The profunda artery perforators: Anatomical study and radiological findings using computed tomography angiography in patients undergoing PAP flap breast reconstruction.

BACKGROUND: The popularity of the profunda femoris artery perforator (PAP) flap is increasing; however, knowledge concerning the standardization of radiological findings and their clinical implications is limited. We evaluated the radiological architecture of posterior thigh perforators using Computed Tomography Angiography (CTA) to identify landmarks to facilitate flap dissection. METHODS: A retrospective study was conducted on 35 patients who underwent unilateral breast reconstruction with a PAP flap. The preoperative CTA scans were analyzed, and the perforator characteristics were evaluated. The perforators were mapped using a Cartesian coordinate system. Data were normalized by anatomical landmarks and overlapped. Perioperative and postoperative results were analyzed. Radiological and intraoperative were compared. RESULTS: Two CTA scans were excluded; 66 thighs were examined. The mean perforator number was 3.2. The mean diameter of chosen perforators was 2.7 mm (DS ± 0.6 mm) at the origin, 2.2 mm (DS ± 0.4 mm) at the adductor space midpoint, and 1.7 mm (DS ± 0.3 mm) at the deep fascia. The mean adipose tissue thickness was 3.35 cm (DS ± 0.94) at the deep fascia and 3.59 cm (DS ± 1.19) at the adductor space midpoint. Intraoperatively, the perforator was located 3.22 cm (DS ± 0.87) from the posterior border of the gracilis muscle and 8.98 cm (DS ± 1.44) from the inferior gluteal crease. A radiological area located 9.33 cm (DS ± 4.81) from the y-axis and 7.48 cm (DS ± 1.88) from the x-axis was identified. CONCLUSIONS: CTA using the volume-rendering technique is a valuable method to study in vivo the radiological anatomy of the posterior thigh perforators.

Stevens-Johnson syndrome and toxic epidermal necrolysis: 11-year retrospective experience in a high-complexity tertiary hospital in Milan, Italy.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe drug-induced hypersensitivity reactions characterized by widespread epidermal necrosis, mucous membrane erosions, and systemic findings. We have provided our 11-year experience from a Milan, Italy tertiary hospital managing SJS/TEN, evaluating the clinical and histopathologic features plus the impact on mortality. We retrospectively analyzed 28 patients diagnosed with SJS/TEN based on the clinical and histopathologic findings, according to the classification criteria of multiple studies. We assessed the dermatographics, comorbidities, drug history, lesion characteristics, clinical findings, treatments, blood tests, and outcomes. Severity scores (SCORTEN, Re-SCORTEN, ABCD-10) were used for treatment evaluation and mortality prediction. Data were statistically analyzed, and significant factors associated with mortality were identified. We found that among the 28 patients, 89.2% had comorbidities, mainly cardiovascular diseases, and 21.4% had autoimmune disorders. All patients had received systemic therapy (46.6% monotherapy, 53.6% combination therapy), with systemic steroids (71.4%) and intravenous immunoglobulins (67.8%) being common treatments. There were complications, including systemic infections (67.9%) and septic shock (10.7%). The overall mortality rate was 17.8%. The statistical analysis indicated that malignancy, a high ABCD-10 score, and a high neutrophil-to-lymphocyte ratio were significantly associated with mortality. The extent of affected body surface area did not correlate significantly with mortality. This study provides insights into SJS/TEN management, revealing factors influencing mortality in a high-complexity tertiary hospital setting.

Th2 Cytokines Affect the Innate Immune Barrier without Impairing the Physical Barrier in a 3D Model of Normal Human Skin.

(1) Background: Atopic dermatitis is one of the most common inflammatory skin diseases characterized by T helper (Th) 2 and Th22 cells producing interleukin (IL)-4/IL-13 and IL-22, respectively. The specific contribution of each cytokine to the impairment of the physical and the immune barrier via Toll-like receptors (TLRs) is poorly addressed concerning the epidermal compartment of the skin. (2) Methods: The effect of IL-4, IL-13, IL-22, and the master cytokine IL-23 is evaluated in a 3D model of normal human skin biopsies (n = 7) at the air-liquid interface for 24 and 48 h. We investigated by immunofluorescence the expressions of (i) claudin-1, zonula occludens (ZO)-1 filaggrin, involucrin for the physical barrier and (ii) TLR2, 4, 7, 9, human beta-defensin 2 (hBD-2) for the immune barrier. (3) Results: Th2 cytokines induce spongiosis and fail in impairing tight junction composition, while IL-22 reduces and IL-23 induces claudin-1 expression. IL-4 and IL-13 affect the TLR-mediated barrier largely than IL-22 and IL-23. IL-4 early inhibits hBD-2 expression, while IL-22 and IL-23 induce its distribution. (4) Conclusions: This experimental approach looks to the pathogenesis of AD through molecular epidermal proteins rather than cytokines only and paves the way for tailored patient therapy.

