Exfoliative Cytology and Genetic Analysis for a Non-Invasive Approach to the Diagnosis of White Sponge Nevus: Case Series.

BACKGROUND: White Sponge Nevus (WSN) is a rare benign disorder associated with mutations in genes coding for cytokeratin 4 (KRT4) and 13 (KRT13) characterized by dyskeratotic hyperplasia of mucous membranes. This study was aimed at examining different approaches (cytology, pathology and genetic analysis) to WSN diagnosis. METHODS: A series of four patients with asymptomatic white diffuse oral lesions were evaluated and, before performing an incisional biopsy for pathology, an oral brush Thin Prep was collected for exfoliative liquid-based cytology (LBC). DNA for genetic analysis was also obtained from patients and both their parents, using buccal swabs. RESULTS: Pathology and cytology showed similar results, leading to the same diagnosis of hyperkeratotic epithelium with acanthosis and spongiosis, without atypia, demonstrating the efficiency of LBC for the differential diagnosis. Sequencing analysis revealed at least 6 rare variants in the KRT4 and KRT13 genes in each patient, contributed in part by both unaffected parents. CONCLUSIONS: Thin Prep for oral exfoliative cytology and genetic analysis are sufficient for an accurate diagnosis of WSN. The combination of cytological and genetic analyses could substitute the histologic exam, providing a non-invasive alternative for incisional biopsy.

The impact of COVID-19 in plastic surgery departments: a comparative retrospective study in a COVID-19 and in a non-COVID-19 hospital.

BACKGROUND: COVID-19 is a new human-infecting coronavirus for which the World Health Organization declared a global pandemic. The first Italian cases occurred in February 2020: since then, there has been an exponential increase in new cases, hospitalizations and intensive care assistance demand. This new and sudden scenario led to a forced National Health System reorganization and review of welfare priorities. The aim of this study is to evaluate the effects of this pandemic on ordinary activities in two plastic surgery divisions in Rome, hosted in a COVID-19 and a non-COVID-19 hospital. METHODS: The data of this comparative retrospective study was collected between 9 March and 9 April 2019 and the same period of 2020 from two plastic surgery units, one in a COVID-19 hospital and second in a non-COVID-19 hospital in Rome, Italy. The 2019-2020 data of the two hospitals was compared regarding the number of surgeries, post-operative dressings and first consultations performed. RESULTS: Both units sustained a decrease in workload due to lockdown effects. Statistically significant differences for day surgery procedures (p value = 0.0047) and first consultations (p value < 0.0001) were found between the COVID-19 and non-COVID-19 institutes, with a drastic trend limiting non-urgent access to COVID-19 hospitals. CONCLUSIONS: The long-term effects of healthcare reshuffling in the "COVID-19 era" imply a delay in the diagnosis and treatment of skin cancer and cancellation of many reconstructive procedures. These findings pose a question on the future consequences of a long-term limitation in plastic surgery healthcare.Level of evidence: Level III, risk/prognostic study.

Randomized Double-Blind Controlled Study on the Safety and Efficacy of a Novel Injectable Cross-linked Hyaluronic Gel for the Correction of Moderate-to-Severe Nasolabial Wrinkles.

INTRODUCTION: The current study compares two hyaluronic acid fillers, Ial System Duo and Belotero Basic/Balance, for the treatment of wrinkles. MATERIALS AND METHODS: This is a single-center, double-blind randomized controlled study. Inclusion criteria consisted of subjects with bilateral nasolabial wrinkles. Each subject was treated with both products: One was applied on the right side and the other on the left side of the face. The quantity of product injected and any problems or local reactions (erythema, edema, pain or itching) were recorded and reassessed at 3 and 6 months and then monthly until complete absorption of the product. The Wrinkle Severity Rating Scale (WSRS) and the Global Aesthetic Improvement Scale (GAIS) were used for the assessment, as well as an ultrasound measurement of the skin thickness. RESULTS: Complete data were available for 59 subjects. At 3 and 6 months, both products showed improvement in the WSRS and GAIS score in the areas treated compared to pre-treatment assessments, although no significant differences were observed between them. No resulting significant differences were observed on skin thickness among the two products, which were completely reabsorbed in 285 ± 34 days (Ial System Duo) and 277 ± 34 days (Belotero Basic/Balance; Student's t test: p = 0.2181). No significant differences were observed with regard to the subject's satisfaction and adverse events. CONCLUSIONS: The Ial System Duo achieves long-term permanence (more than 9 months confirmed by ultrasound) in correction of moderate and severe wrinkles, similar to Belotero Basic/Balance. Both products showed a high safety profile and a high degree of subject and physician satisfaction. LEVEL OF EVIDENCE II: 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 .

