Raffaella Perello

Esthetic restoration in progressive hemifacial atrophy (Romberg disease): structural fat grafting versus local/free flaps.

BackgroundProgressive hemifacial atrophy, also called Parry-Romberg disease, is a craniofacial disorder that typically involves the subcutaneous layer of 1 side of the face. Autologous reconstruction is achieved through various techniques, including autologous grafting of fatty tissue, the use of pedicled flaps, and free tissue transfer based on microvascular anastomoses. Thus far, a systematic literature review devoted to compare different surgical techniques has not been published. MethodsThe study selection process was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data were identified by performing a systematic search on Medline, Ovid, Embase, the Cochrane Database, Current Contents, PubMed, Google, and Google Scholar. ResultsThe initial search resulted in 871 articles through online access on July 2013. Sixty-six articles were included and fully reviewed for data extraction of the surgical procedures and divided into the following 4 groups: pedicled flaps, free flaps, structural fat grafting, and conjoint treatment (free flaps plus lipofilling). ConclusionsThe therapeutic management of progressive hemifacial atrophy is based on the severity of the disease. Except for minor degrees of atrophy, for which lipofilling can satisfy the requirements, vascularized fatty tissue is essential for long-term contour correction. Microsurgical transfer of buried flaps can be considered the most effective surgical treatment of middle and severe Romberg disease in long-term correction, complication rate, and reoperative rate.

Late-onset gluteal Escherichia coli abscess formation 7 years after soft tissue augmentation with Bio-Alcamid™ in a HIV-positive patient

In 2002, a 41-year-old woman had been treated for severe buttock lipodystrophy resulting from highly active antiretroviral (HAART) therapy medication. During a single session the loss of subcutaneous fatty tissue had been compensated by injections of an undefined quantity of polyalkylimide 4% (Bio-Alcamid , Polymekon Biotech Industry, Milan, Italy). The post-treatment course had been uneventful and the patient had initially been satisfied with the result of this treatment. Seven years later, the patient presented with a redness and swelling of the area (Figure 1) by our unit. The area was hard and extremely painful on touch. All previous antibiotic therapies led only to temporary relief of these symptoms. A bedside drainage of the abscess was performed through a 20-gauge intravenous cannula that was inserted in the thin collagen capsule

Successful combined approach to a severe Fournier's gangrene.

We present a case of a successful reconstruction of a severe Fourniers gangrene (FG) involving the scrotum, the perineum, the right ischial area and extended to the lower abdomen. There are many different surgical techniques to repair and reconstruct the defect following debridement in FG. The authors treated this complex wound using negative pressure wound therapy (NPWT), dermal regeneration template and a split-thickness skin graft. Complete recovery was achieved and no major complications were observed. The patient showed a satisfying functional and aesthetic result.

Six factors justify the pathologic analysis of subcutaneous mastectomy specimens in patients with gynaecomastia

Figure 1 A total of 54 patients underwent subcutaneous ma (1965e2013) and Cochrane databases (2000e2013)). (lipomastia), which is characterised by fat deposition only without glandular proliferation. Surgical treatment of gynaecomastia consists of a subcutaneous mastectomy with or without pathologic examination of the specimens. Here, we question whether routine pathologic examination is justified, and we attempt to identify the risk factors that justify examination in relation to the overall costs. We performed a literature review using the MEDLINE (1965e2013) and Cochrane databases (2000e2013) to collect patients who had undergone subcutaneous mastectomy for gynaecomastia and had abnormal tissue (Figure 1). We retrieved 54 patients from the published papers: the mean age was 36.5 (range, 5e89 years), and 34 patients (63%) were younger than 30 years old; 29 patients (53.7%) had unilateral gynaecomastia, and 25 (46.4%) had bilateral gynaecomastia. We further analysed the incidence of tumour following pathologic examination according to age, risk factors, unilateral/bilateral location, oestrogen/progesterone receptor positivity, tumour type, BRCA1/BRCA2 positivity and chromosomal analysis. Thirtyone patients (57.4%) had malignant tumours, and 23 patients (42.6%) had benign disease (atypical ductal hyperplasia). According to the patients’ age, 16 patients (51.6%) who were under 30 years old had a malignant tumour versus 15 patients (48.4%) who were older than 30 years. We then studied the tumour group based on the risk factors excluding 12 cases in which data were not available (n Z 19). Eight patients (42%) had no risk factors, and the remaining 11 patients (58%) had obesity (nZ 3), oestrogen/

Through-and-through Nasal Reconstruction with the Bi-Pedicled Forehead Flap.

Background Nasal reconstruction is one of the most difficult challenges for the head and neck surgeon, especially in the case of complex full thickness defects following malignant skin tumor resection. Full-thickness defects require demanding multi-step reconstruction. Methods Seven patients underwent surgical reconstruction of full-thickness nasal defects with a bi-pedicled forehead flap shaped appropriately to the defect. Patients were aged between 58 and 86 years, with a mean age of 63.4 years. All of the tumors were excised using traditional surgery, and in 4 of the patients, reconstruction was performed simultaneously following negativity of fresh frozen sections of the margins under general anesthesia. Results Nasal reconstruction was well accepted by all of the patients suffering non-melanoma skin tumors with acceptable cosmetic outcomes. The heart-shaped forehead flap was harvested in cases of subtotal involvement of the nasal pyramid, while smaller defects were reconstructed with a wing-shaped flap. No cartilaginous or osseous support was necessary. Conclusions This bi-pedicled forehead flap was a valid, versatile, and easy-to-implement alternative to microsurgery or multi-step reconstruction. The flap is the best indication for full-thickness nasal defects but can also be indicated for other complex facial defects in the orbital (exenteratio orbitae), zygomatic, and cheek area, for which the availability of a flap equipped with two thick and hairless lobes can be a valuable resource.

