Double Free Transverse Upper Gracilis Flap Breast Reconstruction: Advantages of Using LD Flap as a Salvage Solution.

The lower abdominal tissue is still the most common donor site used for free autologous breast reconstruction. If this site is not available, multiple secondary choices exist. The transverse upper gracilis flap is a valuable choice and it can be used alone or in combination with other flaps. We present a case of a 49-year-old patient who underwent delayed unilateral breast reconstruction by using a double transverse upper gracilis flap. Due to venous thrombosis, the flap inserted in the lower pole was lost. We managed the complication tailoring a latissimus dorsi flap to close the defect. We reported the advantages of the latissimus dorsi flap as a rescue solution and its superior aesthetic result in this particular case. Breast reconstruction with transverse upper gracilis flap in addition to the latissimus dorsi flap allowed us to obtain an adequate breast volume avoiding the use of breast implants as desired by the patient. We thought that the double free transverse upper gracilis flap for delayed, or immediate unilateral reconstruction of small to moderate breast could be a valuable option to avoid the use of implants and when abdominal tissue is not available. However, it should be taken into consideration the shortness of the transverse upper gracilis pedicle, the necessity to perform a retrograde flow anastomosis at the level of the internal mammary, and the discrepancy of skin color tones with the receiving site. The latissimus dorsi flap was an excellent rescue solution and put in evidence the aesthetic superiority of this flap compared to the transverse upper gracilis flap.

Eccrine porocarcinoma: case report and review of the literature.

Eccrine porocarcinoma is a rare skin cancer that originates from the acrosyringium of eccrine sweat glands. From the clinical point of view the differential diagnosis with other skin cancers such as basal cell carcinoma and squamous cell carcinoma it is often impossible, only the histopathologic features can lead to the definitive diagnosis. Eccrine porocarcinoma can arise from a previous poroma or de novo, it may recur after surgical excision and cause lymph node and visceral metastasis. There are no international guidelines for treatment or follow-up of patients. The aim of this work was to present a rare case of eccrine porocarcinoma of the scalp successfully treated in our clinic and to extrapolate from the international literature the main clinical and histopathological features of eccrine porocarcinoma and the various experiences regarding the types of treatment.

Frontal Trigger Site Deactivation for Migraine Surgical Therapy.

BACKGROUND: The World Health Organization ranked migraine as the 19th worldwide disease causing disability. Recent insights into the pathogenesis of migraine headache substantiate a neuronal hyperexcitability and inflammation involving compressed peripheral craniofacial nerves, and these trigger points can be eliminated by surgery. In this study, we report our experience with minimally invasive surgical procedures for frontal migraine headache treatment. METHODS: From June 2011 to May 2019, we performed 70 frontal migraine decompression surgeries of both supratrochlear and supraorbital nerves (65 bilateral and 5 unilateral) by an endoscopic or transpalpebral approach. In 24 patients (34.2%), frontal migraine emerges as a secondary trigger point following primary occipital and/or temporal migraine surgery. RESULTS: After a mean follow-up of 24 months (range, 3-97 months), patients with frontal trigger site migraine reported a 94% positive response to surgery (32% complete relief and 62% significant improvement); 6% had no change in their symptoms. CONCLUSIONS: Based on our experience, the operation has not caused any serious complication or side effects, and surgical decompression of supraorbital and supratrochlear nerves might be recommended to patients who suffer from a moderate to severe chronic frontal migraine not responding to conventional therapy.

From liposuction to adipose-derived stem cells: indications and technique.

