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 .

Extensive severe intraorbital arteriovenous malformations: report of a rare laser complication and successful management.

Arteriovenous malformations (AVMs) are rare congenital errors of vascular morphogenesis, characterised by abnormal direct communications between arteries and veins, bypassing the normal capillary bed. Apart from the central nervous system, typical locations include the head and neck, and less frequently limbs, trunk or internal organs. AVMs of the head and neck often become clinically evident and symptomatic only in later childhood and are characterised by a history of variable growth, sometimes leading to large, deforming, pulsating masses with a propensity to massive haemorrhage. Therapeutic strategy is based on selective embolisation, surgical excision, or a combination of both. Radical surgical excision of local AVMs is the only effective treatment but it may be mutilating, especially for AVMs of the head and neck. Laser therapy represents a good option to treat the cutaneous aspects of AVMs nevertheless, its efficacy is limited. To the date, pharmacological therapy for AVMs is still on debate due to its controversial outcomes as it seems not as effective as other treatments and usually requires a longer course of application. However, pharmacological therapy could be useful in selected patients and for AVMs nonresponsive to traditional treatment, allowing them to obtain acceptable results without serious complications. This paper reports the case of a serious laser complication of extensive intraorbital AVM successfully treated by local reconstruction and topical pharmacological treatment.

Freestyle Perforator Puzzle Flap for Posterior Trunk Reconstruction.

BACKGROUND: Closure of extensive defects of posterior trunk can be challenging for reconstructive surgeons owing to the need of a large bulk of well-vascularized tissue to resurface the skin and the exposed hardware and to fill the dead spaces. We hypothesized that elevating multiple perforators flaps in various patterns would allow for reconstruction of large posterior trunk defects with tension-free primary closure and minimal donor site morbidity. PATIENTS AND METHODS: Between January 2013 and December 2016, 23 patients with large posterior trunk defects underwent reconstruction with a multiple freestyle perforator flaps approach. We experimented a freestyle perforator-based reconstruction, which consists of designing a sequence of flaps, able to adequately fit the defects, allowing for tensionless primary closure. RESULTS: The average age of patients was 60.2 years (range, 18-80 years). A total number of 62 perforator flaps was performed, with an average of 2.6 flaps per patient. We were able to successfully cover defects up to 27 × 29 cm. A single perforator was used in 58 flaps, whereas more than 1 perforator was applied in 4 flaps. In all cases, the donor sites were closed primarily, and patients healed uneventfully. Six patients underwent radiotherapy after surgery, but no complication occurred. CONCLUSIONS: In this series of extensive defects of the posterior trunk, a tension-free closure was achieved by distributing the tension to multiple freestyle perforator flaps, supplying sufficient volume of tissue and reliable vascularization. This approach can be a valid tool in facing reconstruction of large and complicated defects of the posterior trunk.

Diversity of dermal fibroblasts as major determinant of variability in cell reprogramming.

Induced pluripotent stem cells (iPSCs) are adult somatic cells genetically reprogrammed to an embryonic stem cell-like state. Notwithstanding their autologous origin and their potential to differentiate towards cells of all three germ layers, iPSC reprogramming is still affected by low efficiency. As dermal fibroblast is the most used human cell for reprogramming, we hypothesize that the variability in reprogramming is, at least partially, because of the skin fibroblasts used. Human dermal fibroblasts harvested from five different anatomical sites (neck, breast, arm, abdomen and thigh) were cultured and their morphology, proliferation, apoptotic rate, ability to migrate, expression of mesenchymal or epithelial markers, differentiation potential and production of growth factors were evaluated in vitro. Additionally, gene expression analysis was performed by real-time PCR including genes typically expressed by mesenchymal cells. Finally, fibroblasts isolated from different anatomic sites were reprogrammed to iPSCs by integration-free method. Intriguingly, while the morphology of fibroblasts derived from different anatomic sites differed only slightly, other features, known to affect cell reprogramming, varied greatly and in accordance with anatomic site of origin. Accordingly, difference also emerged in fibroblasts readiness to respond to reprogramming and ability to form colonies. Therefore, as fibroblasts derived from different anatomic sites preserve positional memory, it is of great importance to accurately evaluate and select dermal fibroblast population prior to induce reprogramming.

The venae comitantes clipping test for the evaluation of the venous drainage of the radial forearm free flap.

