Isabella C. Mazzola

Management of Tracheostomy Scar by Autologous Fat Transplantation: A Minimally Invasive New Approach

BackgroundTracheotomy is a life-saving operation but may have bothersome sequelae. Because the defect resulting from tracheostomy is often allowed to repair spontaneously by secondary intention, hypertrophic scar formation is a frequent consequence. Furthermore, skin-to-trachea adhesions may develop, creating a “tracheal tug,” that is, the skin movement in conjunction with the trachea, causing discomfort on swallowing. The aim of this study was to verify whether lipofilling could treat the aesthetic and functional disturbances by remodeling tracheostomy scars. MethodsTen patients, aged 20 to 51 years, with retracted and/or hypertrophic tracheostomy scar underwent fat injection under local anesthesia or sedation. Fat harvesting was by a 2-mm blunt cannula connected to a 10-mL syringe. Before inserting the refined fat with a 19-gauge cannula, the fibrotic bands of the retracted scar between skin and underlying tissue were released with a sharp needle. The procedure required 2 sessions with an interval of 6 to 12 months. In the first session, 3.0 to 10 mL of fat were inserted. A further 3 to 5 mL were delivered during the second course. In 3 cases, scar excision was performed under local anesthesia as a final procedure. ResultsAll 10 patients achieved an aesthetic and functional improvement and were satisfied with the result at long-term follow-up (mean, 21.3 months). ConclusionsFat grafting proved to be a safe, minimally invasive, and effective procedure for the treatment of the tracheostomy scar both for functional and aesthetic purposes. It can be considered as a valid alternative to major open surgery.

History of fat grafting: from ram fat to stem cells.

Fat injection empirically started 100 years ago to correct contour deformities mainly on the face and breast. The German surgeon Eugene Hollaender (1867-1932) proposed a cocktail of human and ram fat, to avoid reabsorption. Nowadays, fat injection has evolved, and it ranks among the most popular procedures, for it provides the physician with a range of aesthetic and reconstructive clinical applications with regenerative effects on the surrounding tissues. New research from all over the world has demonstrated the role of adipose-derived stem cells, present in the adipose tissue, in the repair of damaged or missing tissues.

Fat injections for the treatment of velopharyngeal insufficiency.

Abstract The aim of this article was to describe the technical details of a fat injection procedure for the treatment of mild to moderate velopharyngeal insufficiency (VPI). Before surgery, the velopharyngeal gap is assessed by means of flexible nasoendoscopy, and speech intelligibility, hypernasality, and nasal air escape are perceptually evaluated and scored by independent raters; nasal airflow during speech is objectively measured. The lipoaspirate is centrifuged at 1200g for 3 minutes to separate and remove blood, cell debris, and the oily layer. Patients are injected with 3.5 to 8 mL of fat in the posterior and lateral pharyngeal walls and soft palate under general anesthesia. The fat is placed within the superior constrictor muscle on the posterior pharyngeal wall to avoid injection behind the prevertebral fascia and possible intraoperative or postoperative fat displacement in a caudal direction. A 19-gauge malleable, blunt, single-hole cannula is used for fat grafting, and the operative field is exposed by means of a Digman mouth gag. Two Nelaton probes are inserted through the nostrils and retracted from the mouth under moderate tension to favor visualization of the nasopharynx. No donor-site or injection-site morbidity has been observed so far, and the 12 patients (aged 5–48 y) treated so far have not manifested snoring or nasal obstruction at any time after surgery. Improved voice resonance is audible soon after the operation, and no hyponasality can be detected. The patients are discharged the day after surgery. Subsequent fat grafting procedures can be performed to achieve further improvement. Correctly performed fat injections improve voice resonance and reduce nasal air escape in VPI, as demonstrated by nasoendoscopy, speech perceptual evaluation, and the objective measurement of nasal airflow and represent an alternative to velopharyngoplasty for mild to moderate VPI.

Facial clefts and facial dysplasia: revisiting the classification.