BACKGROUND AND AIM OF THE WORK: Adipose tissue is an organ of energy storage, an endocrine organ, a soft tissue filler and a cosmetically unnecessary tissue discarded by liposuction. Liposuction was designed to correct unaesthetic deposits of subcutaneous fat; it produces satisfactory silhouette contouring when performed by appropriately trained operators using properly selected technologies. However, from lipoaspirate it is possible to obtain autologous fat graft and adipose-derived stem cells (ASCs) for reconstructive surgery and regenerative medicine. Autologous fat transplantation uses include the correction of body contour, malformations and post-surgical outcomes. The regenerative properties of ASCs allow treating damaged tissues such as wounds, burns, scars and radiodermatitis. The aim of this study was to perform a literature review highlighting the crucial role of adipose tissue in plastic and reconstructive surgery, from liposuction to lipofilling and ASCs, exposing the indications, procedures and complications of these surgical techniques. METHODS: Literature review of publications concerning liposuction, lipofilling and adipose-derived stem cells (ASCS). RESULTS: The introduction of liposuction allowed the use of adipose tissue for many clinical uses. The adipose tissue filling properties have been highlighted by the advent of lipofilling. The regenerative properties evidence of autologous fat transplantation encouraged the research on the clinical use of ASCs. CONCLUSIONS: Adipose tissue is not only the main energy storage of our body but also an important source of stem cells that can be used in various fields of regenerative medicine and tissue engineering with encouraging results for the future.

Single center evidence for the treatment of basal cell carcinoma of the head and neck.

AIM: Basal Cell Carcinoma (BCC) alone accounts for 80% of cases of non-melanoma skin cancer (NMSC), which characteristically develops on sun-exposed skin. Indeed the most common site of BCC is the head and neck region (80%). The purpose of this study to review the experience of our center with BCC in the head and neck region to report the sites of occurrence and treatment. MATERIALS AND METHOD: We retrospectively reviewed 77 patients with BCC of the head and neck, who revived surgical treatment within our plastic surgery division. Basic demographic data, cancer site and size, surgical treatment and histological data were collected. The mean follow-up period was 12 months. RESULTS: The study population included 37 males and 40 females, with a mean age of 74.12 years. The nasal unit was the main site of BCC (31.82%), followed by the periorbital (13.64%) and cervical (12.5%) units. Primary closure was the main surgical procedure performed (72.5%), followed by local flap (26.1%) and full-thickness skin grafts (1.4%). The safety resection margin ranged from 4.5 to 9 mm, with a 98.7% complete removal rate. Neither recurrence nor any newly-developed lesions were reported during follow-up in any patient. DISCUSSION: Our work reflects the shift in the incidence of BCC, which now seems to be more frequent in females. Furthermore, our data strengthens the association between UVR exposure and BCC, confirms its predilection to occur on the nasal unit and validates surgical excision as the gold standard treatment for skin cancer.

Breast reconstruction with breast implants.

BACKGROUND: Breast cancer is the most common noncutaneous malignancy among women worldwide. After a breast cancer removal procedure, women are asked to decide about breast reconstruction, mainly to improve their life quality, and they can choose from among many options. Broadly, there are two different types of breast reconstruction procedures: prosthetic implant-based reconstruction and autologous tissue-based reconstruction. METHODS: Implant-breast reconstruction is a minimally invasive procedure compared with autologous breast reconstruction. It is associated with fewer short- and long-term complications. RESULTS: The ideal candidates for implant-based reconstruction are patients with non-redundant soft tissue coverage, who desire a moderate sized non-ptotic breast and have not been previously irradiated. CONCLUSION: The state of the art for implant-breast reconstruction is briefly described in this article.

Umbilical reconstruction: different techniques, a single aim.

The umbilicus is a unique physiologic scar of human life resulting from the healing process of the cut umbilical cord at birth. Its absence leads to an unnatural abdominal appearance, and an abnormally shaped or misplaced umbilicus may draw undue attention to the central abdomen. Loss of the umbilicus can be an embarrassing deformity; this occurs when older techniques of umbilical hernia or incisional hernia repair are employed and after abdominoplasty, urachal cyst repair, omphalocele repair, gastroschisis repair, some tumor excisions, and mobilization of bipedicled or bilateral TRAM/DIEP flaps for breast reconstruction. Umbilicoplasty, in which the umbilicus remains anchored to the deep abdominal fascia but is transposed through a newly-formed aperture in the upper abdominal skin flap, is performed in abdominoplasty either for abdominal flap harvest or purely for aesthetics. On the other hand, umbiliconeoplasty describes the de novo creation of an umbilicus that is absent for either congenital or acquired reasons. The optimal umbilical reconstruction should be reliable, reproducible, aesthetically appropriate, and associated with low morbidity. Ideally, it is also single-staged, except in the case of an infected wound, in which case a delayed primary approach may be prudent. (www.actabiomedica.it).

