Marco Marcasciano

A Simple Device for Syringe-to-Syringe Transfer During Lipofilling

Since the end of the 19th century, autologous fat grafting has been performed often by plastic surgeons. The procedure evolved from work by Coleman, who developed the lipostructure technique.1 With the “Coleman technique,” fat tissue is extracted by nontraumatic liposuction, purified after centrifugation, and injected to fill tissues or to contribute cells to damaged tissues. Autologous fat grafting has many applications, including breast reconstruction, breast augmentation, facial rejuvenation, primary and secondary facial lipoatrophy, liposuction sequelae, buttock augmentation, scar revision, and radiodermatitis. Grafted fat is an ideal filler because it is biocompatible, versatile, stable, long lasting, and provides a natural appearance; however, the results are dependent on technique.2 Many surgeons have refined their techniques to obtain long-term survival of adipocytes and to improve cosmetic results. When large amounts of adipose tissue are needed, such as in breast reconstruction, performing syringe aspiration or connecting syringes of different volumes can be tedious and time-consuming. The estimated mean volume of …

Delaying implant-based mammary reconstruction after radiotherapy does not decrease capsular contracture: An in vitro study☆

We read with great interest the article entitled “Delaying Implant-Based Mammary Reconstruction After Radiotherapy Does Not Decrease Capsular Contracture: An In Vitro Study (J Plast Reconstr Aesthet Surg. 2017 June; pii: S1748-6815(17)30256-5). El-Diwany et al. have published a very interesting in-vitro study about fibrosis and capsular contracture after radiotherapy (RT). In this study they demonstrated with in vitro experiments that RT causes irreversible cellular changes which permanently alter the microenvironment in favour of fibrosis so that delaying breast reconstruction does not decrease the percentage of capsular contracture. This is a very remarkable study since it shows the effects of RT on cellular and biological level and how the modifications can facilitate capsular contracture. We previously published a manuscript to evaluate the interaction between RT and the breast implants’ biomaterials and we demonstrated that no variations occurred in term of mechanical characterization and microstructural

An Alternative Treatment Strategy for Complicated Chronic Wounds: Negative Pressure Therapy over Mesh Skin Graft

Extensive skin defect represents a real problem and major challenge in plastic and reconstructive surgery. On one hand, skin grafts offer a practical method to deal with skin defects despite their unsuitability for several complicated wounds. On the other hand, negative pressure wound therapy (NPWT), applied before skin grafting, promotes granulation tissue growth. The aim of the study is to evaluate the improvement in wound healing given by the merger of these two different approaches. We treated 23 patients for large wounds of multiple factors. Of these, 15 were treated with the application of V.A.C.® Therapy (KCI Medical S.r.l., Milan, Italy), in combination with skin grafts after a prior unsuccessful treatment of 4 weeks with mesh skin grafts and dressings. Another 8 were treated with only mesh skin graft. Pain reduction and wound area reduction were found statistically significant (p < 0.0009, p < 0.0001). Infection was resolved in almost all patients. According to our study, the use of the negative pressure wound therapy over mesh skin grafts is significantly effective especially in wounds resistant to conventional therapies, thereby improving the rate of skin graft take.

Surgical treatment of nasal non-melanoma skin cancer in elderly patients using dermal substitute.

Abstract Conclusions: The nose is often involved by non-melanoma skin cancer (NMSC) and the increase in the incidence of such tumors, the morbidity and treatment-related costs represent a significant burden to healthcare systems. A bioresorbable dermal substitute (Hyalomatrix®) has been used for immediate dermal coverage and nose restoration after excision of infiltrating nasal NMSCs in elderly ASA III patients. Further studies on dermal substitutes are needed to improve benefit to patients. Objective: Surgical treatment of nasal non-melanoma skin cancer (NMSC) in elderly patients. Materials and methods: Ten elderly ASA III patients with nasal defects after resection of infiltrating NMSC were reconstructed in a two-stage strategy. The surgical protocol targeted an initial wide tumor excision and apposition of a dermal induction template (Hyalomatrix®) and successive full thickness skin autograft. Results were documented by photography, visual analog scale for patient satisfaction, and Vancouver scar scale for evaluation of final graft characteristics. Results: All patients were tumor-free during the 2 years follow-up. The procedure achieved acceptable nose reshaping and graft scarring evolution. Patient satisfaction was good-to-high.

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

BACKGROUND Although 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. METHODS Between 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. RESULTS Complications 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 (p < 0,05). CONCLUSION Following 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.

