Far Infrared Radiation Therapy for Gynecological Cancer-Related Lymphedema Is an Effective and Oncologically Safe Treatment: A Randomized-Controlled Trial.

Background: Gynecological cancer-related lymphedema (GCRL) is a devastating condition that adversely influences function, health, and quality of life. We conducted a randomized-controlled clinical study as well as in vitro experiments to investigate the efficacy and safety of far infrared radiation (FIR) to treat lymphedema in patients having previously undergone surgery for gynecological tumors. Materials and Methods: Seventy-four women with GCRL, cancer free for 5 years or more, were randomly allocated into two treatment groups: standard of care with bandage treatment and treatment with FIR plus bandage. Variations of fluid, circumference of lymphedematous limbs, serum tumor markers (cancer antigen 125 [CA125]), inguinal-pelvic lymph nodes, vagina, lungs, and adverse reactions were assessed after 1 year. In vitro experiments examined the effects on cell viability, proliferation, apoptosis, and the cell cycle of fibroblast, A2780, SKOV-3, HELA, and Ishikawa cells. Results: The FIR+bandage group showed significantly decreased tissue fluid and reduced limb circumference (p < 0.05) in comparison with the control group at 1 year. There was no increase of serum CA125 in both groups, and no recurrence of neoplasia or lymphadenopathy was detected. No adverse reactions were recorded. In addition, no changes were detected after FIR treatment for fibroblast, A2780, SKOV-3, HELA, and Ishikawa cells in cell viability, proliferation, apoptosis, and cell cycle. Conclusion: FIR can be used to treat patients with GCRL following gynecological cancer treatment. Following clinical and experimental studies, we confirm that FIR is an oncologically safe treatment for lymphedema in gynecological tumor patients.

The Injection for the Lower Eyelid Retraction: A Mechanical Analysis of the Lifting Effect of the Hyaluronic Acid.

BACKGROUND: It has been reported that the injection of the hyaluronic acid (HA) into the lower lid area could improve lower eyelid retraction. However, the published studies offered few insights into the mechanism of this treatment. When the underlying mechanism is not clear, many surgeons will not trust the method enough to apply it in their clinical practice. The purpose of this article was to propose a possible explanation for the underlying mechanism of the treatment and further verify the method by a series of cases. METHODS: The authors performed a mechanical analysis on the physical impact of HA on the lower eyelid. In the clinical cases, we injected the fillers under the orbicularis muscle to correct lower lid retraction. The results were evaluated by the standardized marginal reflex distance 2 (MRD2) immediately and 9 months later. RESULTS: From October 2013 to October 2015, the injections were carried out in 27 cases (14 post-blepharoplasty and 13 involuntary). In 26 cases (96.3%), the retraction was completely corrected and did not recur through the last follow-up. The average improvement of the standardized MRD2 was 0.84 mm immediately after the injection and 1.19 mm 9 months later. Complications were not reported. CONCLUSION: Lower eyelid retraction could be treated by the injection of HA under the orbicularis muscle. The filler in this situation acted as a lifter because the filler changed the balance of force of the lower lid, forcing it to shift upward to gain the new balance. The 'lifter' mechanism could be applicable to other facial injections that generate elevating effects. 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 .

Strabismus in Bronzino's paintings: a hallmark of a realistic painter?

The present article analyses eleven paintings of Bronzino, one of the major painters of the late Italian Mannerism, in which the sitters are portrayed with deviating eyes. The reasons why Bronzino may have included a truant eye in his subjects are herein discussed. We consider the 'wandering' eye as a hallmark of Bronzino's style. The inclusion of strabismus may be part of the Mannerism tendency of using exaggerated hallmarks but pursuing at the same time an increasing realism that was typical of the 15th and 16th century movements.

Correction of cicatricial ectropion using non-ablative fractional laser resurfacing.

