Shaping the nasal dorsum.

Shaping a proper dorsum must constitute an essential part of rhinoplasty. This article addresses the main current concepts that play a significant role in dorsal modifications: proper exposure at the keystone, component separation and incremental reduction, straightening the septum and positioning it in the midline, mobilizing and reshaping the nasal bones by osteotomies and osteoplasties, and finally reconstituting a barrel vault of appropriate width and proper contour. The importance of power tools and piezoelectric instrumentation is highlighted, as well as the relevance of simulation and computed tomography (CT) imaging as key to bone and septal work. Finally, the key principles of rebuilding the dorsum in revision rhinoplasty are detailed.

Positive compared with negative margins in a single-centre retrospective study on 3957 consecutive excisions of basal cell carcinomas. Associated risk factors and preferred surgical management.

The rate of margins involvement and the associated recurrence risk in basal cell carcinomas (BCCs) varies widely in published works (7%-25% and 26%-67%, respectively). This study investigated the risk factors associated with incomplete excision and their relevance in surgical management when positive margins occur in 3957 BCCs excised in 2358 patients. This study performed a multivariate analysis on the database collected from all patients operated for BCCs in the Plastic Surgery Department between 1 January 1992 and 1 September 2007. All data collected (3957 excisions; 2358 individuals) were divided into complete and incomplete excisions groups and analyzed according to 14 variables. The overall rate of incomplete excisions was 14%. Mean age (68), size of the lesion (< 0.5 cm), BCC subtype (nodular with sclerosant aspects, sclerosant and basosquamous), location (face), infiltration depth (hypodermis and deep tissues), recurrent BCC and re-excised BCC were significantly associated with a higher rate of incomplete excision. The recurrence rate for incompletely excised tumours was 26.8%, while only 5.9% for completely excised tumours. Most of the risk factors associated to incomplete excision can be identified before surgery (by simple anamnesis and clinical examination) and successfully overcome by appropriate surgical margins. The high recurrence rate after incomplete excision and the low patient compliance towards follow-up should lead the surgeon to early re-excise residual cancer.

Study on the photodegradation of amidosulfuron in aqueous solutions by LC-MS/MS.

Sulfonylurea herbicides are extensively widespread for the protection of a variety of crops and vegetables because of their low application rates, high selectivity and low persistency in the environment; unfortunately, their low persistence does not always correspond to a lower toxicity, since new species potentially more toxic and stable than the precursor herbicides can form, owing to natural degradation processes. Here, the photodegradation of amidosulfuron in aqueous solutions was studied by high-performance liquid chromatography with diode array detection and tandem mass spectrometry to identify the degradation products in order to outline the environmental fate of the molecules generating from the simulation of one of the natural processes that can occur, i.e., photoinduced degradation. The photodegradation process results in a first order kinetic reaction with a t 1/2 value of 276 h (11.5 days) and a kinetic constant of 0.0027 h(-1), and three possible degradation products were identified. The results obtained are then compared to those obtained in previous works carried out in comparable experimental conditions about nicosulfuron and tribenuron-methyl, two sulfonylurea herbicides belonging to different classes, and to literature data: hypotheses on the existence of preferential degradation pathways are then drawn, in consequence of the molecular structure of the sulfonylurea pesticide. In particular, the use of organic solvents to obtain complete solubilization of the sample plays a fundamental role and deeply influences the degradation processes that, therefore, not always fully adhere to the actual natural photodegradation pathways. Moreover, considerations about toxicity were driven since the complete mineralisation of the sample is not reached: even when the parent pesticides are totally degraded, they are, however, transformed into other organic compounds showing, if subject to ecotoxicological tests, at least the same toxicity of the precursor herbicides. The evidence here presented suggests that, at least for the class of sulfonylurea pesticides, their professed low persistence actually does not produce any real advantage.

HPLC-DAD-MSn to investigate the photodegradation pathway of nicosulfuron in aqueous solution.

The environmental interest of sulfonylurea herbicides was derived from the possibility of diffusion and penetration of these herbicides in the deepest layers of the ground, in particular in sandy or clay-poor soils, up to the ground waters; another interest of the study is their natural degradation pathway which leads to the formation of new species that are potentially more toxic and stable than the precursor herbicides. In this case, a lower persistence in the environment unfortunately does not correspond to a lower toxicity: hence, the importance of the identification of the species can be potentially formed. Here, nicosulfuron, a typical sulfonylurea herbicide, is considered in order to outline the environmental fate of the molecules generating from the simulation of one of the natural processes that can occur, i.e. photoinduced degradation. Aqueous nicosolfuron solutions underwent a simulated sun irradiation: the new species formed during the degradation process were identified by HPLC-DAD-MS/MS and a degradation pathway was proposed. The effect of temperature and the contribution of the hydrolysis were also evaluated. The use of ESI in both positive ion (PI) and negative ion (NI) mode and APCI in PI mode permits to obtain integrated information about the transformation products that can form; moreover, a study of the total ion chromatogram followed by the extraction of the SIM chromatograms of the most intense m/z signals made possible the identification of five possible photodegradation transformation products.