Effects of topical application of B-Resorcinol and Glycyrrhetinic acid monotherapy and in combination with fractional CO2 laser treatment for benign hand hyperpigmentation treatment.

BACKGROUND: Hand solar lentigines are frequent benign lesions of elderly population, requiring longtime treatments with topical agents or laser to lighten. AIMS: The aim of this study was to evaluate and compare the efficacy of CO2 fractional laser photothermolysis followed by topical application of B-Resorcinol and Glycyrrhetinic acid vs. only topical B-Resorcinol and Glycyrrhetinic acid application for hand solar lentigines treatment. METHODS: Hand solar lentigines of eleven volunteers were divided into two groups: Group A spots received CO2 fractional laser photothermolysis followed by 4 weeks topical application of B-Resorcinol and Glycyrrhetinic acid, and Group B spots received only 4 weeks topical treatments. All hands were photographed, and hand solar lentigines scanned with dermatoscope at the beginning of the study (T0 ), 1 month after laser treatment (T1 ), and at the end of the study (T2 ) to document spots dimensions and color. A blinded dermatologist evaluated dermoscopic T0 and T2 images. The considered variables were assessed for significance by the nonparametric Mann-Whitney U-test. RESULTS: In all volunteers, investigators and blinded dermatologist's evaluation hand solar lentigines features improved, with no statistical differences in the two groups. CONCLUSION: Topical application of B-Resorcinol and Glycyrrhetinic acid is effective to lighten hand solar lentigines after 4 weeks of treatment, with or without a previous fractional laser photothermolysis.

Ionic Hydrogel Monotherapy and in Combination with Antiviral-Antibiotic Prophylaxis, in the Post-procedure Management of Fractional Laser-Treated Patients.

Objective: The pre- and postoperative care for fractionated laser resurfacing is still controversial, especially in regard to the use of antibiotics to prevent bacterial infection and potential consequences. Recently, an ionic hydrogel has shown to be useful in the postoperative treatment of minor burns. The aim of this study is to evaluate the use of this hydrogel after fractional laser treatments targeting photoaging and chronoaging damage to skin. Design: A randomized prospective study. Setting: one plastic surgeon private practice. Participant: Fifty patients with chronoaging and photoaging cosmetic issues were enrolled in two different post-treatment regimens: ionic hydrogel alone and ionic hydrogel in combination with antibiotics. Measurements: Patients were evaluated for healing time, complications, and postoperative pain, the latter assessed with a 10-point visual analogue score. A questionnaire to investigate how patients managed through the postoperative phase was also provided to each patient. Results: No significant differences between the two groups were observed in regard to healing time, postoperative pain, complications, and patient satisfaction. Conclusion: Ionic hydrogel alone has shown to provide adequate skin care support in the postoperative phase of fractional-laser-resurfacing-treated patients.

Prospective control study using fibrin sealants and Harmonic® scalpel in Latissimus Dorsi flap transfer.

BACKGROUND: Latissimus dorsi flap (LD) is used in breast reconstruction procedures, although prolonged donor site drainage is a frequent complication. To decrease this problem, quilting sutures and/or fibrin sealants were proposed, with alternate results. The primary objective of this study was to assess the effectiveness of Tisseel® in association with the Harmonic Synergy® blade system to reduce this complication. MATERIALS AND METHODS: Between 2010-2012, 20 consecutive patients undergoing immediate unilateral breast reconstruction with LD were enrolled in the study (Group A) and matched with 20 patients in which LD was raised with electrocautery (Group B), and 20 patients in which LD was harvested with Harmonic® (Group C). After informed consent acquisition, Harmonic® was used in Group A for LD harvesting, but differed from other groups as fibrin glue was applied to the donor site prior to closure. In all groups donor site drainage measurements at 24 and 48 hours, total drain volume, days to drain removal, operation time, and complication rate were recorded. Pearson's Chi-squared, ANOVA, and Bonferroni post-hoc tests were used to analyze the data. RESULTS: Data analysis did not show any statistical difference. Prolonged drains output ≥ 15 days occurred in one patient of Group A and C, and in three Group B patients. CONCLUSION: Although the combined use of Harmonic® and Tisseel® presents a low donor site fluid collection rate, the fibrin glue seems not to have further beneficial effects in reducing the post-operative serous drainage or to lead to an early drain removal when compared to Harmonic® only.

