Giovanni Di Benedetto

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.

Forefoot reconstruction by reversed island flaps in diabetic patients.

Soft-tissue coverage of the foot is often difficult, especially when the distal third of the foot (dorsal or plantar aspects) is involved. The clinical situation can be further complicated when diabetic patients are affected by painful and unstable wounds of this kind because of the familiar phenomenon of vasculopathy. The purpose of this study was to evaluate the possibility of using distally based foot flaps to cover forefoot defects in diabetic patients. Preoperative selection of patients was the key to this study; those who had other major disease, chronic infection, bone involvement, and/or insufficient foot vascularization were excluded from the study. The authors report a series of 12 diabetic patients in whom the reconstruction of medium-sized defects (ranging from 1.5 × 2.0 cm to 3.0 × 7.0 cm) of the forefoot was performed using distally based dorsalis pedis flaps or medial plantar flaps. The transferred flaps survived and adapted well to the defects, except for one flap in a patient who had a slight venous insufficiency at outset. Wearing their own footwear, patients could walk after 20 to 30 days. After the follow-up period (3 months to 3 years), no skin breakdown in the treated areas was observed. Temporary donor-site pain was reported by medial plantar flap patients, and partial skin graft loss at the donor site occurred in some of the dorsalis pedis patients. The authors suggest that in selected cases, medium-sized soft-tissue defects involving the dorsal aspects or the weight-bearing areas of the diabetic foot can be successfully covered with distally based island flaps.

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical‐related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high‐risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWTs effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re‐operation and re‐hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero‐haematoma formation and on the re‐operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

Human skin-derived mesenchymal stem cells as a source of VEGF and nitric oxide

Researches on stem cells bring promise to functional skin repair. In particular, it has been recently suggested that mesenchymal stem cells (MSCs) could positively affect cutaneous wound healing through differentiation and paracrine action. The molecular mechanisms are not clear, even if there is increasing evidence for an important action of nitric oxide (NO), probably mediated by the regulation of the gene encoding for vascular endothelial growth factor (VEGF). The aim of our study was to investigate the immunohistochemical expression of VEGF and nitric oxide synthase (NOS) isoforms in human skin-derived MSCs, as well as the production of VEGF and NO, because these cells are less well characterized than bone marrow MSCs. MSCs were obtained from skin biopsies of healthy adult patients undergoing cosmetic plastic surgery, expanded and characterized for specific surface antigens. The cells were then evaluated for the immunohistochemical expression of VEGF, and NOS isoforms, as well as for VEGF and NO secretion in cell culture medium. Our immunohistochemical analysis showed that proliferating MSCs derived from human skin exhibit VEGF expression at cytoplasmic level as well as cytosolic and nuclear localization of all the three isoforms of NOS, even if with different patterns. In addition, our data evidenced the release of both VEGF and NO in cell culture supernatants. In conclusion, our results suggest that a therapeutic approach based on the human skin-derived MSCs may have a positive effect in wound healing conditions, through their ability to provide VEGF and NO to the damaged area.

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.)

Sebum Production Alteration after Botulinum Toxin Type A Injections for the Treatment of Forehead Rhytides: A Prospective Randomized Double-Blind Dose-Comparative Clinical Investigation

BACKGROUND Research has investigated the decrease in human skin sebum after the application of botulinum toxin. Few studies of the mechanism and objective assessments of this phenomenon have been conducted and the correlation between the sebum production and injection dosages or techniques remains unclear. OBJECTIVES We prospectively investigated the sebum regulation and its gradient around the injection site in patients who received intramuscular injections of botulinum toxin A (BTX-A) for forehead rhytides, comparing two injection doses. METHODS Forty-two female volunteers with rhytides on the forehead region were randomly assigned to receive 10 or 20 units of BTX-A, which was administered in five standard injection sites. The baseline and post-treatment sebum production was measured using a Sebumeter. RESULTS Treatment with BTX-A exhibited significant sebum alteration at the injection site of both groups, with a sebum gradient surrounding the injection point. The efficacy did not improve at higher injection doses, with the four-unit regimen generally not being more potent than the two-unit regimen. The sebum production recovered to normal levels at the 16 week follow-up for both treatment groups, indicating that a higher dosage (four units) did not result in a longer duration until relapse compared with the two-unit dose. CONCLUSIONS We determined that the sebum production has a positive correlation with the distance away from the injection point. Intramuscular injection of BTX-A significantly reduces sebum production at the injection site but increases the sebum production of the surrounding skin at a radius of 2.5 cm at the 2, 4, and 8 week follow-ups. LEVEL OF EVIDENCE 2 Therapeutic.

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 enhanced healing of a high-risk, clean, sutured surgical incision by prophylactic negative pressure wound therapy as delivered by prevena™ customizable™: Cosmetic and therapeutic results

According to the literature, incisional closure complications may range from postoperative surgical site infections, representing 17–22% of health care‐associated infections, surgical wound dehiscence and formation of haematomas or seromas, and can lead to delayed or impaired incision healing. These kinds of situations are more common when wounds are closed under tension or in specific patient morbidities. Obesity, in particular, is associated with an impaired blood flow to tissues, predisposing the patient to increased risk of wound complications by various mechanisms. Incisional complications can become relevant economic burdens for health care systems because of an increase in the average length of hospital stay and readmissions, and additional medical and surgical procedures. Thus, a preventive therapy may have a critical role in the management of healing. Negative pressure wound therapy (NPWT) technology as delivered by Prevena™ Customizable™ (Kinetic Concepts Inc., San Antonio, TX) has recently been the focus of a new investigation, as a prophylactic measure to prevent complications via immediate postoperative application in high‐risk, clean, closed surgical incisions. The authors present a 62‐year‐old class II obese female, who underwent bilateral inguinal dermolipectomy. Prophylactic NPWT as delivered by Prevena™ was performed successfully over surgical incisions. Cosmetic and therapeutic results are shown.