Gabriele Giunta

A new mucosal propeller flap (deep lingual artery axial propeller): the renaissance of lingual flaps.

Background: Lingual flaps provide ideal mucosal coverage for intraoral defects but traditionally require two surgical stages. The authors present an axial mucosal propeller flap for single-stage intraoral reconstruction. The flap includes the mucosa of the lateral side of the tongue, islanded on the deep lingual vessels. Methods: Between 2011 and 2013, 23 patients underwent intraoral mucosal reconstruction with a deep lingual artery axial propeller flap after cancer resection in the cheek (n = 16), floor of the mouth (n = 2), retromolar trigone (n = 2), hard palate (n = 2), and soft palate (n = 1). Mean defect size was 19.5 cm2. Preoperative and postoperative intraoral function was evaluated with the Functional Intraoral Glasgow Scale. Results: The authors always achieved one-stage reconstruction with primary donor-site closure. The only complications were an infection treated conservatively and a late oronasal fistula caused by radiotherapy. All patients resumed an oral diet after 1 week and none required surgical revision. Mean 12-month postoperative Functional Intraoral Glasgow Scale score was better than the preoperative score (13.5 versus 12.8). Conclusions: The deep lingual artery axial propeller flap combines the advantages of the traditional lingual flap (i.e., reliable axial vascularization and like-with-like reconstruction) with those of a propeller flap (i.e., one-stage transfer of like tissue and extreme mobility) and has wider indications than a conventional lingual flap. The technique is fast and has low morbidity and good functional results, and the authors recommend it as a first-choice technique to reconstruct moderate to large intraoral defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Male breast cancer: Modified radical mastectomy or breast conservation surgery? A case report and review of the literature

Introduction Male breast cancer (MBC) is a rare disease that accounts for <1% of breast cancer cases. The most common treatment is modified radical mastectomy (MRM). Recently, breast conservative surgery (BCS) is getting popular for MBC treatment. We report a case and reviewed the literature to investigate whether emerging BCS can be considered as an alternative of a more radical surgery. Presentation of case A 46 y.o. patient, presented with a painless left breast lump over a period of six months. The patient underwent a quadrantectomy at another institution. Pathology revealed an intraductal carcinoma in close proximity to the margins of excision. Adjuvant hormonal therapy was proposed to the patient, who refused and was referred to our Institution. We performed a MRM and a sentinel lymph node biopsy (SLNB). A contralateral breast liposuction and an adenectomy were also performed. The patient underwent also a nipple-areolar complex reconstruction. The patient didn’t receive adjuvant therapy. Discussion Both oncological safety and satisfactory cosmetic outcomes are the goals of MBC treatment. No specific guidelines for MBC treatment have been proposed. MRM is currently the surgical gold standard of MBC (approximately 70% of all cases). Some authors reported that male BCS associated with radiation therapy is a feasible alternative MRM. Taking into account data from the literature and considering the previous surgery, in the case we report, we offered a MRM, SLNB and a contralateral breast symmetrization. Conclusion MRM with SLNB and reconstruction of male breast asymmetry should be still considered as the treatment of choice of MBC.

Identification and Expansion of Adipose Stem Cells with Enhanced Bone Regeneration Properties

Introduction: Adipose tissue represents an abundant source of mesenchymal stem-like cells. Adipose-derived stem cell progeny have been investigated and used in regenerative medicine for decades. In the last few years, they have been used to “enrich” lipoaspirates in fat grafting techniques, in an attempt to boost the regenerative potential of adipose tissue when used as autologous “filler”. Materials and Methods: 50 adipose tissue samples from lipoaspirates and subcutaneous breast tissue biopsies were used to generate adipose floating spheroid cell (ASphC) lines. ASphC were characterized for the expression of putative mesenchymal stem cell markers and used in vitro to test their multilineage potential. Furthermore, ASphCs were seeded on dermal regeneration template (Integra®) and implanted into the T8 vertebral laminectomy site of immunocompromised mice. Results: Here, we show that the majority of ASphCs are in a quiescent state and express the putative surface stem cell marker CD271. Unlike CD271- cells, CD271+ ASphCs grew indefinitely in vitro as undifferentiated spheres in serum-free medium, maintaining their multilineage differentiation potential ability. Importantly, p107, a functional adipose stem cell marker, is strictly expressed in ASphCs and barely present in their differentiated mesenchymal lineages. These sphere cells display an enhanced ability in vitro to differentiate into distinctive end-stage cell types, such as osteoblasts, chondrocytes and adipocytes. Gene expression profiling analysis indicated that ASphCs are endowed with stem cell potential that is gradually lost during specific differentiation. Finally, ASphCs facilitate bone inter body repair and regeneration after laminectomy. Conclusions: We conclude that ASphCs possess a pronounced in vivo activity to regenerate the bone injury. Overall, ASphCs represent a heterogeneous population of stem-like cells harbouring multilineage differential potential and representing a prospective promising tool in cell therapy and tissue engineering.