Oral commissure reconstruction with orbicularis oris elastic musculomucosal flaps.

Surgical reconstruction of the oral commissure aims to restore both symmetry of the lips at rest and, more importantly, full oral competence. Moulding the lip commissure with functional and cosmetic fidelity remains till today a difficult task. A possible surgical solution, the 'elastic flap' principle described by Goldstein, may be found in the wide full-thickness mobilization of the upper and lower vermilion as two composite myocutaneous flaps - tissue sandwiches consisting of labial skin, orbicularis oris muscle and oral mucosa - on the axial pattern of the superior and inferior labial arteries. Based on the contralateral commissure, both flaps are easily 'stretched', accordion-like, to reach the predetermined point of the new commissure, using to full advantage the inherent elastic potential of both vermilions. The fibres of the orbicularis oris muscle at each end of both flaps are embricated to reconstitute a neo-modiolus, which is anchored to the residual buccinator muscle in primary reconstructions, or to the available peri-oral fibrous tissue in secondary procedures. The authors present a select group of 22 patients, who, between 1993 and 2008, underwent this reconstruction procedure for primary or secondary defects involving the oral commissure. The results were generally satisfactory, both functionally and cosmetically. The advantages of this procedure include full restoration of the dynamic function of the orbicularis ring in a single-stage operation and avoidance of either lipswitching procedures or of mobilization of mucosa and cheek skin. The final scars remain well camouflaged within the oral mucosa and the mucocutaneous junction of each lip.

Circumareolar mastopexy with multiple glandular plications for symmetry of the contra-lateral breast, in patients undergoing breast reconstruction with prosthesis. Experience on 50 cases.

4 years experience on 50 cases using the Elliott's technique for symmetrization of the contra-lateral breast in patients undergoing breast reconstruction with an anatomical prosthesis is presented in this paper.The Elliott's technique with its double superior and horizontal plication is a suitable and long-lasting procedure for patients with small-moderate ptotic breast and elastic skin, who wish to have a simple procedure and an immediate result with minimal scars.

Incompletely excised basal cell carcinomas: Our guidelines.

A retrospective review of 982 patients treated for basal cell carcinoma (BCC) was conducted over a period of 8 years from 1996 to 2004. Of these patients, 16 presented a margin involvement. Two cohorts of patients with involved margin were identified: the group whose basal cell carcinoma was re-excised, and the "wait and see" group. Both sets of results obtained were compared, and then matched with recent international literature reviews. Reexcision is our current practice for incompletely excised tumor. However during the period examined only 36 patients of 116 with margin involvement, proceeded to re-excision, and of the remaining 80 patients just 39 were followed-up. The others were missed mainly because of the difficulty of attending follow-up consultations because of advanced age, poor general conditions, and unavailability of transport facilities. On the basis of several points, including a high number of residual tumors detected in the re-excised patients, and difficulty in maintaining diligent follow-up in the "wait and see" group, we stress the importance of considering an early re-excision in case of margin involvement (focal, lateral, or deep), to avoid a significant risk of recurrence. In this study 16 patients out of 39 in the "wait and see" group had recurrences over 8 years of follow-up; a significant number of recurrences was observed after 5 years. We therefore reserve a clinical follow-up only for patients in whom poor general health dissuades us from re-operation.

Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myo-osseous flap and latissimus dorsi myocutaneous flap.

A combined microvascular flap composed of serratus anterior myo-osseous and a latissimus dorsi myocutaneous flap has been performed for resurfacing massive scalp and skull defects, accompanied by chronic infection and heavy radiation damage. The authors present a case report where the combined procedure allowed a single-stage reconstruction of this complex defect.

The distally based superficial sural flap: our experience in reconstructing the lower leg and foot.

