[Regeneration and rehabilitation. Plastic surgery practice in a rehabilitation centre.] / Rigenerazione e Riabilitazione. Esperienza di chirurgia plastica in un centro di riabilitazione.

OBJECTIVES: Regenerative Surgery aims at the restoration of the loss of structures and functions of the body using four innovative approaches: physical energies, biomaterials, cell products and stem cells. METHODS: The Authors provide an overview of their experience with Regenerative Surgery procedures at the Plastic Surgery Unit of the University of Pavia, Istituti Clinici Scientifici Salvatore Maugeri, in a 10 years period, from 2007 to 2017, for the treatment of extensive acute soft tissue loss, chronic ulcers, disabling scars and degenerative pathologies with different aethiology. RESULTS: Regenerative Surgery is a well-established and effective practice in a modern Plastic Surgery Unit. CONCLUSIONS: Regenerative methods are effectively used both as exclusive options in case of absolute contraindication to traditional surgery and as alternative to the latter in order to provide the same outcome with less invasiveness or in combination with minor traditional surgical procedures to reduce the overall surgical burden.

Versatile use of dermal substitutes: A retrospective survey of 127 consecutive cases.

BACKGROUND: Dermal substitutes are currently largely used for the treatment of huge skin loss in patients in critical general health conditions, for the treatment of severe burns and to promote the healing process in chronic wounds. AIMS: The authors performed a retrospective assessment of their experience with bioengineered skin to possibly identify the most appropriate clinical indication and management for each substitute. MATERIALS AND METHODS: The study involved 109 patients with 127 skin defects repaired with dermal substitutes over a 9 years period, from 2007 to 2016. Hyalomatrix® was used in 63 defects, whereas Integra® and Nevelia® were used in 56 and 8 defects, respectively. RESULTS: The statistical analysis failed to reveal a correlation between the choice of a specific dermal substitute and any possible clinical variable except in the soft-tissue defects of the scalp where Hyalomatrix® was electively used. CONCLUSIONS: In the authors' experience, the scalp defects followed a radical excision of skin tumours that included the periosteum. Here, the preliminary cover with a hyaluronan three-dimensional scaffold constantly allowed for the regeneration of a derma-like layer with a rich vascular network fit for supporting a split-thickness skin graft. Nevertheless, the authors still prefer Integra® when the goal is a better cosmetic outcome and Hyalomatrix® when a faster wound healing is required, especially in the management of deep wounds where the priority is a fast obliteration with a newly formed tissue with a rich blood supply. However, these clinical indications still are anecdotally based.

Unrecognized Cell Torpidity as a Risk Factor in Elective Plastic Surgery.

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[Safety of use assessment in a radio-frequency medical device]. / Valutazione della sicurezza d'impiego di un'apparecchiatura elettromedicale ad emissione di radiofrequenza.

The authors assessed the operating safety physical parameters of a bipolar radiofrequency device for aesthetic purposes. According to both Italian and EU guidelines, the authors considered: magnetic field environmental emission levels, electricity induced in the opertator's limbs, operator's exposure and radiofrequency specific absorbance rate (SAR) in treated tissues. Measurements were carried out with isotropic sensors and an inductive current indicator. Results pointed out excellent safety levels regarding environment, operators and patients as well, although such radiofrequency equipment cannot be used on patients with pacemakers, neurostimulators and other vital function controlling devices.

The biological effects of quadripolar radiofrequency sequential application: a human experimental study.

OBJECTIVE: An experimental study was conducted to assess the effectiveness and safety of an innovative quadripolar variable electrode configuration radiofrequency device with objective measurements in an ex vivo and in vivo human experimental model. BACKGROUND DATA: Nonablative radiofrequency applications are well-established anti-ageing procedures for cosmetic skin tightening. METHODS: The study was performed in two steps: ex vivo and in vivo assessments. In the ex vivo assessments the radiofrequency applications were performed on human full-thickness skin and subcutaneous tissue specimens harvested during surgery for body contouring. In the in vivo assessments the applications were performed on two volunteer patients scheduled for body contouring surgery at the end of the study. The assessment methods were: clinical examination and medical photography, temperature measurement with thermal imaging scan, and light microscopy histological examination. RESULTS: The ex vivo assessments allowed for identification of the effective safety range for human application. The in vivo assessments allowed for demonstration of the biological effects of sequential radiofrequency applications. After a course of radiofrequency applications, the collagen fibers underwent an immediate heat-induced rearrangement and were partially denaturated and progressively metabolized by the macrophages. An overall thickening and spatial rearrangement was appreciated both in the collagen and elastic fibers, the latter displaying a juvenile reticular pattern. A late onset in the macrophage activation after sequential radiofrequency applications was appreciated. CONCLUSIONS: Our data confirm the effectiveness of sequential radiofrequency applications in obtaining attenuation of the skin wrinkles by an overall skin tightening.

