Mirco Raffaini

A new nonenzymatic method and device to obtain a fat tissue derivative highly enriched in pericyte-like elements by mild mechanical forces from human lipoaspirates

Adipose tissue contains multipotent elements with phenotypic and gene expression profiles similar to human mesenchymal stem cells (hMSCs) and pericytes. The chance of clinical translation of the multilineage potential of these cells is delayed by the poor/negligible cell survival within cryopreserved lipoaspirates, the difficulty of ex vivo expansion, and the complexity of current Good Manufacturing Practice (cGMP) requirements for expanded cells. Hence, availability of a minimally manipulated, autologous, hMSC/pericyte-enriched fat product would have remarkable biomedical and clinical relevance. Here, we present an innovative system, named Lipogems, providing a nonexpanded, ready-to-use fat product. The system uses mild mechanical forces in a completely closed system, avoiding enzymes, additives, and other manipulations. Differently from unprocessed lipoaspirate, the nonexpanded Lipogems product encompasses a remarkably preserved vascular stroma with slit-like capillaries wedged between adipocytes and stromal stalks containing vascular channels with evident lumina. Immunohistochemistry revealed that Lipogems stromal vascular tissue included abundant cells with pericyte/hMSC identity. Flow cytometry analysis of nonexpanded, collagenase-treated Lipogems product showed that it was comprised with a significantly higher percentage of mature pericytes and hMSCs, and lower amount of hematopoietic elements, than enzymatically digested lipoaspirates. Differently from the lipoaspirate, the distinctive traits of freshly isolated Lipogems product were not altered by cryopreservation. Noteworthy, the features of fresh product were retained in the Lipogems product obtained from human cadavers, paving the way to an off-the-shelf strategy for reconstructive procedures and regenerative medicine. When placed in tissue culture medium, the Lipogems product yielded a highly homogeneous adipose tissue-derived hMSC population, exhibiting features of hMSCs isolated from other sources, including the classical commitment to osteogenic, chondrogenic, and adipogenic lineages. Moreover, the transcription of vasculogenic genes in Lipogems-derived adipose tissue hMSCs was enhanced at a significantly greater extent by a mixture of natural provasculogenic molecules, when compared to hMSCs isolated from enzymatically digested lipoaspirates.

The temporalis muscle flap in temporo-mandibular joint surgery

In the treatment of the severely damaged TMJ structural components (ankylosis, arthrosis, tumour, perforation or degeneration of the disc), it is advisable to insert a biological interposition between bony articular surfaces. The temporal muscle, due to its anatomical, topographical, and functional properties, can be successfully employed for this purpose. Based on the experience of Tessier, Delaire and Rowe, a temporalis muscle flap, inferiorly based, is rotated downwards and medially to the zygomatic arch, interposed and then fixed to condyle and capsule. Using this surgical technique, 12 patients and 13 temporo-mandibular joints were treated with good functional results and without any complication.

Clinical and cone-beam computed tomography evaluation of the three-dimensional increase in pharyngeal airway space following maxillo-mandibular rotation-advancement for Class II-correction in patients without sleep apnoea (OSA)

AIM The aim of this study was to evaluate three-dimensionally the changes that occur in the pharyngeal airway space (PAS) after maxillo-mandibular advancement surgery (MMA) and to investigate whether patients perceive these changes. MATERIAL AND METHODS A retrospective analysis of 10 patients who underwent MMA surgery for functional and aesthetic complaints was performed, pre and postoperative cone-beam computed tomography scans (CBCT) were obtained for each patient and the changes in the PAS were compared. At follow-up, we asked the patients to complete a questionnaire examining whether they noticed any improvements in their breathing function. RESULTS For all 10 cases, we found a statistically significant increase in the PAS. The average percentage of improvement was 34% in the PAS area, 112% in the PAS minimum axial area and 56% in the PAS volume. MMA results in significant postoperative PAS improvement, and each patient reported a positive perception of the PAS increase. CONCLUSION CBCT is a valid technique for upper airway evaluation. MMA orthognathic surgery results in significant three-dimensional improvement in the PAS, leading the patient to notice a subjective improvement in breathing function.

On the feasibility of intraoral maxillo-malar osteotomy

The maxillo-malar osteotomy is one of the osteotomies developed over the years to correct the deformities of the midface without modifying the nasal projection. After having for many years approached the osteotomy through the classic double access, intraoral and subciliary, we verified the feasibility of this osteotomy via an intraoral route only. For this purpose we modified slightly the classic osteotomy lines, however still including in the mobilized fragment the most prominent and therefore the most aesthetically important portion of the zygoma. At the lower orbital rim the medial osteotomy cut is performed with a fissure bur, the lateral one with an oscillating saw. Both the osteotomies are extended posteriorly in the orbital floor with a fine osteotome. Then, after having performed all other osteotomy cuts, the maxillo-malar complex is down-fractured. The residual thin bone structures which connect the maxillo-malar complex to the cranio-facial skeleton are broken during a careful downfracture, avoiding fracture between the maxilla and zygoma. The complex is advanced and stabilized with intermaxillary fixation, osteosynthesis and bone grafts. A bone graft to the orbital floor is unnecessary.

Full Facial Feminization Surgery: Patient Satisfaction Assessment Based on 180 Procedures Involving 33 Consecutive Patients.

