Tommaso Agostini

Blindness following cosmetic injections of the face.

Background: Complications following facial cosmetic injections have recently heightened awareness of the possibility of iatrogenic blindness. The authors conducted a systematic review of the available literature to provide the best evidence for the prevention and treatment of this serious eye injury. Methods: The authors included in the study only the cases in which blindness was a direct consequence of a cosmetic injection procedure of the face. Results: Twenty-nine articles describing 32 patients were identified. In 15 patients, blindness occurred after injections of adipose tissue; in the other 17, it followed injections of various materials, including corticosteroids, paraffin, silicone oil, bovine collagen, polymethylmethacrylate, hyaluronic acid, and calcium hydroxyapatite. Conclusions: Some precautions may minimize the risk of embolization of filler into the ophthalmic artery following facial cosmetic injections. Intravascular placement of the needle or cannula should be demonstrated by aspiration before injection and should be further prevented by application of local vasoconstrictor. Needles, syringes, and cannulas of small size should be preferred to larger ones and be replaced with blunt flexible needles and microcannulas when possible. Low-pressure injections with the release of the least amount of substance possible should be considered safer than bolus injections. The total volume of filler injected during the entire treatment session should be limited, and injections into pretraumatized tissues should be avoided. Actually, no safe, feasible, and reliable treatment exists for iatrogenic retinal embolism. Nonetheless, therapy should theoretically be directed to lowering intraocular pressure to dislodge the embolus into more peripheral vessels of the retinal circulation, increasing retinal perfusion and oxygen delivery to hypoxic tissues. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, V.

ALK-1-negative anaplastic large cell lymphoma associated with breast implants: a new clinical entity.

Concerns have been raised recently regarding the increasing number of reports of non-Hodgkin lymphoma (NHL) that developed in close proximity to silicone or saline breast implants. In particular, an increased risk of anaplastic large cell lymphoma (ALCL) in patients with breast prostheses has been proposed. We reviewed clinical and pathologic findings in 40 women who received a diagnosis of breast NHL arising in association with breast implants and of 27 patients who had a diagnosis of ALCL with breast involvement reported in the published literature. Among the 40 reported cases of prosthesis-associated breast lymphomas, 28 were anaplastic lymphoma kinase-1-negative (ALK-1(-)) ALCLs, whereas of 27 ALCLs in patients without implants found in the literature, only 10 were ALK-1(-). The finding of 28 cases of breast ALK-1(-) ALCL occurring in patients with implants compared with 10 cases in women without implants is in favor of an association between silicone breast prostheses and ALK-1(-) ALCL. Although the incidence of this type of lymphoma remains remarkably low given that breast prostheses have been widely used for decades, clinical and pathologic evidence for a causative role is becoming dramatically strong. The histologic, phenomenologic, and clinical similarities of the majority of implant-related ALK-1(-) ALCLs suggest a common mechanism, especially when compared with the counterpart of patients without implants in which very few and highly dishomogeneous cases of the same malignancy were detected. There is convincing evidence that primary implant-related ALK-1(-) ALCL represents a distinct clinicopathologic entity that has been inappropriately fitted into the category of systemic ALK-1(-) ALCL. Thus it should be recognized as a separate category and classified on its own.

Wet and dry techniques for structural fat graft harvesting: histomorphometric and cell viability assessments of lipoaspirated samples.

Background: Autologous fat transplantation is among the surgical procedures performed most commonly by plastic surgeons for cosmetic and/or reconstructive purposes. In the procedure, autologous fat is harvested and infiltrated during the same operation, and the success of this procedure relies on harvesting and transferring viable adipocytes. This study was designed to assess the histomorphometric characteristics and viability of the lipoaspirated cells that were harvested through different techniques. Methods: This study enrolled 65 patients undergoing lipofilling for reconstructive purposes. Subcutaneous fat samples were collected manually through the wet and dry techniques using a two-hole Coleman blunt cannula attached to a 10-cc Luer-Lok syringe. Fat tissue preservation was assessed through conventional histomorphometry and a cell viability assessment, evaluating the mitochondrial function through the MTS CellTiter 96 Aqueous One Solution Assay (Promega Corp., Madison, Wis.). Results: No differences were observed between adipocyte samples harvested with or without tumescent solution. The morphometric analysis and adipocyte viability assessment confirmed the visual findings: the mean surface area and shape (circularity index) of the adipocytes were not significantly different in the lipoaspirate collected through the different techniques. Conclusion: The results from the present study provide the first histologic evidence and cell viability assessment to demonstrate that there are no substantial differences in the adipose tissue specimens harvested with the wet and dry techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Anterolateral thigh flap: Systematic literature review of specific donor-site complications and their management

BACKGROUND The anterolateral thigh flap (ALT) is one of the most common flaps used in reconstructive microsurgery, due to its demonstrated lower donor-site morbidity when compared to other sites. Despite this, there are case reports of specific donor-site complications following the raising of an ALT flap. To date, there has been no systematic review of ALT-flap-related complications and overall ALT donor-site morbidity. METHODS A systematic review of the English-language literature was performed to identify specific donor-site complications following ALT-flap creation. RESULTS Fifteen articles met the study criteria and were included for analysis. ALT-flap donor-site complications were classified according to the tissue component involved (vessels/nerves, deep fascia, muscles). CONCLUSIONS Donor-site morbidity following raising of an ALT flap is minimal. ALT-flap versatility fulfils all of the needs of reconstruction, however we identified less common, but straightforward, complications that occurred when elevating overly large skin paddles (with widths measuring more than 10-12 cm), when sacrificing a main motor branch, when developing the pedicle too far proximally, when including too much fascia and when neglecting proper haemostasis. We suggest a basic algorithm for minimising donor-site morbidity and controlling complications, thereby reducing overall patient morbidity, shortening hospital stays and reducing costs.

