The Art of Rhinoplasty: Researching Technical and Cultural Foundations of Western World Rhinosurgery, from the Middle Ages to the Renaissance.

The analysis of the written sources allowed to follow the gradual development of every new technique in the field of rhinoplasty but also to understand the value of this surgery in those ancient times, highlighting a deep connection between traumatologic surgery of the nose and the development of modern "aesthetic and reconstructive" Rhinosurgery. Specifically, we analyzed the techniques described by less known surgeons to emphasize their cultural and surgical value. As a matter of fact, the descriptions offered by these authors clearly show the importance of rhinoplasty as a cardinal and autonomous practice since Antiquity, also clarifying the persistence and development of specific techniques for this surgical practice in the History of medicine. In the manuscript, the contributions of the Italian surgeons, such as Brancas and Vianeos families, are highlighted, demonstrating their influence on the progress of this surgical specialty in the Early Modern Age. Finally, we deepen the description of Gaspare Tagliacozzi's work, pointing out the topics and controversial debates arising from his techniques and innovations in "rhinosurgery" and also in the field of tissue transplantation, laying the foundations of modern Plastic Surgery.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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Lateral Canthal Support in Prevention of Lower Eyelid Malpositioning in Blepharoplasty: The Tarsal Sling.

Lower blepharoplasty is a cornerstone in facial rejuvenation and improvement. Despite its popularity, several adverse effects have been described; of these, postsurgical eyelid displacement, with its aesthetic and functional consequences, is one of the more frequent complications. The tarsal sling procedure is a simplified canthopexy consisting in the fixation of the lateral portion of the septum--the canthal ligament--to the orbital wall periosteum. The aim of the current research is to demonstrate how the tarsal sling technique is effective in the prevention of lower lid malpositioning. A retrospective analysis of 40 consecutive healthy individuals was carried out. In group 1, 20 patients underwent standard blepharoplasty; in group 2, blepharoplasty was associated to the tarsal sling canthopexy. Pre- and postsurgical position of the lower eyelid margin was compared through photographic measurements at 5 time points and statistical analysis performed. Group 1 patients evidenced an increased distance between the interpupillary line and the lateral aspect of the lower lid margin. A progressive spontaneous improvement (reduction in scleral exposition) was detected. Patients who underwent the tarsal sling procedure (group 2) reported a postoperative overcorrection of scleral appearance. Two years postsurgery, progressive relapse occurred, but the lower eyelid did not reach presurgical values and maintained a slight degree of overcorrection. Tarsal sling is an easy, fast, and efficacious procedure to prevent eyelid displacement in lower blepharoplasty. Its routine use is a tool to assure further support to lower lids in the younger patients or when lid laxity is absent during presurgical examination.

The use of a non cultured autologous cell suspension to repair chronic ulcers.

The purpose of this uncontrolled study was to evaluate the clinical effectiveness of ReCell(®) system in the treatment of chronic ulcers. From October 2011 to July 2012, 20 patients, 8 men and 12 women with a mean age of 70 years, with chronic ulcers of different aetiology that were unresponsive to conventional therapies were recruited and treated using the ReCell(®) system. Patient pain rate, scar aesthetics and patient satisfaction were assessed using a Visual Analogue Scale, Manchester Scar Scale and the Rosenberg Self-Esteem Scale, respectively. Complete ulcer healing, defined as 100% reepithelialisation was observed between 40 and 60 days in 14 patients (70%) depending on the type of ulcer and comorbidity. At day 60 postprocedure, 80% reepithelialisation was present in five patients (25%), while one patient with concomitant psoriasis had 50% reepithelialisation. Pain scores improved by day 7 postprocedure. The function and aesthetics of the ReCell-treated patients were good. It is concluded that the ReCell technique may have provided the regenerative tissue stimulation necessary for the rapid healing of chronic ulcers, including those not responsive to more traditional methods.

Role of antioxidants in dermal aging: an in vitro study by q-RT-PCR.