Skin grafted latissimus dorsi flap for reconstruction of lateral aesthetic units of the face.

Reconstruction of large defects of the lateral region of the face is rather challenging due to the unique color, texture, and thickness of soft tissues in this area. Microsurgical free flaps represent the gold standard, providing superior functional and aesthetic restoration. Purpose of this study was to assess reliability of skin-grafted latissimus dorsi (LD) flap, for a pleasant and symmetric reconstruction of the lateral aesthetic units of the face compared to a control group of patients addressed to perforator flaps. From November 2008 to June 2012, 5 patients underwent skin-grafted LD flap reconstruction of defects involving the lateral aesthetic units of the face, with 8.1 ± 0.5 × 9.7 ± 1.3 cm mean size. A 1-to-4 Likert scale was used to assess skin color, texture, shape, and bulkiness. Using the Pressure-Specified Sensory Device epicritic, proprioceptive, and protopathic sensitivities were tested. Outcomes were compared with those of a control group of 5 patients addressed to reconstruction with perforator flaps (3 anterolateral thigh flap, 2 vertical deep inferior perforator flap). At mean 21-month follow-up all flaps healed uneventfully without need for revisions, all developing more satisfactory results in terms of skin color (P = 0.028) and texture (P = 0.021) match, shape (P = 0.047) and bulkiness (P = 0.012) compared with perforator flaps. No differences in epicritic, proprioceptive, and protopathic sensitivities were observed (P > 0.05) between the two groups. Skin-grafted LD flap may be a suitable option for reconstruction of wide defects of the lateral aesthetic units of the face.

Potential regulatory molecules in the human trabecular meshwork of patients with glaucoma: immunohistochemical profile of a number of inflammatory cytokines.

Glaucoma occurs when there are imbalances between the production and the drainage of the eye liquid. The vast majority of the aqueous humor leaves the eye through the trabecular meshwork (TM). The cause of hypertonicity may be due to an alteration in the thickness of the TM. In the majority of cases the molecular changes that determine primary open­angle glaucoma (POAG) are unclear. However, it has been hypothesized that the significant increase in the extracellular matrix (ECM) of the fibrillary bands in the TM is associated with possible inflammatory conditions. In this study the tissue distribution of interleukin (IL)­6, IL­1ß, transforming growth factor-ß1 (TGF­ß1), vascular endothelial growth factor (VEGF) and tumor necrosis factor α (TNF­α) was analyzed in TM samples from patients with POAG by immunohistochemistry. Seven specimens from patients with POAG and three control tissues were analyzed by immunohistochemistry using specific antibodies against these cytokines. Morphological changes in the TM, such as increased cell content, macrophages, fibrosis and accumulation of neutrophils, were observed by transmission electron microscopy. In human TM tissues, an evident immunoreactivity for IL­6, IL­1ß and TNF­α was observed in patients with POAG when compared with the control subjects, indicating that these cytokines may be correlated with disease activity. TM endothelial cells secrete a number of factors and cytokines that modulate the functions of the cells and the ECM of the conventional outflow pathway. In the TM in glaucoma, macrophages produce cytokines, including IL­6, IL­1ß and TNF­α, leading to an acute inflammatory response and recruitment of other immune cells, including T lymphocytes. In addition, TGF­ß1 regulates and induces the expression of IL­6 in TM that indirectly induces angiogenesis by stimulating VEGF expression. The present results support previous evidence that suggests that growth factors and cytokines can induce ECM remodelling and alter cytoskeletal interactions in the TM.

MRI in the evaluation of facial dermal fillers in normal and complicated cases.

