Nefer Fallico

Extracorporeal shock wave therapy for the management of burn scars

Background Hypertrophic and contracture scars are common problems after burn injuries and cause functional and cosmetic deformities. A wide variety of treatments has been advocated for postburn pathologic scars regression. Unfortunately, the reported efficacy has been variable. Objectives To investigate the use of extracorporeal shock wave therapy (ESWT), which mainly targets the fibroblasts in scar tissue, as an effective modality for scar treatment in burn patients. Materials and Methods An experimental study with ESWT was performed in 16 patients with postburn scars contractures, hypertrophic scars, or keloids twice a week for 6 weeks. Digital photographs were obtained and visual analogue scales were completed before and after treatment. Results Already after the first session, scars appeared more pliable, and color mismatch was less evident. At the end of the study period, all treated scars obtained a more acceptable appearance. Conclusions Extracorporeal shock wave therapy is a feasible and cost‐effective treatment in the management of postburn pathologic scars.

Botulinum Toxin for Glabellar Lines

Facial rhytides represent a widespread aesthetic concern. In particular, glabellar lines are perceived as a sign of aging and may give an erroneous impression of negative emotions. The onset of glabellar lines is closely related to the movements of the underlying muscles. Botulinum toxins inhibit the release of acetylcholine into the synaptic cleft and therefore result in temporary muscle paralysis. The observation that botulinum toxin (BTX) smoothed facial lines when used therapeutically led researchers to study the toxin effect on glabellar lines. Nowadays, the use of BTX to smooth glabellar frown lines represents the leading procedure in aesthetic facial treatments and an increasing number of BTX formulations are becoming available.This article provides a comparative evaluation of currently available BTX options for the treatment of glabellar lines. Toxins have been divided into three groups, based on whether they have obtained approval for cosmetic use (approved treatments) or not (off-label treatments), or whether they are still under investigation (experimental treatments). We examine the basic similarities and differences between available botulinum toxins, and summarize the pharmacokinetics and dosing.All approved treatments consist of BTX type A (BTX-A) and differ in their molecular weight, as some formulations are made of a BTX-A complex of 900 kDa while the latest option on the market is a 150 kDa BTX-A that is free from complexing proteins. As for the dosage, the important aspect that emerges from this comparison is that even within a given serotype, such as BTX-A, formulations are not interchangeable as each possesses distinctive characteristics that are attributed to the unique toxin purification and manufacturing processes.There is a substantial body of published evidence on the use of these approved treatments for facial enhancement, proving efficacy and safety. We investigate the methods of evaluation used for each toxin and review the safety and efficacy data reported in the literature. Minor adverse effects, such as headache, blepharoptosis, and injection-site reactions, are relatively frequent but transient, whilst major adverse effects are rare.Some botulinum toxins, i.e. BTX type B, that are approved for therapeutic applications are used off-label for cosmetic indications, thus without the approval of the health regulatory committees and without sufficient published evidence on safety and efficacy. As for experimental treatments, a number of BTX products are currently in development or have been recently launched for aesthetic applications. These products have been specifically designed to overcome some of the limitations present in the older generation of products. However, some of these toxins may be easily purchased via the Internet, without having any license or approval for cosmetic or therapeutic indications; these products must be considered unsafe and are potentially a severe health risk for patients.

The treatment of composite defect of bone and soft tissues with a combined latissimus dorsi and serratus anterior and RIB free flap

Composite defects of bone and soft tissues represent a reconstructive challenge. Several techniques have been described in the medical literature; however, extensive composite defects should be reconstructed with microvascular free tissue transfer. The purpose of this report is to present the use of a composite latissimus dorsi and serratus anterior and rib free flap (LD‐SA/rib) as an alternative procedure in patients who cannot undergo more commonly used vascularized bone‐containing free flap reconstruction.

Free fibular flap with periosteal excess for mandibular reconstruction

In microvascular transfer of fibular osteocutaneous flap for mandible reconstruction after cancer ablation, good bone union is necessary to allow timely radiation therapy after surgery. As the area of bone contact between fibula and the original mandible at the edge of the mandibular defect is small, a periosteal excess at both ends of the fibula covering the bone junction can be used to increase the chance of bone union. The purpose of this study is to investigate whether a periosteal excess surrounding both ends of the fibula flap can provide better blood supply and, therefore, ensure bone union and wound healing at 6 weeks after surgery and before radiation therapy initiation.

Transverse Upper Gracilis Flap with Implant In Postmastectomy Breast Reconstruction: a Case Report

Autologous flaps can be used in combination with prosthesis in postmastectomy breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the preferred choice among autologous tissue transfer techniques. However, in patients with a peculiar figure (moderately large breasts and large thighs with flat stomach), who cannot use their abdominal tissue, the transverse upper gracilis (TUG) flap with implant is investigated as a further option for breast reconstruction. This report presents a patient who underwent the TUG flap plus implant reconstruction. A bilateral skin‐sparing mastectomy was performed removing 340 g for each breast. The volume of the TUG flaps was 225 g (left) and 250 g (right). Preoperative volumes were restored by placing under the TUG muscle a round textured implant. No complications occurred during the postoperative period both in the recipient and donor site and the outcomes of the procedure were good. In cases where the use of the DIEP flap is not possible because of past laparotomies or inadequate abdominal volume, the TUG flap plus implant may be considered as a valid alternative.

