Hyaluronidase: A New and Powerful Ally for Post-Rhinoplasty Fibrosis.

Rhinoplasty outcome may depend on different factors: patient's selection, technique, surgeons' skills and patient's healing. Different surgical maneuvers can be performed in order to reduce post-operative risk of fibrosis such as dead spaces' closure, sub-perichondral and subperiosteal dissection and nasal ligaments preservation or reconstruction. However, in some patients, especially the ones with thick and sebaceous skin, these maneuvers may not be enough. Here we propose a new alternative to treat post-rhinoplasty fibrosis using a combination of Triamcinolone Acetonide and Hyaluronidase. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The "Keystone Angle": Geometry in Preservation Rhinoplasty.

Rhinoplasty outcome may depend on different factors and bony dorsum shape has proven to significantly influence the lateral view result. The "Keystone angle" corresponds to the osseocartilaginous angle formed between bony and cartilaginous dorsum. Usually, the "V" shaped bony dorsum is characterized by a more acute "Keystone angle" compared to the "S" shaped bony dorsum. To achieve the ideal dorsum flatness, corresponding to a "Keystone angle" of 180°, different techniques may be used. Bearing these concepts in mind we suggest that preoperative assessment of the "Keystone angle" can guide the choice of the most appropriate technique for each patient. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Betadine-soaked gauzes intraoperative sizing in breast augmentation surgery.

In breast augmentation surgery, the correct evaluation of the implant size required is crucial to achieve satisfactory final result. Intraoperative volume decision is usually made by the use of silicone gel breast sizers. Intraoperative sizers have some disadvantages: the progressive loss of structural integrity, the increased risk of cross infection, the high costs. However, during breast augmentation surgery, it is mandatory to fill and expand the newly dissected pocket. In our practice we fill the dissected space with Betadine-soaked and then squeezed gauzes. The use of multiple soaked gauzes as sizers is advantageous for the following reasons: they fill and expand the pocket, they are useful to check the volume and to show the circumferential contour of the breast, to keep the pocket clean while dissecting the second one, to check final hemostasis and to compare the two breasts' size before definitive implant insertion. We simulated an "intra operative setting" where standardized volume Betadine-soaked gauzes were packed into a breast pocket. This easily reproducible and accurate technique is inexpensive and produces reliable and highly satisfactory results; it can be incorporated into the practice of any surgeon performing breast augmentation. Evidence Based Medicine (EBM) level: IV.

Glucose Enhances Pro-Tumorigenic Functions of Mammary Adipose-Derived Mesenchymal Stromal/Stem Cells on Breast Cancer Cell Lines.

Adiposity and diabetes affect breast cancer (BC) progression. We addressed whether glucose may affect the interaction between mammary adipose tissue-derived mesenchymal stromal/stem cells (MAT-MSCs) and BC cells. Two-dimensional co-cultures and spheroids were established in 25 mM or 5.5 mM glucose (High Glucose-HG or Low Glucose-LG) by using MAT-MSCs and MCF7 or MDA-MB231 BC cells. Gene expression was measured by qPCR, while protein levels were measured by cytofluorimetry and ELISA. CD44high/CD24low BC stem-like sub-population was quantified by cytofluorimetry. An in vivo zebrafish model was assessed by injecting spheroid-derived labeled cells. MAT-MSCs co-cultured with BC cells showed an inflammatory/senescent phenotype with increased abundance of IL-6, IL-8, VEGF and p16INK4a, accompanied by altered levels of CDKN2A and LMNB1. BC cells reduced multipotency and increased fibrotic features modulating OCT4, SOX2, NANOG, αSMA and FAP in MAT-MSCs. Of note, these co-culture-mediated changes in MAT-MSCs were partially reverted in LG. Only in HG, MAT-MSCs increased CD44high/CD24low MCF7 sub-population and promoted their ability to form mammospheres. Injection in zebrafish embryos of HG spheroid-derived MCF7 and MAT-MSCs was followed by a significant cellular migration and caudal dissemination. Thus, MAT-MSCs enhance the aggressiveness of BC cells in a HG environment.

Rhinoplasty Pre-Surgery Models by Using Low-Dose Computed Tomography, Magnetic Resonance Imaging, and 3D Printing.