OBJECTIVES: To ascertain by MRI the presence of filler injected into facial soft tissue and characterize complications by contrast enhancement. METHODS: Nineteen volunteers without complications were initially investigated to study the MRI features of facial fillers. We then studied another 26 patients with clinically diagnosed filler-related complications using contrast-enhanced MRI. TSE-T1-weighted, TSE-T2-weighted, fat-saturated TSE-T2-weighted, and TIRM axial and coronal scans were performed in all patients, and contrast-enhanced fat-suppressed TSE-T1-weighted scans were performed in complicated patients, who were then treated with antibiotics. Patients with soft-tissue enhancement and those without enhancement but who did not respond to therapy underwent skin biopsy. Fisher's exact test was used for statistical analysis. RESULTS: MRI identified and quantified the extent of fillers. Contrast enhancement was detected in 9/26 patients, and skin biopsy consistently showed inflammatory granulomatous reaction, whereas in 5/17 patients without contrast enhancement, biopsy showed no granulomas. Fisher's exact test showed significant correlation (p < 0.001) between subcutaneous contrast enhancement and granulomatous reaction. Cervical lymph node enlargement (longitudinal axis >10 mm) was found in 16 complicated patients (65 %; levels IA/IB/IIA/IIB). CONCLUSIONS: MRI is a useful non-invasive tool for anatomical localization of facial dermal filler; IV gadolinium administration is advised in complicated cases for characterization of granulomatous reaction. KEY POINTS: • MRI is a non-invasive tool for facial dermal filler detection and localization. • MRI-criteria to evaluate complicated/non-complicated cases after facial dermal filler injections are defined. • Contrast-enhanced MRI detects subcutaneous inflammatory granulomatous reaction due to dermal filler. • 65 % patients with filler-related complications showed lymph-node enlargement versus 31.5 % without complications. • Lymph node enlargement involved cervical levels (IA/IB/IIA/IIB) that drained treated facial areas.

Bilateral condylar resorption in down syndrome.

Asymptomatic idiopathic condylar resorption is a rare disease of difficult diagnosis and treatment. We review the literature about this rare condition and report a case of a patient, affected by Down syndrome, who underwent a complete untreated bilateral condylar resorption in adolescence and then developed pain on chewing only 20 years later. Despite a precise orthodontic and surgical therapeutic plan, treatment had to be discontinued because of patient lack of compliance. This case is the first of its kind to be reported and emphasizes the need for special attention in patients with disability.

Diagnosis and management of dermal filler complications in the perioral region.

BACKGROUND: Lip augmentation with injectable materials is a popular aesthetic procedure. When complications occur, patients often ignore which material was implanted, thus making subsequent treatments difficult. This study aims to present the diagnosis and management of dermal filler complications in the perioral region. STUDY DESIGN: The Medical charts of 26 patients with filler complications in the oral region were reviewed. All patients were submitted to High Frequency Ultrasound, often complemented by Magnetic Resonance Imaging (MRI) and White Blood Cell Scintigraphy, to evaluate filler characteristics and complication types. Antibiotic, corticosteroid or surgical treatment was therefore planned. RESULTS: Imaging always identified dermal fillers in the oral region, distinguishing among infections, fibrosis, granulomatous inflammation and product migration. Nine patients received surgery, ten received medical treatments, six received both, and one refused treatment. Eighty percent of the patients presented an improvement after three- year follow-up. CONCLUSIONS: Complications of oral region fillers are similar in clinical presentation but differ in etiology, therefore necessitating different clinical approaches. Imaging techniques add useful information for treatment planning.

Cutaneous venous malformations related to KRIT1 mutation: case report and literature review.

Cavernous malformations (CMs) are vascular anomalies of the nervous system mostly located in the brain. Cerebral cavernous malformations can present sporadically or familial, as a consequence of an autosomal dominant condition, with incomplete penetrance and variable clinical expression. Occasionally, extraneural manifestations of CMs involving the skin have been described. We report the case of two siblings presenting in adulthood diffuse cutaneous vascular lesions associated with cerebral CMs that, after surgical excision and histopathologic analysis, resulted to cavernous haemangiomas. Genomic DNA was extracted from peripheral blood, and molecular evaluation of KRIT1 gene was performed. Although no signs of neurological impairment were reported, cerebral MRI revealed multiple images in both patients, suggestive of cavernous haemangiomas. The genetic study demonstrated a nonsense mutation (c.535C>T) in the KRIT1 (Krev-1/rap1 interaction trapped 1) gene. Few reports describe extraneural manifestations of Cavernous malformation syndrome (CMs) related to a KRIT1 mutation; these involve the skin and are associated with hyperkeratotic cutaneous capillary-venous malformation. CMs should be suspected in patients developing multiple nodular cutaneous venous lesions in adulthood.