Keratin 17 as a Marker of UVB-Induced Stress in Human Epidermis and Modulation by Vitis vinifera Extract.

Human epidermis responds to ultraviolet (UV)B-induced damage by tolerating it, restoring it, or undergoing programmed cell death when the damage is massive. Recently, compounds rich in polyphenols, such as Vitis vinifera L. leaf extract (VVLe), have attracted a lot of interest for skin protection. We investigated the effect of VVLe pre-treatment (1 h) in a 2D model of HaCaT cells and in 3D organotypic cultures of normal human skin exposed to a single UVB dose to study the immediate specific events 1 h and the response orchestrated in the epidermal layer 24 h after irradiation, respectively. In both models, transmission electron microscopy analysis was carried out. The expression of the inducible keratin K17, the activation of both pSTAT3 and Nuclear Factor (NF)-κB signalling pathways, and the epidermal distribution of Toll-Like Receptor (TLR) 4 were assessed by immunofluorescence in the 2D and 3D model. In 3D organotypic cultures, thanks to the preservation of a multi-layered structure, the epidermal distribution of the differentiation biomarkers K10 and K14 as well as of K16 was analysed by immunofluorescence, while the release of interleukin (IL)-8 was evaluated by ELISA. In skin bioptic fragments, cytotoxicity and genotoxicity were investigated by LDH assay and Alkaline Comet assay, respectively, and then compared to cell proliferation. The epidermal distribution of the histone γ-H2AX, indicating the fragmented DNA, was analysed by immunofluorescence. In both experimental models, VVLe tuned UVB-induced K17 expression to a different extent in HaCaT cells and in the skin. In HaCaT cells, pSTAT3 activation was induced by UVB and reverted by VVLe pre-treatment. TLR4 expression was triggered by UVB in both models, but VVLe pre-treatment abolished this event only in HaCaT cells. NF-κB immunostaining increased both in the nucleus and in the cytoplasm only in HaCaT cells after UVB irradiation. In all irradiated skin samples, VVLe pre-treatment was not able to revert the inhibition of epidermal proliferation, K16 expression, and IL-8 secretion. The effectiveness of VVLe in contrasting the irradiation-induced genotoxicity still remains unclear. In conclusion, our study clearly shows that K17 is a robust marker induced in keratinocytes upon UVB stimulation and that this event can be reverted by a pre-treatment with VVLe. On the whole, these observations represent a novelty in the scenario of the complex relationships between the effects exerted by UVB rays on human skin and significantly improve the knowledge regarding the modulation of the early epidermal response induced by a single exposure to UVB in the presence of VVLe.

A Case of Large Aplasia Cutis Congenita with Underlying Skull Defect: Effective Surgical Treatment with Integra® Dermal Regeneration Template.

INTRODUCTION: Aplasia cutis congenita (ACC) is a rare congenital abnormality characterized by the absence of a portion of skin at birth which most commonly involves the scalp and can affect the galea, the pericranium, the bone, and the dura mater. It can be an isolated condition or associated with other disorders. CASE REPORT: We present a case of ACC with a large defect of the scalp and the underlying bone treated with the use of Integra® Dermal regeneration template. At 5 months of follow-up, the wound is completely healed and the bony defect greatly reduced. Contraction of the area of alopecia was observed. DISCUSSION: Several surgical and conservative options have been described to treat this congenital condition: advanced dressing, skin graft, local flaps, free flaps, and other methods. In our case, we used Integra® Dermal templates which provide a barrier for infections, promote cellular activity for a rapid vascularization, and improve healing.

The psoriatic shift induced by interleukin 17 is promptly reverted by a specific anti-IL-17A agent in a three-dimensional organotypic model of normal human skin culture.

Interleukin 17A (IL-17A), mainly produced by the T helper subclass Th17, plays a key role in the psoriatic plaque formation and progression. The clinical effectiveness of anti-IL-17A agents is documented, but the early and specific mechanisms of their protection are not identified yet. The challenge of the present study is to investigate the possible reversal exerted by a specific anti-IL-17A agent on the psoriatic events induced by IL-17A in a three-dimensional organotypic model of normal human skin. Bioptic skin fragments obtained after aesthetic surgery of healthy women (n=5) were incubated with i) IL-17A biological inhibitor (anti-IL-17A), ii) IL-17A, iii) a combination of IL-17A and its specific IL-17A biological inhibitor (COMBO). A Control group was in parallel cultured and incubation lasted for 24 and 48 h epidermal-side-up at the air-liquid interface. All subjects were represented in all experimental groups at all considered time-points. Keratinocyte proliferation and the presence of epidermal Langerhans cells were quantitatively estimated. In parallel with transmission electron microscopy analysis, immunofluorescence studies for the epidermal distribution of keratin (K)10, K14, K16, K17, filaggrin/occludin, Toll-like Receptor 4, and Nuclear Factor kB were performed. IL-17A inhibited cell proliferation and induced K17 expression, while samples incubated with the anti-IL-17A agent were comparable to controls. In the COMBO group the IL-17A-induced effects were almost completely reverted. Our study, for the first time, elucidates the most specific psoriatic cellular events that can be partially affected or completely reverted by a specific anti-IL-17A agent during the early phases of the plaque onset and progression. On the whole, this work contributes to expand the knowledge of the psoriatic tableau.

