Emanuele Cigna

Survivin, bcl-2, bax, and bcl-X Gene Expression in Sentinel Lymph Nodes From Melanoma Patients

PURPOSEnThe expression of apoptosis-related genes, such as survivin, bcl-2, bcl-X, and bax, has been evaluated by reverse transcriptase polymerase chain reaction (RT-PCR) and by immunohistochemistry in sentinel lymph nodes (SLNs) from melanoma patients and then correlated to the outcome of patients.nnnPATIENTS AND METHODSnThirty-six SLNs were examined. After RNA extraction, an RT-PCR followed by Southern blot hybridization was performed to detect survivin, bcl-2, bcl-X, and bax mRNA. bcl-2, survivin, and bax gene expression was evaluated, whenever possible, also by immunohistochemistry at the protein level.nnnRESULTSnWe found a significant correlation (P <.005) between survivin expression and outcome of patients; in fact, 61.5% of patients expressing survivin gene progressed or died because of the disease, whereas 38.5% are currently disease-free. Among patients negative for survivin expression, 100% are disease-free after a median follow-up time of 52.9 months. We did not find a significant correlation between bcl-2, bax, and bcl-X gene expression and outcome of patients. In fact, these genes were found equally expressed in patients with disease progression and in disease-free patients.nnnCONCLUSIONnOur findings show a variable expression of apoptosis-related genes in SLNs of melanoma patients; more interestingly, we found that survivin expression correlates to outcome of patients in a statistically significant way, whereas the expression of other genes, such as bcl-2, bax, and bcl-X, did not seem to correlate to progression of disease. We suggest that the detection of survivin gene expression by RT-PCR in SLNs may be a useful prognostic indicator.

Skin-Reduction Breast Reconstructions with Prepectoral Implant.

Summary: Skin-reduction mastectomy with prepectoral implant reconstruction is a novel technique for immediate breast reconstruction, with subcutaneous implant placement in patients eligible for skin-reducing mastectomy. Implants were placed above the pectoralis muscles in a compound pocket made by a dermal flap and acellular dermal matrix. The procedure was performed on 33 breasts in 27 selected patients. In three cases, there was skin ischemia; in one case, it healed spontaneously; and in two patients, a surgical necrosectomy and primary closure were needed. No implant loss occurred. This new technique proved to be a useful alternative, with good cosmetic results, in selected patients requiring mastectomy. These preliminary results need to be confirmed by long-term and comparative studies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Salvage of a free flap after late total thrombosis of the flap and revascularisation

We report a case of successful salvage of a free flap after a late total venous thrombosis. A free forearm flap was used to cover an exposed plate over the ankle. After a normal postoperative course, the patient suddenly developed a total venous thrombosis on day 11. Nevertheless the flap was salvaged completely. This event raises further questions about the revascularisation process, which is commonly thought to occur in 7–8 days.

Surgical Correction of Gynecomastia in Thin Patients

BackgroundGynecomastia refers to a benign enlargement of the male breast. This article describes the authors’ method of using power-assisted liposuction and gland removal through a subareolar incision for thin patients.MethodsPower-assisted liposuction is performed for removal of fatty breast tissue in the chest area to allow skin retraction. The subareolar incision is used to remove glandular tissue from a male subject considered to be within a normal weight range but who has bilateral grade 1 or 2 gynecomastia.ResultsGynecomastia correction was successfully performed for all the patients. The average volume of aspirated fat breast was 100–200xa0ml on each side. Each breast had 5–80xa0g of breast tissue removed. At the 3-month, 6-month, and 1-year follow-up assessments, all the treated patients were satisfied with their aesthetic results.ConclusionsLiposuction has the advantages of reducing the fat tissue where necessary to allow skin retraction and of reducing the traces left by surgery. The combination of surgical excision and power-assisted lipoplasty also is a valid choice for the treatment of thin patients.