An Approach to Keloid Reconstruction with Dermal Substitute and Epidermal Skin Grafting

Keloids represent a challenging topic for reconstructive surgeons. Surgical debulking is the main treatment for these lesions, although recurrence rates are reported to be 45–100%. Here, we present a staged reconstructive approach through a dermal regeneration substrate and epidermal grafting in order to minimize recurrence and donor site morbidity. All keloids were excised down to healthy tissue. A bilaminar dermal regeneration template was used to reconstruction, with the silicone lamina oriented superficially. The second step of reconstruction was delayed for at least 21 days to allow for neodermal ingrowth. Once the protective lamina was removed, an epidermal skin graft was applied to the neodermis with nonocclusive dressing. This combined approach limits scar contracture facilitating tension-free wound healing with a consequent lower rate of recurrences.

Combined Approach to Severe Fournier’s Gangrene with Negative Pressure Wound Therapy, Dermal Regeneration, and Split-Thickness Skin Graft

Fournier’s gangrene is an expansive and necrotic acute bacterial infection of soft tissue of the perineum, the scrotum, and the lower part of the trunk. Predisposing factors include diabetes mellitus, severe obesity, prolonged hospitalization, hematologic illnesses, LES, immunosuppression, drug use, alcoholism, poor personal hygiene, and malnutrition. Mortality is 20–50%. The authors describe the etiology, classification, symptoms, diagnosis, and treatment. Vacuum-assisted closure and the dermal regeneration template represent useful tools in reconstruction of the perineum following extensive debulking and can be considered as a valid alternative to immediate skin grafting to cover large defects, yielding excellent aesthetic and functional results.

A New Hybrid Technique for Performing a Safer Bilateral Sagittal Split Osteotomy: Combining Reciprocating Saw and Piezoelectric Devices

Abstract The sagittal split osteotomy (SSO) is an indispensable tool in the correction of dentofacial abnormalities. In elective orthognathic surgery, it is important that surgeons inform patients about the risk of complications related to inferior alveolar nerve damage and unfavorable split. The purpose of this article is to describe a novel, hybrid technique to SSO by combining a reciprocating saw and piezoelectric devices with several advantages over traditional “pure” methods (osteotomies performed by reciprocating saw or piezoelectric devices only) in terms of precision, rapidity, easier splitting, and decreased complications related to inferior alveolar nerve damage and bad split with reduced overall morbidity. The level of evidence was Level IV, therapeutic study.

Metastatic Squamous Cell Carcinoma of the Lower Lip: Analysis of the 5-Year Survival Rate

Objectives The author analyse the impact of extracapsular lymph node spread and bone engagement in the ipsilateral neck of patients suffering squamous cell carcinoma (SCC) of the lower lip. Methods The data of 56 neck dissections performed in patients suffering SCC of the lower lip between January 2000 and December 2008 were retrospectively analysed. Statistical analysis was performed with the Kaplan-Meier life table method, and the survival rate was investigated with the log rank statistic and significance test. The values were considered statistically significant at p<0.05. Results Nine patients took advantage from simultaneous treatment of tumor and prophylactic neck dissection (level I-III), reaching 100% survival rate. Patients suffering metastasized disease, who received radical neck dissection at the time of tumor treatment, presented 83.3% survival rate. Patients who underwent previous surgery and radiotherapy presented worse prognosis although radical neck dissection in case of extra-capsular spread only (24.7%) and osseous engagement (22.2%). Conclusion Prophylactic neck dissection (level I–III) is recommended in T3–T4 N0 SCC. Simultaneous treatment of tumor and cervical lymph nodes provides a better prognosis as respect to delayed nodal management. Extra-capsular spread with or without bone engagement represents independent risk factor responsible for high mortality rate of SCC of the lower lip.

Siliconomas of the lower limb: Tumour-like excision and reconstruction

Background: Silicone oil injection can cause several complications including pain, cellulitis, abscesses, skin compromise, migration, embolism and multiorgan failure. Oil-infested tissue excision remains the solely treatment to prevent such complications. Objectives: The authors evaluate tumor-like excision of the oil-infested tissue as a treatment for patients experiencing silicone injections in the lower limbs, to both preserve aesthetic appearance and solve further risk of complication from silicone. Methods: Between January 2004 and January 2011 a total of 12 consecutive, nonrandomized female patients underwent surgical management of siliconoma of the lower limb. The mean age was 41-years, range from 22 to 61 years and all patients didn’t referred comorbidities. Eight siliconomas were located on the leg and 4 were on the thigh. The mean area of siliconoma was 35 cm2, range from 25 to 60 cm2. Each patient was evaluated by ultrasonography and EchocolorDoppler of the soft tissue and in order to achieve a “staging” of siliconoma. Results: Healing was uneventful in all cases. Three patients (25%) suffering hypertrophic scarring underwent further injection of corticosteroids to improve hypertrophic scars quality. Two patients (16.6%) required a further session of structural fat grafting to improve thighs profile. All patients were satisfied with the cosmetic results and indispositions requiring medical therapy disappeared. Conclusions: Tumor-like excision and immediate reconstruction appears to be a safe and consistent surgical option that preserves aesthetic appearance for patients victims of illegal oil silicone injection of the lower limbs.