Alternative Hydration of the Acellular Dermal Matrix (ADM) to Reduce the Rate of Infection of Breast Reconstructions.

Level of Evidence IV 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 .

About locoregional recurrence risk after lipofilling in breast cancer patients: our experience.

AIM: Lipofilling is a part of the clinical practice for breast reshaping in patients who underwent surgery for breast cancer. A strong debate in the Literature is open about a higher risk of cancer relapse caused by growth factors produced by adipocyte stem cells after their engraftment in the recipient tissue. Nowadays there is no agreement over the use of autologous fat tissue for the correction of aesthetic defects following breast conservative surgery. METHODS: We have considered 151 patients who underwent a breast conservative surgery in the period April 2004-April 2009, followed by one or more lipofilling sessions in the period June 2006-August 2012. A careful pre-operative evaluation of the tumor characteristics has been made, through imaging exams, MRI included. An intraoperative evaluation of the tumor dimensions and its distance from the surgical edges has also been made, followed by a microscopic analysis through a shaving technique. Lipofilling has been offered to all the patients on average 24 months after surgery. RESULTS: We have found no cancer relapses after a mean follow up of 45 months (17-76) after lipofilling and of 69 (27-100) months after surgery. CONCLUSIONS: Considering oncologic surgery, we can affirm that lipofilling is safe for the risk of cancer relapses, if performed using all the parameters included in our clinical protocol.

Conservative surgical treatment of a thin acral lentiginous melanoma of the thumb with no recurrences: a case report.

Surgical treatment for acral lentiginous melanoma (ALM) is usually radical and severely invalidating, given its distinctly aggressive nature and poor prognosis. We report on a 76-year-old male patient with ALM of the left thumb who refused total amputation that would limit his gripping function. A "surgical degloving" was consequently performed, followed by plastic reconstruction with a radial antebrachial (the so-called Chinese) flap. A year after surgery, the patient was able to perform most finalized thumb movements without difficulty, and no metastases were recorded over a 5-year follow-up. The authors discuss the indications for such a treatment for thinner ALM in relation to the biological behavior of ALM.

The MRI as a valid help for oncoplastic surgery: esthetic and oncologic results analysis in a group of 489 patients.

AIM: There is an increased expectation from breast cancer patients to retain their "normal breast appearance". To help to achieve this expectation, many radiologic exams have been created to get the exact extension and position of the tumor. MRI is effective to obtain correct information about neoplasms, especially those with shaded edges, like DCIS. MRI might change the surgical project, thus avoiding second operations for cancer relapses. METHODS: We have performed MRI to all the patients except those with big lesions or adypous breasts. We have chosen for reconstruction various oncoplastic techniques. We have had early complications in 98/489 (20%) cases. RESULTS: As late complications, we have found scar retractions and minus areas in 20/489 cases (4.08%), while we have found asymmetries and bigger deformities in 34/489 cases (6.95%). We have not found any cancer relapse after one year, we have had 3 cases of relapse (0.6%) after five years of follow-up, after 5, 4 and 2 years. Our good oncologic and plastic results have to be attributed to many factors, among which stands out the MRI done in all the cases. CONCLUSION: We think that an immediate breast reshaping following quadrantectomy is the best esthetic and psychologic option for breast cancer patients.

Failure by congestion of pedicled and free flaps for reconstruction of lower limbs after trauma: the role of negative-pressure wound therapy.

Lower limb reconstruction with pedicled or free flaps can be commonly compromised by venous insufficiency. This complication often leads to partial/complete flap necrosis and increases the risk of superinfection. Negative-pressure wound therapy (NPWT) is known to increase local blood flow, decrease edema, promote tissue granulation, and reduce the likelihood of soft tissue infection. This study aims to evaluate the effectiveness of NPWT in the treatment of congested pedicled and free flaps of the lower limb after reconstructions in lower limb traumas. A retrospective analysis was performed on four congested (pedicled and free) flaps on the lower limbs. NPWT was applied in all cases after partial flap debridement. NPWT was able to improve and resolve tissue edema and venous insufficiency, avoid further flap necrosis, and promote granulation. On NPWT removal, a split-thickness skin graft was applied on the wound, achieving complete and uneventful healing. NPWT is a useful instrument in managing flaps affected by venous insufficiency in lower limb reconstruction, although larger studies are necessary to better define the effectiveness and indications of NPWT in this setting.