Risks of failure of the radial forearm free flap (FRFF) are mainly related to venous congestion. Two different venous drainage system have been described for the FRFF, but the choice of the best one is still controversial. The superficial systems have a larger diameter and a thicker wall veins which makes them easier to anastomose. The deep system provides most part of the venous outflow if the caliber of the venae comitantes (VCs) is adequate. We propose an intra-operative method to evaluate the FRFF venous drainage: the VCs clipping test. The test has been used in the choice of the vein to anastomose in 12 consecutive patients with oral cavity post oncological defects reconstructed with the FRFF. The cephalic vein was included in the flap; the VCs were individually clipped with small liga-clips and divided with the radial artery still patent. The flap was kept with arterial inflow and superficial venous outflow till the recipient site was ready. If there were no signs of venous stasis, the VCs were kept clipped and the cephalic vein anastomosis was made. If clinical signs of venous stasis were revealed, the largest of the VCs was anastomosed to a vein of adequate caliber in the neck. No signs of flap venous congestion were observed in the postoperative period. No flap necrosis occurred. In this small series of patients the venae comitantes clipping test showed to be an easy, reliable and reproducible method to assess intra-operatively which vein to anastomose. © 2015 Wiley Periodicals, Inc. Microsurgery 36:647-650, 2016.

The utility of the high-resolution ultrasound technique in the evaluation of autologous adipose tissue lipofilling, used for the correction of post-surgical, post-traumatic and post-burn scars.

PURPOSE: Lipofilling technique is significantly increasing and the need of a non-invasive method to assess the success of the procedure is becoming mandatory. In particular, US can be considered an alternative method to MRI for evaluation of tissue lipofilling due to the simplicity and easy access of the technique and can be also used for monitoring the efficacy of the surgical procedure. The goal of this study was to demonstrate, the utility of the high-resolution ultrasound technique in the evaluation of autologous adipose tissue lipofilling, used for the correction of post-surgical, post-traumatic and post-burn scars. MATERIALS AND METHODS: Twenty-five patients (21 females), aged between 14 and 62 years, underwent surgical correction of scars with ''lipofilling'' technique. To evaluate the effectiveness of such treatment serial ultrasound examinations were performed at both the region affected from skin dimorphism through the adjacent skin region, using a high frequency transducer. Furthermore, it was assessed the presence of complications ranging from oedema or hematoma to necrosis or adipocyte migration of the graft. Finally, was calculated the average percentage of one-year survival of autologous fat transplant. RESULTS: Quantitative evaluations obtained with time series of ultrasound showed that the greatest benefits of autologous adipose tissue lipofilling, are found at the level of the hypodermis, but that also all the other layers of the skin can benefit from this procedure. CONCLUSION: The data acquired demonstrate that the eco color Doppler with high resolution can be considered a valid non-invasive tool for the assessment of morphological and quantitative degree of engraftment of autologous adipose tissue transplanted. Lipofilling is an accurate and effective choice for the correction of congenital or acquired skin disorders for its filler effect and consequent benefit for all tissue layers.

A surgical algorithm for partial or total eyebrow flap reconstruction.

The eyebrow is one of the five aesthetic sub-units of the forehead and it plays a key role in communication and facial expression. Reconstruction of this region can be challenging. Several methods have been described, mostly based on the size of the defect and on the part of the eyebrow that they involve. We describe our experience in 48 patients underlining the importance of a surgical algorithm for repairing eyebrow defects.

Superficial ulnar artery perforator flap.

Superficial ulnar artery is a rare finding but shows significant surgical implications. Its thinness and pliability make this flap an excellent solution for soft tissue reconstruction, especially in the head and neck region. We hereby report a successful free superficial ulnar artery perforator forearm flap transfer for tongue reconstruction. A 64-year-old man presenting with a squamous cell carcinoma of the left tongue underwent a wide resection of the tumor, left radical neck dissection, and reconstruction of the tongue and the left tonsillar pillar with the mentioned flap. No complications were observed postoperatively. The flap survived completely; no recurrence at 6 months of follow-up was detected. Superficial ulnar artery perforator flap has shown to be a safe alternative to other free tissue flaps in specific forearm anatomic conditions.

Clavicle Fracture Site Surgical Contouring: A Case Report.

Clavicle fractures are frequent injuries accounting for approximately 4% of all fractures in adults with about 35% occurring in the shoulder region among which midshaft fractures are the most common (>66%). Nonsurgical management is the treatment of choice for most clavicle fractures; however, poor functional and aesthetic outcomes may result from nonunion, symptomatic malunion, and aesthetic impairment which are the most common complications. A young woman was referred to our clinic for a "Step Deformity" resulting after primary, nonsurgical treatment of a midshaft clavicle fracture. Residual deformity was corrected with a novel simple and little invasive approach. Midshaft clavicle fractures typically only require conservative nonsurgical treatment, nevertheless suboptimal outcomes may occur. Selective osteotomies and fixation are deemed too invasive when only cosmetic impairment of the clavicle contour is present without any functional or sensitive damage and most patients are discouraged from undergoing surgery. Thus far, no specific focus on this topic, nor exploration of possible correction can be found in the published literature. These residual deformities may be very noticeable sometimes and cause psychological distress and social life impairment. Despite no related functional impairment, this deformity should still be addressed, to improve patients' quality of life.