Hyaluronan-induced cosmetic reconstruction of the nostril.

Tissue loss of the nostrils presents a considerable surgical challenge due to the greatly reduced availability of local tissue within such a peculiar anatomical region. The traditional reconstructive methods, such as direct suture, secondary healing, skin grafts, and local skin flaps, have shown poor provision of desirable cosmetic outcomes in this area. The authors propose an innovative and alternative method of cosmetic reconstruction of small skin defects of the nostril based on a hyaluronan-induced skin regeneration. Such a procedure allowed the healing of relatively large areas of skin loss with the formation of a truly regenerated tissue whose clinical features closely resemble those of the local normal skin. Nevertheless, the proposed procedure is lengthy and time-consuming and requires high levels of cooperation from patients. In our practice, the hyaluronan-induced skin regeneration is now considered the first choice for cosmetic reconstruction of small defects of the nostril in needy patients.

The role of rehabilitative camouflage after cervicofacial reconstructive surgery: a preliminary study.

A randomized, prospective, controlled study was carried out at the Plastic and Reconstructive Surgery Unit of the University of Pavia, Salvatore Maugeri Research and Care Institute, Pavia, Italy, to evaluate the psychological benefits from corrective medical camouflage (CMC) following surgical treatment for skin cancer of the face. Twenty-four female patients, following recovery from facial skin cancer surgery, were enrolled in the study over a period of 1 year. The study was performed using two health-related quality of life tests, the Satisfaction Profile (SAT-P) test and the Body Uneasiness Test (BUT). The patients were randomized into two groups: group A, patients undergoing CMC; and group B, controls. Both the SAT-P and BUT demonstrated statistically significant better results in the treated patients versus the controls in the following functional parameters: Psychological Functionality (PsF), Physical Functionality (PhF), and Work Performance (WP) for the SAT-P test and Compulsive Self-Monitoring (CSM) for the BUT. The PsF demonstrated a better result 6 months post-treatment. Such a difference was particularly significant when comparing the performance at 6 months versus that at 3 months. The PhF demonstrated a better outcome at 6 months post-treatment. The WP demonstrated a better result comparing the performance at 6 months versus that at 3 months. The CSM demonstrated a better outcome at 6 months post-treatment. The CMC promoted a significant improvement in patients' physical appearance and in their self-image and perceived social role as a means of their desire to disguise their body disfiguration.

Refinements in brow reconstruction: synergy between plastic surgery and aesthetic medicine.

OBJECTIVE: The purpose of this study was the introduction in clinical practice of the combined application of traditional reconstructive surgery and intense pulsed light (IPL) for the restoration of a post-traumatic eyebrow defect. CASE: The authors present a case of surgical eyebrow reconstruction with an axial temporal hair-bearing scalp island flap. A persistent localized erythema and a marked difference in hair density in comparison with the contralateral one harmed the eventual surgical outcome. RESULTS: A combined sequential treatment with IPL achieved both hair density and skin erythema reduction, and eventually allowed for a very satisfactory result. CONCLUSIONS: Our experience demonstrated the efficacy of the integrated multidisciplinary approach involving traditional plastic reconstructive surgery and the innovative new technologies in aiming for perfection.

Long term assessment of intralipotherapy in Madelung's disease.

Madelung's disease is characterised by multiple symmetric abnormal fat masses in the head, neck and upper limbs. Surgical excision or liposuction is the only realistic available option, although palliative in nature. The serial intralipotherapy with phosphatidylcholine/deoxycholate has been proposed as a non-invasive treatment of Madelung's disease. The authors used serial intralipotherapy with phosphatidylcholine/deoxycholate in two patients affected by Madelung's disease. Three injections per lesion per patient were performed with 1 month's interval. Pre- and 6 months' post-treatment dimensions were assessed with ultrasound scan and patients were observed along a 5 years' clinical follow-up. A 42.5% average size reduction was reported in all treated lesions. About 33% recurrence rate was observed in the 5 years' follow-up. We confirm the efficacy of intralipotherapy in the non-invasive palliative treatment of Madelung's disease, as a valid option to reduce the volume and limit the growth of the pathological adipose masses.

