Management of Implant Exposure in One-Stage Breast Reconstruction Using Titanium-Coated Polypropylene Mesh: Sub-Mammary Intercostal Perforator Flap.

INTRODUCTION: One-stage implant-based breast reconstruction using titanium-coated polypropylene mesh is a novel approach widely used in Europe. Complication rates in breast reconstruction with the use of titanium-coated meshes seem to be comparable to those in patients with implant-based breast reconstruction alone. However, the use of synthetic meshes in implant-based breast reconstructive surgery leads to new clinical scenarios with the need for the breast surgeon to face new complications. We present an innovative treatment of implant exposure in the absence of infection in patients who underwent nipple-sparing mastectomy and immediate breast reconstruction with silicone implants and titanium-coated polypropylene mesh by using a pedicled sub-mammary intercostal perforator flap. CASES PRESENTATION: Four patients who experienced implant exposure without infection have been treated with the use of a sub-mammary intercostal perforator flap. Whole coverage of the exposed implant/mesh with a sub-mammary intercostal perforator flap was obtained in all cases. No post-operative complications have been observed, whereas a pleasant aesthetic result has been achieved. Patients' post-operative quality of life and satisfaction levels were measured by the European Organisation for Research and Treatment of Cancer breast cancer-specific quality of life QLQ-BR23 questionnaire and showed an average good satisfaction with the post-operative outcomes (mean QLQ-BR23 score 1.9). DISCUSSION: For the first time, a sub-mammary intercostal perforator flap has been used with the aim of treating implant exposures without removing the prosthesis even in the presence of synthetic meshes, when wound infection was excluded. Although tested on a small series, the sub-mammary intercostal perforator flap might represent a simple, versatile and cost-effective procedure for the management of implant exposure following nipple-sparing mastectomy and immediate reconstruction with silicone implants and synthetic meshes. It should be considered to avoid implant removal followed by delayed free flap reconstruction as "salvage surgery." LEVEL OF EVIDENCE V: This journal requires that the 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 .

Intraoral approach for nasal tip upturning.

BACKGROUND: The nose is an important landmark in facial beauty, and slight modifications lead to dramatic changes. The authors describe their surgical technique to upturn the tip of the nose with an intraoral approach sectioning the fibers of muscle depressor septi. METHODS: There were 14 patients (5 male and 9 female patients) in this study. All patients complained of nasal tip ptosis. The surgical procedure was explained to the patients, and the informed consent was obtained; preoperative frontal and lateral photographs were taken. The same surgical procedure was performed in all patients. RESULTS: No complications were observed. Tip upturning, with satisfaction of the patients, was observed in all cases and was confirmed comparing preoperative and 6-month postoperative photographs. CONCLUSIONS: From the outcomes of this short case series, the surgical technique described to upturn the tip of the nose with an intraoral approach sectioning the fibers of muscle depressor septi and with the skeletization of the premaxilla is an easy, safe, and inexpensive technique that can be easily performed at the office.

Polyacrylamide gel injection for treatment of human immunodeficiency virus-associated facial lipoatrophy: 18 months follow-up.

BACKGROUND: Lipoatrophy of the face affects the quality of life and body image of individuals receiving antiretroviral therapy. The objective of this study was to assess the safety and efficacy of a permanent nonbiodegradable polyacrylamide gel filler, used for facial wasting rehabilitation. METHODS: Thirty-two individuals positive for the human immunodeficiency virus (HIV) were enrolled in the study between January 2007 and January 2009 and treated using nonbiodegradable polyacrylamide gel injections for a facial wasting rehabilitation. RESULTS: Local infection, foreign body reaction, and migration of the product were not observed during follow-up (18 months). Small, palpable, nonvisible nodules were recorded in 13 cases at the end of follow-up. CONCLUSIONS: Polyacrylamide hydrogel is an appropriate treatment option in restoring facial contours in immunocompromised people with HIV. Injections of large volumes of polyacrylamide gel (8 to 12 mL) are not associated with a high rate of complications such as infection and foreign body reaction and allow improvement in quality of life in a limited time.

Easy closure of anterior palatal fistula with local flaps.

