A new treatment of genito-urinary post-menopausal atrophy with autologous micro-fragmented fat tissue: a thirty-six months follow up case series.

OBJECTIVE: Genitourinary atrophy is a menopausal pathological change determined by the definitive drop of ovarian hormones' production that can impact heavily on the health status of women, with important direct and indirect social costs. Unfortunately, available treatments are only symptomatic, and they are not able to reverse the atrophy and other related symptoms. Regenerative medicine, with single local injection of autologous micro-fractured fat tissue, could represent a viable new solution for these patients as it not only helps to relieve symptoms, but it also counteracts the mechanisms that lead to the menopausal genitourinary atrophy. The objective of this paper is to evaluate the long-term effectiveness of micro-fractured fat vulvar injection for genito-urinary atrophy in patients, affected by severe genitourinary atrophy (at least 4 symptoms lasting for at least 4 years). PATIENTS AND METHODS: We present a case series of 35 patients followed for 36 months to evaluate the effectiveness and safety of a single subcutaneous vulvar injection of autologous micro-fragmented fat tissue (MFAT). RESULTS: We have not observed any adverse effects in any patients. All symptoms, and especially pelvic pain and dyspareunia, improved in almost half of patients within 3 months. Ninety-nine percent of patients recovered completely from all symptoms after 9-12 months, reporting no relapse of the symptoms up to the third year of follow up. CONCLUSIONS: Our case series is the first case series, evaluating the long-term (3 years) safety and effectiveness of micro-fragmented adipose tissue graft for urogenital atrophy.

Micro-fragmented fat injection reduces sepsis-induced acute inflammatory response in a mouse model.

BACKGROUND: Severe sepsis has a high mortality rate. There is increasing evidence that human mesenchymal stem cells possess immunomodulatory properties in sepsis, particularly those from adipose tissue. We hypothesised that micro-fragmented human fat, obtained with minimal alteration of the stromal vascular niche, attenuates the inflammatory response and improves outcome in a murine model of sepsis. METHODS: Micro-fragmented fat, lipoaspirate, or saline was administered intraperitoneally 2 h after caecal ligation and puncture (CLP) in C57Bl/6RJ ketamine-xylazine anaesthetised mice. The primary endpoint was the inflammatory score. Secondary endpoints included survival, physiological, histological, and biological parameters. RESULTS: In CLP mice, micro-fragmented fat administration significantly decreased the median (range) inflammatory score compared with saline [17 (14-20) vs 9 (8-12), P=0.006]. Secondary endpoints were also significantly improved in micro-fragmented fat-treated compared with saline-treated CLP mice. Improvement in inflammatory score and in survival was suppressed when micro-fragmented fat was co-administered with liposomes loaded with clodronate (macrophage toxin) or NS-398 (cyclo-oxygenase 2 inhibitor), but not with SC-560 (cyclo-oxygenase 1 inhibitor). CONCLUSIONS: In a murine model of severe sepsis, micro-fragmented fat improved early inflammatory status and outcome, at least in part, by a cyclo-oxygenase-2-mediated mechanism. The potential therapeutic value of micro-fragmented fat in severe sepsis warrants further investigation.

Menopause: new frontiers in the treatment of urogenital atrophy.

