Matteo Torresetti

Microsurgical reconstruction after bisphosphonate-related osteonecrosis of the jaw: our experience with fibula free flap.

BackgroundBisphosphonate-related osteonecrosis of the jaws (BRONJ) is the most serious complication of bisphosphonates therapy. Despite that several treatment modalities have been described, aggressive surgical treatment approach with wide bone resection and vascularized microsurgical reconstruction are controversial. The aim of this study was to evaluate the clinical outcome of 8 new cases of BRONJ treated with radical resection and mandibular reconstruction with fibula free flap, to enforce the evidence about the reliability of this treatment option. MethodsRetrospective data of 8 patients with BRONJ who underwent segmental mandibulectomy and reconstruction with osteocutaneous fibula free flap from January 2004 to January 2008 were collected, including 6 patients with stage 3 BRONJ and 2 patients with recalcitrant stage 2 BRONJ. ResultsAll patients were white, with a mean age of 64.7 years (range, 53–77 y), and 62.5% were women. All bisphosphonates were administered intravenously, and all patients had mandibular localization. The mean period of follow-up was 28.9 months. No flap loss or minor complications and no BRONJ recurrence were observed. All patients were able to ambulate pain-free. ConclusionsDespite initial concerns regarding reliability of the mandibular free-flap reconstruction after BRONJ, this method seems to be a safe and feasible option in cancer patients with reasonable life expectancy, with complete BRONJ resolution and life quality improvement. Our findings confirm data previously published by other authors, without complication and with a much longer median follow-up time.

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.

Bipaddle radial forearm flap for head and neck reconstruction.

BackgroundAlthough the radial forearm free flap has become a workhorse flap in head and neck reconstruction, the skin grafting of the donor is the main drawback resulting in an unacceptable contour deformity and an unsightly appearance. Several technical modifications have been therefore applied to the radial forearm (RF) flap marking, elevation, and inset to overcome this major shortcoming. In this article, we report our clinical series with the bipaddle RF flap. MethodsThe authors described their 11 cases of head and neck oncologic reconstruction with the bipaddle RF flap. The skin island is designed longer and narrower and split into 2 separate skin paddles each nourished by a proximal and a distal independent perforators raising from the radial artery so that the donor site could be closed directly. The narrow design of the skin paddle and the subsequent splitting in its 2 components applying the “perforator-pedicle propeller flap method” allow for the changing of the flap shape according to the shape of the recipient site defect. ResultsFrom 2007 to 2013, the bipaddle RF flap method was used in 11 patients to restore head and neck defects following cancer ablation. The mean age of the patients was 43 years, ranging from 31 to 50 years. The location of the defects was the tongue (n = 7) and the intraoral region (n = 4). The defect sizes varied from 4 × 5 cm to 5 × 6 cm, and the flap maximum width was 3 cm with mean area of 26.4 cm2. The healing was uneventful in all patients with excellent cosmetic and functional results of both donor site and recipient site after 20 months of mean follow-up. ConclusionsThe bipaddle RF free flap is a reliable and versatile option for the reconstruction of a wide range of soft tissue defects of head and neck region. This method allows for a customized resurfacing of the defect because of its large variability in shape and size. The harvesting site is closed primarily, and a second donor site for skin graft is avoided.Clinical Question, Level of Evidence: Therapeutic, IV

MSCs and inflammation: new insights into the potential association between ALCL and breast implants

Possible association between anaplastic large cell lymphoma (ALCL) and breast implants has been suggested. In this context, formation of the periprosthetic capsule has been reported as a cause of inflammation, which plays a key role in tumor onset. Tumors take advantage of inflammation to influence and interfere with the host immune response by secreting multiple factors, and their onset and survival is in turn affected by the paracrine effects from mesenchymal stem cells (MSCs). In this study, we tried to clarify how inflammation can modify the immunobiology and the exerted paracrine effect of MSCs. MSCs derived from both inflamed (I-MSCs) and control (C-MSCs) tissues were isolated and co-cultured with an ALCL cell line. Proliferation rate and the expression of selected cytokines were tested. I-MSCs secrete higher levels of cytokine related to chronic inflammation than C-MSCs. After co-cultures with KI-JK cells, C- and I-MSCs show the same variation in the cytokine expression, with an increase of IL2, IL4, IL5, IL10, IL13, TNF-α, TGF-β, and G-CSF. Proliferation of ALCL cells was not influenced by co-cultures. Our results state that (i) inflamed microenvironment affects the immunobiology of MSCs modifying the profile of the expressed cytokines, and (ii) the paracrine effects exerted by MSCs on ALCL cells are not influenced by inflammation. Moreover, it seems that ALCL cells are able to manipulate MSCs’ immunoregulatory properties to evade the host immune control. Nevertheless, this ability is not associated with inflammation and the question about BIA-ALCL is not proved by our experiments.