BACKGROUND: Anterior palatal fistula is often observed in the treatment of the cleft palate with a push-back palatoplasty. High rate of incomplete closure is reported. We describe a reliable new technique with reverse local flaps to close an anterior palatal fistula. MATERIALS AND METHODS: One hundred seventeen cleft patients, treated with push-back palatoplasty, underwent repair of an anterior palatal fistula by our group. Fistulas were located in the anterior hard palate, with a variable size between 0.1 cm to more than 0.5 cm. Two reverse local flaps from the nasal mucosa of the lateral palatal edges are used to close the fistula. A third flap is elevated from the premaxilla in bilateral clefts. The flaps are elevated toward the center of the fistula. The closure is made in 2 layers for unilateral cleft and in 3 layers for bilateral cleft, using absorbable sutures. RESULTS: Complete closure of the anterior palatal fistula was achieved in 77 patients (65%) after the first surgery, 27 patients (23%) required a second attempt to close the fistula, and 10 patients (8.5%) required a third surgery. Three patients (2.5%) continued to have a fistula after 5 surgeries. CONCLUSIONS: We believe that our method is reliable and easy to perform, and it has a high success rate. The technique is indicated to correct small- to medium-size defects.

Recurrence of ameloblastoma in temporal area: primary treatment influences recurrence rate.

Ameloblastomas are benign odontogenic tumors but are locally aggressive, most commonly occurring in the mandible and in the third to fifth decade of life. The male-to-female ratio is approximately equal. Recurrence of ameloblastoma due to inadequate treatment is often described. Recurrences in the temporal area are very rare and are related to the type of primary treatment. The authors describe a case of ameloblastoma recurrence in the temporal area and review the literature regarding recurrence and treatment.

Observations on the microcirculation of the human burn wound using orthogonal polarization spectral imaging.

Orthogonal polarization spectral imaging (OPS) utilizes the illumination of the tissue with polarized light within the haemoglobin spectrum. We report here on OPS for the assessment of the skin microcirculation non-invasively through the surface of the human burn wound. This allows inspection of individual capillaries of the cutaneous microcirculation and flow through these vessels in real time. Two distinct microcirculatory patterns were seen. Superficial burns had small visible dermal capillaries studied throughout the field of view. The flow of individual erythrocytes through these capillaries was clearly visible in real-time. Conversely, deep burns showed large thrombosed vessel coursing in a criss-cross fashion. There was marked difference between the mean optical densities for normal skin and superficial burns (65.8+/-15.6 and 64+/-14.6, respectively) and deep burns (131.2+/-31.1). These findings indicate that OPS may have utility in the assessment of cutaneous microcirculation in burns.

Trilucent breast implants: voluntary removal following the Medical Device Agency recommendation. Report on 115 consecutive patients.

In June of 2000, the U.K. Medical Device Agency recommended the removal of Trilucent implants as a precautionary maneuver in response to reports of local inflammatory reactions. This decision allowed the authors to operate on 115 consecutive patients between June of 2000 and January of 2001. On the preoperative examination, the authors found a very high incidence of rippling (66 percent), whereas capsular contracture was seen in only three patients (2.6 percent). Rippling was significantly more common in patients with subglandular implants. Five implants were found ruptured during the operation. This figure, together with the relative ease of implant breakage at removal, shows a premature deterioration of the implant shell. The authors also comment on implant bleeding, which seems common in this type of breast implant. The authors think that this is a possible cause for the rippling phenomenon, resulting from a reduction of the implant content. On the basis of these findings, the authors conclude that Trilucent implants are associated with a poor cosmetic outcome and a high rate of complications.

A case of a giant submandibular gland calculus perforating the floor of the mouth.

Sialolithiasis is characterized by the obstruction of salivary gland secretion by a calculus. It is associated with swelling, pain, and infection of the affected gland. More than 80% of all salivary calculi occur in the submandibular gland. One reason for this is the makeup of the saliva in the submandibular gland, which includes a higher mucus content, a greater degree of alkalinity, and greater concentrations of calcium and phosphate salts compared with the saliva of the parotid and sublingual glands. Other factors are that its duct is longer and its saliva flows against gravity. Sialoliths that reach several centimeters in diameter (megaliths, or giant calculi) are rare. Perforation of the floor of the mouth by a giant calculus is extremely rare. We report such a case in a 56-year-old man who presented with a 2-day history of severe pain in the left sublingual area and painful swelling in the left submandibular area. Removal of the stone and the left submandibular gland was performed via an extraoral incision. On gross examination, the sialolith measured 5.6 cm.