Surgical therapy of cutaneous squamous cell carcinoma: our experience.

INTRODUCTION: Cutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer, with an excellent prognosis after surgical removal. However, nodal metastasis are present in about 5% of cases and the death rate is about 2%. PRESENTATION OF CASE: The aim of this study is to report our experience about the surgical treatment of cSCC at the Cutaneous, Regenerative, Mininvasive and Plastic Surgery Unit, University of Parma, Italy, between January 2014 and February 2016. We statistically analyzed the group of patients regarding the average age, gender, localization and size of the lesions. The surgical margins of the excisions are studied and we report the results obtained after a follow up of 3 to 25 months. DISCUSSION: Between January 2014 and February 2016 in our Cutaneous, Regenerative, Mininvasive and Plastic Surgery Unit, we removed 36 squamous cell carcinomas, including 11 cSCCs in situ. The average annual incidence of squamous cell carcinoma in northeast of Italy is about 28,9  cases per 100,000 individuals.The number of cSCCs that we removed is lower than the Italian average. In our opinion, this is due to an increase in the early diagnosis of precancerous lesions and their medical or surgical treatment. This reduces the incidence of squamous cell carcinomas developing from precancerous lesions. CONCLUSION: The excision of cutaneous squamous cell carcinoma should be undertaken with a safety margin of at least 0.9 mm to minimize recurrence and metastasis.

Surgical Therapy of Temporal Triggered Migraine Headache.

BACKGROUND: The auriculotemporal and zygomaticotemporal nerves are the 2 primary trigger points in the temporal area of migraine headache. Different surgical approaches are described in literature, either open or endoscopic ones. METHODS: We described and delineated the currently adopted strategies to treat temporal trigger points in migraine headache. Furthermore, we reported our personal experience in the field. RESULTS: Regardless of the type of approach, outcomes observed were similar and ranged from 89% to 67% elimination / >50% reduction rates. All procedures are minimally invasive and only minor complications are reported, with an incidence ranging from 1% to 5%. CONCLUSIONS: Just like upper limb compressive neuropathies, migraine headache is believed to be caused by chronic compression of peripheral nerves (ie, the terminal branches of trigeminal nerve) caused by surrounding structures (eg, muscles, vessels, and fascial bands) the removal of which eventually results in improvement or elimination of migraine attacks. Particular attention should be paid to the close nerve/artery relationship often described in anatomical studies and clinical reports.

Off-label use of adipose-derived stem cells.

BACKGROUND: Adipose-derived stem cells (ASCs) have a broad range of clinical applications. The ease of cell harvest and high yield with minimal donor-site morbidity makes adipose tissue an ideal source of stem cells. Further, the multi-lineage potential of these cells present significant opportunities within the field of tissue engineering, with studies successfully demonstrating their ability to produce a range of tissue types. MATERIALS AND METHODS: Literature review of publications on the use of ASCs, in the context of current European and US regulations. RESULTS: According to European and US regulations, many clinical trials reported in literature to date could be considered off-label. CONCLUSION: In Europe, clinical trials involving cultured ASCs and/or the use of collagenase, which causes changes in the structural and functional properties of stem cells, and/or ASCs application in non-homologous tissue, should be considered off-label. ASCs should be non-cultured, isolated mechanically, and used only in the subcutaneous tissue.

Facial transplantation. An update of results and perspectives from tissue engineering.

BACKGROUND/AIM: Facial transplantation is a revolutionary procedure developed recently, which is indicated if autologous transfers fail to restore human appearance. More than 30 patients have undergone facial transplantation in different centers worldwide. Here, we provide an update on its main anatomical, surgical, immunological, ethical, and follow- up aspects. We also provide innovative perspectives of regenerative medicine and tissue engineering that could hold promise for this emerging surgical field. METHODS: Through careful review of the anatomical, surgical, and tissue-engineering literature, we documented the main aspects of this innovative surgical procedure and its potential improvements in regenerative plastic surgery. RESULTS: Compatibility for the major blood groups (ABO) and human leukocyte antigen system between donor and recipient is critical to transplantation success. Major complications are tissue rejection and side effects of immunosuppression. The functional outcomes of facial transplantation are encouraging, with slow recovery of motor and sensory functions. Psychological impact on the family of the donor and recipient is essential for the success of facial transplantation. CONCLUSIONS: Uncertainty of long-term outcomes, immunosuppression-related concerns and ethical debates limit worldwide application of facial allotransplantation. However, in selected patients it is a unique reconstruction method with promising outcomes. Recent developments in regenerative medicine open a new frontier for application of patient-tailored, biocompatible and engineered reproductions of the various anatomical components of the face, and their application to transplant technology. Further research in transplant immunology, survival and conservation of grafts, and regenerative treatments of lesioned and/or transplanted tissues hold the key to advances in this emerging surgical option. KEY WORDS: Facial transplantation, Plastic surgery, Reconstructive surgery, , Regenerative medicine, Tssue engineering.