AbstractMost craniofacial malformations are identified by their appearance. The majority of the classification systems are mainly clinical or anatomical, not related to the different levels of development of the malformation, and underlying pathology is usually not taken into consideration. In 1976, Tessier first emphasized the relationship between soft tissues and the underlying bone stating that “a fissure of the soft tissue corresponds, as a general rule, with a cleft of the bony structure”. He introduced a cleft numbering system around the orbit from 0 to 14 depending on its relationship to the zero line (ie, the vertical midline cleft of the face). The classification, easy to understand, became widely accepted because the recording of the malformations was simple and communication between observers facilitated. It represented a great breakthrough in identifying craniofacial malformations, named clefts by him. In the present paper, the embryological-based classification of craniofacial malformations, proposed in 1983 and in 1990 by us, has been revisited. Its aim was to clarify some unanswered questions regarding apparently atypical or bizarre anomalies and to establish as much as possible the moment when this event occurred. In our opinion, this classification system may well integrate the one proposed by Tessier and tries at the same time to find a correlation between clinical observation and morphogenesis.Terminology is important. The overused term cleft should be reserved to true clefts only, developed from disturbances in the union of the embryonic facial processes, between the lateronasal and maxillary process (or oro–naso–ocular cleft); between the medionasal and maxillary process (or cleft of the lip); between the maxillary processes (or cleft of the palate); and between the maxillary and mandibular process (or macrostomia).For the other types of defects, derived from alteration of bone production centers, the word dysplasia should be used instead. Facial dysplasias have been ranged in a helix form and named after the site of the developmental arrest. Thus, an internasal, nasal, nasomaxillary, maxillary and malar dysplasia, depending on the involved area, have been identified.The classification may provide a useful guide in better understanding the morphogenesis of rare craniofacial malformations.

Congenital midline cervical cleft: Clinical approach to a congenital anterior neck defect

Numerous malformations can affect the anterior part of the neck presenting at birth as a real diagnostic challenge for the pediatrician or the primary care physician who initially evaluate the baby. Congenital midline cervical cleft represents a rare defect of the midline neck, which is sometimes wrongly diagnosed as a thyroglossal duct anomaly, dermoid cyst, branchial cleft anomaly or “birthmark”. A prompt clinical diagnosis and surgical treatment during early infancy are essential to ensure both functional and aesthetic outcome. We report a case of a female neonate with a midline cervical cleft diagnosed immediately after birth. The main features of other congenital anomalies of the anterior neck are also discussed referring to their embryologic origin.

The fascinating history of fat grafting.

The origin of fat grafting goes way back in 1893, when the German surgeon Gustav Neuber (1850Y1932) transplanted adipose tissue from the arm to the orbit to correct adherent, depressed scars sequelae of osteomyelitis. Soon after, another German, Victor Czerny (1842Y1916), excised a lipoma and grafted it into the breast to fill in the empty space after removal of nodules for fibrocystic mastitis. At the turn of the 19th century, correction of depressions, reestablishment of contour irregularities, and volume enhancement were mainly done through paraffin injection. Paraffin wax, discovered in 1830 by Baron Carl von Reichenbach (1788Y1869), a notable German chemist and a member of the prestigious Prussian Academy of Sciences, was the first injectable material ever used in modern times. J. Leonard Corning (1855Y1923), a New York City neurologist, the pioneer of spinal anesthesia, and the Viennese physician Robert Gersuny (1844Y1924) began to experiment with paraffin in the late 19th century apparently simultaneously and independently. Corning used paraffin to prevent reunion of nerves after subcutaneous neurotomy and to enhance the antalgic effect of cocaine on some nerves of the sensibility, whereas Gersuny used paraffin to solve featural imperfections, urinary incontinence, velopharyngeal incompetence, the Romberg disease, and the like. One of the most common indications was the correction of saddle nose secondary to cartilage reabsorption, a problem often encountered due to the spreading out of the syphilis, the 19th-century plague. Attempts to build up noses using internal prostheses or bone and cartilage grafts were numerous, but these techniques were complex, time-consuming, and often unsuccessful. Paraffin, in contrast, seemed the ideal solution. With a melting point between 46-C and 68-C (115-F and 154-F), paraffin could be introduced in the recipient site using a syringe without incisions either alone or, at different times, in combination with Vaseline alone or Vaseline with olive oil. Apparently, the material resulted inert, giving amazing results. However, disasters appeared soon. Paraffin penetrated within the tissues, which not only caused hard swellings that are difficult to remove, the so-called paraffinomas, but also migrated inducing pulmonary embolism, infections, and the like.