The bovine pericardial patch in breast reconstruction: a case report.

In the last years there has been a growing demand of plastic surgery for soft tissue reconstruction. In response to this, many biological and synthetic devices have been produced, aiming to allow wide and complex body reshapings. Acellular dermal matrices are one of these devices, and are made of human or animal tissues made acellular after their sampling. They are used for cervical, breast and abdominal wall reconstruction. Tutopatch®, generally used for face reconstruction or neurosurgery, is made of acellular bovine pericardium, and its high amount of collagen allows a fast tissue healing and a scaffold for the surrounding tissue regeneration. In our case report Tutopatch® has been used in immediate breast reconstruction after mastectomy. This device has been used to close laterally the subpectoral pocket, allowing a bigger volume prosthesis to be placed We have not experienced particular postoperatory complications, and after 12 months of follow up we have found a valid functional and aesthetic result. We consider Tutopatch® as a valid alternative to other acellular dermal matrices specifically designed for breast reconstruction.

Locally advanced breast implant-associated anaplastic large-cell lymphoma: a combined medical-surgical approach.

OBJECTIVE: Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare form of non-Hodgkin's T-cell lymphoma that develops around breast implants. CASE PRESENTATION: This report illustrates the case of a patient affected by a locally advanced BIA-ALCL which infiltrated the thoracic wall (stage T4N0M0) following implant-based reconstruction after left mastectomy. Given the initial inoperability due to the patient's poor general condition, the treatment plan provided for a primary cycle of systemic neoadjuvant immunotherapy/chemotherapy, surgical removal of the mass, and subsequent systemic chemotherapy/immunotherapy. This resulted in complete remission - the patient remained disease-free even over a year later - without the need for adjuvant radiotherapy. CONCLUSIONS: Our real-life case shows how the existing guidelines can be successfully adapted as part of an individualized approach to advanced and/or difficult cases.

Autologous micrografts and methotrexate in plantar erosive lichen planus: healing and pain control. A case report.

Erosive lichen planus is an uncommon variant of lichen planus. We report a case of longstanding and refractory plantar ELPs causing disabling and opiate-resistant pain treated with 'classic' meshed skin graft combined with Rigenera®  micrografts. After approximately 9 months follow-up, no clinical recurrence or pain were observed. Erosive lichen planus (ELP) is an uncommon variant of lichen planus, involving oral cavity and genitalia and, less often plantar areas, where it usually presents with chronic erosions of the soles, along with intense, disabling pain and progressive loss of toenails. An abnormal immune cellular response (CD8+ lymphocytes and macrophages) and the consequent altered production of multiple mediators (interleukin-12, interferon-γ, tumor necrosis factor-α, RANTES and MMP-9), seem to play a crucial role in the pathogenesis, although the etiology remains uncertain. From a histological point of view, ELP shows keratinocyte apoptosis, intense inflammatory response and basal epithelial keratinocytes TNF-α overexpression. Several therapies have been proposed, with variable and controversial results. While topical corticosteroids and topical calcineurin inhibitors are the treatments of choice for localized forms, short pulses of systemic glucocorticoids, phototherapy, and systemic immunosuppressants are recommended for generalized cases. Surgery has been reported as a possible therapeutic option in refractory and stable cases with localized lesions, either alone or with cyclosporine. Herein, we report a case of longstanding and refractory plantar ELPS causing disabling and opiate-resistant pain treated with 'classic' meshed skin graft combined with Rigenera® micrografts.

Penis invalidating cicatricial outcomes in an enlargement phalloplasty case with polyacrylamide gel (Formacryl).

