Arms lift in a case of pseudoxanthoma elasticum.

Pseudoxanthoma elasticum (PXE) is a rare hereditary disorder of elastin fibers, characterized by yellowish coalescent papules in flexural surfaces with abnormally lax and corrugated skin. It can be associated to systemic manifestations mostly regarding eyes and vessels. Aesthetic surgery of cutaneous hyperlaxity was described in the international literature only in few cases, mostly as neck lift. A 40-year-old woman presented with cutaneous signs of PXE, demanding brachioplasty. Results after a nine-month followup are quite satisfying, and no signs of local recurrence or scar alterations are present.

The trochanteric fat pad.

Technological developments based on the use of autologous white adipose tissue (WAT) attracted attention to minor fat depots as possible sources of adipose tissue. In plastic surgery, the trochanteric fatty pad is one of the most used WAT depots for its location and organoleptic characteristics that make it particularly suitable for reconstructive procedures. Despite its wide use in clinic, the structure of this depot has never been studied in detail and it is not known if structural differences exist among trochanteric fat and other subcutaneous WAT depots. The present study was performed on trochanteric fat pad with the aim to clarify the morphology of its adipocytes, stroma and microcirculation, with particular reference to the stem niches. Histological and ultrastructural studies showed that the main peculiar feature of the trochanteric fat concerns its stromal component, which appears less dense than in the other subcutaneous WATs studied. The intra-parenchymal collagen stroma is poor and the extracellular compartment shows large spaces, filled with electron-light material, in which isolated collagen bundles are present. The adipocytes are wrapped in weak and easily detachable collagen baskets. These connective sheaths are very thin compared to the sheaths in other subcutaneous WAT depots. The capillaries are covered by large, long and thin elements surrounded by an external lamina; these perivascular cells are poor in organelles and mainly contain poly-ribosomes. In conclusion, when compared to other WAT deposits, the trochanteric fatty pad shows structural peculiarities in its stroma and microcirculation suggesting a high regenerative potential. Resistance, dissociability, microvascular weft and high regenerative potential make the trochanteric fatty pad a privileged source for harvesting in autologous WAT-based regenerative procedures.

Subcutaneous adipose tissue classification.

The developments in the technologies based on the use of autologous adipose tissue attracted attention to minor depots as possible sampling areas. Some of those depots have never been studied in detail. The present study was performed on subcutaneous adipose depots sampled in different areas with the aim of explaining their morphology, particularly as far as regards stem niches. The results demonstrated that three different types of white adipose tissue (WAT) can be differentiated on the basis of structural and ultrastructural features: deposit WAT (dWAT), structural WAT (sWAT) and fibrous WAT (fWAT). dWAT can be found essentially in large fatty depots in the abdominal area (periumbilical). In the dWAT, cells are tightly packed and linked by a weak net of isolated collagen fibers. Collagenic components are very poor, cells are large and few blood vessels are present. The deep portion appears more fibrous then the superficial one. The microcirculation is formed by thin walled capillaries with rare stem niches. Reinforcement pericyte elements are rarely evident. The sWAT is more stromal; it is located in some areas in the limbs and in the hips. The stroma is fairly well represented, with a good vascularity and adequate staminality. Cells are wrapped by a basket of collagen fibers. The fatty depots of the knees and of the trochanteric areas have quite loose meshes. The fWAT has a noteworthy fibrous component and can be found in areas where a severe mechanic stress occurs. Adipocytes have an individual thick fibrous shell. In conclusion, the present study demonstrates evident differences among subcutaneous WAT deposits, thus suggesting that in regenerative procedures based on autologous adipose tissues the sampling area should not be randomly chosen, but it should be oriented by evidence based evaluations. The structural peculiarities of the sWAT, and particularly of its microcirculation, suggest that it could represent a privileged source for regenerative procedures based on autologous adipose tissues.

Soft cohesive silicone gel breast prostheses: a comparative prospective study of aesthetic results versus lower cohesivity silicone gel prostheses.

