Objective and subjective evaluation of Velopharyngeal Dysfunction (VPD) following surgical repair of the cleft palate using the furlow palatoplasty - A new tool.

Velopharyngeal dysfunction (VPD) diagnosis and speech surgery outcomes are currently based solely on subjective evaluation criteria consisting of perceptual speech assessment and functional imaging. This study describes an objective and comparable method in VPD assessment and investigates the concurrence between the objective and subjective evaluations. The present study included 20 paediatric patients presenting with VPD after primary repair (intravelar veloplasty) of cleft palate. Our protocol was based on computerized analysis of voice parameters by means of an objective tool, spectrography integrated with Multi-Dimensional Voice Program (MDVP). The protocol also included perceptual evaluation by speech therapist and phoniatrician (consensus listening), and parents. This is a single surgeon, single centre experience and all patients underwent a secondary Furlow's palatoplasty. Assessments were performed pre- and postoperatively and upon completion of speech therapy. Results were compared using the two-tailed t student test for paired data. Statistical significance was set for p-values <0.05. Data analysis confirmed an improvement in velopharyngeal closure after surgery and speech therapy consistently with the results of perceptual evaluations. The results of the study confirmed the availability and reliability of an objective method for VPD evaluation based on the analysis of voice parameters with investigations that are simple and easily available in a hospital setting.

Engineered mucoperiosteal scaffold for cleft palate regeneration towards the non-immunogenic transplantation.

Cleft lip and palate (CL/P) is the most prevalent craniofacial birth defect in humans. None of the surgical procedures currently used for CL/P repair lead to definitive correction of hard palate bone interruption. Advances in tissue engineering and regenerative medicine aim to develop new strategies to restore palatal bone interruption by using tissue or organ-decellularized bioscaffolds seeded with host cells. Aim of this study was to set up a new natural scaffold deriving from a decellularized porcine mucoperiosteum, engineered by an innovative micro-perforation procedure based on Quantum Molecular Resonance (QMR) and then subjected to in vitro recellularization with human bone marrow-derived mesenchymal stem cells (hBM-MSCs). Our results demonstrated the efficiency of decellularization treatment gaining a natural, non-immunogenic scaffold with preserved collagen microenvironment that displays a favorable support to hMSC engraftment, spreading and differentiation. Ultrastructural analysis showed that the micro-perforation procedure preserved the collagen mesh, increasing the osteoinductive potential for mesenchymal precursor cells. In conclusion, we developed a novel tissue engineering protocol to obtain a non-immunogenic mucoperiosteal scaffold suitable for allogenic transplantation and CL/P repair. The innovative micro-perforation procedure improving hMSC osteogenic differentiation potentially impacts for enhanced palatal bone regeneration leading to future clinical applications in humans.

Advances in bioengineering of complex tissues: state of the art of mucosae decellularization protocols.

The loss or deficiency of a tissue or organ is a serious health problem and severely affects the patients' quality of life. In the near future, an option for solving this problem will be the development of bio-derived extracellular matrices (ECM) from huPlastic Romaman or animal tissues and their usage for in vitro or in vivo cellular reseeding. Many researchers are working on this development. Nowadays, different decellularization protocols have been developed to manufacture ECMs but there is not yet a consensus about the most efficient procedures. This review aims to describe the state of the art in the field of decellularization of complex mucosal tissues, analizing and comparing the most recent and most valiant articles published about this procedure.

Processing techniques of the adipose tissue: centrifugation vs decantation.

The processing techniques of the adipose tissue represents one of the most debated topics. There are different processing techniques. As of today, the standard considered procedure is the centri1Romafugaton according to Coleman. In addition, other procedures include decantation/sedimentation, filtration and water jet force, which offer the specialist valid alternatives. In the present review, the clinical evidence of the techniques of centrifugation and decantation will be evaluated by studying histological data; maintenance of tropism and the maintenance of mesenchymal cells. These two aspects are different in the centrifugation and decantation techniques.

New body contouring technique in male: the muscular sculpture.