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.

Comparative study of pre- and postauricular flaps for external auditory canal defect reconstruction.

Background: Malignancies involving the external auditory canal deserve critical evaluation due to this area's aesthetic and functional importance. Flaps can be very useful for the restoration of the external auditory canal. A variety of flaps available for the surgical treatment of external acoustic meatus defects exist, depending on the precise location and size. Objectives: Our study aimed to compare aesthetic and functional results in the postoncological reconstruction of external auditory canal defects using a preauricular flap and postauricular revolving door flap. Methods: Sixteen patients treated at our plastic surgery unit for defects involving the external auditory canal between January 2014 and December 2020 were included in the study. All defects were the result of a primary or secondary skin cancer excision. Patients were divided into two groups, one receiving the preauricular flap technique and the other the postauricular revolving door flap technique. Results: Three separate visual analog scales reported excellent scores for the two procedures, though the postauricular revolving door flap had slightly better results. Both preauricular flap and postauricular revolving door flap reconstructive techniques showed good options for external auditory canal reconstruction in postexcision skin cancer patients. From an aesthetic point of view, the revolving door flap appeared to be a more elegant surgical approach in this type of reconstruction because the scar was hidden in the postauricular sulcus. Conclusions: Reconstruction with a postauricular revolving door flap allowed for a more natural movement with no external pedicle. Evidence-Based Medicine EBM Level: IV.

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.

Epithelioid Hemangioma of the Nose: A Challenging Diagnosis.

Epithelioid hemangioma is a rare reactive vasoproliferative disease presenting with painless vascular nodules in the dermal and subcutaneous tissues of the head and neck. Clinical diagnosis can be difficult as, in most cases, the only symptom is a progressively tender swelling next to a vessel course. Thus far, few cases of epithelioid hemangioma localized to the nose have been described in the literature. Herein, we present a case of a 47-year-old woman with just such a lesion of the nose, focusing on its diagnosis and treatment.

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.

Ligaclip for Preauricular Skin Tags in the Newborn.

INTRODUCTION: Skin tags are benign lesions, that often represent only an aesthetic problem; if subjected to trauma, they can occasionally bleed with possible infection and pain. When they occur in the preauricular region, attention should be paid to the diagnosis and approach; in fact, controversy exists in the differential diagnosis between hair follicle nevi, accessory tragus, and skin tag. Misdiagnosis and failure of treatment can lead to serious consequences, such as chondritis. MATERIALS AND METHODS: In our retrospective study, we evaluated 19 newborns affected by single, unilateral skin tag in the preauricular region. Each patient underwent a careful clinical examination; lesions without a pilosebaceous unit and with a thin, soft pedicle were treated in the nursery with Ligaclip (Johnson & Johnson). RESULTS: Skin tag falls between day 7 and 10. We had no cases of edema, cellulitis, clip loss, or bleeding. Scarring results were extremely satisfactory at 3-month follow-up. CONCLUSION: We believe that after a careful clinical examination, cases of skin tags in the preauricular area can be selected and treated with Ligaclip. This procedure can be considered rapid, safe, economical, and simple in the newborn patients.

Pericranial and scalp rotation flaps for occipitocervical hardware exposure with CSF leak in rheumatoid arthritis patient: A case report and review of the literature.

BACKGROUND: There are several etiologies of craniocervical junction instability (CCJI); trauma, rheumatoid arthritis (RA), infections, tumors, congenital deformity, and degenerative processes. These conditions often require surgery and craniocervical fixation. In rare cases, breakdown of such CCJI fusions (i.e., due to cerebrospinal fluid [CSF] leaks, infection, and wound necrosis) may warrant the utilization of occipital periosteal rescue flaps and scalp rotation flaps to achieve adequate closure. CASE DESCRIPTION: A 33-year-old female with RA, cranial settling, and high cervical cord compression underwent an occipitocervical instrumented C0-C3/C4 fusion. Two months later, revision surgery was required due to articular screws pull out, CSF leakage, and infection. At the second surgery, the patient required screws removal, the application of laminar clamps, and sealing the leak with fibrin glue. However, the CSF leak persisted, and the skin edges necrosed leaving the hardware exposed. The third surgery was performed in conjunction with a plastic surgeon. It included operative debridement and covering the instrumentation with a pericranial flap. The resulting cutaneous defect was then additionally reconstructed with a scalp rotation flap. Postoperatively, the patient adequately recovered without sequelae. CONCLUSION: A 33-year-old female undergoing an occipitocervical fusion developed a postoperative persistent CSF leak, infection, and wound necrosis. This complication warranted the assistance of plastic surgery to attain closure. This required an occipital periosteal rescue flap with an added scalp rotation flap.