Breast reconstruction with anatomical implants: A review of indications and techniques based on current literature.

One important modality of breast cancer therapy is surgical treatment, which has become increasingly less mutilating over the last century. Breast reconstruction has become an integrated part of breast cancer treatment due to long-term psychosexual health factors and its importance for breast cancer survivors. Both autogenous tissue-based and implant-based reconstruction provides satisfactory reconstructive options due to better surgeon awareness of "the ideal breast size", although each has its own advantages and disadvantages. An overview of the current options in breast reconstruction is presented in this article.

Reduction mammoplasty techniques in post-bariatric patients: our experience.

BACKGROUND AND AIM OF THE WORK: Excessive body weight represents a huge problem affecting a wide part of world population, causing significant physical and psychological consequences. To solve their obesity-related problems, patients should begin a bariatric treatment to lose an adequate percentage of their body mass and therefore, they should be subjected to body contouring surgery. In this article we describe our experience in applying breast remodeling techniques to post-bariatric patients. METHODS: We did a retrospective study on our post-bariatric patients subjected to breast reduction and/or mastopexy during a five-years period, considering breast features, kind of surgery performed, aesthetic and psychological outcomes and postoperative complications. RESULTS: Thirty-six post-bariatric patients underwent breast surgery in our unit between 2010 and 2015; their average age was 43 years. The follow up period ranged from 6 months to 4 years and an half. The most frequent surgical techniques performed were Thorek and inferior pedicle breast reduction. The prevalent complications observed were surgical wound delayed healing and nipple-areolar complex (NAC) partial or complete necrosis as immediate ones and unfavorable scarring as delayed ones. CONCLUSIONS: Breast reshaping after a massive loss of weight should be forerun by an accurate analysis of breast volume, shape and ptosis degree, in order to obtain optimal results both for the surgeon and the patient.

Procedure, applications, and outcomes of autologous fat grafting.

OBJECTIVE: To systematically review the procedure, applications, and outcomes of autologous fat grafting, a promising technique with various clinical applications. PATIENTS AND METHODS: Literature review of publications concerning autologous fat grafting. RESULTS: Since its introduction, lipofilling has become increasingly popular; however, its results are variable and unpredictable. Several modifications have been made to the procedures of fat harvesting, processing, and injecting. Surgical excision and low negative-pressure aspiration with large-bore cannulas minimize adipocyte damage during fat harvesting. The "wet" method of fat harvesting involves fluid injection at the donor site and facilitates lipoaspiration while minimizing pain and ecchymosis. For fat processing, centrifugation at a low speed is preferable to high-speed centrifugation, gravity separation or filtration. Fat injection at the recipient site should be performed using small-gauge cannulas in a fanning out pattern over multiple sessions, rather than a single session. Fat grafts exhibit not only dermal filler properties but also regenerative potential owing to the presence of stem cells in fat tissue. Thus, the clinical applications of autologous fat grafting include correction of secondary contour defects after breast reconstruction, release of painful scar contractures, and treatment of burn scars and radiodermatitis. Lipofilling is also used in aesthetic surgery, such as facial and hand rejuvenation, augmentation rhinoplasty, and breast and gluteal augmentation. The complications of lipofilling are minimal and include bruising, swelling, pain, infection, necrosis, and calcification. CONCLUSIONS: Lipofilling is a low-risk procedure that can be used to correct soft-tissue defects in the face, trunk, and extremities, with minimal discomfort for patients.

