Roberto Grella

Changing the Metabolic Profile by Large-Volume Liposuction: A Clinical Study Conducted with 123 Obese Women

Adipose tissue is a metabolically active tissue. The hypertrophic fat cells of obese patients produce increased quantities of leptin and tumor necrosis factor-α (TNF-α) and are less sensitive to insulin. This study aimed to determine whether aspirating large amounts of these subcutaneous fat cells by large-volume liposuction (LVL), could change the metabolic profile in 123 obese women. All the patients had a main central body fat distribution (waist–hip ratio, 0.91±0.01) and a body mass index of 32.8 ± 0.8 kg/m). They were studied for 90 days after LVL to determine their changes in insulin sensitivity, resting metabolic rate, serum adipocytokines, and inflammatory marker levels. During 3 months of follow-up evaluation, LVL resulted in a significantly improved insulin sensitivity, resting metabolic rate, serum adipocytokines, and inflammatory marker levels. Such parameters correlate with a decrease in fat mass and waist–hip ratio. Interestingly, no significant changes were seen between the first (21 days) and second (90 days) metabolic determinations after LVL. However, these findings, confirm other preliminary data published previously, and could change the actual role of LVL in the multidisciplinary treatment of obesity.

Modification of Cysteinyl Leukotriene Receptor Expression in Capsular Contracture: Preliminary Results

The development of a fibrotic capsule around foreign material in the body is a physiologic reaction undertaken by the body to protect itself from a material it does not recognize. The periprosthetic capsule can pathologically contract, pressing on the implant; it can cause pain, firmness, and sometimes implant extrusion. The pathogenesis of capsular contracture is still unclear, but most reports indicate a multifactorial explanation. The aim of this study is to investigate the role of cysteinyl leukotriene receptors (cysLTR) on the inflammatory cells involved in the development of the capsular contracture. We recruited 20 patients affected by severe capsular contracture (Baker III–IV) and a control group composed of normal patients who had undergone implant substitution. In both groups, we performed a semiquantitative analysis of mRNA encoding for cysLTR1, cysLTR2, tumor necrosis factor-α (TNF-α) and interleukin 10 (IL-10) on myofibroblasts and macrophages of the periprosthetic capsular tissue. The molecular analysis showed an increase in the cysLTR2, TNF-α gene expression but no change in the cysLTR1 and IL-10 genes in patients affected by capsular contracture. These preliminary findings suggest a primary role for cysteinyl leukotrienes in the activation and up-regulation of capsular contraction mechanisms.

Modification of Cysteinyl Leukotriene Receptors Expression in Capsular Contracture: Follow-up Study and Definitive Results

Periprosthetic capsular contracture represents a specific iatrogenic phenomenon with different side effects. Recently, interesting data have disclosed a potential role of leukotrienes as important mediators of inflammation in the reactivation process of capsular contracture. Some preliminary studies have assessed the efficacy of leukotriene antagonists in the prevention and treatment of capsular contracture. These clinical data are still lacking of a potential biomolecular basis. The aim of our present study was to evaluate the expression of the protein receptor cysteinyl leukotriene receptors (CysLTR). We included 50 patients with severe capsular contracture (Baker III–IV) and a control group consisting of healthy patients who underwent an implant replacement. In both groups, we performed the protein extraction and semiquantitative analysis for the determination of protein concentration on myofibroblasts and macrophages. Western Blot analysis of protein levels shows a significant increase in the expression of CysLTR in patients with capsular contracture. Our final results show that the increase in the levels of mRNA coding for CysLTR actually translates into an effective increase in protein levels of these mRNA transcripts. These findings could at least partially provide a biomolecular basis that justifies the use of specific antileukotriene drugs in the treatment of this disease.