Comparison of piezosurgery and traditional saw in bimaxillary orthognathic surgery

PURPOSE Investigators have hypothesised that piezoelectric surgical device could permanently replace traditional saws in conventional orthognathic surgery. METHODS Twelve consecutive patients who underwent bimaxillary procedures were involved in the study. In six patients the right maxillary and mandible osteotomies were performed using traditional saw, whilst the left osteotomies by piezoosteotomy; in the remaining six patients, the surgical procedures were reversed. Intraoperative blood loss, procedure duration time, incision precision, postoperative swelling and haematoma, and nerve impairment were evaluated to compare the outcomes and costs of these two procedures. RESULTS Compare to traditional mechanical surgery, piezoosteotomy showed a significant intraoperative blood loss reduction of 25% (p = 0.0367), but the mean surgical procedure duration was longer by 35% (p = 0.0018). Moreover, the use of piezoosteotomy for mandible procedure required more time than for the maxillary surgery (p = 0.0003). There was a lower incidence of postoperative haematoma and swelling following piezoosteotomy, and a statistically significant reduction in postoperative nerve impairment (p = 0.003). CONCLUSIONS We believe that piezoelectric device allows surgeons to achieve better results compared to a traditional surgical saw, especially in terms of intraoperative blood loss, postoperative swelling and nerve impairment. This device represents a less aggressive and safer method to perform invasive surgical procedures such as a Le Fort I osteotomy. However, we recommend the use of traditional saw in mandible surgery because it provides more foreseeable outcomes and well-controlled osteotomy. Further studies are needed to analyse whether piezoosteotomy could prevent relapse and promote bony union in larger advancements.

Adipofascial anterolateral thigh free flap for tongue repair

With the advent of microsurgery fasciocutaneous free flaps have become a well known and accepted option for the repair of tongue defects. Many authors have tried to recover tongue function by modifying this approach. An innovative method for the repair of tongue defects using an adipofascial anterolateral thigh free flap is presented in this paper. The results are compared with those of tongue reconstructions implementing traditional fasciocutaneous free flaps performed at our institution. The histological features of the flaps were investigated postoperatively. Although this preliminary report has to be confirmed by further experience, it seems to solve many tongue-reconstruction related problems.

Indications, outcomes, and complications of pedicled propeller perforator flaps for upper body defects: a systematic review.

Background The aim of this investigation was to systematically review the current literature to provide the best data for indications, outcomes, survival, and complication rates of pedicled propeller perforator flaps for upper body defects. Methods A comprehensive literature review for articles published from January 1991 to December 2011 was performed using the PubMed, Medline, and Cochrane Databases. Articles without available full-text, single case reports or papers with excessive missing data were excluded. Papers reporting pedicle-perforator (propeller) flaps used for lower extremity reconstruction were excluded from meta-analysis. Results From the initial 1,736 studies our search yielded, 343 studies qualified for the second stage of selection. Of 117 full-text reports screened, 41 studies, met the definitive inclusion and exclusion criteria. Of the selected 41 articles, 26 were case series, original papers or retrospective reviews and were included, whereas 15 were case report papers and therefore were excluded. Two hundred ninety-five propeller flaps were reported to have been used in a total of 283 patients. Indications include repair of trauma-induced injuries, post-trauma revision surgery, cancer resection, chronic infection, pressure sores, and chronic ulcers with a major complication rate (3.3%) comparable to that of free flaps. No specific exclusion criteria for the procedure were presented in the studies reviewed. Conclusions Pedicled propeller flaps are a versatile and safe reconstructive option that are easy and quick to raise and that provide unlimited clinical solutions because of the theoretical possibility of harvesting them based on any perforator chosen among those classified in the body.

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.

Anterolateral thigh flap thinning: techniques and complications.

BackgroundA thinned anterolateral thigh flap is often necessary to achieve optimal skin resurfacing. In this article, we describe the techniques available for immediate flap thinning and the vascular complications that can follow trimming. Materials and MethodsA systematic literature review was performed to identify the different thinning techniques and any possible complications. Data were identified by performing a systematic search on Medline, Ovid, Embase, the Cochrane Database of Systematic Reviews, Current Contents, PubMed, Google, and Google Scholar. We cross-referenced the identified articles and conference abstracts in the English and French languages. ResultsThe study selection process was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and 34 were articles compiled by using the study inclusion criteria. These articles were then reviewed for the author name(s), the publication year, the flap dimensions, the flap thickness (both before and after thinning), the perforator type, the type of flap transfer, the complications that followed the thinning, the thinning technique used, the amount of deep fascia preserved around the perforator, the number of cases in the study, the area of application, and the technique used for donor-site closure. We analyzed the possible vascular complications that stemmed from the flap area site selected, the flap thickness, the thinning technique used, and whether the deep fascia was spared. ConclusionsThe subfascial dissection of anterolateral thigh flaps revealed that the safest method for minimizing vascular complications accounted for a 3.1% probability for marginal necrosis, which can be managed conservatively. The overall breakdown of the vascular-related complications that followed flap thinning totals 13.4% and can be broken down as follows: partial flap loss of 4.1%, partial distal necrosis of 3.5%, marginal necrosis of 3.1%, and total flap loss of 2.5%.

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.