Comparison of two techniques of cinch suturing to avoid widening of the base of the nose after Le Fort I osteotomy.

All Le Fort I osteotomies have the potential to alter the dimensions of the alar base, and widen it. Surgical techniques to control this lateralisation of the base of the nose, including those of cinch suturing of the alar base, have been widely described and modified. We have compared two techniques of cinch suturing to try and prevent widening of the base of the nose after Le Fort I osteotomy. We studied 40 patients with skeletal class III facial deformities treated by orthognathic operations by the same surgeon. They were randomly divided into two groups of 20 each, one of which was treated with a classic cinch suture and the other by a modified technique. The distances between the nasofacial skinfold at the left alar bases, the columella, and the right nasofacial skinfold were recorded before and six months after operation. The results of the modified technique were more stable than those after classic suturing. In only 3/20 patients in the classic group did the suture prevent nasal widening, whereas in the modified group the number was 14/20.

Electrical injuries due to theft of copper.

This study shows that the theft of copper, mainly from electrical wires, is becoming a more frequent crime as the value of this metal rises. We have collected all the data from the Burn Centre of the Hospital of Palermo, Italy, from 1992 to 2007. Over the last two decades, we assisted to a dramatic increase of patients admitted to our hospital, reporting burn injuries while attempting to steal it in dangerous conditions. The circumstances of the injury, the clinical management of the case, and the long-term consequences are presented and discussed. We found that the electrical burn related to the theft of copper is often a life-threatening event because of the high-voltage electrical current passing through the patients. Patients, due to the type of activity, often requiring physical effort, were generally young and healthy. From a review of the literature on the subject, we have noticed that theft of copper is not reported as an important risk factor for electrical burns. Our report clearly shows that theft of copper-related electrical injury is becoming more frequent in the community and should be added as a "new" risk factor. The already high incidence reported here may actually be lower than the actual incidence because many patients tend not to come to the hospital because of the risk of being prosecuted by the police.

Calcitonin gene-related peptide and thermal injury: review of literature.

The aim of this review article is to report about the anti-inflammatory properties of calcitonin gene-related peptide (CGRP) in burns. CGRP is a 37-amino acid neuropeptide, primarily released from sensory nerves and is well known as the most potent and long-lasting microvascular vasodilator in vitro and hypotensive agents in vivo.A wide range of proinflammatory stimuli can induce the release of neuropeptides from cutaneous sensory nerves, including heat, physical trauma, UV radiation, and irritant chemicals. These proinflammatory stimuli are known to induce the release of CGRP from cutaneous sensory nerves. The anti-inflammatory effects of CGRP in a range of species and in human clinical conditions are detailed, and potential therapeutic applications based on the use of antagonists and gene targeting of agonists are discussed.

Soft tissue defects of the heel: a surgical reconstruction algorithm based on a retrospective cohort study.

UNLABELLED: The hindfoot is a special anatomical location, requiring unique forms of reconstruction of the thick, durable heel pad, the underlying calcaneus, and the Achilles tendon and its thin, pliable soft tissue envelope. Perhaps more than in any other region of the foot, the heel poses a reconstructive challenge to the surgeon who must consider both form and function when repairing wounds in this location. There are many possible reconstructive options, including local, distant, and free flaps. These flaps could be of muscular, myocutaneous or fasciocutaneous tissues. We reconstructed heel defects in 46 consecutive patients using several reconstructive options, and reviewed the results. Patients were classified according to preoperative demographic variables, including size, depth, site, etiology, age, vascularity, sensation, Achilles tendon condition, bone exposure or bone loss, and the patient's functional needs. Neither partial nor total flap losses were observed; the reconstructions were evaluated and considered satisfactory both by surgeons and patients if they fulfilled certain criteria, namely complete coverage, durability upon weight bearing and walking, sensation, donor site morbidity, and cosmetic appearance. No recurrences of the defects were observed during the follow-up period. Heel reconstruction is a challenging task for foot and ankle reconstructive surgeons. Every step should be taken to avoid recurrences and ulcerations. In this article we present a surgical reconstruction algorithm that may allow easy and reliable decision making based on the preoperative assessment of the defect and other clinical features. LEVEL OF CLINICAL EVIDENCE: 2.