UNLABELLED: Optimal male body contouring considers the entire body and drapes tight skin over the muscles. Males have pride in the appearance of their muscular development. There should be a deliberate effort to achieve an athletic body contour that reveals superficial musculature and selectively highlights adherences. We describe a new technique of male body contouring to achieve tight skin that very well reveals muscular bulk and accentuates adherences; minimal observable scars; a male muscular and athletic body, even for patients who are not, nor have been in the past, bodybuilders. Normal-weight and overweight patients need one operative step, in which the fat is removed and the muscles are sculpted at the same time by using selective liposuction, and if necessary, the fat is repositioned through lipofilling. The ex-obese patients need two operative steps: in the first, we perform abdominoplasty with inguinal scar (to remove the excess abdominal tissue and to lift the pubis) and periareolar scar (to breast lift and reduction); in the second, we sculpt the muscles and the adherences by selective liposuction. In all male patients, the authors strive to achieve a trapezoid chest and sculpted pectoralis major muscle, pronounced alba and semilunar lines, evident muscular bulk, and adherences in both the abdomen and extremities. 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.

Prepuce-sparing plasty and simple running suture for phimosis.

AIM: Circumcision is the most common procedure for phimosis. In recent years, the value of foreskin properties as well as aesthetic reasons determined to other operations preserving the foreskin. We report 5-years experience with a technique that preserve the physical foreskin appearance intact. PATIENTS AND METHODS: Fifty-two patients, eligible to undergo phimosis surgery, underwent prepuce-sparing plasty and simple running suture. Evaluation of results was made with photos comparative and verified by using presence/absence of recurrence, scarring evaluation, and VAS for patient satisfaction. RESULTS: Forty-eight patients reported no complications. There were no cases of bleeding, infection, pathological scarring, phimosis recurrence. The scar showed a good pliability and a thin thickness. Patient satisfaction was high. CONCLUSIONS: The association of prepuce-sparing plasty and simple running suture highlighted an effective and easy method for the correction of acquired phimosis in adult patients, with excellent functional and cosmetic results.

Multicentric osteolytic lesion of the middle finger of the hand. Case report.

Giant cell-rich osteolytic lesions may have overlapping clinical, radiologic, and histopathologic features, with an important degree of difficulty of diagnosis and treatment. We report a case of double osteolytic lesion at the middle-finger in a young man without previous history of hand trauma. He underwent en-bloc resection of the bone lesions and reconstruction by graft of hydroxyapatite, resulting in a good morpho-functional result. Histological diagnosis was giant cell reparative granuloma (GCRG), although several features were considered atypical, including the appearance of the giant cells and the areas of the stroma that more closely resembled a giant cell tumor. GCRG is a benign rare intraosseous lesion and the true nature is controversial and unknown. The theories are that it could be a reactive lesion, a developmental anomaly or a benign neoplasm. It appears as an osteolytic lesion that must be considered in the differential diagnosis of other "critical" bone lesions similar in clinical, as well as radiologic and pathological appearance. Further characterization studies are helpful and necessary for the proper management.

Comparative analysis between nasolabial and island pedicle flaps in the ala nose reconstruction. Prospective study.

The goals of reconstructing deformities of the face secondary to skin cancer include reconstructing the area with similar tissue. The comparison between different types of local flaps for reconstruction of nasal ala is presented in a prospective, randomized study. The objective of this study was to compare the functional and esthetic outcomes between the nasolabial and island flaps. A total of 60 patients with skin cancer of the nose underwent ala reconstruction: 30 cases by nasolabial flap (group A) and 30 by island flap (group B). The two groups were homogeneous for sex, age, and anatomical area. Complications, scarring according to the scale of Vancouver, cosmetic appearance, and disorders of sensations were analyzed and statistical analysis was performed. In group A, early complications were more common than in group B. The scars of group B patients were more like those of undamaged skin. A total of 10% patients of group A evaluated the cosmetic appearance of their nose as very good, while in group B, 30% patients gave such an evaluation. Local flaps provide better reconstruction and the island flap appears to have more efficacy when compared with nasolabial flap for nasal ala reconstruction.

Extensive facial trauma caused by dog bites in woman suffering from systemic fluconazole-resistant Candida infection.