Depletion of the nasal reserve after a mole excision.

The authors present an original case report to warn of a possible severe functional complication that might follow a simple facial skin procedure. A 55-year-old woman underwent excision of a mole along the alar-facial groove, which seemingly healed without immediate complications. Ultimately the patient reported an ipsilateral nasal obstruction 2 months postoperatively. Intranasal inspection and a computed tomography scan revealed a severe septum deviation that had been previously clinically unapparent. The authors argue that the skin-scarring process progressively counterbalanced the action of the levator labii superioris alaeque nasi muscle fascicle to the nostril. Such an action had been compensating for a subtotally compromised nasal air flow from a preexisting severe septal deviation. In this context, skin scarring was enough to impair a minimal residual nasal respiratory reserve. The authors therefore advise performing an internal nasal inspection at all times prior to any sort of skin surgery around the alar-facial groove. This will allow detection of any subclinical functionally compensated preexisting septal deviation or any other intranasal obstruction that could manifest at a later stage.

Hyaluronic acid three-dimensional scaffold for surgical revision of retracting scars: a human experimental study.

An observational study was carried out at the Plastic and Reconstructive Surgery Unit of the University of Pavia - Salvatore Maugeri Research and Care Institute, Pavia, Italy, to assess the clinical and histological long-term outcomes of autologous skin grafting of fresh surgical wounds following previous repair with a hyaluronic acid three-dimensional scaffold (Hyalomatrix®). Eleven fresh wounds from surgical release of retracted scars were enrolled in this study. A stable skin-like tissue cover was observed in all of the treated wounds in an average 1 month's time; at the end of this study, after an average of 12 months' time, all of the reconstructed areas were pliable and stable, although an average retraction rate of 51·62% was showed. Histological observation and immunohistochemical analysis displayed integration of the graft within the surrounding tissues. A regenerated dermis with an extracellular matrix rich in type I collagen and elastic fibres and with reduced type III collagen rate was observed. The epidermis and dermoepidermal junction featured a normal appearance with well-structured dermal papillae, too. Although the histological features would suggest regeneration of a skin-like tissue, with a good dermis and no signs of scarring, the clinical problem of secondary contracture is still unsolved.

Study to determine whether intraoperative frozen section biopsy improves surgical treatment of non-melanoma skin cancer.

Skin cancers are the most common types of cancer and their incidence has shown an increase of ∼4 to 8% per year over the last 40 years. The majority of skin cancers (∼97%) are non-melanoma skin cancers, mainly represented by basal cell (80%) and squamous cell carcinomas (20%). The use of intra-operative frozen section remains controversial in the surgical treatment of non-melanoma skin cancer, being commonly considered an optional tool, the reliability and effectiveness of which remain questionable. A large retrospective study was conducted to examine 670 surgical excisions of non-melanoma skin cancers of the head and neck in 481 patients over a period of nine years, between May, 2002 and December, 2011, at the Plastic and Reconstructive Surgery Unit of the University of Pavia, Salvatore Maugeri Research and Care Institute, Pavia, Italy. Results demonstrated the paradoxical ineffectiveness of an intra-operative frozen section biopsy in pursuing higher rates of radical excision in non-melanoma skin cancers. Nevertheless, a more detailed analysis on the use of frozen sections focusing on the various anatomical sites of the body demonstrated a reverse trend in the eyelids and canthi, where a higher success rate (87.50 vs. 69.77%) in the surgical treatment of non-melanoma skin cancers was obtained with the use of an intra-operative frozen section biopsy. Results of the present study suggested that intra-operative frozen section biopsy be routinely used in the surgical treatment of nonmelanoma skin tumors involving the eyelids and canthi.

[Update on electrical safety of equipment used in surgery and interventional medicine]. / Attualità sulla sicurezza elettrica delle apparecchiature in uso in chirurgia e medicina interventistica.

Update on electrical safety of medical equipment used in Surgery and Interventional Medicine. Expanding on the theme of relevant operating safety has become extremely topical as a result of the broad diffusion of electro-medical equipment in medical and surgical practice. This aspect is related to the technical features of the equipment, to regulations to be observed inside medical facilities, to the correct use of the equipment. The article suggests a setting-up of the problem, outlining the physiological and pathological effects of electric currents on the human body and indicating regulations in force as to electric safety of electro-medical equipment and of facilities used for medical and surgical purposes, and examines common clinical situations at electrical risk.