OBJECTIVE: Urogenital atrophy is a degenerative process that may occur during menopause causing debilitating disorders and painful symptomatology. Estrogen therapy slows the onset of atrophy, but it requires ongoing therapy to maintain its effectiveness. To mitigate the degenerative evolutions associated with menopause, patients may benefit from new therapeutic approaches, such as the use of mesenchymal stem cells. Among the many sources, the adipose tissue is considered one of the smartest, due to its abundance and easy access. This study investigated the feasibility and potential benefits of using an autologous adipose tissue to treat the symptoms of urogenital atrophy. PATIENTS AND METHODS: In 2014, the first three women affected by post-menopausal urogenital atrophy were treated with injections of autologous and micro-fragmented adipose tissue (Lipogems®). Clinical outcomes were determined at 3, 6, 9, 12, 18, 24, and 36 months by evaluating vaginal dryness, burning, itching, stranguria, sensitivity, and dyspareunia. Pre- and 36 months post-op biopsies and vaginal discharge were also collected. RESULTS: The three women reported a significant improvement of the symptoms at 6 months with complete resolution at 9 months. This benefit, subjectively reported and confirmed by clinical evaluation, remained constant without recurrence at least until 36 months. Immunohistochemical analysis revealed a total recovery of vaginal vitality with production of glycogen, vasculature hyperplasia and regeneration of the epithelium and subcutaneous tissue at 36 months. The analysis of vaginal discharge showed a restoration of an acid pH with the colonization of lactobacilli. No postoperative complications nor adverse events were recorded. CONCLUSIONS: The results of these first three cases pointed to autologous and micro-fragmented adipose tissue as a safe, feasible and effective therapeutic approach for the treatment of post-menopausal urogenital atrophy.

Temporal galeal fascia cover of custom-made gold lid weights for correction of paralytic lagophthalmos: long-term evaluation of an improved technique.

BACKGROUND: Chronic paralytic lagophthalmos is a condition that is often conservatively treated with ophthalmic ointments and eye drops, but usually requires definitive surgical correction. PURPOSE: An effective modification of the gold lid loading technique is described, which we have found to be the simplest and most reliable method for lid reanimation. MATERIAL: After empiric evaluations with lead fisherman's weights 'glued' to the eyelid, a custom-made gold lid weight is made by a jeweller on the basis of the tarsal dimensions of the individual patient, and then sutured to the tarsus under local anaesthesia and covered with a fine sheet of temporal galea. Other ancillary procedures (lower lid suspension, lateral tarsal strip, lateral tarsoplasty) are added as required. METHODS: Between 1990 and 1996, 27 patients underwent this type of surgery, of whom 24 were re-evaluated after a mean follow-up period of 73.2 months (range 36-96 months), 14 of these for a minimum of 5 years. RESULTS: None of the gold weights was extruded, all 24 patients experienced marked improvement of their dry-eye symptoms and expressed a high degree of satisfaction. Six patients underwent further minor surgery (lateral McLaughlin tarsorrhaphy) in order to improve relative underaction. Two patients had ptosis (less than 2 mm of asymmetry) of the affected side but refused further correction. CONCLUSION: The use of custom-made gold lid weights and a protective galeal layer is a simple, reliable and successful means for permanently rehabilitating paralysed eyelids.

[A new "light" maxillomandibular fixation system]. / Un nuovo sistema "leggero" di fissazione maxillo-mandibolare.

BACKGROUND: A new "light" maxillo-mandibular fixation system for treatment of mandibular fractures, based on use of special pins, is proposed. METHODS: Fifteen patients with non-displaced mandibular fractures (angle, body and symphysis), have been treated at the Department of Maxillofacial Surgery, S. Paolo University Hospital, Milan. The system is based on pins formed by a no. 1 metal wire and a bead. The free end of the pin is threaded around a tooth and then wound three or four times around the bead to fix it in place and, at the same time, separate it from the gingiva. One pin is usually positioned on each quadrant. Once the pins are in place they are tied to each other using a loop no. 0 to complete the maxillo-mandibular fixation. Particular attention was paid to maintain a correct individual occlusion. The time of maxillo-mandibular block was 10-15 days. RESULTS: Results were good with complete healing of all fractures, restoration of individual occlusion, minimal periodontal lesions and a good compliance for the treatment by the patients. CONCLUSIONS: It is suggested to use this system routinely because quick, economic, easy on periodontium and relatively comfortable for the patients. The contraindication include an unstable occlusion, the absence of a suitable pair of teeth on both sides of the jaws, avulsion or trauma or periodontopathy of one of the teeth needed for the fixation system.

The "triple technique" for treating stable Graves' ophthalmopathy.