Lower eyelid malposition is the most frequent and severe complication after blepharoplasty and ectropion is observed in 1% of patients after surgery. This article describes a non-surgical method to treat lower eyelid cicatricial ectropion using a non-ablative laser as an alternative to surgery. Twelve patients with unilateral or bilateral lower lid cicatricial ectropion, following surgery or trauma, underwent laser therapy from 2012 to 2016. Laser therapy was performed with a fractional non-ablative laser emitting at a wavelength of 1540 nm. Ten patients had a full correction of their ectropion and two patients had a partial recovery after laser therapy at 6-month follow-up visit. No serious adverse events were reported. Non-ablative fractional laser resurfacing can successfully treat cicatricial ectropion by remodeling the periocular scar tissue and improving the scar texture, and as such may be considered as a valuable alternative to surgery in selected patients.

Sandro Botticelli's Madonna of the Pomegranate: the hidden cardiac anatomy.

Sandro Botticelli was one of the most renowned artists of the 15th century. He was based in Florence during the flourishing of the Renaissance, a time when anatomical knowledge of ancient times was reclaimed through cadaveric dissection. This report proposes that such knowledge enabled Botticelli to enhance the iconography of his masterpieces, Madonna of the Pomegranate, by incorporating a concealed image of the heart and cardiac anatomy within it.

Secret hand gestures in paintings.

During the Renaissance period, hands were as important a focus of attention as the face was, because they were the only other visible area of the body. Hence, representation of the position of the hands became a decorative element that was almost as important as the face. Thus, given its high visibility, hand gestures in portraits and paintings have been one of the most effective ways of conveying secrets, codes and messages. From the historical and religious perspective, hand signs in visual art may provide clues about the underlying iconographical symbols. This paper will examine the eventual hidden meanings behind a peculiar hand gesture that has been widely used by several painters. (www.actabiomedica.it).

The Goitrous Salting Madonnas: Iconography of Goiter in Religious Portraits.

INTRODUCTION: George Salting was an art collector, who bequeathed his collection of paintings to the National Gallery of London. The present investigation has revealed five portraits of five different artists belonging to this collection in which the Holy Mother holding the child has been portrayed with a variable grade of thyroid gland enlargement. The name Salting, applied to the Madonnas with child by Antonello da Messina, Robert Campin, Dirk Bouts, Cima da Conegliano, and Andrea del Verrocchio, denotes George Salting, the collector who donated the masterworks to the gallery in 1910. MATERIALS AND METHODS: The five paintings were analyzed to determine the accuracy of the diagnosis of neck swelling and the underlying iconographical significance of this depiction, which is relatively uncommon in religious artworks. RESULTS: The present investigation highlighted an abnormal profile of the neck of the Virgin Mary, which is suggestive of a presumptive medico-artistic diagnosis of goiter. The inclusion of thyroid swelling in a holy sitter is relatively uncommon and is related to specific meanings that the painter wanted to illustrate in the work, the reasons for which are herein discussed. CONCLUSIONS: It seems likely that the integration of the goiter in the paintings is a stylistic hallmark. Indeed, the depiction of a slight neck enlargement is most probably a rhetorical tendency of representing an idealized female beauty, especially in holy sitters, imbued by a balanced neck and graceful body. At the same time, it probably also reflects better anatomic accuracy and knowledge of Renaissance artists applied toward a more realistic and precise representation of subjects.

The handedness of Michelangelo Buonarroti.

The handedness of Michelangelo Buonarroti (1475-1564), one of the greatest artists of all time, is still controversial. Although there is no doubt that almost all of his well-attributed drawings were drawn with the right hand, the hatch marks of the shading going downward from right to left; it has been often neglected in the literature that he was an innate left-hander. An unfairly unknown autobiography of Raffaello da Montelupo stated that Michelangelo, a natural left-hander, trained himself from a young age to become right-handed. The same biography also underlined that Michelangelo restricted the use of his left hand only to works requiring force such as hammering, carving, and chiseling marble. The sign of the wooden crucifix donated to Santo Spirito in 1492 and two autographic sketches by Michelangelo-one left alongside a poem in 1509, and the other in the dress of the Vittoria Colonna sketch in 1525-are useful tools for analyzing the artist's evolution from left to right handedness when drawing, writing, and painting. Clin. Anat. 31:645-647, 2018. © 2018 Wiley Periodicals, Inc.