Therapeutic Algorithm for Congenital Ptosis Repair with Levator Resection and Frontalis Suspension: Results and Literature Review.

BACKGROUND: Several treatments have been described for the treatment of congenital ptosis, but there are few studies that analyze the effectiveness of a therapeutic approach rather than a single technique. AIMS: In this study, we aim to evaluate the effectiveness of our therapeutic algorithm, which relies on levator muscle resection and frontalis suspension with silicone rods, polytetrafluoroethylene (PTFE), or autologous fascia lata. METHODS: We retrospectively analyzed all patients affected by congenital ptosis who underwent corrective surgery at a single department between January 1998 and January 2016. RESULTS: A total of 116 procedures were performed in 86 patients, accounting for 35 levator resections, 67 frontalis suspensions, and 14 revisions. A satisfactory result was observed in 65 cases after one procedure (75.6%). Complications occurred in 13 cases after primary surgery (15.1%). Ptosis relapse was observed in 25 cases after primary procedure (21.5%). Frontalis suspension displayed a higher number of complications than levator resection (22.2% vs 3.1%, p=0.02). CONCLUSION: Our therapeutic algorithm was effective in 75.6% after one procedure. Frontalis suspension procedures encountered a higher rate of complication than levator resection. Fascia lata should be preferred to silicon rods whenever possible due to the lower recurrence rate. These issues confirm the therapeutic algorithm, although larger prospective studies are necessary to validate our approach.

Epidermal barrier reaction to an in vitro psoriatic microenvironment.

Keratinocytes (KCs) and Langerhans cells (LCs) contribute to create the epidermal barrier. To form a functional epidermis, KCs express filaggrin and Toll-like Receptors (TLRs). LCs are the first line of epidermal defence and can be activated by interleukin (IL)-17 and Tumor Necrosis Factor (TNF)-alpha. In psoriasis, an alteration of TLR expression, a defective expression of filaggrin, and LC activation occur. In organotypic cultures of human skin we investigated the interplay between IL-17 and TNF-alpha on i) expression of filaggrin, TLR2, 7 and 9, and Nuclear Factor (NF)-kB localization by immunofluorescence and ii) LC ultrastructural features by transmission electron microscopy. Normal human skin was obtained after aesthetic surgery (n=7), overnight incubated in a Transwell system, and exposed to TNF-alpha and/or IL-17 for 24 (T24), 48 (T48), and 72 (T72) hours. Cytokines always influenced the expression of filaggrin. TNF-alpha alone activated LCs only starting from T48. TLR2 and TLR7 expressions were affected at T24 by IL-17 and the combination of cytokines, but not by TNF-alpha. TLR9-positive cells were detectable in the granular layer after cytokine exposure. A nuclear localization of NF-kB was always observed after cytokine incubation. In conclusion, each cytokine possess an intrinsic activity on the different components of the epidermal barrier.

Breast Cerclage: An Innovative Expedient for Perimammary Dehiscence Healing.

The perimammary zone is a critical area for healing, due to high incidence of dehiscences, expecially sternal ones. Although deep sternal wound complications are nowadays less common after cardiac surgery, in some at risk patients, dehiscences still represent important complications of major cardiac or vascular surgeries and they are directly correlated to an increased risk of patient's morbidity and mortality. A heavy breast represents a source of tension on the perimammary wound, inhibiting or delaying a complete recovery. We report the case of a 66-year-old female patient with a critical post-surgical sternal dehiscence and multiple chronic comorbidities. The dehiscence was managed with a routinely performed primary intention closure combined with an innovative breast cerclage. To our opinion, this is the first reported description of a breast cerclage used as an expedient to reduce tension on the wound and minimize the risk of relapse, allowing a rapid and complete healing. This novel technique has proved to be effective and satisfactory in the achievement of both a functional and aesthetic results and we are confident that it could become a fully-fledged wound healing issue in chest wall reconstruction.

Interleukin 22 early affects keratinocyte differentiation, but not proliferation, in a three-dimensional model of normal human skin.