BACKGROUND: Reactive oxygen species production is the final step in skin aging. These unstable molecules can damage and destroy DNA, proteins, and membrane phospholipids. The aim of this study was to test the in vitro effect of an antioxidant precursor, N-acetylcysteine (NAC), on human dermal fibroblasts. NAC alone and a solution of NAC and amino acids together, used in aesthetic medicine as intradermal injection treatment, were tested. METHODS: The expression levels of some connective related genes (HAS1, HYAL1, ELN, ELANE, DSP, GDF6, and IGF1) were analyzed on cultures of dermal fibroblasts using real-time reverse-transcription polymerase chain reaction (real time RT-PCR). RESULTS: All genes were upregulated after 24 h of treatment. CONCLUSIONS: An interesting effect of gene induction by administration of NAC and amino acids in vitro was demonstrated. Upregulation of elastin-, hyaluronic acid-, and GDF6-encoding genes supports the evidence of clinical improvement induced by NAC biostimulation in the prevention and correction of skin aging.

Treatment of traumatic scars using fat grafts mixed with platelet-rich plasma, and resurfacing of skin with the 1540 nm nonablative laser.

BACKGROUND: Many treatments have been proposed for cosmetic or functional improvement of scars. It is known that fat grafts and laser treatment can have beneficial effects on remodelling of scar tissue, and platelet-rich plasma (PRP) can be effective during the wound-healing process. We hypothesized that these combined treatments would be effective in improving traumatic scars, with minimal recovery time and few side-effects. AIM: The purpose of this study was to compare and evaluate the efficacy of three procedures for the treatment of traumatic scars. METHODS: We treated 60 patients affected by traumatic scars involving different body parts. All patients were randomly allocated to one of three groups (20 patients per group) and underwent one of three different procedures. Group A was treated with fat grafts mixed with PRP, group B was treated with nonablative laser, and group C was treated with both procedures. RESULTS: Comparison of the groups showed that PRP produced a significant difference in these treatments. The most effective scar treatment was the combination of fat grafts mixed with PRP plus nonablative laser resurfacing (group C). This treatment resulted in group C having an increase of 22% in wound healing compared with group A, and an increase of 11% compared with group B. CONCLUSIONS: The data confirm the efficacy of all three treatments, with the most effective scar treatment being the fat grafts mixed with PRP, followed by skin resurfacing with nonablative laser. This combined treatment appeared to be safe and effective for scar treatment. Further studies are needed to explore the potential use of this combined treatment.

A case of psoriasis with secondary amyloidosis, associated symbrachydactyly of the hand and a transverse deficiency of the foot.

Secondary amyloidosis is associated with a variety of chronic inflammatory diseases such as rheumatoid arthritis, ankylosing spondylitis, familial Mediterranean fever, osteomyelitis, inflammatory bowel diseases and infective or neoplastic conditions. Few cases of secondary amyloidosis complicating psoriasis have been reported. We describe a 58-year-old patient with secondary amyloidosis, psoriasis, an associated symbrachydactyly of the hand and a transverse deficiency of the foot. To the best of our knowledge, no case of this association has been previously reported.

Platelet-rich plasma and blood components for non-transfusion use: technical and medicolegal aspects.

There are a large number of publications describing the use of platelet-rich plasma (PRP) in multiple fields of application. These illustrate a large number of therapeutic elements with different and specific actions within 'platelet gel' (this term is used in the current regulations to define this product). This term, however, lacks specificity and, depending on the method used in its production is variable both in its blood composition and in platelet concentration, and several publications consider better and easier methods of platelet gel production, which may or may not lead to greater standardization in the product. The authors illustrate the general aspects of PRP and other blood components for non-transfusion use, briefly touching on the history and different fields of application and the rational of for its use. Given the increased use of such preparations, the authors describe critically the regulations in force in Europe and propose a new regulatory framework aimed to simplify and facilitate the use of such material as a therapeutic agent within medicine.

Use of a novel autologous cell-harvesting device to promote epithelialization and enhance appropriate pigmentation in scar reconstruction.