Concealed lung anatomy in Botticelli's masterpieces the primavera and the birth of venus.

Sandro Botticelli was one of the most esteemed painters and draughtsmen among Renaissance artists. Under the patronage of the De' Medici family, he was active in Florence during the flourishing of the Renaissance trend towards the reclamation of lost medical and anatomical knowledge of ancient times through the dissection of corpses. Combining the typical attributes of the elegant courtly style with hallmarks derived from the investigation and analysis of classical templates, he left us immortal masterpieces, the excellence of which incomprehensibly waned and was rediscovered only in the 1890s. Few know that it has already been reported that Botticelli concealed the image of a pair of lungs in his masterpiece, The Primavera. The present investigation provides evidence that Botticelli embedded anatomic imagery of the lung in another of his major paintings, namely, The Birth of Venus. Both canvases were most probably influenced and enlightened by the neoplatonic philosophy of the humanist teachings in the De' Medici's circle, and they represent an allegorical celebration of the cycle of life originally generated by the Divine Wind or Breath. This paper supports the theory that because of the anatomical knowledge to which he was exposed, Botticelli aimed to enhance the iconographical meaning of both the masterpieces by concealing images of the lung anatomy within them.

Alternative vascular constructs of lymph node flap transfer.

Vascularized lymph node transfer is a quite innovative physiological surgical procedure for the lymphedema treatment. Although is gaining more popularity due to its promising results, there are some concerns regarding difficult to harvest it and the potential risk of iatrogenic lymphedema. Here, we present alternative vascular constructs of lymph node flap for the treatment of lymphedema, which provide the benefits of a technically easier dissection and physiological reconstruction of the damaged lymphatics. Furthermore, we introduce a classification based on the flap vascular supply including six types of flaps and we provide the details of the surgical technique.

Prefabricated Cervical Skin Flaps for Hemi-Facial Resurfacing: Elucidating the Natural History of Postoperative Edema Using Indocyanine Green.

BACKGROUND: The increases in capillary wall permeability and capillary hydrostatic pressure are considered to be the causes for the acute swelling seen in flaps; however, disruption of the circulating flap lymphatics could be another contributory factor. In this study we monitor the development of flap edema in a series of 18 prefabricated flaps and aim to delineate the natural history of this phenomenon by use of lymphography. METHODS: Postoperative swelling was monitored in a series of 18 pre-expanded prefabricated cervical skin flaps used for hemi-facial burns-scar resurfacing. Time to spontaneous resolution, presence or absence of venous congestion, and clinical outcome were recorded. In two cases, indocyanine-green (ICG) lymphography was used to monitor the dermal backflow pattern until swelling had completely resolved. Average moving velocity of ICG after injection as well as flap thickness was also recorded over the follow-up period. RESULTS: The average moving velocity of ICG in the flap lymphatics improved from 0.48 cm/min to 1.5 cm/min in the first 12 days after flap transfer. The dermal backflow pattern was stardust in the first 12 days, indicating moderate lymphedema, transforming to splash from week three, and a robust collecting lymphatic vessel occurring from the fifth month, indicating mild lymphedema and lymphatic channel recovery, respectively. CONCLUSION: Transient swelling was observed in all prefabricated flaps in our series. We postulate that this is mostly secondary to lymphatic disruption that subsides as lymphangiogenesis takes place. ICG lymphography is an inexpensive, safe, and easy-to-use imaging technology that could be used in the monitoring of postoperative lymphedema seen in prefabricated flaps.

Application of Indocyanine Green in Flap Surgery: A Systematic Review.