Graves' ophthalmopathy may range from mild eyelid retraction to a devastating process that involves the entire orbit and culminates in gross ocular congestion, massive proptosis, and even blindness. Whether the ophthalmopathy is mild or severe, patients are managed on an individual basis according to the predominant clinical findings, which may include congestion, myopathy, lid retraction, proptosis, and optic neuropathy. The process usually becomes quiescent after 6 months to 3 years; however, the changes caused by fibrosis (lid retraction and ocular muscle enlargement) are permanent. The cornerstone of surgical treatment for severe cases is bony orbital decompression; however, in our experience, mild to moderate Graves' ophthalmopathy is better treated by combining eyelid surgery and orbital lipectomy. Our approach consists of a conservative orbital lipectomy, the lengthening of the levator-Müller complex by means of marginal myotomies, and a limited lateral tarsal apposition. These three different surgical steps, which have been described previously as isolated procedures, are undertaken on both eyes at the same time and modulated according to the deformity of the patient. The operation can be performed under local anesthesia with sedation, thus allowing intraoperative monitoring of the correction; the patient can be discharged after a few hours. The results in 32 operated eyes of 16 patients have been a marked aesthetic and functional improvement, with no complications after 6 to 18 months of follow-up. The relative simplicity and very low morbidity of this procedure, as well as its reliability, make it ideal in patients with mild to moderate aesthetic and functional impairment who are looking for a substantial improvement but are unwilling to undergo a relatively major procedure such as a transosseous decompression, which, in our opinion, is the operation of choice only when the patient presents with optic neuropathy or major proptosis.

The "round block" purse-string suture: a simple method to close skin defects with minimal scarring.

We report the use of a subcuticular purse-string suture for closure of surgical skin defects, a simple maneuver that we have found to be very useful in closing difficult wounds and reducing scarring. The purse-string suture is performed with a large nonabsorbable suture that is passed intradermally and left in situ at least 4 weeks. This technique has been applied in 196 patients for a total of 221 sutures over a period of 2 years, being used to close skin defects from 2 x 2 to 8 x 11 cm in many areas of the body. All the patients showed, at closure, a large number of concentric redundant folds as well as considerable distortion of nearby structures; both improved impressively over a period of 2 to 3 weeks and became nearly normal at the time of suture removal (4 to 8.2 weeks, mean 5.7 weeks). The initially very limited and almost circular scar oriented itself along the skin tension lines over a period of a few weeks and, when matured, was always shorter than the original defect. In general, minimal scar widening occurred when we used larger sutures (more than 0-1) that were left longer (more than 6 weeks). Complications have been 23 cases of dehiscence (10.4 percent) in 23 patients (between the fifth and sixteenth days, mean 6.7 days); they were caused by the bad quality of the skin and by the use of too small sutures that cut through the dermis. The "round block" suture has many advantages: 1. It is a simple, inexpensive, and rapid technique for closing wounds by expanding the surrounding skin and often avoiding the use of skin grafts and/or local flaps. 2. It can minimize scarring; the final scars are shorter than the original defect and usually of very good quality. 3. It allows a very useful temporary closure that stretches the surrounding skin while waiting for the definitive histologic report. If this method is not chosen as a definitive closure, later repair with local flaps may be facilitated. 4. For the reasons expressed above, it never compromises the final result even in cases of dehiscence. The main disadvantage is the acceptability of the method on the part of patients, who need to be carefully prepared for both the gross initial distortion and the long time the suture has to be retained; nevertheless, patient satisfaction with the final results in generally very high, especially in large excisions of the face.

Use of a versatile axial dorsonasal musculocutaneous flap in repair of the nasal lobule.