BACKGROUND: Epidermal replacement is an important step in the management of patients with post-traumatic and iatrogenic scars. Skin-colour variation from disease or trauma causes significant changes in self-image and appearance. AIM: The aim of our study was to analyse the results obtained with a novel autologous cell-harvesting system (ReCell) for epidermal replacement in patients with post-traumatic scars that had not improved with any other surgical procedure. METHODS: We recruited 30 patients with post-traumatic or iatrogenic scars admitted to our department over 2 years. The primary endpoints of the study were: (i) time for complete epithelialization (both treated area and biopsy site) and (ii) aesthetic and functional quality of the epitheliaization (colour, joint contractures). Infections, inflammations or any adverse effects of the procedure were also reported. RESULTS: In total, 30 patients were analysed. The aesthetic and functional outcomes were rated by both patient and surgeon. Pigmentation was rated by the Vancouver Scar Scale. Most (80%) of the patients had an excellent or good outcome, with pigmentation rated as normal in 60% of the group. CONCLUSIONS: The procedure is a feasible, simple and safe technique. It gives similar results to skin grafting but because it harvests from much smaller areas, can open possible future applications in the management of patients with large scars.

Treatment of stable vitiligo hands by ReCell system: a preliminary report.

BACKGROUND: The aim of this report was to analyze the results obtained with the ReCell system for the surgical treatment of stable vitiligo hands. MATERIALS AND METHODS: One patient with stable vitiligo of the hands was admitted at the Department of Plastic and Reconstructive Surgery, University of Rome Tor Vergata. The patient underwent to ReCell system for the treatment of stable vitiligo hands. RESULTS: The repigmentation was assessed using the Vitiligo Area Scoring index (VASI). The extent of pigmentation was scored as excellent, good, fair, and poor depending on the percentage of the repigmentation in the previously depigmented site. The color of the repigmented area was compared with the adjacent normally pigmented area. The patient had an excellent repigmentation. CONCLUSIONS: ReCell system is a simple, safe and feasible technique. The method that uses noncultured autologous epidermal suspension is simpler, cheaper, less time consuming and does not require sophisticated laboratory facilities, when compared with methods employing cultured melanocytes.

New trends in breast reconstructive surgery: "Florentine Lily" reductive mastoplasty.

BACKGROUND: To describe a mammoplasty technique that we called "Florentine Lily" because of the shape of the pre-operative drawings similarity with the symbol lily Florentine. METHODS: In a group of 190 women who underwent reductive mammoplasty, 23 women affected by severe enlarged breasts were selected. Main selection requirements were: 18-30 cm rising of the Areola-Nipple Complex (NAC). RESULTS: to obtain a functional and cosmetic result; preservation of mammary gland function; vitality of the areola-nipple complex and its sensitivity. We describe the case of 35 years old woman affected by severe enlargement of the breast and no pathologies. CONCLUSION: We didn't observe necrosis of the skin flaps and NAC in any case. In one case (rising of Nipple-Areola Complex >25 cm) NAC showed NAC 2 days post-surgery, which spontaneously resolved. Minor complications (edema and ematoma) developed in 20 cases. No infections were observed.

A case of labial fusion and urinary pseudo-incontinence in an elderly woman. A surgical treatment and a review.

Labial fusion is defined as either partial or complete adherence of the labia minora (1), and also called vulvar fusion, adhesions of the labia minor or conglutination of the labia minora and sinechia of the vulva. The complete and severe labial fusion is a rare pathology with a small number of cases reported in the literature in adults. We present a case report of a postmenopausal woman who presented with voiding difficulty and incontinence and was treated by surgical division of the adhesions and immediate resolution of the urinary incontinence confirmed by multichannel urodynamic test postoperatively.

Compartment syndrome of the hand with acute bullous eruption due to extravasation of computed tomography contrast material.