BACKGROUND: The vascularization of the distal portions of transferred tissue represents the most critical factor in the success of reconstructive surgery. In recent years, indocyanine green (ICG) fluorescence imaging techniques have been applied during surgery to evaluate flap perfusion. However, this investigation has found that there is little consensus regarding the standard dose of ICG as well as the pre-operative requirements of ICG allergy testing. The aim of this study is to summarize the applications of ICG to tissue transfers and safe dosing practices and to provide insight to the possible adverse effects of ICG on flap surgery with the goal of helping clinicians apply ICG safely and efficiently to tissue transfer procedures. METHODS: A literature search was performed using, Wiley InterScience, and Springer with the key words, 'Flap,' 'indocyanine green,' 'surgery,' and related mesh words for all publications between 2005 and 2015. Title and abstract screening was performed using predefined in- and exclusion criteria. RESULTS: Seventy-three articles were included. These were classified as "application of ICG in flap surgery" and "the security of applying ICG in flap surgery". CONCLUSIONS: ICG fluorescence imaging preoperatively facilitates the detection of perforators in tissue flaps with thickness <20 mm, aids in the evaluation of flap microcirculation and perfusion, and allows surgeons to select dominant cutaneous nerves while evaluating the quality of vascular anastomoses and locating thromboses. The literature also concluded that potential allergic reactions to ICG should be taken into consideration.

Microsurgical dissection of facial nerve in parotidectomy: a discussion of techniques and long-term results.

BACKGROUND: Parotidectomy has well-documented post-operative complications. Dissection of the facial nerve branches can be challenging even under loupe magnification, and partial, or complete injury of the nerve branches can occur during surgery. To reduce this risk and the associated complications, we propose a number of microsurgical best practices, which can be performed during parotidectomy. METHODS: A retrospective survey was conducted on 109 patients (45 males and 64 females, average age 46.2 years, range of 6 to 74 years) who underwent parotidectomy in two different institutions. RESULTS: Our data showed no permanent injury to the facial nerve, and 17% of neuroapraxia that had resolved with time. Post-operative complications have occurred in 33 cases (30% rate). In the superficial parotidectomy cohort (78 patients), the number of complications was 17 (21%). In the total parotidectomy cohort (31 patients), the number of complications was 16 (51%). CONCLUSIONS: Based on our results, we believe that the use of microsurgical techniques during parotidectomy may represent a useful tool in improving accuracy and minimising local tissue trauma that can affect nerve recovery. This is particularly true in situations such as tumor recurrence, tissue fibrosis or in case of sizeable tumors around the facial nerve branches. We believe that the decreased risk of facial nerve post-operative symptoms outweigh the disadvantage of increased operative time of this procedure.

Acellular Dermal Matrices and Paraffinoma: A Modern Tool for a Nearly Obsolete Disease.

Paraffinoma is a destructive complication of paraffin oil injection, usually associated with massive tissue destruction, thus requiring radical surgery and subsequent complex reconstruction. Although breast and penile paraffinomas have been widely described and their management is quite standardized, paraffinomas of the knee are still rare and only few case reports or small case series are available in the current literature. We describe the case of a 77-year-old man with a large paraffinoma of the right knee that occurred after self-injection of paraffin oil, 58 years before. He underwent wide surgical resection of the soft tissues overlying the knee and subsequent two-stage reconstruction by using acellular dermal matrix and, after 20 days, split-thickness skin grafts. Follow-up after 16 months showed no signs of skin ulcerations or inflammation, with an overall improvement in function. Even though conventional flap reconstructions may be still useful, the authors believe that acellular dermal matrices represent a safe, reliable, and less invasive alternative for challenging soft tissue reconstructions even in elderly patients with multiple medical problems.

Far infrared ray (FIR) therapy: An effective and oncological safe treatment modality for breast cancer related lymphedema.