Preliminary Outcomes of Distal IMAP and SEAP Flaps for the Treatment of Unstable Keloids Subject to Recurrent Inflammation and Infections in the Lower Sternal and Upper Abdominal Areas.

BACKGROUND We present the clinical application of the sixth internal mammary artery perforator (IMAP) and superior epigastric artery perforator (SEAP) flaps for the treatment of defects resulting from the excision of large lower sternal and upper abdominal keloids. Perforator selection and flap design were based solely on preoperative multidetector-row computed tomographic angiography (MDCTA) of the areas adjacent to the soft tissue defects. METHODS Between January 2009 and June 2014, 15 patients with large, unstable keloids subject to recurrent inflammation and infections and with a history of multiple failed treatments underwent surgical excision and early postoperative radiation therapy. The defects were located in the upper abdomen (n = 6) or lower sternum (n = 9). All patients underwent preoperative MDCTA for perforator localization. RESULTS A total of 15 patients underwent keloid removal followed by IMAP (n = 10) and SEAP (n = 6) flap coverage combined with early postoperative low-dose radiation therapy (350 cGy/5 fractions/5 days or 400 cGy/4 fractions/4 days). Flap sizes ranged from 9 × 5 to 17 × 6 cm. Only one IMAP flap developed a 2 × 2 cm tip necrosis, which was managed with dressing changes. The remaining flaps healed uneventfully with no keloid recurrence at 23.4 months. In all cases, the perforator location determined by preoperative MDCTA was precisely consistent with the intraoperative findings. CONCLUSION The sixth IMAP and SEAP flaps combined with early postoperative radiation therapy provided a valid and feasible approach for the surgical treatment of large keloids in the lower sternal and upper abdominal. MDCTA enabled detailed preoperative assessment of the perforators, facilitating both flap design and dissection, and saving operating time. Although longer follow-up is required, these preliminary results are encouraging.

A peculiar case of large primary cutaneous Ewing’s sarcoma of the foot: Case report and review of the literature

Highlights • Primary cutaneous Ewing sarcoma of the foot are rare and usually small tumors.• The present case is the largest primary cutaneous Ewing sarcoma of the foot.• We treated this tumor with surgery alone.• These tumors should be considered into differential diagnosis of superficial lesions.

A Simple Method to Inset and Position Polyurethane-Covered Breast Implants

AbstractBackground Polyurethane-covered breast implants have been used increasingly for cosmetic and revision breast surgery. The incision for insertion should be of minimal length and the placement of these implants in the pocket can be more difficult than that of conventional implants because of the highly adherent textured surface of the polyurethane external layer that grasps the surrounding tissues. The use of a sterile plastic insertion sleeve that is open on both sides is suggested by the manufacturer to overcome the friction between the polyurethane implant and the skin and surrounding tissues.MethodsA new method to facilitate polyurethane implant insertion and adjustment in all cases of primary breast augmentation and revision surgery is presented. After the implant, which is in the sleeve, is located in the pocket, the plastic sleeve is filled with saline and antibiotics so the solution lubricates the surface around the implant. The sleeve is then twisted so that the solution is squeezed inside the pocket while the sleeve itself is pulled back and removed.ResultsBetween 2010 and 2013, this method was used in 73 cases of primary augmentation and revision breast surgery without any complications.ConclusionThe method described here allows for easier removal of the plastic sleeve during polyurethane implant insertion without any complications or evidence of implant migration or rotation at follow-up.Level of Evidence IVThis journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Aesthetic Refinement of the Dog Ear Correction: The 90° Incision Technique and Review of the Literature