Allogenic platelet gel in the treatment of pressure sores: a pilot study.

Although platelet gel is considered one of the most popular tools in the treatment of chronic ulcers, current consensus on its use is not unanimous. A prospective randomised trial was carried out at the Plastic Surgery Unit of the 'Salvatore Maugeri' Foundation Hospital of Pavia (Italy). The study involved 13 patients affected by spinal cord injury with 16 pressure sores over a period of 20 months. The ulcer was considered the experimental unit of the study irrespective of the number of ulcers per patient. Each consecutive ulcer was randomised to be treated either with allogenic platelet gel or with current best practice approach to chronic wounds dressing protocol. At the end of the treatment 15 ulcers out of 16 improved clinically. No statistically significant difference was demonstrated in volume reduction between the two groups, although a statistically significant difference could be demonstrated in the onset time of granulation tissue proliferation as in the wounds treated with platelet gel the healing process was triggered earlier. Our study suggests that platelet gel is mostly effective within the first 2 weeks of treatment while a prolonged treatment does not provide any significant advantage versus the current best practice approach to chronic wounds protocols.

Is breast reduction a functional or a cosmetic operation? Proposal of an objective discriminating criterion.

Classification of breast reduction as a functional or cosmetic operation is an unresolved issue. Surgical reduction of the breast is equally indicated both for correction of functional sequelae of breast hypertrophy and for a merely subjective aesthetic discomfort. Although several criteria are currently adopted by the national and international associations of plastic surgeons, none of them appears to fulfil the aim of objectively discriminating the functional from cosmetic indications. An original, simple and synthetic objective criterion was developed at the Plastic and Reconstructive Surgery Department of the University of Pavia using some basic anthropometric measurements.

Breast sculpturing: overcoming the limits of traditional approaches in breast reduction.

BACKGROUND: A technique based on original refinements of the vertical breast reduction was developed in our department. The aim of the technique was the safe and aggressive sculpture of an attractive breast mound with minimal scarring and long-lasting results that is easy to perform and suitable for teaching purposes in a surgical training unit. METHODS: Fifty consecutive patients who were to undergo bilateral breast reduction were prospectively enrolled in the study. Accurate standard anthropometric measurements and photographs were taken preoperatively and postoperatively at 2, 6, 12, 24, and 36 months. A selective breast liposuction plus a superior pedicle breast reduction with a vertical scar skin pattern was performed in all cases. RESULTS: Nipple lifting ranged from 5 to 14 cm; reduction of the distance between the inframammary fold and the nipple ranged from 0.5 to 7 cm; breast base width reduction ranged from 0 to 7 cm. CONCLUSION: This technique further contributes to vertical mammaplasty refinements, enhancing the key role of selective liposuction prior to surgical dissection of the breast. The basic principle is to convert a large breast into a middle-sized one, making vertical scar breast reduction the most appropriate technique for all cases. A thorough and selective liposuction of the breast mound reduces the breast cone base width safely and with virtually no limitations, thus breaking a taboo of traditional breast reduction techniques.

Generation of human epidermal constructs on a collagen layer alone.

Because engineered tissues are designed for clinical applications in humans, a major problem is the contamination of cocultures and tissues by allogenic molecules used to grow stem cells in vitro. The protocols that are commonly applied to generate epidermal equivalents in vitro require the use of irradiated murine fibroblasts as a feeder layer for keratinocytes. In this study, we report a simple procedure for growing human keratinocytes, isolated from adult skin, to generate an epidermal construct on a collagen layer alone. In this model, no human or murine feeder layers were used to amplify cell growth, and isolated keratinocytes were seeded directly at high cell density on the collagen-coated flasks or coverslips in an epithelial growth medium containing low calcium concentration. Morphological, immunochemical, and cytokinetic features of epithelial colonies grown on the collagen layer were typical of keratinocytes and were comparable with those reported for keratinocytes grown on a feeder layer. The stratification of keratinocytes generated 3-dimensional synthetic constructs displaying a tissue architecture comparable with that of natural epidermis. Epithelial cells expressed specific markers of keratinocyte terminal differentiation, including involucrin and filaggrin. Nevertheless, the number of cell layers was lower than in natural skin, and electron microscopical analysis revealed that the overall organization of these layers was poor compared with natural epidermis, including the formation of junctional complexes, basement membrane, and keratinization. The lack of epithelial-mesenchymal interactions that occur during skin histogenesis may account for such an incomplete maturation of epidermal constructs.