[History of breast cancer reconstruction treatment]. / Historique du traitement du cancer du sein.

The authors summarize in those six pages of drawings the history of breast cancer reconstruction treatment. The focus is on the variety of techniques available for breast reconstruction and on the debates around different indications.

Clinical, histomorphological and therapeutic features of the Van der Woude Syndrome: literature review and presentation of an unusual case.

BACKGROUND: Van der Woude syndrome (VWS), an autosomal dominant condition associated with lower lip pits and/or cleft palate, is caused by mutations in the interferon regulatory factor 6 gene (lRF6 gene). The genetic alterations identified to date that contribute to expression of the syndrome are chiefly mutations located on chromosome 1 (the largest of our chromosomes), mutations at p36 that codifies the gene GRHL (grainy-head transcriptor factor) and mutations involving IRF6 (interferon regulatory factor). With frequency ranging from 1:35,000 to 1:100,000, depending on ethnicity, gender, and socio-economic status, the syndrome accounts for about 2% of orofacial clefts. The clinical and histomorphological aspects of VWS are studied, and a case of heterozygous female twins of whom only one was affected with VWS is reported. CONCLUSION: This very rare case (no similar case has been reported to date) contributes further evidence on modifying factors in the expression of this condition.

[History of aesthetic rhinoplasty]. / Histoire de la rhinoplastie esthétique.

One of the first surgical procedures described in the history of medicine is reconstructive surgery of the nose. Over the centuries, surgeons have developed techniques aimed at reconstructing noses amputated or traumatized by disease. The concept of aesthetic rhinoplasty was only introduced at the end of the 19th century. Since then, techniques have evolved toward constant ameliorations. Nowadays, this surgery is one of the most performed aesthetic procedures. Current technical sophistication is the result of over a century of history marked by many surgeons. All of these techniques derive from a detailed understanding of the anatomical nose from the surgical and artistic point of view.

Outcomes of structural fat grafting for paralytic and non-paralytic dysphonia.

Aims of this prospective study were to evaluate the results of vocal fold structural fat grafting for glottic insufficiency and to compare the outcomes obtained in unilateral vocal fold paralysis (UVFP) and congenital or acquired soft tissue defects in vocal folds. Sixty-six consecutive patients with breathy dysphonia, in 43 cases (aged 16-79 years) related to UVFP and in 23 cases (aged 16-67 years) related to vocal fold iatrogenic scar or sulcus vocalis, underwent autologous structural fat grafting into vocal folds. Lipoaspirates were centrifuged at 1200 g for 3 min to separate and remove blood, cell debris and the oily layer. The refined fat was injected under direct microlaryngoscopy in a multilayered way. The main outcome measures were grade, roughness, breathiness, asthenicity and strain (GRBAS) perceptual evaluation, maximum phonation time (MPT), self-assessed Voice Handicap Index (VHI), and voice acoustic analysis, considered pre-operatively and at 3 and 6 months after fat grafting. After surgery, MPT, VHI, G and B improved in both groups (p < 0.05). In particular, G and VHI functional subscales showed a significantly greater decrease in patients with UVFP (p < 0.05). The acoustic variables improved significantly only in the UVFP group (p < 0.005). From 3 to 6 months postoperatively, most variables showed a trend with further improvement. Vocal fold structural fat grafting was significantly effective in treating glottic insufficiency due to UVFP or soft tissue defects. Perceptual, acoustic and subjective assessments confirmed that patients with UVFP had better outcomes than those with soft tissue defects.

Autologous fat injection to face and neck: from soft tissue augmentation to regenerative medicine.

Minimally-invasive autologous fat injection of the head and neck region can be considered a valid alternative to major invasive surgical procedures both for aesthetic and functional purposes. The favourable outcomes of autologous fat injection in otolaryngological practice are due to the filling of soft tissue and, mainly, to the potential regenerative effect of adipose-derived mesenchymal stem cells. Herewith, some important biological preliminary remarks are described underlying the potential of autologous fat injection in regenerative medicine, and personal experience in using it for both consolidated clinical applications, such as fat grafting to the face and vocal fold augmentation in the treatment of glottic incompetence, and more recent applications including the treatment of post-parotidectomy Frey syndrome and velopharyngeal insufficiency.

Reconstruction of the nose--a historical review.

