The "Keystone Angle": Geometry in Preservation Rhinoplasty.

Rhinoplasty outcome may depend on different factors and bony dorsum shape has proven to significantly influence the lateral view result. The "Keystone angle" corresponds to the osseocartilaginous angle formed between bony and cartilaginous dorsum. Usually, the "V" shaped bony dorsum is characterized by a more acute "Keystone angle" compared to the "S" shaped bony dorsum. To achieve the ideal dorsum flatness, corresponding to a "Keystone angle" of 180°, different techniques may be used. Bearing these concepts in mind we suggest that preoperative assessment of the "Keystone angle" can guide the choice of the most appropriate technique for each patient. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clavicle Fracture Site Surgical Contouring: A Case Report.

Clavicle fractures are frequent injuries accounting for approximately 4% of all fractures in adults with about 35% occurring in the shoulder region among which midshaft fractures are the most common (>66%). Nonsurgical management is the treatment of choice for most clavicle fractures; however, poor functional and aesthetic outcomes may result from nonunion, symptomatic malunion, and aesthetic impairment which are the most common complications. A young woman was referred to our clinic for a "Step Deformity" resulting after primary, nonsurgical treatment of a midshaft clavicle fracture. Residual deformity was corrected with a novel simple and little invasive approach. Midshaft clavicle fractures typically only require conservative nonsurgical treatment, nevertheless suboptimal outcomes may occur. Selective osteotomies and fixation are deemed too invasive when only cosmetic impairment of the clavicle contour is present without any functional or sensitive damage and most patients are discouraged from undergoing surgery. Thus far, no specific focus on this topic, nor exploration of possible correction can be found in the published literature. These residual deformities may be very noticeable sometimes and cause psychological distress and social life impairment. Despite no related functional impairment, this deformity should still be addressed, to improve patients' quality of life.

Comparative study of pre- and postauricular flaps for external auditory canal defect reconstruction.

Background: Malignancies involving the external auditory canal deserve critical evaluation due to this area's aesthetic and functional importance. Flaps can be very useful for the restoration of the external auditory canal. A variety of flaps available for the surgical treatment of external acoustic meatus defects exist, depending on the precise location and size. Objectives: Our study aimed to compare aesthetic and functional results in the postoncological reconstruction of external auditory canal defects using a preauricular flap and postauricular revolving door flap. Methods: Sixteen patients treated at our plastic surgery unit for defects involving the external auditory canal between January 2014 and December 2020 were included in the study. All defects were the result of a primary or secondary skin cancer excision. Patients were divided into two groups, one receiving the preauricular flap technique and the other the postauricular revolving door flap technique. Results: Three separate visual analog scales reported excellent scores for the two procedures, though the postauricular revolving door flap had slightly better results. Both preauricular flap and postauricular revolving door flap reconstructive techniques showed good options for external auditory canal reconstruction in postexcision skin cancer patients. From an aesthetic point of view, the revolving door flap appeared to be a more elegant surgical approach in this type of reconstruction because the scar was hidden in the postauricular sulcus. Conclusions: Reconstruction with a postauricular revolving door flap allowed for a more natural movement with no external pedicle. Evidence-Based Medicine EBM Level: IV.

Betadine-soaked gauzes intraoperative sizing in breast augmentation surgery.

In breast augmentation surgery, the correct evaluation of the implant size required is crucial to achieve satisfactory final result. Intraoperative volume decision is usually made by the use of silicone gel breast sizers. Intraoperative sizers have some disadvantages: the progressive loss of structural integrity, the increased risk of cross infection, the high costs. However, during breast augmentation surgery, it is mandatory to fill and expand the newly dissected pocket. In our practice we fill the dissected space with Betadine-soaked and then squeezed gauzes. The use of multiple soaked gauzes as sizers is advantageous for the following reasons: they fill and expand the pocket, they are useful to check the volume and to show the circumferential contour of the breast, to keep the pocket clean while dissecting the second one, to check final hemostasis and to compare the two breasts' size before definitive implant insertion. We simulated an "intra operative setting" where standardized volume Betadine-soaked gauzes were packed into a breast pocket. This easily reproducible and accurate technique is inexpensive and produces reliable and highly satisfactory results; it can be incorporated into the practice of any surgeon performing breast augmentation. Evidence Based Medicine (EBM) level: IV.