Extended rotation flap for reconstruction of partial thickness defects of the tip and nasal ala region: in search of better aesthetic results.

BACKGROUND: Basal cell carcinoma is the most common non-melanoma skin cancer of the nose. Defects of the nasal ala and tip region are among the most difficult to repair due to their intrinsic characteristics. OBJECTIVE: To present our experience with the extended rotation flap for reconstruction of nasal ala defects and evaluate the outcome using the Patient and Observer Scar Assessment Scale (POSAS). METHODS AND MATERIALS: Twenty-two patients with partial thickness nasal ala defects reconstructed using the extended rotation flap were assessed. Final cosmetic and functional outcomes were evaluated using the POSAS. RESULTS: Flaps survived in all the reported cases and no major complication was recorded. Histology showed complete excision of the tumour in all cases. Using the POSAS, the mean overall evaluation for patients was 1.8/10, while the mean overall evaluation for the evaluation panel was 2.2/ 10. CONCLUSION: Although similar flaps have been previously described, the extended rotation flap for nasal ala and tip reconstruction represents a functionally and cosmetically appealing wound closure option, respecting and avoiding any distortion of the alar crease.

Decellularization for the Preparation of Highly Preserved Human Acellular Skin Matrix for Regenerative Medicine.

Extracellular matrix (ECM) provides biophysical and biochemical stimuli to support self-renewal, proliferation, survival, and differentiation of surrounding cells due to its content of diverse bioactive molecules. Due to these characteristics, the ECM has been recently considered a promising candidate for the creation of biological scaffolds to boost tissue regeneration. Emerging studies have demonstrated that decellularized human tissues could resemble the native ECM in their structural and biochemical profiles, preserving the three-dimensional (3D) architecture and the content of fundamental biological molecules. Hence, decellularized ECM can be employed to promote tissue remodeling, repair, and functional reconstruction of many organs. Selecting the appropriate decellularization procedure is crucial to obtain acellular tissues that retain the characteristics of the ideal microenvironment for cells. The protocol described here provides a detailed step-by-step description of the decellularization method to obtain a reproducible and effective cell-free biological ECM. Skin fragments from patients undergoing plastic surgery were scaled down and decellularized using a combination of sodium dodecylsulfate (SDS), Triton X-100, and antibiotics. To promote the regular and homogeneous transport of the solution through the samples, they were enclosed in embedding cassettes to ensure protection from mechanical insults. After the decellularization procedure, the snow-white color of skin fragments indicated complete and successful decellularization. Additionally, decellularized samples showed an intact and well-preserved architecture. The results suggest that the proposed decellularization method was effective, fast, and reproducible and protected samples from architectural damages.

Combined Timed Surgery and Conservative Management of Primary Necrotizing Fasciitis of the Breast: A Case Report.

BACKGROUND Necrotizing fasciitis is a life-threatening infection that involves the deep fascia and the surrounding tissue, but rarely involves the female breast. The most common treatment for necrotizing fasciitis of the breast is total mastectomy. However, the use of negative pressure wound therapy (NPWT), after surgical debridement, is reported to promote the more rapid development of granulation tissue, before reconstructive surgery. This report presents the case of a 53-year-old woman with necrotizing fasciitis of the breast who underwent combined timed surgery and conservative management. CASE REPORT A 53-year-old woman presented with necrotizing fasciitis of the right breast, involving the right lateral chest wall and flank. She was referred to the Intensive Care Unit (ICU) of the hospital with septic shock. After hemodynamic stabilization was achieved, she underwent surgical debridement. Excised breast tissues were sent for histology, and intraoperative swabs were collected and sent for microbiological examination. Intravenous antibiotic therapy and hyperbaric oxygen therapy commenced. The patient was managed with NPWT dressings, followed by reconstructive breast surgery. The right chest and flank completely healed. CONCLUSIONS This case has shown that early diagnosis and management of necrotizing fasciitis of the breast can be life-saving and may allow for breast conservation. Early aggressive debridement combined with NPWT dressings and reconstructive breast surgery resulted in successful wound healing and preservation of the breast with a satisfactory cosmetic outcome.