Extracorporeal Shock Wave Therapy: An Emerging Treatment Modality for Retracting Scars of the Hands

Prolonged and abnormal scarring after trauma, burns and surgical procedures often results in a pathologic scar. We evaluated the efficacy of unfocused shock wave treatment, alone or in combination with manual therapy, on retracting scars on the hands. Scar appearance was assessed by means of the modified Vancouver Scar Scale; functional hand mobility was evaluated using a range-of-motion scale, whereas a visual analogue score was implemented for detecting any improvements in referred pain. Additionally, biopsy specimens were collected for clinico-pathologic correlation. For each active treatment group, statistically significant improvements in modified Vancouver Scar Scale were recorded as early as five treatment sessions and confirmed 2 wk after the last treatment session. Analogous results were observed when assessing pain and range of movement. Histopathological examination revealed significant increases in dermal fibroblasts in each active treatment group, as well as in neoangiogenetic response and type-I collagen concentration.

Therapeutic Management of Hypothenar Hammer Syndrome Causing Ulnar Nerve Entrapment

Introduction. The hypothenar hammer syndrome is a rare traumatic vascular disease of the hand. Method and Materials. We report the case of a 43-years-old man with a painful tumefaction of the left hypothenar region. The ulnar artery appeared thrombosed clinically and radiologically. The patient underwent surgery to resolve the ulnar nerve compression and revascularise the artery. Results. The symptoms disappeared immediately after surgery. The arterial flow was reestablished. Postoperatively on day 20, a new thrombosis of the ulnar artery occurred. Conclusion. Hypothenar hammer syndrome is caused by repetitive trauma to the heel of the hand. The alterations of the vessel due to its chronic inflammation caused an acute compression of the ulnar nerve at the Guyons canal and, in our case, do not allow a permanent revascularisation of the ulnar artery.

Vulvo-vaginal reconstruction after radical excision for treatment of vulvar cancer: Evaluation of feasibility and morbidity of different surgical techniques

BACKGROUNDnVulvar cancer is a rare disease accounting for approximately 5% of female genital tract tumors worldwide. Currently surgery represents the mainstay alone or sometimes, in combination with chemo-radiotherapy, for locally advanced tumors and recurrent disease. However, significant physical and sexual impairment mostly due to anatomical distortion of external genitalia are a consequence of radical surgical treatment. Postoperative reconstruction after demolitive surgeries improves aesthetic and functional results, guarantees an adequate coverage of large tumors and assures safe surgical margin. The present study aimed to analyze feasibility and complication rates of fascio-cutaneous flap after excision for vulvovaginal malignancies.nnnMETHODSnPubMed (MEDLINE), Web of Science, and CINAHL were searched for records of validated vulvovaginal reconstructive techniques after demolitive surgery for vulvar cancer. All cohorts were rated for quality using a scoring method taking into account the design of the study, the sample size and quality of report of surgical data and complications.nnnRESULTSnA total of 24 studies metxa0all eligibility criteria for this systematic review. All the studies were realized between 1996 and 2015. The overall sample size was 443 patients. Two major group of flap according to type of movement were identified: Advancement Flap (V-Y Gluteal Fold Flap; Medial Thigh Flap) and Transpositional Flap (Lotus Petal Flap; Gluteal Thigh Flap; Gluteal Fold Flap and Anterolateral Thigh Flap). The overall complications rates reported for advancement (26.7% among 165 patients on 11 series) and transposition flaps (22.3% among 278 patients on 13 series) were comparable.nnnCONCLUSIONSnA tailored procedure, based on patients characteristics, size and location of the defect is still the goal of a successful reconstructive surgery. Proper planning of the surgical procedures, knowledge of the different surgical options and technical skills are required in order to obtain reliable and satisfying results.

The Figure-of-Eight Suture Technique Used for Complicated Wound Closure

Frequently we have to deal with infected and traumatic wounds, and with dehiscence of previous sutures. Furthermore, some patients may be intolerant of materials commonly used for resorbable sutures. In these cases, the suture is prone to wound breakdown and dehiscence. As an alternative to the usual techniques using interrupted stitches (i.e., the Donati-Blair stitch) commonly applied for skin closure, we started to use the ‘‘figure-ofeight’’ stitch and experienced better results. This stitch has several advantages. First, it is removable. Second, it allows closure of two layers simultaneously. Third, because of its geometric structure, it does not cause excessive ischemia at the edge of the suture compared with the Donati-Blair stitch. In addition, this technique enables any length difference between the flaps to be evened up and sutured. If done properly, a thin, flat, linear wound is produced. Therefore, for round or elliptical defects, the figure-ofeight stitch makes it possible to reduce the two ‘‘dog ears’’ to a minimum because it is performed on two different planes, cutaneously and subcutaneously (Fig. 1). The ‘‘dog ears’’ complication may depend not only on the surgical excision, but also on the surgical suture technique. It is more common on a convex surface such as arms and legs.