INTRODUCTION: Dog bites present a complex problem. Extensive facial trauma is a challenging problem to treat with priority for functional outcome. This paper describes the conservative treatment in a very difficult case of facial trauma with unusual infections due to the bites. CASE REPORT: A 45 year-old woman was admitted in hypovolaemic shock with amputation of nose, upper and lower lips, left cheek and chin caused by dog bites. After vital parameters and volaemy were stabilized, wound toilet was performed, followed by skin and mucosal rotation flaps and anterior nasal tamponade; the lesion has then been covered with a collagen/oxidized regenerated cellulose dressing and sterile gauzes. Culture test highlighted coagulase-negative Staphylococcus and Candida albicans. However after few days, the patient developed septic-undulant hyperpyrexia, retinitis, renal candidiasis, folliculitis. Systemic Candida infection resistant to fluconazole was diagnosed. Amphotericin B was given to the patient and the facial wound was managed conservatively with an active medication because of inoperability conditions. The outcome of the use of active medications was an immediate response with excessive granulation tissue followed by a rapid re-epithelization. CONCLUSION: As our case has shown, conservative treatment can be a valid alternative therapy in the treatment of large wounds with invasive candidosis and candidaemia or other major contraindications to surgery. In fact, in cases where surgical reconstruction is not a feasible option, conservative treatment can allow a rapid repair of the skin barrier.

Comparison of surgical methods in catastrophic antiphospholipid syndrome (CAPS).

Antiphospholipid syndrome (APS) is an autoimmune condition characterized by vascular thromboses and/or pregnancy morbidity in the presence of antiphospholipid antibodies. The variant "catastrophic" (CAPS) is defined as a potential life-threatening disease, characterized by multiple small vessel thromboses that can lead to multiple organ failure. Surgery is between precipitating factors in CAPS International Registry, but it's still unclear the relationship between surgery and syndrome. The present study reports two surgical procedures, performed on two patients with APS admitted with diagnosis of loss of substance of the lower limb needing of reconstructive treatment. We compared and analyzed aggressive and minimally invasive surgery.

Customized mini-plate for scaphoid fractures and nonunions.

Scaphoid fractures detected in the subacute stage require a more meticulous and prompt approach to prevent chronicity and regain wrist function. Oblique-type scaphoid fractures are potentially unstable and may result in detrimental sequelae. Aim of this study is to suggest an easy surgical approach to restoration of the oblique-type scaphoid fractures or nonunions by using of a customized mini-plate, italic-S shaped. This surgical intervention is associated with promising outcomes and at long-term follow-up showed to avoid the development of a carpal collapse with concomitant arthritis of the radiocarpal joint.

A single blind controlled comparison of tramadol/paracetamol combination and paracetamol in hand and foot surgery. A prospective study.

The objective of this study was to compare the efficacy and effectiveness between an analgesic combination of tramadol/paracetamol (37.5+325 mg), and paracetamol monotherapy (1000 mg) for acute postoperative pain after hand and foot surgery. The study design was a single blind randomized controlled trial. A total of 114 patients who underwent hand and foot surgery under brachial plexus block were randomized to receive either paracetamol monotherapy (group P, n=57) or tramadol/paracetamol (group TP, n=57) postoperatively. The number of patients who required an extra-dose of analgesic pain score, and adverse affects were compared between the two groups. Analgesic requirement was significantly lower in those in the TP group when compared with the P group. In the TP group, the pain score after surgery was significantly lower than in the P group. Adverse effects did not significantly differ between the two groups. There were no serious adverse events in either group. The association of tramadol and paracetamol appears to have more efficacy when compared with paracetamol monotherapy for acute postoperative pain after hand and foot surgery.

Treatment of persistent radial nerve palsy through "tendon minimal transfer" technique.

Palliative tendon transfer procedures for radial nerve palsy are continuing to evolve. This paper reports outcomes of 10 patients with isolated and traumatic radial nerve palsy underwent "minimal transfer". All patients improved functionally and could attend their routine activities. The flexor carpi ulnaris and palmaris longus tendon transfer has some advantages in terms of simplicity, shorter operative time, less morbidity, better wrist and finger extension and thumb extension and abduction.

Ulnar artery thrombosis and nerve entrapment at Guyon's canal: our diagnostic and therapeutic algorithm.

Hypothenar hammer syndrome is a rare condition of ulnar artery aneurysm or thrombosis, which can be associated with a neuropathy of the ulnar nerve. There is no agreement regarding an optimal diagnosis and treatment for this syndrome. Most authors suggest angiography as the gold standard for diagnosis and recommend observation for the thrombotic type, and reconstructive surgery for the aneurysmal type. We report here our diagnostic and therapeutic algorithm, reviewing 9 patients with ulnar artery thrombosis and nerve entrapment at Guyon's canal; and an evaluation of the type of management including: anamnesis, diagnostic tests, and reconstructive surgery. We consider resection of the arterial thrombotic segment as the treatment of choice, due to the fact that ulnar arterial thrombosis can induce severe chronic inflammation into Guyon's canal and ulnar nerve sufferance. Therefore, we propose a planned approach, including 3 steps: clinical evaluation with Tinel and Allen's tests; magnetic resonance and ultrasound images; ulnar nerve decompression and arterial reconstruction. We believe that this practice is important for the early therapy of ulnar arterio-neuropathy in affected patients.