Freestyle-Like V-Y Flaps of the Eyebrow: A New Outlook and Indication of an Historical Technique

The eyebrow region is of utmost importance for facial movement, symmetry, and the overall cosmetic appearance of the face. Trauma or tumor resection often leave scars that may dislocate the eyebrow producing an alteration both in static symmetry of the face and in the dynamic expressivity. The authors present a technique for eyebrows defects repair using the remaining eyebrow advancement by means of a “freestyle-like” V-Y flap. In the past two years a total of eight consecutive patients underwent excision of skin lesions in the superciliary region and immediate reconstruction with this technique. On histology, six patients were affected from basal cell carcinomas, one from squamous cell carcinoma, and one from congenital intradermal melanocytic nevus. The pedicle of the flap included perforators from the supratrochlear, supraorbital, or superficial temporalis artery. Advancement of the entire aesthetic subunit that includes the eyebrow using a V-Y perforator flap was performed successfully in all cases achieving full, tension-free closure of defects up to 3.0 cm. “Freestyle-like” V-Y flaps should be considered as a first-line choice for partial defects of the eyebrow. The greater mobility compared to random subcutaneous flaps allows to reconstruct large defects providing an excellent cosmetic result.

Adipose-derived stem cells: true or false? A different point of view.

In the past decade, isolation of multipotent cells from adipose tissue, termed adipose-derived stem cells (ASCs) or mesenchymal stromal cells (MSCs), has triggered an increasing interest for application in tissue engineering. 1 This type of stem cells has shown the ability to differentiate toward different mesenchymal cell lineages, such as osteogenic, chondrogenic, and adipogenic as well as other cell types, including myocytes, and nerve cells. Unlike MSCs harvested from bone marrow, ASCs are abundant and easy to harvest, with no morbidity to the donor site, and because of their osteogenic properties, they have been used in craniofacial surgery animal models for calvarial defect reconstruction. When referring to these cells, however, the term stem cell has broadly applied to a specific cell population, harvested through liposuction of healthy donors and displaying specific properties, such as adherence to plastic, fibroblastlike morphology, and the ability to differentiate toward selected mesenchymal cell lineages. As described, however, such cells share few characteristics with stem cells from other tissues. The work of our department during the last decade has shown that stem cells from different organs grow under different culturing conditions (in suspension), in serum-free conditions, and display a phenotype characterized by round cells that do not adhere to plastic supports and aggregate in clusters termed spheroids (multiclonal) and spheres (monoclonal). Recently, our group is studying a cell fraction extracted from the adipose tissue that resembles stem cells present in other tissues, reopening the debate on the proper nomenclature of ASCs. Upon isolation of these cells, we noted that they clearly displayed a different phenotype from that of the traditional ASCs commonly used in tissue engineering. This stem cell fraction could, indeed, represent an upstream stage of the traditional ASCs before they enter an early differentiation pathway and adhere to plastic solid supports. Certainly, the manipulation of lipoaspirate and culture conditions in which the stem cells grow plays a pivotal role in the maintenance of the undifferentiated stage of the cells in suspension. We hope, with our future studies, to put an end to the scientific diatribe on whether true stem cells are present in the adipose tissue. Our preliminary data suggest that the fibroblastlike adherent stromal cells, considered as stem cells until now, may be downstream precursors of the true stem cells present in the adipose tissue. Indirectly, the presence of such downstream precursors and the presence of upstream spherelike cells represent indirect proof of the existence of true stem cells in the adipose tissue. Should these cells prove to be upstream progenitors of the traditional ASCs, their ability to grow in suspension as spheres (and not as a monolayer) could provide new directions for tridimensional tissue engineering, whereas their growth in serum-free cultures could overcome the important limitations of autologous, allogenic, and xenograft serum necessary for the growth of the adherent ASCs. This could represent an initial step toward clinical translation and routine application of such cells. Furthermore, their use in serum-free conditions may find an indication in the immunomodulation of vascularized composite allografts, providing advantages over the currently used infusion of MSCs harvested from bone marrow. The characterization and assessment of the biologic behavior, the differentiation properties (multipotency versus pluripotency), and the immunomodulatory properties of this cell niche, in comparison with other stem cell types, are currently under investigation in our laboratory.