The closure of any circular or asymmetric wound results in puckering or excess of tissue known as dog ears. Tissue dynamics, wound geometry, surface contour, and surgical technique affect dog ear formation [1,2]. Despite good preoperative planning for skin management techniques including Burows triangle, V-Y advancement flap, M-plasty [3], and S-plasty [4], and despite following intraoperative procedures including proper undermining of a shallow wound, proper 90° angle of the scalpel blade, precise suture placement, and removal of excess underlying fat, sometimes a dog ear occurs anyhow. Methods for correcting dog ears include excision of the excess tissue in the shape of a triangle, crescent or ellipse; excision of conical folds of tissue at the end of the wound in the same direction as the long axis of the original wound; and excision of the dog ear at a 120° angle to the long axis of the existing excision line in a shape resembling a hockey stick [5]. They are extensively described in the literature, but they all lead to wound extension. Only M-plasty allows for reduction in the scars length but produces a double-tailed scar, so if the total length with the two tails is considered, the new scar is still longer than the original one. We have developed a new and easy technique for dog ear correction without extending the length of the original wound.

Topical use of α‐tocopherol acetate in delayed wound healing

Dear Editors, Vitamin E, first described in 1922 by Evans and Bishop as an essential micronutrient for reproduction in rats (1), is a fat-soluble vitamin with important functions of maintaining the integrity of the intracellular membrane by protecting its physical stability and providing defence against any tissue damage caused by oxidation (2). Molecular and cellular effects of vitamin E have been explained by regulating membranes and proteins activities by specific reactive oxygen species (ROS) and nitrous oxide systems (NOS) or by interacting and regulating specific enzymes and transcription factors and influencing cellular structures such as membranes and lipid domains (3). Vitamin E is present in plants in eight different molecular forms with more or less equal antioxidant potential, nevertheless, in higher organisms only α-tocopherol (α-T) is preferentially retained suggesting a specific mechanism for the uptake for this analogue (4). As the natural vitamin E analogue is relatively unstable, several stabilised vitamin E derivatives [e.g. α-tocopherol acetate (α-TA)] have been synthesised for usage in supplements and cosmetics. These vitamin E derivatives are water-soluble esters of α-T that can be considered to be provitamins that are converted to their natural forms by epidermal esterases (5). A common phenomenon in patients with disorders in wound healing is the acute phase response resulting in elevated levels of inflammatory markers. An imbalance between proand antioxidants is suggested to favour cell damage and to enhance inflammatory process (6). The antioxidant capacity of α-TA and its effect on reprogramming of gene expression allow its topical use in skin diseases in which an inflammatory process is activated. Furthermore, it has been demonstrated that epidermal esterases remove the acetic acid from α-TA that may act against microorganisms simply by lowering the pH and creating an anhydrous environment unsuitable for their growth and multiplication (7). In the last 3 years, we have used α-TA for treatment of superficial burns, post-traumatic superficial ulcers and skin graft donor sites, even in presence of wound infection. The presence of exudate, pain and delayed reepithelialisation, absence of tissue necrosis and/or sepsis were criteria for topical use of α-TA, avoiding conventional treatments such as local antibiotics, polyurethane foams and other occlusive dressings (8). Bacterial growth was assessed in 35 patients; wound tissue cultures were obtained, 20 (57⋅1%) of 35 patients had positive results for bacterial cultures: all of them had a single organism infection. The isolated organisms cultured from the wound tissue were Staphylococcus aureus (N = 6, 17⋅1%), Staphylococcus epidermidis (N = 6, 17⋅1%), Pseudomonas aeruginosa (N = 4, 11⋅4%), Proteus mirabilis (N = 2, 5⋅71%) and Escherichia coli (N = 2, 5⋅71%). Three of the six S. aureus isolated were multiple antibiotic resistant microorganisms. A

Surgical Management of Pressure Ulcers

The occurrence of pressure ulcers has an important influence on the patient’s quality of life [1].