Extensive severe intraorbital arteriovenous malformations: report of a rare laser complication and successful management.

Arteriovenous malformations (AVMs) are rare congenital errors of vascular morphogenesis, characterised by abnormal direct communications between arteries and veins, bypassing the normal capillary bed. Apart from the central nervous system, typical locations include the head and neck, and less frequently limbs, trunk or internal organs. AVMs of the head and neck often become clinically evident and symptomatic only in later childhood and are characterised by a history of variable growth, sometimes leading to large, deforming, pulsating masses with a propensity to massive haemorrhage. Therapeutic strategy is based on selective embolisation, surgical excision, or a combination of both. Radical surgical excision of local AVMs is the only effective treatment but it may be mutilating, especially for AVMs of the head and neck. Laser therapy represents a good option to treat the cutaneous aspects of AVMs nevertheless, its efficacy is limited. To the date, pharmacological therapy for AVMs is still on debate due to its controversial outcomes as it seems not as effective as other treatments and usually requires a longer course of application. However, pharmacological therapy could be useful in selected patients and for AVMs nonresponsive to traditional treatment, allowing them to obtain acceptable results without serious complications. This paper reports the case of a serious laser complication of extensive intraorbital AVM successfully treated by local reconstruction and topical pharmacological treatment.

Glucose Enhances Pro-Tumorigenic Functions of Mammary Adipose-Derived Mesenchymal Stromal/Stem Cells on Breast Cancer Cell Lines.

Adiposity and diabetes affect breast cancer (BC) progression. We addressed whether glucose may affect the interaction between mammary adipose tissue-derived mesenchymal stromal/stem cells (MAT-MSCs) and BC cells. Two-dimensional co-cultures and spheroids were established in 25 mM or 5.5 mM glucose (High Glucose-HG or Low Glucose-LG) by using MAT-MSCs and MCF7 or MDA-MB231 BC cells. Gene expression was measured by qPCR, while protein levels were measured by cytofluorimetry and ELISA. CD44high/CD24low BC stem-like sub-population was quantified by cytofluorimetry. An in vivo zebrafish model was assessed by injecting spheroid-derived labeled cells. MAT-MSCs co-cultured with BC cells showed an inflammatory/senescent phenotype with increased abundance of IL-6, IL-8, VEGF and p16INK4a, accompanied by altered levels of CDKN2A and LMNB1. BC cells reduced multipotency and increased fibrotic features modulating OCT4, SOX2, NANOG, αSMA and FAP in MAT-MSCs. Of note, these co-culture-mediated changes in MAT-MSCs were partially reverted in LG. Only in HG, MAT-MSCs increased CD44high/CD24low MCF7 sub-population and promoted their ability to form mammospheres. Injection in zebrafish embryos of HG spheroid-derived MCF7 and MAT-MSCs was followed by a significant cellular migration and caudal dissemination. Thus, MAT-MSCs enhance the aggressiveness of BC cells in a HG environment.

Epithelioid Hemangioma of the Nose: A Challenging Diagnosis.

Epithelioid hemangioma is a rare reactive vasoproliferative disease presenting with painless vascular nodules in the dermal and subcutaneous tissues of the head and neck. Clinical diagnosis can be difficult as, in most cases, the only symptom is a progressively tender swelling next to a vessel course. Thus far, few cases of epithelioid hemangioma localized to the nose have been described in the literature. Herein, we present a case of a 47-year-old woman with just such a lesion of the nose, focusing on its diagnosis and treatment.

Decellularization for the Preparation of Highly Preserved Human Acellular Skin Matrix for Regenerative Medicine.

Extracellular matrix (ECM) provides biophysical and biochemical stimuli to support self-renewal, proliferation, survival, and differentiation of surrounding cells due to its content of diverse bioactive molecules. Due to these characteristics, the ECM has been recently considered a promising candidate for the creation of biological scaffolds to boost tissue regeneration. Emerging studies have demonstrated that decellularized human tissues could resemble the native ECM in their structural and biochemical profiles, preserving the three-dimensional (3D) architecture and the content of fundamental biological molecules. Hence, decellularized ECM can be employed to promote tissue remodeling, repair, and functional reconstruction of many organs. Selecting the appropriate decellularization procedure is crucial to obtain acellular tissues that retain the characteristics of the ideal microenvironment for cells. The protocol described here provides a detailed step-by-step description of the decellularization method to obtain a reproducible and effective cell-free biological ECM. Skin fragments from patients undergoing plastic surgery were scaled down and decellularized using a combination of sodium dodecylsulfate (SDS), Triton X-100, and antibiotics. To promote the regular and homogeneous transport of the solution through the samples, they were enclosed in embedding cassettes to ensure protection from mechanical insults. After the decellularization procedure, the snow-white color of skin fragments indicated complete and successful decellularization. Additionally, decellularized samples showed an intact and well-preserved architecture. The results suggest that the proposed decellularization method was effective, fast, and reproducible and protected samples from architectural damages.