The treatment of soft-tissue defects of the lower third of the leg and foot is often an awkward problem to tackle because of the frequent involvement of muscle, tendon, and bone, which is caused by the thinness and poor circulation of the skin covering them and by the small quantity of local tissue available for reconstruction. The authors present their experience with the use of sural flaps for the treatment of small- and medium-size defects of the distal region of the lower limb. The flap used was a distally based fasciocutaneous flap raised in the posterior region of the lower two thirds of the leg. Vascularization was ensured by the superficial sural artery, which accompanies the sural nerve together with the short saphenous vein. The authors treated 18 patients (12 men and 6 women) from May 1997 to August 1999 at the Division of Plastic Surgery, University of Turin, Italy. Superficial necrosis without involvement of the deep fascia (which was grafted 1 month later) occurred in 1 patient of the 18 treated. In another 2 patients, defects were found in the flap margins, but no additional surgical revision was necessary, and recovery occurred by secondary intention. In every patient the sural flaps provided good coverage of the defects, both from a functional and an aesthetic point of view. The major advantages of this flap are its easy and quick dissection. Because the major arterial axis is not sacrificed, this flap can be used in a traumatic leg with damaged major arteries.

The effect of pulsed electromagnetic fields on flexor tendon healing in chickens.

This study was designed as a pilot investigation of the effect of pulsed electromagnetic fields (PEMF) stimulation on early flexor tendon healing in a chicken model using a similar stimulus to that used clinically. The PEMF used caused a decrease in tensile strength and an increase in peritendinous adhesions.

Giant neurofibromatosis of the chest wall: two patient reports.

Two patients with severely deforming giant neurofibromatosis of the chest wall secondary to von Recklinghausen's disease are presented. Pain, respiratory compromise, recurrent ulcerations, cosmetic considerations, and the malignant potential of these lesions indicated wide excision and reconstruction. It is impossible to completely eradicate all neurofibromas, which may affect virtually every nerve within the chest wall including the mediastinum. However, excision of the primary mass may reduce the possibility of malignant degeneration into neurofibrosarcoma or malignant schwannoma. This type of major, full-thickness chest wall resection is now possible using musculocutaneous flaps to achieve satisfactory closure with a single-stage procedure with minimal morbidity and a short hospital stay. At the 10-year follow-up, neither patient exhibited evidence of recurrence.

Distally based fasciocutaneous flaps: a versatile option for coverage of difficult war wounds of the foot and ankle.

Early reconstructive treatment of war-related lower extremity injuries can be feasible even when evacuation to ideal tertiary facilities is impossible. However, in such instances, lengthy procedures considered "state of the art" in the everyday civilian practice of plastic surgery are often impractical, and alternative options need to be sought. Undelayed distally based fasciocutaneous flaps of the leg have recently been used in 12 cases of extensive defects of the foot due to antipersonnel mine injuries. All patients, treated during the conflict in Bosnia-Herzegovina, were smokers and were between 17 and 45 years of age. No preoperative arteriography or Doppler was available. One flap was totally lost, and two others suffered tip necrosis. All other cases healed uneventfully. We were impressed at the reliability of distally based fasciocutaneous flaps, even with length-to-width ratios of up to 5:1, and even after distal deepithelialization or tubing of the pedicle. The whole foot can be reached when the appropriate lateral or medial based flap is selected. Obvious disadvantages are the grafted secondary defect of the leg and the lack of sensation, although the latter is a common feature shared by most other flaps to the foot. Also, free-muscle transfer is preferable for very deep defects with extensive bone loss. However, for the ease of dissection, versatility, and short operating time, distally based fasciocutaneous flaps find a definite place in reconstructive trauma surgery.

Brachial plexus surgery. An historical perspective.

Clinical observations on brachial plexus palsy belong to the last decades of the 19th century. True brachial plexus surgery is even more recent, starting with the beginning of this century. Surgical endeavors on the plexus have been varied and have met with alternating fortunes, undertaken by surgeons in a fascinating blend of sheer enthusiasm and deep pessimism.

The use of split-thickness hypothenar grafts for coverage of fingertips and other defects of the hand.

Over a four year period, hypothenar split-thickness skin grafts were used to resurface a variety of fingertip and other hand defects in 27 patients. All patients achieved uncomplicated primary wound healing with minimal donor site morbidity. At one year follow-up, there was no evidence of late wound breakdown or fissuring of the wounds treated with hypothenar skin grafts.

The treatment of chronic thumb metacarpophalangeal joint instability in an adolescent secondary to thumb hypoplasia.

A fourteen-year-old female presented with untreated thumb hypoplasia consisting only of chronic instability of the thumb metacarpophalangeal joint. Successful treatment consisted of metacarpophalangeal joint fusion.

Diffusion of antibiotics across tissue expanders: an in vitro study.

