Destructive granulomatous reaction to polyacrylamide lip injection: solution for a complex case.

The inappropriate and careless use of permanent fillers causes severe and undesirable side effects, as shown by a number of reported clinical cases. The dramatic case described in this report strongly demonstrates that inadequate knowledge of implanted materials has a heavy impact on the patient's health and his or her desired results. Both are aspects that sometimes prove very difficult to ameliorate. Moreover, the solution for the reported case clearly demonstrates that only the careful application of fine surgery can solve these problems. This is true also for cases initially believed to be hopeless.

A vast intranasal filler-induced granulomatous reaction: a case report.

The widespread and inappropriate use of permanent fillers has given rise to several problems. The reported case clearly demonstrates that inadequate knowledge of the surgical technique and the material implanted has a heavy impact on the postoperative outcome. The application of fine surgical techniques and adequate knowledge of the materials can solve and prevent these problems.

[Computer-based preoperative planning for breast reconstruction in the woman with unilateral breast hypoplasia]. / Pianificazione computerizzata per la ricostruzione mammaria in donne affette da ipoplasia mammaria unilaterale.

BACKGROUND: Aim of this paper is to describe a computer program which can provide objective and quantitative data useful for the selection of the proper implant in order to obtain the symmetry with the contralateral breast in case of unilateral breast reconstruction by tissue expansion, especially for the surgeon without experience or for the occasional operator. METHODS: Our C++ program provides the final implant volume using the measurements of the semi-circumference and projection of the contralateral breast performed on the supine patient. The aim is the symmetry of the two breasts. RESULTS: According to our experience in breast reconstruction by tissue expanders, this program allows non invasive and simple measurements of the breast volume, useful to obtain the mammary symmetry. CONCLUSIONS: In case of breast reconstruction by tissue expansion, the preoperative evaluation is usually based on the surgeon's experience and on empirical observations without knowing the correct volume to reach. For this reason our program is useful to know the necessary volume for breast reconstruction, and therefore it allows the surgeon to obtain a better plastic result.

[Experimental model for the evaluation of topical application of a solution to help myocutaneous flap transposition]. / Modèle expérimental pour l'évaluation d'une solution topique améliorant la survie des lambeaux myocutanés.

The aim of this article is the evaluation of the topical application of a solution of hydrogen peroxide (H2O2) 8% and dimethyl sulphoxide (DMSO) 50% in order to reduce ischaemic failure in random skin flaps. This study was performed using a rabbit model. Two parallel, cephalad-based para-midline random cutaneous flap (10 cm x 2.5 cm) were elevated and resutured in place on the dorsum of 40 New Zealand rabbits. The 80 flaps thus obtained were then randomly divided into one control group and three experimental groups of 20 flaps each. Flaps from the control group (group A) were topically treated with saline, while flaps from experimental group B were treated with H2O2 8%, flaps from experimental group C with DMSO 50%, and flaps from experimental group D with a solution of 50% DMSO + 8% H2O2. Each solution was topically applied, 20 cc per three times a day, on the flaps for seven days, starting on the immediate postoperative period. Transcutaneous oxygen tension (Ptc O2) measurements were carried out in all flaps, 72 h after flap elevation. The percentage of surviving skin area of each flap was determined by planimetry 7 days after flap elevation. The mean surviving area of the group A (control) flaps was 71%. The mean surviving area of the group B (H2O2-treated) flaps was 72%. The mean surviving area of the group C (DMSO-treated) flaps was 76%, and that of the group D (DMSO + H2O2-treated) flaps was 92%. While no statistically significant differences were found between the survival rates of both the flaps treated with H2O2 or DMSO alone and that of the control group, the mean surviving rate of the DMSO + H2O2 treated flaps (+20%) was statistically higher than that of the control flaps. Similarly, a statistically significant difference has been found between the mean Ptc O2 values of the DMSO + H2O2 flaps and those of the other three groups of flaps.