Pericranial and scalp rotation flaps for occipitocervical hardware exposure with CSF leak in rheumatoid arthritis patient: A case report and review of the literature.

BACKGROUND: There are several etiologies of craniocervical junction instability (CCJI); trauma, rheumatoid arthritis (RA), infections, tumors, congenital deformity, and degenerative processes. These conditions often require surgery and craniocervical fixation. In rare cases, breakdown of such CCJI fusions (i.e., due to cerebrospinal fluid [CSF] leaks, infection, and wound necrosis) may warrant the utilization of occipital periosteal rescue flaps and scalp rotation flaps to achieve adequate closure. CASE DESCRIPTION: A 33-year-old female with RA, cranial settling, and high cervical cord compression underwent an occipitocervical instrumented C0-C3/C4 fusion. Two months later, revision surgery was required due to articular screws pull out, CSF leakage, and infection. At the second surgery, the patient required screws removal, the application of laminar clamps, and sealing the leak with fibrin glue. However, the CSF leak persisted, and the skin edges necrosed leaving the hardware exposed. The third surgery was performed in conjunction with a plastic surgeon. It included operative debridement and covering the instrumentation with a pericranial flap. The resulting cutaneous defect was then additionally reconstructed with a scalp rotation flap. Postoperatively, the patient adequately recovered without sequelae. CONCLUSION: A 33-year-old female undergoing an occipitocervical fusion developed a postoperative persistent CSF leak, infection, and wound necrosis. This complication warranted the assistance of plastic surgery to attain closure. This required an occipital periosteal rescue flap with an added scalp rotation flap.

Extended rotation flap for reconstruction of partial thickness defects of the tip and nasal ala region: in search of better aesthetic results.

BACKGROUND: Basal cell carcinoma is the most common non-melanoma skin cancer of the nose. Defects of the nasal ala and tip region are among the most difficult to repair due to their intrinsic characteristics. OBJECTIVE: To present our experience with the extended rotation flap for reconstruction of nasal ala defects and evaluate the outcome using the Patient and Observer Scar Assessment Scale (POSAS). METHODS AND MATERIALS: Twenty-two patients with partial thickness nasal ala defects reconstructed using the extended rotation flap were assessed. Final cosmetic and functional outcomes were evaluated using the POSAS. RESULTS: Flaps survived in all the reported cases and no major complication was recorded. Histology showed complete excision of the tumour in all cases. Using the POSAS, the mean overall evaluation for patients was 1.8/10, while the mean overall evaluation for the evaluation panel was 2.2/ 10. CONCLUSION: Although similar flaps have been previously described, the extended rotation flap for nasal ala and tip reconstruction represents a functionally and cosmetically appealing wound closure option, respecting and avoiding any distortion of the alar crease.

Ligaclip for Preauricular Skin Tags in the Newborn.

INTRODUCTION: Skin tags are benign lesions, that often represent only an aesthetic problem; if subjected to trauma, they can occasionally bleed with possible infection and pain. When they occur in the preauricular region, attention should be paid to the diagnosis and approach; in fact, controversy exists in the differential diagnosis between hair follicle nevi, accessory tragus, and skin tag. Misdiagnosis and failure of treatment can lead to serious consequences, such as chondritis. MATERIALS AND METHODS: In our retrospective study, we evaluated 19 newborns affected by single, unilateral skin tag in the preauricular region. Each patient underwent a careful clinical examination; lesions without a pilosebaceous unit and with a thin, soft pedicle were treated in the nursery with Ligaclip (Johnson & Johnson). RESULTS: Skin tag falls between day 7 and 10. We had no cases of edema, cellulitis, clip loss, or bleeding. Scarring results were extremely satisfactory at 3-month follow-up. CONCLUSION: We believe that after a careful clinical examination, cases of skin tags in the preauricular area can be selected and treated with Ligaclip. This procedure can be considered rapid, safe, economical, and simple in the newborn patients.