Differential expression of cyclooxygenases in hypertrophic scar and keloid tissues

Hypertrophic scar (HS) and keloid (KL) are two forms of an abnormal cutaneous scarring process, mainly characterized by excessive extracellular matrix deposition and fibroblast proliferation. Despite the increased understanding of the molecular and cellular events leading to HS and KL, the pathogenesis of these lesions remains poorly understood. A pivotal role in the formation of abnormal scars has been ascribed to transforming growth factor‐β, whose activity appears to be mediated through a link with pathways acting via cyclooxygenases (COX‐1 and COX‐2). To date, there is no report on the in vivo expression of COX‐1 and COX‐2 in human HS and KL tissues. Therefore, using immunohistochemistry and Western blot analysis, we investigated 36 cases of KL, 32 cases of HS, and 25 cases of normal skin in order to define the localization and distribution of COX‐1 and COX‐2 in the tissues of these scar lesions and the overlying epidermis. The results mainly show the following: (a) a significant overexpression of COX‐1 in HS tissues and the overlying epidermis as compared with normal skin and KL tissues and (b) a significant overexpression of COX‐2 in KL tissue and the overlying epidermis in contrast to normal skin and HS tissues. Our data support the hypothesis that both COXs are involved in the pathogenesis of scar lesions in different ways and, particularly, COX‐1 in the formation of HS and COX‐2 in the formation of KL. In addition, the overexpression of COX‐1 and COX‐2 in the epidermis overlying HS and KL tissues, respectively, underlines the importance of epithelial–mesenchymal interactions in the pathogenesis of scar lesions.

Role of subcutaneous abdominal fat on cardiac function and proinflammatory cytokines in premenopausal obese women.

The role of surgically removing subcutaneous fat by abdominoplasty on circulating inflammatory markers and myocardial dysfunction, evaluated by myocardial performance index (MPI), were investigated. Twenty volunteers submitted to the abdominoplasty (abdominoplasty group), and other 28 women treated by hypocaloric diet (diet group) were evaluated. Echocardiographic parameters of MPI, circulating levels of tumor necrosis factor (TNF)-&agr; and interleukin (IL)-6, were performed at baseline and 2 months later. Compared with nonobese women, obese women had increased concentrations of TNF-&agr; (P < 0.01), IL-6 (P < 0.01), and higher MPI (P < 0.02), indicating ventricular dysfunction. Subcutaneous fat concentrations of TNF-&agr; and IL-6 were related to MPI impairment. After 60 days, waist-to hip ratio was significantly reduced in the abdominoplasty group. Anthropometric changes were accompanied by a significant decline in plasma concentrations of TNF-&agr; and IL-6 levels as well as by significant improvements of MPI in abdominoplasty group compared with diet group. Abdominoplasty may represent a safe method for ameliorating cardiac function in obese women.

Hepatic omphalocele in an adult

The finding of an untreated omphalocele in adulthood is extremely rare. We report the case of a 29‐year‐old patient, who presented to us with a congenital defect of the abdominal wall and protrusion of underlying viscera.

Histologic Analysis of Zafirlukast's Effect on Capsule Formation Around Silicone Implants: some considerations.

We have read with profound interest the article by Bastos and colleagues entitled Histologic Analysis of Zafirlukast’s Effect on Capsule Formation Around Silicone Implants. We have truly enjoyed this study because it focuses on the very important issue of ongoing research toward pharmacologic therapy for the treatment of periprosthetic capsule contracture. The latter has an incidence in the range of 0.5% to 50% [3]. Despite persistent clinical and laboratory investigation, to date, no solution has been developed to solve or prevent this problem. For several years, many investigators have evaluated the use of antileukotriene drugs, which could be effective in the treatment of periprosthetic capsule contracture. Unfortunately, their use still is not evidence based and has no biochemical or biomolecular support. At the same time, the use of drugs with no specific indication is strongly criticized and discouraged for moral, medical, and legal reasons [6]. Investigations into a molecular basis to justify the use of CysLT antagonists have evaluated the potential modification of cysLTR expression in human contracted capsules [2]. The conclusions of the study by Bastos and colleagues are supported by several clinical studies, which are reviewed in their studies. However, the authors failed to review the animal models proposed to date (rabbits, pigs, rats). Although these animal studies are very accurate, they have disadvantages in terms of reproducibility, standardization, and of course translation to the human setting [1, 4, 5, 7]. In all the experiments, the authors tried to induce contracture through different methods (bacterial contamination, fibrin glue), stressing the fundamental cellular and biochemical difference between the contracted capsule and the physiologic periprosthetic capsule. Unfortunately, Bastos and colleagues used an animal model that, in our opinion, is not accurate with respect to a contracted capsule. Indeed, the authors did not induce capsular contracture in their animal model. With the fundamental differences between contracted and uncontracted capsules in mind, the immunohistochemical and histopathology analysis was carried out on periprosthetic physiologic capsules. Thus, the reduced presence of inflammatory cells and the reduced vascular density in the experimental groups (explained by the intrinsic antiinflammatory activity of zafirlukast) cannot definitely be proof of a therapeutic effect of the drug in reducing or preventing capsular contracture. Moreover, it is unclear why the authors decided to remove the prostheses 90 days after the implantation to analyze the capsules, assuming them to be contracted. Despite these criticisms, we thank Bastos and colleagues for focusing their attention on a very serious problem in plastic surgery and for proposing a histologic and immunohistochemical analysis of the development of capsular contraction. We hope that many other investigators will undertake the same approach in fighting against this frustrating problem that afflicts patients, plastic surgeons, and manufacturers.