Interleukin (IL)-22 is a pro-inflammatory cytokine driving the progression of the psoriatic lesion with other cytokines, as Tumor Necrosis Factor (TNF)-alpha and IL-17. Our study was aimed at evaluating the early effect of IL-22 alone or in combination with TNF-alpha and IL-17 by immunofluorescence on i) keratinocyte (KC) proliferation, ii) terminal differentiation biomarkers as keratin (K) 10 and 17 expression, iii) intercellular junctions. Transmission electron microscopy (TEM) analysis was performed. A model of human skin culture reproducing a psoriatic microenvironment was used. Plastic surgery explants were obtained from healthy young women (n=7) after informed consent. Fragments were divided before adding IL-22 or a combination of the three cytokines, and harvested 24 (T24), 48 (T48), and 72 (T72)h later. From T24, in IL-22 samples we detected a progressive decrease in K10 immunostaining in the spinous layer paralleled by K17 induction. By TEM, after IL-22 incubation, keratin aggregates were evident in the perinuclear area. Occludin immunostaining was not homogeneously distributed. Conversely, KC proliferation was not inhibited by IL-22 alone, but only by the combination of cytokines. Our results suggest that IL-22 affects keratinocyte terminal differentiation, whereas, in order to induce a proliferation impairment, a more complex psoriatic-like microenvironment is needed.

Chronic Ulcer by Cutaneous GvHD After Bone Marrow Transplantation Treated With Skin Allograft From HLA-Identical Donor: Case Report and Literature Review.

We present a successful split-thickness skin allograft for a chronic cutaneous graft-versus-host disease of the thigh in an immunosuppressed patient, treated for acute myeloid leukemia with allogenic bone marrow stem cells transplant.

Human adipose-derived stem cells isolated from young and elderly women: their differentiation potential and scaffold interaction during in vitro osteoblastic differentiation.

BACKGROUND AIMS: Several authors have demonstrated that adipose tissue contains multipotent cells capable of differentiation into several lineages, including bone, cartilage and fat. METHODS: This study compared human adipose-derived stem cells (hASC) isolated from 26 female donors, under 35 and over 45 years old, showing differences in their cell numbers and proliferation, and evaluated their in vitro adipocytic and osteoblastic differentiation potential. RESULTS: The cellular yield of hASC from older donors was significantly greater than that from younger donors, whereas their clonogenic potential appeared slightly reduced. There were no significant discrepancies between hASC isolated from young and elderly women regarding their in vitro adipocytic differentiation, whereas the osteoblastic potential was significantly reduced by aging. We also assessed the influence of hydroxyapatite (HAP) and silicon carbide (SiC-PECVD) on hASC. Even when cultured on scaffolds, hASC from younger donors had better differentiation into osteoblast-like cells than hASC from older donors; their differentiation ability was up-regulated by the presence of HAP, whereas SiC-PECVD produced no significant effect on hASC osteoblastic differentiation. CONCLUSIONS: The large numbers of hASC resident in adipose tissue and their differentiation features suggest that they could be used for a successful bone regeneration process in vivo. We have shown that age does not seem to affect cell viability and in vitro adipocytic differentiation significantly, whereas it does affects osteoblastic differentiation, in the absence and presence of two-dimensional and three-dimensional scaffolds.

Effects of mild hypothermia on blood coagulation in patients undergoing elective plastic surgery.

BACKGROUND: The aim of this prospective, controlled study was to evaluate the effects on coagulation function of active patient warming during elective plastic surgery. METHODS: Seventy-six patients undergoing elective plastic surgery (additive and reductive mastoplasty, rhinoplasty, and liposuction) were either covered with standard sterile drapes (control group, n = 38) or actively warmed during surgery with countercurrent fluid warming and forced-air skin warming (treatment group, n = 38). Complete evaluation of the coagulation activity was performed 1 hour before general anesthesia was induced and then at the end of surgery. RESULTS: Although no differences in preoperative core temperature were observed (36.0 +/- 0.5 degrees C in the control group and 36.1 +/- 0.4 degrees C in the treatment group; p = 0.12), core temperature was lower at the end of surgery in the control group (34 +/- 1.0 degrees C) than in the treatment group (36 +/- 0.6 degrees C) (p = 0.0005). No differences in prothrombin time and fibrinogen plasma concentrations were observed between the two groups. At the end of surgery, control group patients showed significantly larger activated partial thromboplastin times (36.8 +/- 3.5 seconds) and bleeding times (8.1 +/- 1.6 minutes) as compared with patients maintained normothermic during surgery (34.0 +/- 2.9 seconds and 4.3 +/- 1.1 minutes; p = 0.0005 and p = 0.0005, respectively). CONCLUSION: Actively maintaining intraoperative normothermia allows patients to maintain normal coagulation function during elective plastic surgery lasting longer than 2 hours, potentially reducing the occurrence of bleeding-related complications after plastic surgery.