A low-cost scalable 3D-printed sample-holder for agitation-based decellularization of biological tissues.

Decellularized extracellular matrix is one of the most promising biological scaffold supporting in vitro tissue growth and in vivo tissue regeneration in both preclinical research and clinical practice. In case of thick tissues or even organs, conventional static decellularization methods based on chemical or enzymatic treatments are not effective in removing the native cellular material without affecting the extracellular matrix. To overcome this limitation, dynamic decellularization methods, mostly based on perfusion and agitation, have been proposed. In this study, we developed a low-cost scalable 3D-printed sample-holder for agitation-based decellularization purposes, designed for treating multiple specimens simultaneously and for improving efficiency, homogeneity and reproducibility of the decellularization treatment with respect to conventional agitation-based approaches. In detail, the proposed sample-holder is able to house up to four specimens and, immersed in the decellularizing solution within a beaker placed on a magnetic stirrer, to expose them to convective flow, enhancing the solution transport through the specimens while protecting them. Computational fluid dynamics analyses were performed to investigate the fluid phenomena establishing within the beaker and to support the sample-holder design. Exploratory biological tests performed on human skin specimens demonstrated that the sample-holder reduces process duration and increases treatment homogeneity and reproducibility.

Combined Timed Surgery and Conservative Management of Primary Necrotizing Fasciitis of the Breast: A Case Report.

BACKGROUND Necrotizing fasciitis is a life-threatening infection that involves the deep fascia and the surrounding tissue, but rarely involves the female breast. The most common treatment for necrotizing fasciitis of the breast is total mastectomy. However, the use of negative pressure wound therapy (NPWT), after surgical debridement, is reported to promote the more rapid development of granulation tissue, before reconstructive surgery. This report presents the case of a 53-year-old woman with necrotizing fasciitis of the breast who underwent combined timed surgery and conservative management. CASE REPORT A 53-year-old woman presented with necrotizing fasciitis of the right breast, involving the right lateral chest wall and flank. She was referred to the Intensive Care Unit (ICU) of the hospital with septic shock. After hemodynamic stabilization was achieved, she underwent surgical debridement. Excised breast tissues were sent for histology, and intraoperative swabs were collected and sent for microbiological examination. Intravenous antibiotic therapy and hyperbaric oxygen therapy commenced. The patient was managed with NPWT dressings, followed by reconstructive breast surgery. The right chest and flank completely healed. CONCLUSIONS This case has shown that early diagnosis and management of necrotizing fasciitis of the breast can be life-saving and may allow for breast conservation. Early aggressive debridement combined with NPWT dressings and reconstructive breast surgery resulted in successful wound healing and preservation of the breast with a satisfactory cosmetic outcome.

Decellularized Human Dermal Matrix as a Biological Scaffold for Cardiac Repair and Regeneration.

The complex and highly organized environment in which cells reside consists primarily of the extracellular matrix (ECM) that delivers biological signals and physical stimuli to resident cells. In the native myocardium, the ECM contributes to both heart compliance and cardiomyocyte maturation and function. Thus, myocardium regeneration cannot be accomplished if cardiac ECM is not restored. We hypothesize that decellularized human skin might make an easily accessible and viable alternate biological scaffold for cardiac tissue engineering (CTE). To test our hypothesis, we decellularized specimens of both human skin and human myocardium and analyzed and compared their composition by histological methods and quantitative assays. Decellularized dermal matrix was then cut into 600-µm-thick sections and either tested by uniaxial tensile stretching to characterize its mechanical behavior or used as three-dimensional scaffold to assess its capability to support regeneration by resident cardiac progenitor cells (hCPCs) in vitro. Histological and quantitative analyses of the dermal matrix provided evidence of both effective decellularization with preserved tissue architecture and retention of ECM proteins and growth factors typical of cardiac matrix. Further, the elastic modulus of the dermal matrix resulted comparable with that reported in literature for the human myocardium and, when tested in vitro, dermal matrix resulted a comfortable and protective substrate promoting and supporting hCPC engraftment, survival and cardiomyogenic potential. Our study provides compelling evidence that dermal matrix holds promise as a fully autologous and cost-effective biological scaffold for CTE.