This article presents a case of an 80-year-old woman with severe hematoma and consequently a compartmental syndrome of the hand complicated with acute bullous eruption due to extravasation of contrast material. Compartment syndrome of the hand has been linked to a number of various etiologies. Failure to adequately diagnose and treat compartment syndromes of the hand can lead to irreparable functional loss. In the majority of the cases extravasation results only in minimal swelling or erythema. However, severe skin necrosis, ulceration and compartment syndrome may occur with extravasation of large volumes. Compartment syndrome was diagnosed, and the patient underwent immediately fasciotomy. After fasciotomy we weekly followed up our patient with medications and after she regained the full use of the hand. We report this case to assess the importance of a careful evaluation of the intravenous administration site and close monitoring of the patient during contrast material injection to obtain minimal or prevent every kind of extravasation injuries.

Use of platelet rich plasma and hyaluronic acid on exposed tendons of the foot and ankle.

Platelet rich plasma was used as an autologous scaffold for cellular growth, in combination with hyaluronic acid as a temporary dermal substitute. This aided healing of acute and chronic open wounds of the foot and ankle.

Fibroadenoma in the bilateral accessory axillary breast.

The authors treated a case of bilateral accessory axillary breast tissue. Excision with histologic examination confirmed the diagnosis of fibroadenoma. Treatment left the woman with incision scars (3.5 cm) in the axillary pyramid, a location often not seen during a patient's normal movements. Thus, despite a minor aesthetic incision, gives the advantage of complete histologic analysis was gained. Liposuction treatment was used in this case. The scar results were good.

A neglected giant subcutaneous leiomyosarcoma of the shoulder: a case report.

Superficial leiomyosarcoma is an exceeding uncommon malignant tumor, which can be located either cutaneous or subcutaneous tissues. It may occur anywhere in the body, but there is a predilection for the thighs. The distinction between cutaneous or subcutaneous, increased mass size (> 5 cm) and depth are considered to have worst prognosis in terms of recurrence and metastasis. We report a rare case of an 81-year-old woman, presented with a 20-cm leiomyosarcoma of the shoulder. The patient reported that the mass was completely asymptomatic and its growth was slow. A CT study showed a lesion closely apposed to the head of the humerus and revealed no a clear relationship with the surrounding muscles. There was no regional lymphadenopathy or the evidence of metastatic disease. After tumor resection, a large skin and soft-tissue defect was remained and the repair was performed by myocutaneous rotational free flap of latissimus dorsi. The conclusion of the histological analysis was: subcutaneous leiomyosarcoma pT2--grade 1+ (NCI system). The delayed diagnosis and the surgical treatment and giant size of soft tissue leiomyosarcoma may adversely affect the final result.

Description of columellar defects and its tridimensional remedial techniques.

Columella is an important facial component and provides support and projection to the tip of the nose. Columella defects may cause significant aesthetic and functional deformities. We present our case-load of 2007: 61 patients operated in that year had been carried out and concluded. Surgical techniques for the correction of columellar defects were classified as "open tip" and "closed tip". Then, depending on the defect, it was possible to intervene on different structures. Of the 61 patients who underwent corrective surgery, only 6 (<10%) maintained or presented again, after a temporary improvement, with the columellar defect at the end of the follow-up. For all the other patients, the final outcome was more than satisfactory. A very good aesthetic result was obtained with no functional complications. In fact, nose functionality is supported by medial crura, laid one upon the other, providing considerable resistance to the columella.

Use of cell fat mixed with platelet gel in progressive hemifacial atrophy.