[Computer-aided preoperative planning of tissue expansion]. / Pianificazione preoperatoria dell'espansione tissutale supportata dal computer.

OBJECT: The aim of this paper is to introduce a computer program developed to provide objective and quantitative data useful to provide proper expander selection when a rectangular tissue expander has to be used. METHODS: The program has been developed to calculate the volume of a rectangular tissue expander to obtain the exact amount of yield necessary to allow for reconstruction of a determined defect. The only data to be supplied are the length and the width of the defect to be reconstructed. RESULTS: The accuracy of the results obtained by the computer program was tested clinically comparing preoperative data with volume measurements obtained at the end of the expansion procedure. In our study the resulting data did not show any statistically significant difference (p<0,05) between the two groups. CONCLUSIONS: In our opinion, although its use is not aimed at replacing clinical judgment based on experience and careful observation, this program may be considered a simple and useful adjunct for the inexperienced surgeon (or the occasional operator) planning to use a rectangular tissue expander.

[Minimally-invasive endoscopic transthoracic sympathectomy of the upper limbs. A new method]. / Denervazione simpatica mini-invasiva degli arti superiori. Nuova metodica.

OBJECTIVE: Indications for endoscopic transthoracic upper dorsal sympathectomy are axillary and palmar hyperhidrosis, upper extremities ischemia (due to, e.g., Raynaud s disease), and upper extremities causalgia. METHODS: At present, this methodology relies on (at least) double trocar insertion (per side) and/or carbon dioxide insufflation. Thus, although this approach, compared with the traditional open sympathectomy techniques, it guarantees the smallest number of postoperative complications, it still determines a certain amount of postoperative discomfort as well as a risk of complications related to carbon dioxide insufflation, as intraoperative profound bradycardia and hypotension due to mediastinal shift, and postoperative subcutaneous emphysema. From December 1995, we are using a minimally-invasive endoscopic transthoracic sympathectomy technique, performed by a single-entry specifically modified thoracoscope and without the need for carbon dioxide insufflation, with the aim to reduce the drawbacks associated with the above-mentioned currently adopted endoscopic techniques. After general anesthesia with double-lumen endotracheal tube, with the patient placed in a half-sitting position with both arms abduced to 90 degrees, a 1 cm incision is performed, along the midclavear line (in male patients) or the anterior axillary line (in female patients), in the second or third intercostal space. RESULTS: The effects of sympathectomy are immediate, and the patients wake up with warm and dry hands and axillae. CONCLUSIONS: In personal opinion, this single-entry technique, compared with other reported approaches, should minimize any damage to the intercostal neurovascular bundle, while avoiding the complications connected with carbon dioxide insufflation.

[Computer planning for postmastectomy breast reconstruction by tissue expansion]. / Pianificazione computerizzata per la ricostruzione mammaria postmastectomia mediante espansione tissutale.

Aim of this paper is to present a computer program able to provide objective and quantitative data useful to guarantee the selection of the proper implant in order to obtain symmetry with the contralateral breast, in case of unilateral breast reconstruction by tissue expansion, especially for surgeons without experience or for occasional operators. Our C++ program provides the final implant volume using the measurements of the semi-circumference and projection of the contralateral breast performed on the supine patient. The aim is the symmetry of the two breasts. According to personal experience in breast reconstruction by tissue expanders, this program allows non invasive and simple measurements of the breast volume, useful to obtain the mammary symmetry. In case of breast reconstruction by tissue expansion, the preoperative evaluation is usually based on the surgeon experience and on the empirical observation without knowing the correct volume to reach. Since this program is useful to know the precise necessary volume for breast reconstruction, it allows the surgeon to obtain a better plastic result.

Quantitative benefits provided by acute tissue expansion: a biomechanical study in human cadavers.