As the central and most prominent part of the human face, the nose contributes to determine the beauty of a person significantly. Certain ancient populations, particularly in India, had the common tradition to cut off a person's nose as an act of humiliation to thieves and prisoners of war or vengeance for some real or fancied wrong. To erase the signs of this cruel disfigurement, the ingenuity of surgeons conceived different solutions over the centuries, therefore the birth and evolution of plastic surgery strictly parallel the art of replacing missing noses. Nasal restoration by means of a skin flap taken from the arm is an operation of Italian origin, whereas by a skin flap taken from the forehead is an operation of Indian origin. This review highlights the development of this interesting and at the same time challenging surgical technique. Currently, the forehead flap is considered the solution of choice due to the excellent colour match. However, for the success of the repair it is essential to have the forehead flap of a correct size and shape depending on the defect. Nowadays, the operation has achieved excellent results due to the accuracy of technical details. Defects of the nasal tip require replacement of the different layers, mucosa, framework and cover. Donor areas must be carefully selected to leave minimal local morbidity, whereas recipient sites are treated aesthetically so as to obtain the most successful type of repair. In conclusion, the lesson from our forefathers has positively influenced the evolution of nasal reconstruction techniques.

Platysma flap for oral reconstruction.

In the authors' series of 12 consecutive patients who had oral reconstruction using the indications described above, flap survival always was achieved. Venous congestion was observed often: the flap became intensively red, showing a disappointing color that resolved spontaneously with only skin de-epithelialization. In one case of floor-of-the-mouth repair, a marginal necrosis of the distal portion of the flap occurred, possibly because of a venous drainage problem. The secondary defect healed spontaneously, without fistula formation. The time required to outline the flap is less than for most other flaps, and donor site morbidity is minimal. In selected cases, a platysma flap is an easy and rewarding solution for repairing various oral defects.

The Guastella-Mantovani septal-valve splint: an intranasal biplanar and multivectorial orthopedic device.

A new internal nasal device, the Guastella-Mantovani septal-valve splint, ensures the correct healing of the crucial area of the internal valve, simultaneously "centering" the septum orthopedically after nasal surgery.

A possible sequela of transoral approach to the upper cervical spine. Velopharyngeal incompetence.

The authors describe a case of velopharyngeal incompetence (VPI), as a consequence to the neurosurgical treatment for a complex malformation of the cranio-spinal junction. A 61-year-old woman underwent a transoral-transvelar surgical approach for odontoid resection. One month later surgical fixation of the posterior spine with autologous iliac bone graft was performed. Following these operations the patient presented a marked alteration of speech intellegibility due to hypernasal voice resonance and through incapability to articulate the oral phonemes correctly. She also complained of nasal regurgitation of fluids and solids while swallowing. She underwent a clinical phoniatric assessment of voice and speech. Videonasopharyngoscopy allowed us to inspect the velopharyngeal sphincter and to show clearly the type and morphology of its closure defect. Correction of VPI was achieved by means of a velopharyngoplasty (pharyngeal flap), in spite of technical difficulties due to local scarring and to a problematic exposure of the surgical field.

Secondary rhinoplasty: analysis of the deformity and guidelines for management.

Secondary rhinoplasty aims at modifying the functional and cosmetic defects caused by an improperly performed a primary procedure. Correction follows a logical sequence from which there is no reason to deviate if one wishes to achieve sure results. The sequence includes analysis of the deformity, accurate photographic documentation, functional and diagnostic examination, consultation with the patient, and precise planning of the different steps of surgery. Deformities are grouped in four different sectors depending on the characteristics of the repair: upper, intermediate, lower, and inner. However, defects may involve more than one sector, making it difficult or impossible to establish a precise boundary between them. The surgical technique requires a wide exposure of the operating field so that the surgeon can clearly evaluate the anatomical deformities and carry out the necessary corrections. For this reason, the open approach is the solution of choice. Two types of grafts are commonly used in revision rhinoplasty, cartilage and bone. They become necessary to reestablish function and to restore volume and/or contour. We strongly believe that only autologous grafts can be used. Grafting materials, their sources, and applications in different clinical cases are described here.

Secondary unilateral cleft lip nose: the external approach.

No single procedure developed until now has given satisfactory results to provide an ideal surgical method for cleft lip nasal deformity correction. This paper emphasizes the concept that nasal surgery is the end result on an overall treatment program for secondary cleft lip. The first step is correcting skeletal deformities. The second step of modifying the overlying nasal pyramid can only be performed when the alar base and the floor of the nose are at the same level through orthodontic alignment of the maxillary segments and bone grafting. Prior to deciding on the type of strategy, it is essential to carefully analyze the severity of the deformity, the patency of the airways, the nasal lining, and the nasal tip projection. An external approach, using the marginal-transcolumellar incision, provides excellent visualization essential for the accuracy of the correction to be carried out. The technique presented here includes modification of the following points as a single stage operation: septal surgery, suturing the medial crura together, suspension of the alar cartilage to the periosteum of the nasal bone, alar base repositioning, orbicularis muscle suturing, and increasing tip projection.