Evidence-Based Evaluation Technique to Assess Augmentation Mammaplasty Results: A Simple Method to Objectively Analyze Mammary Symmetry and Position

BACKGROUND Despite the great variety of mammaplasty techniques, outcome assessment remains a challenging issue. OBJECTIVES The authors devised an objective method to evaluate mammary symmetry based on statistical analysis of objective manual breast measurements and validated the method by applying it to results of a randomized controlled trial on the correction of breast asymmetry. METHODS Sixty consecutive patients with hypoplastic breasts and small-volume asymmetry were enrolled in the study and randomly assigned to 1 of 2 groups. One group received a fixed-volume implant in 1 breast and an adjustable-volume implant in the other. The other group received 2 fixed-volume implants of different sizes. The differences in specific breast and chest measurements, obtained before surgery and during follow-up, were analyzed statistically with the Wilcoxon signed rank test. RESULTS Correction of the asymmetry resulted in the reduction of the differences between left and right values for each specific breast measurement. Placement of an adjustable implant on 1 side yielded better symmetry than placement of 2 fixed-volume prostheses of different sizes. Patient and physician satisfaction was high for both groups. CONCLUSIONS This objective analysis of clinical parameters enables comparing results for different patients in large clinical trials and for the same patient at different follow-up periods. LEVEL OF EVIDENCE 3.

Latissimus dorsi-rib pedicle flap for mandibular reconstruction as a salvage procedure for failed free fibula flap.

BackgroundMandibular reconstruction is usually performed by using free vascular flaps. However, there are instances in which it must be carried out with pedicle flaps. Insofar, the main option recommended is the pectoralis major (PM) + rib pedicle flap. MethodsA 45-year-old patient affected by a primitive mandibular tumor presented after an unsuccessful reconstruction with free fibula flaps. He refused a PM + rib pedicle reconstruction, while he accepted to undergo a latissimus dorsi (LD) + rib flap reconstruction. ResultsThe postoperative course was uneventful. Also, the range of movements of the upper limb involved in the operation showed no significant changes after surgery. ConclusionsThe LD + rib flap proved to be a useful alternative procedure for mandibular reconstruction after cancer ablation in patients who are not candidates for vascularized bone-containing free flaps and refuse the PM + rib flap reconstruction.

Nodular Cutaneous Amyloidosis of the Scalp Reconstructed With a Free Anterolateral Thigh Flap: A Case Report

i p r T r s w a c n Amyloidosis is a rare disease of unknown cause that is characterized by the extracellular deposition of an amorphous fibrillar insoluble substance (amyloid) in the extracellular spaces of various organs and tissues, resulting in the loss of normal tissue structure. This can give rise to variable functional and structural impairments, depending on the location and intensity of the amount of protein deposition, eventually leading to organ dysfunction. Depending on the biochemical structure of the precursor protein, the amyloid fibrils can be deposited and can affect every organ of the body. Clinical manifestations are nonspecific and are determined by the organ or system concerned. The definitive diagnosis is made by biopsy using Congo red staining. The authors report a unique case of nodular cutaneous amyloidosis in the temporal region of the scalp that was treated by excision and anterolateral thigh (ALT) free flap reconstruction.

Microsurgical Training with the Three-Step Approach

Background Microsurgery is very challenging, requiring a high degree of dexterity and manual skills that should be fully trained outside of the operating room. Common microsurgery courses usually follow a stepwise training approach beginning practice on nonliving models and proceeding with live rats. However, training on live rats raises certain issues, including ethical concerns as well as the associated costs. As such, there is an increasing drive toward alternative models. The current article describes a three‐step training approach (latex glove‐endovascular prosthesis‐human placenta), which aims to prepare trainees for the clinical direct application. Also, to validate it, this approach was compared with microsurgical training on rats. Methods Overall, 20 residents were randomly assigned to two different microsurgical training courses, each based on one of the aforementioned approaches. Residents were evaluated in terms of correct handling of the instruments, correct use of the microscope, adventectomy, triangulation technique, posterior wall technique, success of the end‐to‐end anastomosis, and ability in assisting the tutor during the arterial anastomosis. Results The three‐step and the live rats groups evidenced similar scores in term of acquired basic skill levels. Conclusions The three‐step model allows to progressively gain skills on microsurgical techniques and to perform a good vascular anastomosis without the need of further steps on rats. The availability of both endovascular prosthesis and human placenta makes this training model definitely accessible from a practical and logistical point of view.

Association between abdominal separation and inguinal or crural hernias: Our experience and surgical indications

Abstract Abdominal wall weaknesses present several causative factors, both local and systemic and, as a consequence, abdominal hernias may develop in more than one site. Also, simultaneous hernia repair has been rarely reported in published reports. In the present study, the association of multiple weaknesses of the abdominal wall in patients undergoing conventional abdominoplasty or hernia repair were evaluated, and the advantages of simultaneous repair in a single operation are discussed. In a 3-year time period, all patients undergoing abdominoplasty or abdominal hernia repair were clinically and instrumentally evaluated for the association between median abdominal wall weakness and inguinal and/or crural hernias. The body mass index (BMI) was also considered and photographic documentation was taken before the operation and during the follow-up. When this association was confirmed, patients underwent contemporary correction of both conditions using an abdominoplasty approach. The presence of inguinal and/or crural hernias was observed in 10% of all patients undergoing conventional abdominoplasty and in 14.5% of patients with laparocele in the institution. The BMI was higher in patients with the association than in those without. Good aesthetic and functional results were achieved and the complication rate was low. The role of obesity as a triggering factor of abdominal wall weaknesses is confirmed by the higher BMI in patients with associated diseases. These observations remark the fact that the association between median abdominal wall weakness and inguinal or crural hernias should always be investigated. If this association is confirmed, it is preferable to treat both conditions simultaneously.