The present article reports the case of a patient subjected to polyacrylamide polymers-composed gel cutaneous infiltration in the penis for cosmetic purposes, resulting in severe invalidating outcomes. A significant tissue reaction to the subcutaneous injection of polyacrylamide gel for the penis enlargement purpose resulted in permanent and invalidating scars both on the esthetic and functional levels. Such a result must be simply taken into account both singly and in the light of the international literature to exclude this method as standard uro-andrologic activity.

Soft-tissue defects of the Achilles tendon region: Management and reconstructive ladder. Review of the literature.

INTRODUCTION: Defects of the Achilles tendon region represent a challenge for reconstructive surgeons. Several options are available but there is still no reconstructive ladder for this specific and tricky area. An up-to-date reconstructive ladder according to local and general conditions is proposed based on our multicentre experience and an extensive review of the English literature on PubMed. MATERIALS AND METHODS: An extensive review of the English literature was performed on PubMed using the following key-words: "Achilles region", "heel", "soft-tissue reconstruction", "flaps", "grafts" and "dermal substitutes". RESULTS: A total of 69 complete papers were selected, covering the last thirty years' literature. Although most of the studies were based on limited case-series, local and general conditions were always reported. A comprehensive reconstructive ladder of all the available reconstructive techniques for the Achilles region has been created based on our personal multicentre experience and the results of the literature review. CONCLUSIONS: The reconstructive ladder is a concept that is still a mainstay in plastic surgery and guides decisions in the repair strategy for soft tissue defects. The optimal solution, according to the experience of the surgeon and the wishes of the patient, is the one that implies less sacrifice of the donor site. Perforator flaps should be the first-line option for small-to-moderate defects; the distally-based sural flap is the most reported for moderate-to-large defects of the Achilles region, and free flaps should be reserved mainly for complex and wide reconstructions.

[A case of transareolar mastocele (tuberous breast) following an early lateral thoracotomy]. / Su di un caso di mastocele transareolare (tuberous breast) conseguito a toracotomia laterale precoce.

The paper reports a rare case of breast anomaly, classified as "tuberous breast", which was of a specific nature since it was the result of a lateral thoracotomy performed at the age of 7 days old to esophageal atresia. The paper analyses the possible etiopathogenetic mechanisms. The use of an original reparative technique enable an adequately shaped and protruding breast to be obtained without the use of prosthesis and without leaving additional scars.

[A rare case of breast ectopy associated with partial agenesis of osteo-muscular structures of the thoracic wall. Proposal of an original reparative technique]. / Un raro caso di ectopia mammaria, associato ad agenesia parziale delle strutture osteomuscolari della parete toracica. Proposta di una metodica riparativa originale.

The Authors report a case of chest wall malformation characterized by costal defect (6th and 7th ribs), hypoplasia of the serratus and pectoralis major muscles, left mammary ectopy and mucoviscidosis. The case is reported because of the very singular malformative association and the originality of the reparative procedure. Appearance has been improved and a good shape and breast projection achieved.

[The postoperative expansion of a myocutaneous flap of the large dorsal muscle in postmastectomy breast reconstruction]. / L'espansione postoperatoria del lembo miocutaneo di muscolo gran dorsale nella ricostruzione mammaria postmastectomia.

BACKGROUND: Reconstructive breast surgery using the myocutaneous flap of the latissimus dorsi muscle with simultaneous insertion of a prosthesis represents a very useful procedure from a clinical standpoint. METHODS: Twenty-one breast reconstructions were performed using this type of surgery at the Plastic Surgery Clinic of the University of Udine between December 1993 and December 1995. RESULTS: Good aesthetic results can be obtained due to the relatively moderate functional and scarring complications, as well as to the vitality of the transposed tissue. The percentage of capsular contractures observed frequently in the past was lowered through the use of technologically-advanced prosthetic materials with a texturized surface. CONCLUSIONS: In addition, since the reconstructed breast can be expanded postoperatively through definitive Becker expanders, aesthetically satisfactory results can be achieved even with contralateral ptosic and/or large breasts.

Radiation-induced angiosarcoma of the breast: case report and self-criticism of therapeutic approach.