Local infection remains a significant complication of tissue expansion. Subclinical infection of pockets with permanent prosthesis used in breast reconstruction has also been associated with capsular contracture around the implant. In an in vitro model, we used four groups of eighteen 50-ml tissue expanders, each containing Bactrim, Ancef, Nafcil, or saline only, in beakers containing fresh frozen plasma, placed in a rotary shaker for 48 hours. Inoculums of Staphylococcus aureus and Staphylococcus epidermidis were then selectively added to the medium external to the expanders in each group. The growth of such strains was found to be variably inhibited. We thus determined that antibiotics can diffuse through a tissue expander's Silastic membrane and establish an efficient bacteriostatic level in the surrounding fluid. This information could have potential clinical application in reducing infections associated with the use of expanders.

Carbofilm-covered prostheses in plastic surgery: preliminary observations.

The optimal interface between an implant and the host organism is that which minimizes uncontrolled and irregular growth of fibrous tissue around the foreign material. One way to achieve this goal is to coat the outer surface of the implant with a biocompatible material. A thin film of turbostratic carbon (Carbofilm, Sorin Biomedica, Saluggia, Italy) can be applied as a thin coating on tissue expanders and breast implants made of silicone elastomers. The success of biologic trials with such implants in rats and cytologic studies with murine and human fibroblasts encouraged us to employ the Carbofilm technology in clinical situations. Preliminary results indicate that Carbofilm-coated implants satisfy the requirements of an ideal alloplastic material and induce a minimal periprosthetic inflammatory reaction, with the formation of a thin, soft, pliable, fibrous capsule around coated gel-filled silicone implants.

[Angioma of a finger: the usefulness of a graft from the hypothenar eminence for covering the defect]. / Angioma di un dito della mano: utilità dell'innesto dall'eminenza ipothenar per la copertura del difetto.

Skin grafting remains the simplest option when bone is not exposed in soft tissue losses of the digits of the hand. As opposed to traditional donor sites, a split-thickness skin graft from the hypothenar eminence provides specialized skin similar to the one to be replaced. The graft remains elastic and soft in follow-up, without hyperpigmentation, hyperkeratosis, fissuring and hypertrophic scarring at the margins. As well as in acute trauma situations, the use of split-thickness skin grafting from the hypothenar eminence can also be extended to resurfacing defects in elective hand surgery. As an example, we describe a case of an ulcerated capillary hemangioma on the dorsal surface of the fifth digit at the distal interphalangeal joint.

A new prospect on the approach to open, complex, craniofacial trauma.

Complex craniofacial trauma has been traditionally managed in three stages: urgent craniotomy, secondary orbitofacial repair and delayed cranioplasty. Departing from this conventional approach, we employ an early single-stage neuro and plastic-surgical reconstruction for patients presenting open cranial wounds of the frontobasilar region coexisting with orbitofacial fractures. Neurological outcome does not seem to be affected by the additional operating time, nor is the incidence of infection raised, although bone fragments are repositioned, primary bone grafting is employed, and metallic material is used for fixation. Adequate direct exposure followed by reduction and rigid internal fixation results in primary bone healing and permits to avoid the difficult complications related to soft tissue contracture over misaligned bone. Compared with the conventional staged approach, immediate reconstruction appears functionally and aesthetically preferable, as well as technically easier.

Early single-stage repair of complex craniofacial trauma.

The traditional surgical management of complex craniofacial injuries is performed in three stages: immediate craniotomy, orbitofacial repair in 7 to 10 days, and cranioplasty delayed 6 to 12 months because of the perceived risks of infection and prolonged anesthesia in the head-injured patient. Cosmetic considerations have always played a secondary role; however, there are reports that suggest that bone fragments and grafts can be safely placed even in contaminated wounds. In addition, advances in neuroanesthetic technique allow for prolonged administration of anesthesia without untoward effects on the patient. The purpose of this prospective study was to determine if early single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality. In this study, 13 patients (9 men, 4 women) ranging in age from 3 to 53 years, with Glascow Coma Scale scores of 10 to 15, all had a combined single-stage repair of their complex craniofacial injuries within 24 hours of their trauma. After initial assessment and resuscitation, all patients were evaluated with computerized tomography of the face and head before surgery. Bicoronal skin flaps were used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, and calvarial reconstruction. Dural grafts were necessary in 12 of 13 patients (92%), and supplementary bone grafting was required in 9 of 13 patients (69%), of which 3 of the 9 (33%) had iliac bone grafts, where split calvarial grafts were used in the other 6 of 9 (67%). No artificial cranioplasty material was used.(ABSTRACT TRUNCATED AT 250 WORDS)