Surgical Treatment with Locoregional Flap for the Nose

Nonmelanotic skin cancers (NMSCs) are the most frequent of all neoplasms and nasal pyramid represents the most common site for the presentation of such cutaneous malignancies, particularly in sun-exposed areas: ala, dorsum, and tip. Multiple options exist to restore functional and aesthetic integrity after skin loss for oncological reasons; nevertheless, the management of nasal defects can be often challenging and the best “reconstruction” is still to be found. In this study, we retrospectively reviewed a total of 310 patients who presented to our Department of Plastic and Reconstructive Surgery for postoncological nasal reconstruction between January 2011 and January 2016. Nasal region was classified into 3 groups according to the anatomical zones affected by the lesion: proximal, middle, and distal third. We included an additional fourth group for complex defects involving more than one subunit. Reconstruction with loco regional flaps was performed in all cases. Radical tumor control and a satisfactory aesthetic and functional result are the primary goals for the reconstructive surgeon. Despite tremendous technical enhancements in nasal reconstruction techniques, optimal results are usually obtained when “like is used to repair like.” Accurate evaluation of the patients clinical condition and local defect should be always considered in order to select the best surgical option.

RE: Prosthetic Breast Implant Rupture: Imaging—Pictorial Essay

AbstractCooperation between plastic surgeons and radiologists is fundamental when breast prosthesis rupture is suspected. We describe our experience managing the case of suspected implant rupture in a patient that underwent CT scan imaging for thoracic pain. Poor clinical information given to radiologists leads to wrong diagnosis: during surgery, both prostheses were checked revealing no signs of rupture. Full communication among different specialists involved in the multidisciplinary approach is always recommended, and an easy-to-use national breast implant register would allow a better management of patients’ follow-up and eventual preoperative planning. Level of evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Response to “Comments on ‘A Simple Device for Syringe-to-Syringe Transfer During Lipofilling’”

We thank you for allowing us to respond to the interesting comments by Dr Rauso1 regarding our article “A Simple Device for Syringe-to-Syringe Transfer During Lipofilling.”2 A number of techniques have been developed and tested to achieve the highest viability of adipocytes from lipoaspirate, and all authors agree about the need to perform the most “fat-friendly” and atraumatic procedures during manipulation and injection of the fat itself. Nevertheless, there is not level I evidence on the best harvesting and processing technique; the mechanism of fat-graft survival is not clear and multicenter trials and a database are needed to determine actual survival rates.3 After reviewing the literature, it is evident that there are many factors implicated in fat-graft survival, including harvesting technique, centrifugation, wash/treatments, …

Skin cancers and dermal substitutes: Is it safe? Review of the literature and presentation of a 2‐stage surgical protocol for the treatment of non‐melanoma skin cancers of the head in fragile patients

Non‐melanoma skin cancers (NMSC) represent the most common skin tumours of the head region. We describe the use of dermal substitute in a 2‐stage surgery protocol for selected fragile patients to remove NMSC of the head region. A review of the literature focusing on dermal substitutes’ safety after skin tumours excision is provided. A total of 45 fragile patients with NMSC in the head region were selected and scheduled for the 2‐stage surgical protocol. The first stage consisted of traditional surgical excision and immediate coverage with Hyalomatrix (Fidia Advanced Biopolymers, Abano Terme, Italy). After histology confirmed diagnosis and clearance of the margins, full‐thickness skin autografts were performed. All of the patients reached complete tumour excision and wound healing. No local recurrences were registered during 24 months follow up. The 2‐stage surgical therapeutic‐diagnostic‐reconstructive approach represents a less stressful and oncologically safe surgical protocol in selected fragile patients. When patients cannot tolerate invasive and long surgical procedures, general anaesthesia, and long hospitalisation, skin grafting following temporary skin substitute coverage can achieve oncological clearance and provide good functional and aesthetic results. The use of dermal substitutes represents a valid alternative surgical option in cases of ASA III, fragile patients non‐eligible for complex reconstructive surgery. To our knowledge, this is the first paper reviewing literature focusing on dermal substitutes’ applications and safety after skin tumour excision.

New application of purse string suture in skin cancer surgery

Closure of large wounds may require full‐thickness skin grafts, but their use is burdened by donor tissue availability and morbidity; the use of the purse string technique is an elegant way to overcome this problem. The study highlights the gain in terms of graft donor site morbidity and oncological radicality. The study included a group of 47 patients who underwent surgical excision for skin cancer and whose wounds were covered using a purse string suture and a skin graft. Radius of the defect left was measured after the lesions excision and after the purse string suture. Thereafter, the difference between the initial defect area and the area after purse string suture was calculated. Initial defects ranged from 3.85 to 61.5 cm2. After skin graft, the purse string suture ranged between 2.2 and 40 cm2 (mean area = 14 cm2). Gained area before the graft measured from 1.3 to 21.5 cm2 (mean gained area = 7.1 cm2). Average reduction was 33%. The technique allows a reduction of the size of the area to be grafted and the skin graft donor area, thus increasing the possibility of the feasibility of full‐thickness grafts. In addition, it allows an optimal observation both of the area of tumour excision and margins during follow‐up controls.