Abdominoplasty: Thromboembolic Risks for Both Sexes

During surgical procedures, coagulation complications may occur. Discriminating factors are multiple and may vary because of the anatomical regions involved and because of preexisting diseases. The aim of this study was to analyze changes in such hematological parameters of patients undergoing conventional abdominoplasty with standard surgical procedures under general anaesthesia.For the study, 40 patients (20 men and 20 women) 30 to 60 years with normal coagulation assessments, no previous or current history of hemorrhagic or thrombotic disease, and no primary family history of such problems were selected. All the patients underwent conventional abdominoplasty surgical procedures.Analysis of the results suggests that immediately after surgery, in the absence of any preexisting hypo- or hypercoagulability state, there was no circumstantial modification in coagulation factors considered predictive for thromboembolic risk. However, an interesting difference between male and female patients was noted. In the male group, there was an insignificant uniform downward trend of all values immediately after surgery.In conclusion, women are less hypercoagulative than men in the postoperative period, suggesting that women have limited protection from the development of thromboembolic complications immediately after surgical procedures.

A useful method to overcome the difficulties of applying silicone gel sheet on irregular surfaces

To date, silicone gel and silicone occlusive plates are the most useful and effective treatment options for hypertrophic scars (surgical and traumatic). Use of silicone sheeting has also been demonstrated to be effective in the treatment of minor keloids in association with corticosteroid intralesional infiltration. In our practice, we encountered four problems: maceration, rashes, pruritus and infection. Not all patients are able to tolerate the cushion, especially children, and certain anatomical regions as the face and the upper chest are not easy to dress for obvious social, psychological and aesthetic reasons. In other anatomical regions, it is also difficult to obtain adequate compression and occlusion of the scar. To overcome such problems of applying silicone gel sheeting, we tested the use of liquid silicone gel (LSG) in the treatment of 18 linear hypertrophic scars (HS group) and 12 minor keloids (KS group) as an alternative to silicone gel sheeting or cushion. Objective parameters (volume, thickness and colour) and subjective symptoms such as pain and pruritus were examined. Evaluations were made when the therapy started and after 30, 90 and 180 days of follow‐up. After 90 days of treatment with silicone gel alone (two applications daily), HS group showed a significant improvement in terms of volume decrease, reduced inflammation and redness and improved elasticity. In conclusion, on the basis of our clinical data, we find LSG to be a useful method to overcome the difficulties of applying silicone gel sheeting on irregular surface.

Combined epigastric hernia repair and mini-abdominoplasty. Case report

The objectives of abdominal hernia repair are to restore the structural integrity of the abdominal wall. Current techniques include primary closure, staged repair and the use of prosthetic materials. Techniques for mini-abdominoplasty include the use of the transverse lower abdominal incision and the resection of excess skin. We report a case of epigastric hernia repair through a transverse lower abdominal incision with the resection of excess of skin. Our purpose is to evaluate the results of the procedure by incorporating these aspects into an epigastric hernia repair, we found out that the procedures are made safer and the results are improved. Proper indication and details of the technique are described.The objectives of abdominal hernia repair are to restore the structural integrity of the abdominal wall. Current techniques include primary closure, staged repair and the use of prosthetic materials. Techniques for mini-abdominoplasty include the use of the transverse lower abdominal incision and the resection of excess skin. We report a case of epigastric hernia repair through a transverse lower abdominal incision with the resection of excess of skin. Our purpose is to evaluate the results of the procedure by incorporating these aspects into an epigastric hernia repair, we found out that the procedures are made safer and the results are improved. Proper indication and details of the technique are described.