The aim of this study was to test the ex vivo biomechanical properties of acutely expanded cutaneous flaps to quantitatively assess the efficacy of intraoperative tissue expansion. A total of 14 fresh male cadavers were used for the study. In each cadaver, a rectangular (15 x 8 cm), proximally based flap was designed on each side of the body, in three different locations: lateral arm, anterior thorax, anterior thigh. In each cadaver, one randomly selected flap per each body region underwent acute-intermittent expansion, whereas the contralateral flap served as control. The biomechanical properties (stress/strain ratio, mean stiffness) of both expanded and control flaps were then assessed by means of a dynamometer and a force-transducer. The obtained data showed that the biomechanical benefits provided by acute tissue expansion were statistically different (P< 0.05) from those obtained by simple subcutaneous undermining. While no changes of length have been observed in the acutely expanded skin flaps as compared to control cutaneous flaps, a statistically significant gain in the compliance of the former has been recorded as compared to the biomechanical behaviour of the latter.

[Intraoperative expansion of scalp flaps. Quantitative assessment]. / Espansione intraoperatoria di lembi di scalpo. Valutazione quantitativa.

BACKGROUND: The aim of this study was to test the ex-vivo biomechanical properties of acutely expanded scalp flaps, in order to quantitatively assess the efficacy of acute scalp expansion. METHODS: A total of 14 fresh male cadavers were used for the study. In each cadaver, a rectangular (4 x 10 cm), laterally-based flap was designed on each side of the scalp, starting from the superior margin of the external auditory canal. One randomly-selected flap per each scalp underwent acute-intermittent expansion (3-minute expansion-3-minute rest cycle per three times with the maximal expansion achievable), while the contralateral flap served as control. After the expansion process, the acutely-expanded flaps were measured to assess if the applied biomechanical stress have determined any changes in their dimensions. The biomechanical properties (stress/strain ratio, mean stiffness) of both expanded and control flaps were then assessed by means of a dynamometer and a force-transducer. RESULTS: The obtained data showed that the biomechanical benefits provided by acute scalp expansion were not statistically different (p < 0.05) from those obtained by simple subgaleal undermining. Neither any change of length nor any gain in the compliance have been observed in the acutely-expanded flaps as compared to control scalp flaps. CONCLUSIONS: In our opinion, a possible explanation (to be further validated) for the lack of effect of acute scalp expansion might be that inelastic galea aponeurotica did not allow the mechanical creep to exploit the inherent elastic properties of the overlying scalp skin.

Cleft lip: a histochemical and ultrastructural analysis of lip muscles.

AIMS: In order to evaluate the pathogenesis of cleft-lip in relation to both the anatomical and structural anomalies of the mesenchymal tissues, the authors concluded that the presence of structural anomalies in the examined tissues could not explain the malformation, but might be a consequence of it. Delayed muscular development, asymmetrical distribution of the muscular fibres and their anomalous insertion suggest that the anatomical/functional loss clinically detectable in the orbicular muscle could be the result of a perinatal dysmorphological process rather than of a simple mesenchymal hypoplasia. METHODS: Schendel et al. suggested that a metabolic defect in the mitochondrial function could cause a deficiency in cell migration and proliferation responsible for the malformation in question. To establish whether the pathogenesis of the cleft-lip is associated with an alteration in mitochondrial functionality, eight patients affected by unilateral cleft-lip were subjected to a biopsy of the orbicular muscle during the course of reparative surgery. RESULTS: The results obtained showed: 1) a great variation in the size of muscle fibres; 2) the absence of ragged red fibres; 3) a normal oxidative function in the muscle fibres examined; 4) the absence of typologically significant groupings positive for myofibral ATPases. Furthermore, the morphology of the mitochondria was preserved in all cases and neither inclusions nor morphological or volumetric changes were detected. CONCLUSIONS: This preliminary data did not confirm the constant presence of mitochondrial pathology responsible for the malformation in question. In our opinion, the growth deficiency of the maxillary segment could be ascribed to the cicatrization of the surgical repair of the cleft-lip.