Background: Gender dysphoria refers to the discomfort and distress that arise from a discrepancy between a person’s gender identity and sex assigned at birth. The treatment plan for gender dysphoria varies and can include psychotherapy, hormone treatment, and gender reassignment surgery, which is, in part, an irreversible change of sexual identity. Procedures for transformation to the female sex include facial feminization surgery, vaginoplasty, clitoroplasty, and breast augmentation. Facial feminization surgery can include forehead remodeling, rhinoplasty, mentoplasty, thyroid chondroplasty, and voice alteration procedures. Described here is an assessment of patient satisfaction after facial feminization surgery, including outcome measurements after forehead slippage and chin remodeling. Methods: Thirty-three patients between 19 and 40 years of age were referred for facial feminization surgery between January of 2003 and December of 2013, for a total of 180 procedures. Surgical outcome was analyzed both subjectively through questionnaires administered to patients and objectively by serial photographs. Results: Most facial feminization surgery procedures can be safely completed in 6 months, barring complications. All patients showed excellent cosmetic results and were satisfied with their procedures. Both frontal and profile views achieved a loss of masculine features. Conclusions: Patient satisfaction after facial feminization surgery is high. The reduction of gender dysphoria has psychological and social benefits and significantly affects patient outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Orthognathic surgery with or without autologous fat micrograft injection: Preliminary report on aesthetic outcomes and patient satisfaction

Orthognathic surgery leaves the intrinsic volume of the facial soft tissues untouched, sometimes resulting in unsatisfactory improvements in aesthetics. The aim of this study was to evaluate the aesthetic outcomes and patient satisfaction following bimaxillary orthognathic surgery with or without simultaneous facial lipofilling procedures. The preoperative and postoperative facial appearances of 210 patients were compared through analysis of photographs and postoperative clinical evaluation. A patient questionnaire was used to assess the perceived improvement in aesthetics. One hundred and twenty patients (mean age 20.3 years) underwent bimaxillary orthognathic surgery and simultaneous facial lipofilling procedures (group I). The remaining 90 patients (mean age 19.8 years) underwent skeletal procedures only (group II). The overall aesthetic improvement was similar in the two groups (group I 92.5%, group II 91.1%). Greater higher-level aesthetic improvement scores were recorded for group I (group I 80%, group II 55.6%). The overall patient satisfaction was 98.3% for group I and 97.8% for group II. Greater higher-level satisfaction scores were recorded for group I (group I 14.2%, group II 6.7%). The simultaneous use of the autologous fat micrograft is a promising technique that may improve the aesthetic outcomes of orthognathic surgery, leading to greater patient satisfaction.

Jaeger's jugal extended incision to approach the pterygomaxillary region

In oncological surgery of the pterygomaxillary fossa it is essential to achieve a wide access. For this purpose we have employed the old Jaegers incision extended posteriorly in association with access osteotomies (zygoma and coronoid). In our experience (9 cases) the jugal access has provided good results without noticeable cutaneous scars. The technique is described with the presentation of 2 cases.

Classification of tongue cancer resection and treatment algorithm

Reconstruction of tongue cancer defects is challenging due to the complex anatomy and physiology of the tongue. Here, we classify patterns of tongue tissue loss and describe a treatment algorithm for achieving good functional and oncologic outcomes.

The effect of a Le Fort I incision on nose and upper lip dynamics: Unraveling the mystery of the "Le Fort I lip".

INTRODUCTION Postoperative flattening of the upper lip with loss of lip pout and down turning of the corners of the mouth is often seen after Le Fort I surgery. We aim to determine which facial muscles are involved in this phenomenon to update the literature on this subject. METHODS In 6 cadavers, a unilateral Le Fort I incision was executed. After removal of the skin, all individual facial muscles were identified and submitted to bilateral tactile traction, comparing incised sides with non-incised sides. CONCLUSION All the components of the deep layer of the modiolus alae nasi (transverse part of the nasalis muscle and the myrtiformis muscle) and the deep layer of the midface musculature (levator anguli oris muscle) were transected by the Le Fort I incision. After performing the incision, the majority of the depressor septi nasi is intact. Further, the superficial layer of the midface musculature is intact but it loses tension because of its connection to the deep layer. This study suggests the importance of correctly suturing the deep muscular layers to maintain the 3-dimensional facial contour. Moreover, in this cadaver study, we attempt to predict the functional consequences on the impairment of facial mimics related to the Le Fort I incision.

Complex craniofacial advancement in paediatric patients: Piezoelectric and traditional technique evaluation

PURPOSE The piezoelectric device allows bone cutting without damaging the surrounding soft tissues. The purpose of this study was to assess the role of this surgical instrument in paediatric craniofacial surgery in terms of safety and surgical outcomes. METHODS Thirteen consecutive paediatric patients underwent craniofacial Le Fort osteotomies type III and IV. The saw was used on the right side in seven patients and on the left side in six patients; the piezoelectric instrument was used on the right side in six patients and on the left side in seven patients. Intraoperative blood loss, surgical procedure length, incision precision, postoperative haematoma and swelling, and nerve impairment were evaluated to compare the outcomes of both procedures. RESULTS A longer surgical procedure was observed in 28% of the patients when using the piezoelectric device (p = 0.032), with an intraoperative blood loss reduction of 18% (p = 0.156). Greater precision in bone cutting was reported, together with a reduction in the requirement to protect and incise adjacent soft tissues during piezoelectric osteotomies. There was a lower incidence of postoperative haematoma and swelling following piezo-osteotomy, and a significant reduction in postoperative nerve impairment (p = 0.002). CONCLUSIONS The ultrasonic surgical device guaranteed a clean bone cut, preserving the integrity of the adjacent soft tissues beneath the bone. Although the time required for a piezoelectric osteotomy was longer, the total operation time remained approximately the same. In conclusion, the devices lack of power appears to be a minor problem compared with the advantages, and an ultrasonic device could be considered a valuable instrument for paediatric craniofacial advancement.