The back-and-forth septoplasty.

This paper describes a new technique of septoplasty especially devised to minimize and simplify surgery and to preserve at the same time the integrity of mucosa at the critical area of articulation between the caudal quadrangular cartilage and the vomeropremaxillary crest. Two special instruments specifically designed for this type of operation are illustrated. The technique finds a specific clinical application to cosmetic surgery of the nose when a functional problem exists.

Alessandro Benedetti, a fifteenth century anatomist and surgeon: his role in the history of nasal reconstruction.

Alessandro Benedetti (about 1445-1525) was Professor of Anatomy and Surgery at Padua University. He became famous for the construction of the first anatomical theater ever built, where he personally used to carry out dissections. He published articles on many subjects, first of all on anatomy. His work Anatomice, sive Historia Corporis Humani (Anatomy, or the History of the Human Body), first printed in Venice in 1502, was very popular and influential at that time. Of the many topics treated in the book, one is of special interest to plastic surgeons, i.e., the description of nasal reconstruction by means of a skin flap taken from the arm. The procedure is the same as the one the Branca family practiced in Sicily in the middle of fifteenth century. It is well known that the Brancas kept secret the operation and never published it. Hence, Alessandro Benedetti played an important role in the history of plastic surgery because he first reported in the Western surgical literature the procedure of nasal repair, later called the "Italian" method, almost 100 years before Tagliacozzi's publication in 1597.

A forgotten innovator in facial reconstruction: Pietro Sabattini.

Pietro Sabattini (1810-1864), a creative surgeon from Bologna, Italy, first had the idea of repairing a posttraumatic upper lip defect using a flap taken from the lower. The flap contains the three elements--skin, muscle, and mucosa--and is based on a specific vessel, the circumlabial artery. Therefore, it anticipates the musculocutaneous flap concept of today. Sabattini published his paper in 1838, 60 years before Abbé. This paper provides the first English translation of the original text and a biography of this forgotten innovator in facial reconstruction.

Guidelines for pharyngostome closure.

The reconstructive procedure for pharyngostome closure includes single-stage restoration in three steps: lining, intermediate layer, and covering. The lining repair is the key factor to the successful outcome of the operation. Three clinical situations may be distinguished. First, the mucosa is sufficient to restore a new gullet. In this case, it is widely undermined and sutured along the midline without any tension. Second, the mucosa is only partially sufficient. The same procedure as above is adopted to close the lower two-thirds of the pharyngostome, while an advancement flap is outlined from the base of the tongue to restore the upper third. Third, the mucosa is not sufficient. A musculocutaneous flap solves the problem. Reconstruction of the intermediate layer involves rotation of one (or both) sternomastoid muscle(s), if present. The possibilities for coverage include a submandibular flap, a thoracoacromial flap, and/or musculocutaneous flaps. By following these guidelines, the authors have successfully closed 37 pharyngostomes.

Choice of techniques in nasal repairs.

The authors after classifying skin loss of the nose according to their size and site, resume the techniques they normally use in every kind of loss. They suggest those most reliable and easy to perform.

History of nasal reconstruction. A brief survey.

Nasal reconstruction goes back to very early times; it was practised in ancient India about 1000 B.C. The first reports in the Western World come from the Branca family in Sicily (mid XV century) and from the Vianeo family in Calabria (mid XVI century): this art was later taken up by Tagliacozzi and published by him in 1597. A review of the literature reveals that the numerous procedures now available to repair the nose had already been devised by the middle of the nineteenth century in Germany and France as well as in England. Outstanding contributions were also made in Italy and the United States.

Evolving concepts in lip reconstruction.

An extensive review of world literature reveals that current innumerable procedures to repair upper and lower lip defects were already devised about the middle of the nineteenth century. There is little that can be defined as original after that time. In fact, most of the so-called new methods for labial reconstruction are a modification of old ideas. In tracing the steps of evolution in lip repair, the authors emphasize that only few concepts should be regarded as decisive to achieve a good final result. The use of lip tissue to repair lip defects should be one of the aims of modern cheiloplasty. Following this principle, it is possible to reestablish interrupted sphincteric functions of the orbicularis oris and, at the same time, most of the expression of emotions. When insufficient material is available for reconstruction, full-thickness local flaps of cheek can be considered the alternative solution, far better than distant lined flaps, which create a static, unaesthetic barrier.

Our experience with lip reconstruction. A lesson from history.

The authors' philosophy in performing labial reconstruction has evolved from unsatisfactory results using classic procedures. Such results prompted attempts with procedures that are both more cosmetic and functional and that give greater emphasis to the restoration of the oral sphincter.