Late unilateral hematoma after breast reconstruction with implants: case report and literature review.

UNLABELLED: Although reports of late hematoma after placement of breast implants are rare, there has been a noticeable increase in these reports in recent years. Various etiologies have been proposed, usually relating to history of trauma, anticoagulant use, or physical strain. In this case report, we describe a 61-year-old patient who slowly developed a unilateral intracapsular hematoma 2 years after breast reconstruction with Biocell (Natrelle; Allergan, Inc, Irvine, California) textured implants. This case is unique because of the intraoperative finding of 2 capsules surrounding the implant, with the hematoma between the 2 layers. We also discuss the possible pathophysiological mechanisms of this phenomenon. LEVEL OF EVIDENCE: 5.

The utility of high-frequency ultrasound in dermal filler evaluation.

Aim of this study is to describe the use of high-frequency ultrasound to ascertain the site, quantity, and type of filler injected in the soft tissue of the face, with respect to reliability of the procedure and the analysis costs. Between December 2006 and August 2010, 80 subjects aged 25 to 65 years, who underwent facial filler augmentation, were submitted to high-frequency sonography. Of total, 42 patients (22 after temporary filler and 20 after permanent filler) were healthy and satisfied of the treatment, and 38 patients sought consultation for filler-related problems. The nature of the injected filler was known in 86.25% of the patients, whereas it was unknown in 13.75% of the patients. Besides 4 patients, previously treated with temporary products, in which no foreign material was detected, high-frequency sonography was able to identify and quantify the presence of filler in the soft tissue of 97% of patients. Moreover, it was possible to detect inflammatory reaction (that were often silent), granulomas, and recognize the presence of diverse fillers in the same area. Ultrasonography has proved to be a useful, inexpensive, noninvasive tool for the identification of the site, quantity, and often even nature of the filler injected.

High-frequency sonography of temporary and permanent dermal fillers.

BACKGROUND: Dermal fillers are used widely; some have a permanent effect, whereas others are temporary. The aim of this study is to describe the ultrasonographic features of permanent and temporary fillers injected into patients for cosmetic purposes. MATERIALS AND METHODS: Between December 2006 and April 2009, 36 subjects, aged 25-45, who had received lips or nasolabial fold filler augmentation, were enrolled for a high-frequency sonographic examination by a blinded investigator. The criteria for exclusion were a history of autoimmunity, infection, neoplastic diseases or episodes of local reactions to the injected filler. Twenty patients underwent a sonographic exam after the injection of a temporary filler (collagen or hyaluronic acid) by FRG; the rest were enrolled among patients seeking a consultation for further cosmetic reasons, but had been treated with an identifiable filler before. RESULTS: It was always possible to identify the filler at the site of injection. Seldom was it possible to discover a silent inflammatory reaction, otherwise unsuspected. The sonographic images differed according to the temporary or the permanent nature of the filler. CONCLUSION: Ultrasonography has proved to be a useful, non-invasive tool for the identification of the presence and type of the filler injected.

Management of craniofacial development in the Parry-Romberg syndrome: report of two patients.

OBJECTIVE: The aim of this article is to describe the orthodontic therapy for Parry-Romberg syndrome. The therapeutic goal is to minimize the wasting effects of progressive atrophy on facial development of a part of the face. DESIGN: To correct problems affecting craniofacial development of these patients, occurring during puberty, an orthodontic appliance was employed, which helps maintain parallelism of the facial planes, in particular the mandibular plane. SETTING: Orthodontic care was carried out in the Dental Clinic of the Catholic University of the Sacred Heart of Rome. INTERVENTION: Two patients underwent orthodontic therapy for 6 years. Appliances were checked every month and modified periodically so as to adapt to facial bone growth. RESULTS: At the end of craniofacial growth, the mandible was almost symmetric and the problem relating to atrophy remained confined to the initial area. Cephalometric analyses demonstrated that the occlusal plane and the mandibular plane maintained a straight orientation in relation to the bizygomatic plane. The ratio between the left and right side of the ramus and condyle, in the mandible, improved. CONCLUSIONS: The use of orthodontic therapy allows patients affected by hemifacial progressive atrophy to present a more harmonic face at the end of puberty when final reconstruction can be planned. These results provide for a limitation of surgical intervention to the sclerodermic area alone.