The flexibility of lower cohesivity silicone prostheses is the main reason for wrinkling, rippling and evidence of implant edges. The soft cohesive silicone implants promise to minimize such effects with minimal softness reduction. Forty consecutive patients received soft cohesive prostheses (INAMED Style 110 ST) and were studied prospectively. A historical group, made up by the 40 consecutive patients who received lower cohesivity silicone implants (INAMED Style 110) in the immediately preceding months, was used as a control. Wrinkling, prosthetic edge perceptibility and capsular contracture degree were assessed six months after surgery. The tissue coverage thickness was measured using ultrasonography. The patients were then asked to evaluate the breast softness by means of an anonymous questionnaire, where they also expressed their overall satisfaction by means of the five-steps linear analogical scales. The wrinkling prevalence was 9.2% in the soft cohesive group vs. 55% in the lower cohesivity one (p<0.01). The edge perceptibility was 14% in the soft cohesive group vs. 22% in the lower cohesivity one (no statistical significance). The coverage tissue thickness was not found to be significantly related to the wrinkling prevalence or to the edge perceptibility. The capsular contracture rate was almost identical in the two groups (Baker II: 2.6% vs. 2.7%, no Baker III or IV). A higher stiffness was noted in the soft cohesive group (average score: 4.2 vs. 4.4 in the control group, p<0.05), but the overall satisfaction degree was higher for soft cohesive implants (average score: 4.5 vs. 3.8, p<0.01). The soft cohesive prostheses offered better overall results than the lower cohesivity silicone prostheses, even if a longer term follow-up should be advised. The soft cohesive prostheses showed a higher firmness, but this seemed not to have any influence on the overall satisfaction degree.

Filler injection enhances the projection of the reconstructed nipple: an original easy technique.

BACKGROUND: Reduced nipple projection is the main reason for unsatisfactory nipple-areola complex reconstruction, and many techniques have been proposed to maintain projection of the reconstructed nipple. METHODS: For 70 patients, 90 nipples were reconstructed using either a small wedge from the labia minora (LMW) (n=70) or nipple sharing (NS) (n=20). Two months after reconstruction, each reconstructed nipple was injected with DermaLive. Second and third injections were performed 2 and 5 months later. The injected volume was tailored to the desired projection. Nipple projection was measured at the moment of implant, before and after each injection, and 6 and 12 months after the last injection. RESULTS: Nipple projection was satisfactory in all cases and comparable with that of the contralateral nipple. The average nipple projection at 6 months was 5.8 mm in the LMW group and 3.8 mm in the NS group (p<0.01) and, respectively, 5.6 mm and 3.5 mm at 12 months (p<0.01). No complications occurred, except for one positron emission tomography (PET) false-positive result. CONCLUSIONS: The described method is simple and safe. It provides precise projection with no need for intraoperative forecasting of tissue reabsorption. The result was better for the LMW patients, perhaps because of their higher distensibility.

The tuberous breast syndrome.

The tuberous breast syndrome is the result of a complex series of defects with various degrees of expression. However, much confusion has been generated in the literature by the use of often inadequate terminology, which is partly the cause of multiplicity of managements being proposed that mainly aim to correct the major defect and not the entire syndrome. The surgical approach adopted by our group stems from the improvement of classic techniques, consisting essentially of a combination of periareolar mastopexis, additive mastoplasty, and gland base enlargement by cross incision. Our results were fully satisfying both aesthetically and functionally. We achieved a correct shape, resolved ptosys and reduced areolas with no double-fold effect, and attained good symmetry in more complex unilateral cases.

The impact of genetics on Crohn's disease.

BACKGROUND/AIMS: Reports focusing on the familiarity and "pedigree" of patients with Crohn's Disease (CD) are increasing. The study of the role of genetics as a predisposing factor in providing the ideal milieu upon which environmental agents and immuno-inflammatory responses may act, could be paramount in finding the pith of the etiopathogenesis of this disease. METHODOLOGY: In order to determine the impact of familiarity on CD, a series of 187 patients, managed between January 1965 and January 1997, was subdivided into two groups. In group I (145 pts.), the family history relied only on direct information from the patient, while in group II (42 pts.) a prospective study was carried out involving both close and distant relatives who were interviewed and, in some cases, clinically investigated. RESULTS: In this study, relatives with suspected CD were 9 out of 122 in group I patients (7.4%), while in the more detailed assessment of group II, 18 out of 42 cases (43%) had an ascertained CD familiarity. CONCLUSIONS: The importance of familiarity in the pathogenesis of CD may be higher than expected if properly sought for. Reports on the possibility that the onset of CD may be strongly influenced by genetics, favor our hypothesis that the true etiology may find its base in a hemolymphatic disorder of the mesentery followed by superimposed inflammatory responses.

A new approach in the management of Crohn's disease: observations in 20 consecutive cases.