We present our 17 years of experience in using a sliding axial musculocutaneous flap from the nasal dorsum in the repair of 53 nasal lobular defects (follow-up 3 to 212 months, mean 47.3 months). This flap is a modification of the classic Rintala flap but is based on a greater understanding of surgical anatomy, the biomechanical properties of skin, and physiology of flaps, all of which allow a more aesthetically satisfactory closure of very distal nasal lobular defects. After excising the tumor, two parallel incisions are made along the sides of the nasal dorsum, and flap is raised in the gliding plane deep to the fibromuscular layer of the nose and superficial to the cartilage and bone and then advanced over the defect, which can be as large as the entire nasal lobule. The flap is very reliable (no failure in our series) and easy to perform; furthermore, it is a fast, one-step reconstructive procedure that leaves the scars in areas of natural shadow. This flap makes use of a wide dorsal and glabellar undermining to recruit sufficient skin; it takes advantage of the mild tension exerted by the underlying nasal framework to lengthen the flap reliably without the need for an extra incision or Burow's triangles, as originally described by Rintala. Neither tip rotation nor glabella flattening has ever been found to be a real problem in our series because the flap elongates in a period of 2 to 6 weeks and tip always comes down, provided that the nasal framework is not modified. We believe that the axial musculocutaneous sliding flap has distinct advantages over other alternative local flaps in the repair of lobular nasal defects; moreover, although this simple operation cannot compete with the quality of the aesthetic results achieved by very skilled masters using frontal flaps, it is an easy, quick, one-step procedure that allows acceptable and reliable aesthetic results to be achieved by the majority of surgeons, and it does not harm the precious forehead donor site, which may become essential in case of the need for further reconstruction.

The treatment of chronic flexion contractures of the proximal interphalangeal joint.

A method of treatment of chronic flexion contractures of the PIP joint is presented, with the results obtained in 19 patients treated between 1989 and 1992 after a follow-up of from 6 to 53 months. The flexion contractures, with an extension deficit which ranged between 70 and 90 degrees, had been present for a period of between 2 months and 24 years. Our treatment program involves the surgical release of the unreducible PIP joint followed by the use of static and/or dynamic splints. Surgery is performed using a midlateral approach; the accessory collateral ligament and the flexor sheath are incised and, after the volar plate and check-rein ligaments have been excised, forced hyperextension is applied. The main collateral ligaments are carefully spared and freed from the condyle if there are any remaining adhesions. In our 19 patients, complete extension of the finger was achieved in 11 cases (57.9%); in the remaining 8 cases (42.1%) the residual extension deficit ranges from 10 to 15 degrees. In our experience this combined surgical and rehabilitative approach had led to consistently good results with minimal complications.

Iatrogenic nostril stenosis: aesthetic correction using a vestibular labial mucosa flap.

Nostril stenosis is an infrequent finding that often has an iatrogenic cause. It is a very difficult problem to resolve and usually requires several months of prosthetic support in order to counteract the recurrence of internal scarring and shrinking. We present a 4-year-old child with a monolateral iatrogenic nostril stenosis. A satisfactory and stable correction was obtained using a "piercing" flap taken from the labial vestibule. The use of a nasal stent (not placed immediately and worn only at night) was necessary for only 2 months. This technique has a number of advantages: the absence of external scars, little or no tendency to recurrence due to the absence of contraction provided by the well-vascularized flap tissue, and the ease and rapidity of the surgical procedure.

Reverse dorsal digital island flap.

The anatomic and clinical bases for a reliable and versatile homodigital flap for covering difficult distal dorsal and dorsolateral wounds of the long fingers are presented. This one-step procedure, which uses the dorsal skin of the first or second phalanx transposed as a reverse island flap, preserving the collateral nerve and artery to the fingertip, has proved valuable in salvaging the severely injured digits of nine patients (for a total of 12 flaps). It would seem to be a relatively simple way of achieving early recovery because it does not require distant flap reconstruction, the immobilization of adjacent digits, or homodigital flaps that might jeopardize an already injured finger. Furthermore, it reduces the time of hospitalization and improves patient welfare.

Anatomical basis for a safe and easier approach to composite rhytidectomy.