Angiosarcoma (AS) of the breast is a rare and highly aggressive vascular cancer. It presents as a primitive or radioinduced form. The case of a 46-year-old woman who underwent quadrantectomy of the breast plus axillary lymph node dissection and radiotherapy postoperatively (QUART) for ductal infiltrant carcinoma is reported in the following. Ten years later, the patient underwent mastectomy with immediate reconstruction, for local recurrence that was diagnosed as an AS of the breast at final pathological examination. She did not receive any adjuvant treatment due to local post-operative complications related to breast reconstruction. We criticize our therapeutic approach and we recommend more attention about local recurrence suggesting that tru-cut needle biopsy of local recurrence of the breast after QUART, should be the correct diagnostic approach.

Pregnancy and tram-flap breast reconstruction after mastectomy: a case report.

A 38-year-old patient had a right radical (Patey) mastectomy for an infiltrating ductal carcinoma followed by chemotherapy and, one year later, a TRAM flap breast reconstruction. She was given clear and exhaustive information about the possible consequences of pregnancy, but despite this she became pregnant four months after the reconstruction. The pregnancy was taken to term despite the appearance at four months of a slow-growing abdominal hernia. In the light of our experience and that of others, we recommend an interval of at least 12 months between breast reconstruction with a TRAM flap and pregnancy.

Myofasciocutaneous expansion in the tegumentary rehabilitation of the amputation stump.

In post-traumatic amputations, in particular in leg amputations, the presence of an unstable scar or of ulcerous areas that are difficult to heal in the site of the amputation stump constitutes a repair problem that is not easily solved. In this specific field of reconstruction skin expansion has earned significant agreement, and is even considered to be a safe and reliable method for the surgical rehabilitation of the amputation stump, allowing us to obtain high-quality tegumentary covering, with no excessive thickness, that adapts well to the prosthesis and to the underlying skeleton, and that is characterized by good sensitivity of protection. Tegumentary amplification may, in some cases, also become myocutaneous, allowing us to obtain more tissue thickness for protection in patients submitted to chronic loading that lasts longer and in those with thin teguments, in which traditional expansion could determine excessive narrowing of the tegumentary covering, following atrophy caused by compression of the subcutaneous adipose tissue.

[A nasal reconstruction via the expansion of the tissue]. / La ricostruzione nasale mediante espansione cutanea.

The techniques that offer the best results in total nasal reconstruction are those that use frontal skin. Even if traditional procedures meet most of the reconstructive needs, they are often limited by the size of the tissues to be transplanted and by the scarring they leave in the donor area. The stiffness and scarce pliability of the frontal skin hinder fine modelling of the alae, of the columella and of the nasal tip. Expanded forehead flaps to day offer a substantial advantage. In the period from 1986 to 1991 total nasal reconstruction was performed in 12 patients (4 males and 8 females). Their ages ranged from 4 to 69 years. Four patients presented a recurrence of a basal cell carcinoma, 1 patient presented a trichoepithelioma. In 3 cases an arteriovenous vascular malformation was present, in 1 there were radiodermatitic lesions while in another 3 cases there was extensive scarring. In all cases a rectangular skin expander without base and with a remote filling port was used. The nominal volume ranged from 100 cc to 260 cc. All expanders were introduced through a vertical hair incision in the subgaleal plane, except in 1 case in which it was placed over the frontal muscle. The mean time of expansion was 79 day. The mean volume at the end of the expansion was 283 cc. The results obtained are presented and the advantages of the technique are exposed. These are: 1) the possibility of obtaining forehead flaps wide enough to cover large defects, 2) the direct closure of the donor area even if large flaps are raised, and 3) the improved pliability of the expanded frontal skin. A minor complication present in all the patients treated was moderate pain during inflation of the expander, easily controlled with common analgesics. A bony crest was frequently observed around the base of the skin expander which, however, was easily removed with a curette. Only in one case was a major complication observed; that of a preoperative infection necessitating removal of the expander, which was reapplied a few months later in order to complete the initial reconstructive program.