The use of pedicled and free flaps in laryngeal cancer recurrences: postoperative considerations and functional results.

The objective of the study was to compare the rate of complications and the functional outcomes following reconstructive surgery with pedicled and free flaps for recurrences after laryngeal cancer treatment. A retrospective analysis was conducted among the clinical records of the Department of Otolaryngology Head Neck Surgery of the University of Pavia from January 1995 to December 2004. Twenty-three patients were identified as having been reconstructed with pedicled or free flaps for hypopharyngeal recurrences after laryngeal cancer treatment. We observed a higher rate of postoperative complications after pedicled flaps (60%) than free flaps reconstructions (23%). The pedicled flaps group evidenced a longer hospitalization time (35 versus 14 days); a lower rate of patients with pedicled flaps (14% versus 69%) was able to resume a normal feeding 1 year after surgery; no patient achieved an esophageal voice, but the entire free flaps group reached an intelligible voice with the positioning of a voice prosthesis. The possibility to achieve such functional results in this kind of patient justifies the use of a surgical approach that generally requires a longer operation time than pedicled flaps, and the need for a surgical team with special skills in microsurgical techniques.

Regenerative Approach to Velopharyngeal Incompetence with Fat Grafting

Surgical management of velopharyngeal incompetence (VPI) aims at improving voice resonance and correcting nasal air escape by restoring a competent velopharyngeal sphincter. Assessment of VPI requires the examination of multiple variables. The dynamic study of movements of the velopharyngeal port during speech and the quantification of the closure gap, using flexible videonasoendoscopy and/or videofluoroscopy, is essential. Autologous fat injection represents a minimally invasive alternative to major surgery in the management of mild to moderate VPI that minimizes the risk of complications and sequelae, and can be performed without modifying the anatomy of the velopharyngeal port.

History of reconstructive rhinoplasty.

Amputation of the nose was practiced as a sign of humiliation to adulterers, thieves, and prisoners of war by certain ancient populations. To erase this disfigurement, numerous techniques were invented over the centuries. In India, where this injury was common, advancement cheek flaps were performed (around 600 BC). The forehead flap was introduced much later, probably around the 16th century. The Venetian adventurer Manuzzi, in writing a report about the Mughal Empire in the second half of the 17th century gave the description of the forehead rhinoplasty. Detailed information concerning the Indian forehead flap reached the Western world in 1794, thanks to a letter to the editor that appeared in the Gentlemans Magazine. From this episode, one can date the beginning of a widespread interest in rhinoplasty and in plastic surgery in general. In Europe, nasal reconstruction started in the 15th century in Sicily with the Brancas, initially with cheek flaps and then with arm flaps. At the beginning of the 16th century, rhinoplasty developed in Calabria (Southern Italy) with the Vianeos. In 1597, Gaspare Tagliacozzi, Professor of Surgery at Bologna, improved the arm flap technique and published a book entirely devoted to this art. He is considered the founder of plastic surgery.

History of Facial Rejuvenation

Humankind has always been concerned by death and old age, something unavoidable in life. As we get old, we lose our vitality, mental capacity, and beauty. It is no wonder that people seek and try to invent items and solutions that stop aging or reverse aging. The question is, exists somewhere the Fountain of Youth (Fig. 1), a myth for anything that potentially increases longevity and maintains beauty? Did anyone find it? The legend goes back to at least fifth century B.C., when Greek historian Herodotus wrote of such a fountain, which contains a special type of water in the land of the Macrobians, which gives the Macrobians their exceptional longevity. In the sixteenth century, the Spanish explorer Juan Ponce de Leon (1474–1521) and his crew were the first recorded Europeans to set in Florida. According to a popular anecdote, Ponce de Leon discovered Florida while searching for the Fountain of Youth, a magical water source capable of reversing the aging process and curing sickness.