peripheral blood from patients with MM, few studies have focused on the involvement of cell adhesion molecules in SLNs of such patients. Fibronectin and laminin are two adhesion molecules that have been shown to be involved in melanoma progression even though their role in SLNs has been poorly investigated. Recently, our group investigated the molecular profile of SLNs, suggesting a role as prognostic indicators for survivin, tyrosinase, MIA and Mart-1 expression. In this study we investigated the role of fibronectin and laminin mRNA expression as prognostic indicators in SLNs of patients with MM and correlated the results to progression of disease in a median follow-up of 51Æ5 months. The presence of capsular naevus cells in SLNs was tested and the positive samples were excluded from the study. We analysed 72 SLNs from 48 patients (mean age 58Æ3 years) with MM; informed consent was obtained from each patient. There were 22, 20 and six patients with stage I, II and III disease, respectively. Sections of each lymph node were stained with haematoxylin and eosin, and immunohistochemistry was performed by using antibodies to HMB-45 antigen and S100 protein that were detected with the avidinbiotin-peroxidase technique. Negative controls were obtained by using normal animal serum instead of specific primary antibodies. The results are shown in Table 1. After surgical excision the SLNs were frozen in liquid nitrogen and stored at –80 C until use in the RT-PCR assay. One microgram of total RNA extracted from the frozen tissues was reverse transcribed in a final volume of 20 lL, then 5 lL of cDNA was amplified in PCR buffer containing 25 pmol each of upstream and downstream specific primers. All the recommended precautions were taken to avoid the possibility of false-positive results. Each RT-PCR experiment included a sample without RNA as negative control and RNA extracted from the SK-MEL 5 melanoma cell line as positive control. The amplification products were separated by electrophoresis on 2% agarose gel: those showing specific amplification products were considered positive. The suitability of all samples was investigated by an RT-PCR with b-actin-specific primers. Laminin expression was found to be positive in 45 of 72 and negative in 27 of 72 samples examined. Positive expression was associated with death or disease progression in 20 of 45 cases, whereas negativity was associated with disease progression in 16 of 27 cases; 11 of 27 remain disease free. Fibronectin gene expression was found in 61 of 72 specimens: positivity was associated with disease progression in 26 of 61 positive samples, while 35 of 61 were disease free. Eleven of 72 samples did not have fibronectin gene expression: negativity was associated with death or disease progression in 10 of 11 cases, whereas one of 11 is currently disease free. The features of patients and the results obtained by the RT-PCR assay are listed in Table 1. Agarose gel electrophoresis of RT-PCR products is shown in Figure 1. In order to verify the statistical significance of our results we first determined the correlation between overall survival, Clark level and fibronectin and laminin expression by the Kaplan– Meier method. We failed to find a statistically significant correlation for the expression of laminin (P = 0Æ57); in contrast, a significant correlation was found between the Clark level and overall survival (P = 0Æ0036) and between negativity for fibronectin and overall survival (P = 0Æ0024). The log-rank test showed a strong correlation between absence of fibronectin expression and Clark level (Spearman correlation P = 0Æ35). The Cox proportional hazards model was applied to the multivariate survival analysis and demonstrated that absence of fibronectin expression and Clark level are statistically significant negative prognostic factors (P = 0Æ012 and P = 0Æ030, respectively).