Although the "modern history" of Crohn's disease dates back to 1932, the etiology is still nebulous, the medical treatment inefficient and resective surgery results in a high recurrence rate. Twenty consecutive patients with terminal ileitis underwent ileo-cecal resection and mesenteric-epiploonplasty to enhance collaterals and lymphatic drainage. This approach was advised by experimental observations (the ligation of colonic lymphatic ducts in rabbits), by the intraoperative use of optics to better appreciate the details of the diseased bowel before and after injecting dye and by the angiographic results in one patient. In rabbit experiments, the obliteration of lymphatic drainage led to Crohn's disease-like macroscopic and microscopic patterns, while diffusion of the dye injected in the diseased segment showed altered lymph flow. The angiographic study in one patient confirmed the presence of vascular anomalies. Direct observation through optics revealed large vessels in the serosa with milky contents and the oozing of sticky exudate. In the 8 patients who underwent this procedure over 5 years ago, there were no recurrences. We strongly believe in the vasculo-lymphatic etiology of Crohn's disease and in mesentery-epiploonplasty as the only actual indirect approach to resolve hemolymphatic obstructions.

[Transrectal ultrasonography in the study of recurrences in patients surgically treated for rectal neoplasms]. / Studio mediante ecografia transrettale delle recidive nei pazienti operati per neoplasia rettale.

The value of transrectal US is known in the preoperative staging of rectal cancer but remains debated in the follow-up of the patients submitted to anterior resection or local therapy. The authors report their experience with the postoperative follow-up of 80 patients submitted to 125 transrectal US exams to study method reliability. The results were 9 true positive, 2 false positive, 113 true negative and 1 false negative cases, with 90% sensitivity, 98.3% specificity and 97.6% accuracy rates. Positive predictive value was 81.8% and negative predictive values was 99.1%. Twelve patients were submitted also to MRI which correctly diagnosed one false negative result of transrectal US. Twenty-one patients were examined also with transrectal Doppler and color-Doppler US: in rectal cancer recurrences the peak velocity of hemorrhoid vascular flow was higher than in non-recurrent patients. On the basis of our results, transrectal US deserves to be included in the postoperative follow-up of the patients submitted to anterior resection or to local therapy for rectal cancer. Moreover, according to our preliminary findings, Doppler and color-Doppler US can improve transrectal US reliability in detecting local recurrences.

Long-term survival after right nephrectomy, caval prosthesis and failed left renal-vein reconstruction, in managing an enormous retroperitoneal tumor.

The left renal vein is endowed with a rich network of collaterals, therefore distal division does not jeopardize global renal function and this is true under particularly favourable conditions, even if the right kidney is missing. A woman presented with an enormous retroperitoneal liposarcoma and a carcinoma of the breast. She underwent a radical mastectomy and the resection of a 13 kg retroperitoneal tumor which required a right nephrectomy, segmental resection of the involved vena cava and reconstruction with a prosthesis joined to the left renal vein by a bovine carotid graft. This graft thrombosed shortly after surgery, without causing apparent damage to the residual kidney. The patient died 77 months after the operation, from diffuse recurrences of the breast cancer while renal function was never impaired. The left renal vein may be interrupted distally for many pathologies and then reconstructed or ligated definitively without renal function failure, even in monorenal patients if collaterals are well developed.

[Surgical therapy of obstructive tumors of the large intestine]. / La terapia chirurgica dei tumori occludenti del grosso intestino.

Current option in managing obstructive colorectal carcinoma is a one stage procedure. Between 1987 and 1991, 47 cases of obstructive colorectal cancer were managed. A statistical analysis showed no significant difference in mortality, morbidity and hospital stay when comparing elective and emergency one staged resection and reconstruction.

[Low colorectal anastomosis: a comparison of manual and mechanical sutures]. / L'anastomosi colorettale bassa: sutura manuale e meccanica a confronto.

Sixty-three carcinomas of the lower third of the rectum operated of anterior resection with low colorectal or coloanal anastomosis are presented. Handsewn anastomoses were performed in 33 patients, while staplers were used in 30 cases. The average distance of the tumor from the anal verge is 10.8 cm. in hand sutured anastomoses and 7.8 cm. in stapled ones. Dehiscences, stenosis and temporary incontinence are observed more frequently after stapled anastomosis, while the incidence of neoplastic recurrences is higher in sutured anastomosis; hospital stay and mortality are similar in the two series. Our results and literature review show that both techniques are comparable though maintaining their own specific identity and precise indication.