BACKGROUND: The incidence of breast cancer related lymphedema is approximately 5%. Far infrared ray (FIR) treatment can potentially reduce fluid volume and extremity circumference as well as the frequency of dermato-lymphangitis (DLA). However, there is no published data on the oncological safety of FIR and the potential for activation of any residual breast cancer cells. The aim of this study is to investigate the safety of far infrared ray (FIR) treatment of postmastectomy lymphedema, clinically and in vitro. METHODS: Patients who underwent mastectomy more than 5years ago complicated by upper extremity lymphedema for more than 1year were included. The enrolled patients were divided into an FIR treatment group and a control group (conservative treatment using bandage compression). Outcome measures included tumor markers (CA153, CA125), ultrasonography of relevant structures and monitoring for adverse reactions 1year after treatment. For the in vitro part of the study, the effects of FIR on human breast adenocarcinoma cell lines (MCF7, MDA-MB231) compared to the effects of FIR on human dermal fibroblasts as a control were considered. The viability, proliferation, cell cycle and apoptotic statistics of the adenocarcinoma and human dermal fibroblast cell lines were analyzed and compared. RESULTS: Results demonstrated that after treatment with FIR, tumor marker (CA153, CA125) concentrations in both the FIR and control groups were not elevated. There was no statistically significant difference between FIR and control group marker expression (p>0.05). Furthermore, no patients were diagnosed with lymphadenectasis or newly enlarged lymph nodes in these two groups. Importantly, there were no adverse events in either group. The in vitro experiment indicated that FIR radiation does not affect viability, proliferation, cell cycle and apoptosis of fibroblasts, MCF-7 and MDA-MB-231 cells. CONCLUSIONS: FIR should be considered as feasible and safe for the treatment of breast cancer related lymphedema patients 5years after mastectomy. FIR does not promote recurrence or metastasis of breast cancer and is a well-tolerated therapy with no adverse reactions.

Efficacy and safety of far infrared radiation in lymphedema treatment: clinical evaluation and laboratory analysis.

Swelling is the most common symptom of extremities lymphedema. Clinical evaluation and laboratory analysis were conducted after far infrared radiation (FIR) treatment on the main four components of lymphedema: fluid, fat, protein, and hyaluronan. Far infrared radiation is a kind of hyperthermia therapy with several and additional benefits as well as promoting microcirculation flow and improving collateral lymph circumfluence. Although FIR therapy has been applied for several years on thousands of lymphedema patients, there are still few studies that have reported the biological effects of FIR on lymphatic tissue. In this research, we investigate the effects of far infrared rays on the major components of lymphatic tissue. Then, we explore the effectiveness and safety of FIR as a promising treatment modality of lymphedema. A total of 32 patients affected by lymphedema in stage II and III were treated between January 2015 and January 2016 at our department. After therapy, a significant decrease of limb circumference measurements was noted and improving of quality of life was registered. Laboratory examination showed the treatment can also decrease the deposition of fluid, fat, hyaluronan, and protein, improving the swelling condition. We believe FIR treatment could be considered as both an alternative monotherapy and a useful adjunctive to the conservative or surgical lymphedema procedures. Furthermore, the real and significant biological effects of FIR represent possible future applications in wide range of the medical field.

Pre-expanded Bipedicled Supratrochlear Perforator Flap for Simultaneous Reconstruction of the Nasal and Upper Lip Defects.

The double "S" principle should be followed for facial reconstruction: the "similarity" of the donor site to the defect area and the reconstruction should be based on the different "subunits" of the face. In this article the pre-expanded, bipedicled supratrochlear perforator flap method is described, which is used for the resurfacing of both nasal and upper lip defects. This method can provide 2 independent flaps with sufficient tissue from 1 single donor site, resurfacing the nasal and upper lip units separately and providing an unparalleled color and texture match and ideal reconstructive result.

Efficacy of a Novel Optimized Pulsed Light Source (MaxG) for the Treatment of Facial Vascular Lesions.

BACKGROUND AND OBJECTIVE: Facial vascular malformations can cause a number of functional problems, including difficulties in breathing, eating, speech, and mobility. Psychological problems can also arise due to the possible unpleasant appearance of such lesions. Further, these lesions can lead to a number of complications, including pain, ulceration, infection, and significant bleeding. Many treatments have been proposed in the literature. Laser therapy (and its related treatments by non-coherent light sources) is now considered the gold standard in the treatment of the majority of vascular lesions. METHODS: Here, we present our experience with a novel optimized pulsed light source for the treatment of vascular anomalies. In this prospective study, we evaluate the clinical outcomes of 30 patients treated with this method. RESULTS: Our results confirm the efficacy and safety of this treatment for facial vascular lesions. CONCLUSIONS: Based on our experience and results, we believe this device could be considered as both an alternative monotherapy and a useful adjunctive to the already existing laser instruments.