["Step technique" in the treatment of the loss of substance of the lower lip]. / Tecnica "a scaletta" nel trattamento delle perdite di sostanza del labbro inferiore.

The most frequent pathology of the lower lip is the neoplastic pathology and squamous cell carcinoma is the most clinically diagnosed. Wide excision is the correct surgical approach but it may cause severe morpho-functional and aesthetic damages. At the Plastic and Reconstructive Department of Policlinico Umberto I, " Sapienza" University of Rome, from 2005 to 2008 36 patients were treated, 19 only by surgical excision (Group I) and 17 by Johanson's technique (Group II). Follow-up was at 6 and 12 months to evaluate the morpho-functional outcome, the asymmetry and the healing. Moreover a questionnaire of 9 items was proposed to patients to evaluate functional and aesthetic results. Data showed that Johansons' s flap achieves the same results of the complete surgical excision but with better morpho-functional and aesthetic outcomes, greater satisfaction and same staying in hospital for patients.

Innovative microsurgical device in perforator free flaps surgery.

Dissection of the small perforating vessels through the muscle/septum can be difficult, and microsurgical success is closely linked on a clear and well-magnified field vision. Since 2004, Varioscope M5 has been employed in our Plastic Surgery Departments. It is the first and only head-mounted microscope. In this study was examined 10 patients underwent to reconstructive procedures by harvest of perforator free flaps, working with Varioscope M5. At long-term follow-up, all patient present an exceptional outcome. Considering cost-effectiveness, portability, operator freedom, and effectiveness in the perforator flaps dissection and in the anastomosis making, we think that Varioscope M5 offers essential advantages Dissection of the small perforating vessels through the muscle/septum can be difficult, and microsurgical success is closely linked on a clear and well-magnified field vision. Since 2004, Varioscope M5 has been employed in our Plastic Surgery Departments. It is the first and only head-mounted microscope. In this study was examined 10 patients underwent to reconstructive procedures by harvest of perforator free flaps, working with Varioscope M5. At long-term follow-up, all patient present an exceptional outcome. Considering cost-effectiveness, portability, operator freedom, and effectiveness in the perforator flaps dissection and in the anastomosis making, we think that Varioscope M5 offers essential advantages.

[Treatment of a wide cutaneous post-traumatic loss of substance by cell cultures. Case report]. / Trattamento di un'ampia perdita di sostanza cutanea post-traumatica mediante colture cellulari. Case report.

Bioengineering skin represents a successful outcome in the interdisciplinary research applied to reconstructive surgery. In this study we report our experience in the reconstruction of a wide traumatic wound by autologous engineered skin, grown on a biomaterial scaffold. Advantages were rapid reparation of the trauma and good scars.

[Treatment of the capsular contracture around mammary implants: our experience]. / Trattamento della contrattura capsulare da impianto protesico mammario. Nostra esperienza.

The most common complication in patients who underwent mammary implant surgery is capsular contracture. Actually, there is no standard effective treatment for this complication. The aim of this article is to show our experience about LTRAs (leukotriene receptor antagonists) for the treatment of the capsular contracture. The findings indicate that these drugs may reduce pain and breast capsule distortion for patients with long-standing contracture.

[Dupuytren's disease simulated by epithelioid sarcoma with atypical perineural invasion of the median nerve. Case report]. / Malattia di Dupuytren simulata da un sarcoma epitelioide con atipica invasione perineurale del nervo mediano. Caso clinico.

Epithelioid sarcoma is an infrequent tumour, especially in upper limb, which nerve spread is not common. We describe the case of a 27 years old caucasian male with initial diagnosis of Dupuytren's disease. He underwent palmar fascia surgery, but the surgical treatment was followed by recurrence of the deformity in retraction of 4th and 5th finger of the left hand. When he presented himself at our attention, the patient underwent surgical biopsy and new histological examination was made with diagnosis of epithelioid sarcoma. We highlight essentially two aspects of this case: the diagnostic delay of tumour caused by simulation of the Dupuytren's disease and the atypical perineural spread along the median nerve.