Nipple-sparing bilateral prophylactic mastectomy and immediate reconstruction with TiLoop® Bra mesh in BRCA1/2 mutation carriers: A prospective study of long-term and patient reported outcomes using the BREAST-Q

BACKGROUNDnAlthough demand for prophylactic mastectomy is increasing over time among women at a high risk for breast cancer, there is a paucity of studies on long term patient-reported outcomes after this procedure.nnnMETHODSnBetween January 2011 and January 2015, 46 patients documented BRCA1/2 mutation carriers, eligible for prophylactic nipple-sparing mastectomy (NSM) and immediate breast prosthetic reconstruction were registered at our Institution. Patients underwent NSM and subcutaneous reconstruction with implant covered by a titanium-coated polypropylene mesh (TiLoop®). The BREAST-Q questionnaire was given to patients prior to surgery and at 1 and 2 years follow-up points. Capsular contracture was evaluated by Baker scale. Surgical outcomes along with the changes in BREAST-Q score were analyzed over time.nnnRESULTSnComplications were reported in only one case and after two years the capsular contracture rates were acceptable (grade I: 65,2%; grade II: 32,6%; grade III 2,2%). At one year and two year follow-ups patients reported high rates in the measures of overall satisfaction with breasts (72,5 and 73,7 respectively), psychosocial well-being (78,4 and 78,6), sexual well-being (58,8 and 59,4), physical well-being (77,6 and 80,6) and overall satisfaction with outcome (75,7 and 79,7). A statistically significant increase in all BREAST-domains from the preoperative to the postoperative period was reported at one and two years follow-ups (pu202f<u202f0,05).nnnCONCLUSIONnFollowing bilateral prophylactic NSM and immediate subcutaneous reconstruction with TiLoop®, patients demonstrated high levels of satisfaction and quality of life as measured by BREAST-Q. 2-years outcomes confirmed high patient comfort with increased scores from the preoperative baseline level.

Microsurgical anastomosis with the ‘PCA’ technique

BACKGROUNDnIn this study, we introduce a new microvascular anastomosis technique called PCA (Posterior wall first--Continuous interrupted--Airborne). The conventional microvascular anastomosis (CI), with single interrupted stitches, requires a long time to be completed, as each suture must be tied before starting the following stitch. Surgeons are often searching to reduce microsurgery time, particularly when there are multiple vessels to be anastomosed or when there is a prerequisite for the ischemia time to be quick.nnnMETHODSnThe authors conducted a comparative study of PCA and CI on 40 Wistar-albino rats. The femoral arteries and veins of each rat were used, resulting in a total of 160 vessels, with a diameter of 0.8 to 1mm. The rats were divided into two groups. Patency rates were compared between the two groups, using the chi-square test. The times required to perform the anastomosis were compared using the Students t test. A p value<0.001 was considered significant.nnnRESULTSnThe mean time required for microvascular anastomosis of the femoral arteries was 22 minutes (mins) and 46 seconds (secs) in the PCA group, and 28 mins and 50 secs in the CI group. The mean time required for microvascular anastomosis of veins was 19 mins and 20 secs in the PCA group, and 23 mins and 36 secs in the CI group.nnnCONCLUSIONnThe combination of the three different techniques (posterior wall first, continuous-interrupted, and airborne), used for the microvascular anastomosis, is safe, secure, and time-saving. The advantages of this combined method are the benefits of a single stitch, the increased speed of a continuous suture, and the reduced time of tying. The PCA technique may be helpful to selected clinical situations, due to a reduction in microsurgical time, as in such cases of multiple digital replantations, multiple in chain free flaps, vein grafts, and high metabolic free flaps, such as the intestine free microvascular transfer.