Rhinoplasty and surgical reconstruction of cartilaginous structures still remain a great challenge today. This study aims to identify an imaging strategy in order to merge the information from CT scans and magnetic resonance imaging (MRI) acquisitions and build a 3D printed model true to the patient's anatomy, for better surgical planning. Using MRI, information can be obtained about the cartilage structures of which the nose is composed. Ten rhinoplasty candidate patients underwent both a low-dose protocol CT scan and a specific MRI for characterization of nasal structures. Bone and soft tissue segmentations were performed in CT, while cartilage segmentations were extrapolated from MRI and validated by both an expert radiologist and surgeon. Subsequently, a 3D model was produced in materials and colors reproducing the density of the three main structures (bone, soft tissue, and cartilage), useful for pre-surgical evaluation. This study has highlighted that the optimization of a CT and MR dedicated protocol has allowed to reduce the CT radiation dose up to 60% compared to standard acquisitions with the same machine, and MR acquisition time of about 20%. Patient-tailored 3D models and pre-surgical planning have reduced the mean operative time by 20 minutes.

Abdominal tattoo can be useful to avoid a midline abdominal incision.

We report a case in which abdominal tattoo margins were modified and used to hide the surgical incision for desmoid tumour removal. Our patient is a 37-year-old female with history remarkable for atrial septal defect closure at the age of ten, but not for previous abdominal surgeries or trauma. A desmoid tumour diagnosis was made upon needle biopsy of the 5 × 4 cm2 mass confined to the rectus abdominis. Subsequently, tumour was resected with an incision through the tattoo upper margin and abdominal wall was reconstructed with primary fascial closure mesh reinforced. Excision was radical, scar inconspicuous and no incisional hernia, bulging, nor tumour recurrence were detected at 2-year follow-up. This report highlights the fact that an abdominal tattoo might be considered as incision access instead of typical midline incision.

Submental flap as an alternative to microsurgical flap in intraoral post-oncological reconstruction in the elderly.

Oral and oropharyngeal squamous cell carcinoma (Scc) occur most commonly in middle-aged and elderly individuals. Free flaps are commonly used for reconstruction of extensive tumor resection defects in the oral cavity. Age alone is not an independent variable for increased risk in microvascular reconstruction; however operative time and ASA risk score correlated with medical complications but not with surgical complications. The submental island flap has proven to be a reliable alternative in reconstruction of composite oral cavity defects for its thinness, pliability and versatility in design, shared by the radial forearm free flap, and its advantageous donor site. The submental flap can be easily raised and involves shorter operative time and hospital stay compared to the free-flap procedure. It can be an excellent choice in patients with a high ASA risk score, moreover in elderly patients, where the potential complications linked to microsurgical procedures are avoided.

Thrombosed vascular malformation within the flexor tendon sheath of the index finger in the palm.

Vascular malformations are relatively infrequent among benign lesions of the hand. We report the case of an arteriovenous malformation in a 48-year-old white woman presenting a mass in her left hand without any symptoms. The diagnosis was confirmed by histopathology and the lesion completely removed by surgery.

Episode of massive pulmonary embolism after bilateral breast augmentation.

Pulmonary embolism is a rare postsurgical complication, even more so following breast augmentation. Herein we present a case of a 23-year-old woman who survived an episode of massive pulmonary embolism after breast implant surgery. Current literature about this subject is very scarce.

Microvascular free-flap transfer for head and neck reconstruction in elderly patients.

BACKGROUND: With the increase in life expectancy, the incidence of head and neck cancer has grown in the elderly population. Free tissue transfer has become the first choice, among all the reconstructive techniques, in these cases. The safety and success of micro vascular transfer have been well documented in the general population, but its positive results achieved in elderly patients have received less attention. METHODS: We retrospectively studied 28 patients over the age of 60 years. The aim of this paper was to study the success rate of free tissue transfer and investigate the complication incidence in this patient population. RESULTS: Twenty-eight free flaps were performed to reconstruct medium to large cervico-facial surgical defects in six years. No difference was noted between success and complication rates observed between general and elderly population. CONCLUSION: This study indicates that free-flap technique for head and neck reconstruction could be considered a safe option in elderly patients when a good pre-operative general status is present.