The biological and clinical basis for the use of adipose-derived stem cells in the field of wound healing.

Worldwide, hard-to-heal lower limb wounds are estimated to affect 1.5-3% of the adult population with a treatment-related annual cost of $10 billion. Thus, chronic skin ulcers of the lower limb are a matter of economic and public concern. Over the years, multiple medical and surgical approaches have been proposed but they are still inadequate, and no effective therapy yet exists. Regenerative medicine and stem cell-based therapies hold great promise for wound healing. Recently, many plastic surgeons have studied the potential clinical application of adipose-derived stem cells (ASCs), which are a readily available adult stem cell population that can undergo multilineage differentiation and secrete growth factors that can enhance wound-healing processes by promoting angiogenesis, and hence increase local blood supply. ASCs have been widely studied in vitro and in vivo in animal models. However, there are few randomized clinical trials on humans, and these are still ongoing or recruiting patients. Moreover, there is no consensus on a common isolation protocol that is clinically feasible and which would ensure reproducible results. The authors aim to provide readers with an overview of the biological properties of ASCs as well as their clinical application, to help better understanding of present and future strategies for the treatment of hard-to-heal wounds by means of stem cell-based therapies.

Adipose-derived stem cells: Comparison between two methods of isolation for clinical applications.

BACKGROUND: Adipose-derived stem cells are recognized as being an effective mesenchymal stem cell population with enormous potential in different fields of regenerative medicine and stem cell therapy. Although there is unanimous agreement on the harvesting procedure for adipose tissue, there are various protocols for adipose-derived stem cell isolation. The aim of this study was compare two methods of adipose-derived stem cells (ASCs) isolation, one based on a mechanical + enzymatic (ME) procedure and the other one exclusively mechanical (MC), in order to determine which one was superior to the other in accordance with current European and US legislation. METHODS: We reported step by step the two different methods ASCs isolation by comparing them. The ME procedure included the use of a centrifuge, an incubator and collagenase digestion solution (Collagenase NB 6 GMP Grade 17458; Serva GmbH, Heidelberg, Germany). The MC procedure was performed by vibrating shaker and centrifuge, both placed in a laminar airflow bench. RESULTS: With the ME procedure, a mean of 9.06 × 105 ASCs (range, 8.4 to 9.72 × 105; SD ± 6.6 × 105) was collected, corresponding to 25.9% of the total number of harvested cells. With the MC procedure, a mean of 5 × 105 ASCs (range: 4.0 to 6.0 × 105; SD, ±1 × 105) was collected, corresponding to 5% of the total number of harvested cells. CONCLUSION: Based on data collected, from the same amount of lipoaspirate the ME procedure allowed to isolate a greater number of ASCs (25,9%) compared to the MC one (5%).

Autologous fat transplantation for breast reconstruction: A literature review.

INTRODUCTION: The use of autologous fat transplantation to correct volume and contour defects, scars, and asymmetry after breast cancer surgery has increased over the past 20 years. Many developments and refinements in this technique have taken place in recent years, and several studies of the safety of lipofilling in the breast have been published. PRESENTATION OF CASE: We performed a literature review of this technique, highlighting the crucial role of lipofilling in breast cancer reconstruction. DISCUSSION: The efficacy of the fat graft transplantation depends on the experience and the technique used by the surgeon. The ASCs (adipose-derived stem cells) contained in the fat graft has proven to be crucial for breast reconstruction by mean the regeneration of tissue, through the chemotactic, paracrine, and immunomodulatory activities and their in situ differentiation. CONCLUSION: The role of lipofilling for breast reconstruction could be more significant with the application of the findings of experimental research on tissue engineering and ASCs.

Post-bariatric body contouring: oue experience.

Obesity is a growing socio-economic problem especially in the western population. Patients who are undergoing bariatric surgery after a significant weight loss have an altered body profile which may have an important psychological impact. These patients may be candidates for surgical body-lifting. The aim of body-lifting is to obtain a firmer, tighter, rejuvenated appearance for patients who have lax, ptotic tissues. In this paper we describe our experience with two techniques currently practiced by our team, brachioplasty and thigh lift, reporting the indications, the surgical technique and possible complications.