The authors present the anatomical findings that have made an easier approach to composite rhytidectomy possible. The lower lateral border of the orbicularis oculi muscle (OOM) overlies the zygomaticus major muscle (ZMM), the upper third of which tightly adheres to the malar bone. The OOM is innervated throughout over its circumference by a plexus of small facial nerve branches. From its deeper surface, the ZMM is innervated by two to four branches in its upper third and middle third. These branches are jeopardized in an extended sub-SMAS dissection as this tends to go deep into the ZMM. The malar fat pad is superficial to the SMAS layer that invests the zygomaticus and levator labii muscles and, with age, tends to slide downward, medially deepening the nasolabial folds. An extended dissection beyond the OOM tends to remain superficial to the upper part of the ZMM, zygomaticus minor, and levator muscle complex. We have found that extending the suborbicularis dissection inferiorly and laterally offers three major advantages: (1) The correct deep subcutaneous plane just above the ZMM, zygomaticus minor muscle, and levator complex can be found easily, leaving all of the fat attached to the skin. The only structures at risk are some minor motor branches to the OOM that can be divided without any morbidity because of the extensive plexiform innervation.(ABSTRACT TRUNCATED AT 250 WORDS)

The surgical anatomy of the subcutaneous fascial system of the scalp.

The surgical anatomy of the fascial layers and vascularization of the scalp was studied by means of 11 bilateral cadaver dissections. This article is organized as follows: first, a description of the layers and fasciae of the scalp and their relationships with the main vascular structures, and then a description of the histological structure of the subgaleal fascia (composed of multiple connective vascularized sheets that glide over one another) and of its blood supply. In our dissections, we found the constant topographic distribution of the major perforant vessels to the subgaleal tissues as follows: in the temporal region, perforant vessels from the superficial temporal artery near and 10 to 14 cm above the zygomatic arch, where the superficial temporal artery leaves the surface of the galea to enter the superficial subcutaneous tissue, and in the fronto-parieto-occipital region, many small perforant vessels evenly entering the subgaleal plane every 5 to 10 mm. These findings could lead to greater use of fascial or composite flaps from the scalp region.

Spontaneous rupture of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the most frequent malignant tumour of the liver. HCC has an incidence that changes with geographic areas (1.2-2.5% in western countries and 13-53% in Asia and Africa) as the risk of tumour bleeding. The patient arrives to the surgeon in emergency with no possibility of radical resection because of the patient's general conditions, the tumour's stage and the cirrhosis. Palliative treatments are: resection, direct suture of the bleeding tumour, artery embolization and selective binding of the hepatic artery. The Authors describe two cases of spontaneous rupture of HCC observed in the surgical department of Venice Hospital. A review of the literature is also reported.

Epidermal growth-factor receptor and erbb2 protein in colorectal tissue - comparison between cancer and normal mucosa.

Epidermal growth factor receptor (EGFr) and p185neu protein were measured in 55 samples of carcinoma and 55 of normal colorectal mucosa from the same patient, using a ligand binding assay and an ELISA method respectively. The binding characteristics of EGFr were similar in cancer and normal tissue. The concentrations of both EGFr and p185 showed gaussian distribution and were not significantly different between normal and cancer tissue, although a trend toward higher levels of EGFr in normal mucosa was found. Moreover, no significative variations were found in the ratios between cancer and normal tissue after desaturation of the EGFr. No correlations were found between EGFr and p185 and the main clinopathological parameters.

TAF test in primary esophageal carcinoma: comparison with other tumor markers.

An ELISA method for the determination of circulating specific HSV-TAA antibodies has recently become available (TAF test). The presence of TAF was tested in serum of 154 patients with primary esophageal carcinoma, collected in three institutions. The overall TAF-test positivity rate was 57.1%, being significantly lower in stage IV than in stage III patients. The concordance rate between TAF and CEA, ferritin, TPA, SCC and TATI was low, suggesting that TAF is probably independent of the other tumor markers evaluated. The clinical role of TAF-test determination in patients with esophageal carcinoma is currently under evaluation.