Progressive hemifacial atrophy, also known as Parry-Romberg syndrome, is an uncommon degenerative and poorly understood condition. It is characterized by a slow and progressive atrophy affecting one side of the face. The incidence and cause of this alteration are unknown, and the pathogenesis of the syndrome is not clear. Some authors attribute the atrophy of the subcutaneous system to an alteration of the sympathetic system. Others attribute it to an alteration of the nervous system at the encephalic level or to an interstitial neuritis of the trigeminal nerve. The most common complications that appear in association with this disorder are trigeminal neuritis, facial disorders, and epilepsy. The latter is the most frequent complication of the central nervous system. Characteristically, the atrophy progresses slowly for several years and soon becomes stable. After stabilization of the disease, plastic surgery of autogenous fat grafts can be performed. This study aimed through the presentation of clinical cases to suggest a therapeutic plan comprised of two sequential treatments: aquisition of platelet gel from a small volume of blood (9 ml) followed by the Coleman technique for reconstructing the three-dimensional projection of the face contour, restoring the superficial density of the facial tissues. The results obtained prove the efficacy of these two treatments combined, and the satisfaction of the patient confirms the quality of the results.

Regenerative surgery: use of fat grafting combined with platelet-rich plasma for chronic lower-extremity ulcers.

BACKGROUND: The authors present their experience with reconstructive surgery of the lower extremity for chronic ulcers, evaluating the effects related to the use of a platelet-rich plasma combined with fat tissue. METHODS: A total of 20 patients, 25 to 50 years of age (median age, 40 years), have been managed with platelet gel in the Plastic and Reconstructive Surgery Department at the "Tor Vergata," University of Rome. The patients were affected by both lower-extremity chronic ulcers and vascular disease. RESULTS: The authors observed that 16 of 20 chronic lower-extremity ulcers reepithelialized during an average of 9.7 weeks, with platelet releasate suspended on a collagen base (platelet-derived wound-healing factor), compared with 2 of 10 similar wounds treated with medication based on hyaluronic acid and collagen. Collectively, these data provide evidence for the clinical use of platelet technology in the healing of both soft and hard tissue wounds. CONCLUSIONS: Currently, plastic surgery with autogenous fat grafts can be performed for stabilization of chronic lower-extremity ulcers. The objective of this study was, through the presentation of clinical cases, to suggest a therapeutic plan formed by two sequential treatments: acquisition of platelet gel from a small volume of blood (9-18 ml) followed by the Coleman technique for reconstructing the three-dimensional projection and superficial density of tissues. The results proved the efficacy of combining these two treatments, and the satisfaction of the patients confirmed the quality of the results.

Wound infections in body contouring mastopexy with breast reduction after laparoscopic adjustable gastric bandings: the role of smoking.

BACKGROUND: We retrospectively reviewed charts of 42 postbariatric patients who underwent mastopexy and breast reduction for body contouring to determine whether a significant relationship existed between cigarette smoking and postoperative wound infections and to determine the relative risk given by cigarettes and a cut-off value to predict infections. METHODS: We excluded patients with ongoing clinical infections, recent bariatric surgery (within 1 year), recent antibiotic courses, or systemic diseases such as arteriosclerosis and diabetes mellitus. RESULTS: All patients underwent bariatric surgery with the laparoscopic adjustable gastric bending technique and mastopexy with breast reduction for body contouring. Postoperative infections were present in 35.7% (n = 15) of patients, and 60% of these (n = 9) were superficial. Furthermore, 66.7% of them occurred in smoker patients, and 41.7% of smokers vs. 27.8% of nonsmokers developed infections. Significant differences between infected vs. infection-free patients were present for the number of pack years (p < 0.001) and the overall estimated cigarettes smoked (p < 0.001). A cut-off value of approximately 6.85 pack years (50,000 overall estimated cigarettes) distinguished between infections vs. infections-free patients, with 25% of false positives and 8% of false negatives. Relative risk conferred by smoking was 3.8. CONCLUSIONS: The incidence of infections in our series of postbariatric patients undergoing mastopexy and breast reduction is 35.7%. A cut-off of 6.85 pack years (50,000 estimated overall cigarettes) was determined and, according to this value, the relative risk conferred by smoking was 3.8.

Seroma treatment after dermo-lipectomy.

We can consider the seroma as a rather common complication in abdominal dermo-lipectomy surgery. In our case, the possibility has arisen to successfully reduce a remarkable accumulation of liquid using a simple but efficient protocol consisting on cortisone infiltrations.