Resection to restoration: Assessing the synergy of polypropylene mesh (Marlex®) combined with methyl-methacrylate and latissimus dorsi flap for primary chest wall sarcomas

BACKGROUND

Chest-wall sarcomas are treated with extensive resections and complex defect reconstruction to restore chest-wall integrity. It is a difficult surgical procedure that incorporates a multidisciplinary approach for the best outcome, preventing paradoxical chest movement issues and reducing complications.

OBJECTIVE

We aimed to describe our experience of chest-wall reconstruction using polypropylene mesh (Marlex® Mesh) combined with methyl-methacrylate and soft-tissue coverage with a latissimus dorsi flap following sarcoma resection.

PATIENTS AND METHODS

Among the 53 patients treated for primary chest-wall sarcomas at the European Institute of Oncology (IEO) in Milan, Italy, from 1998 to 2020, 14 cases underwent chest-wall resection and reconstruction using polypropylene mesh, methyl-methacrylate and the latissimus dorsi flap. Patients with locally advanced breast cancers, locally advanced lung cancers, squamous cell carcinomas, and other secondary chest-wall malignancies were excluded from the study, as were the patients with different types of chest-wall reconstruction.

RESULTS

In this study, 14 patients (6 men and 8 women) with various primary chest-wall sarcomas were enrolled. On an average, 2 ribs (range: 1-5) were removed during the surgeries, and the chest-wall defects ranged from 20 to 150 cm2 with an average size of 73 cm2. The mean follow-up period for these patients was approximately 63.80 months CONCLUSION: The combination of Marlex® mesh filled with methyl-methacrylate and covered using latissimus dorsi myocutaneous flap provides safe, low-cost and effective single-stage chest-wall reconstruction after surgery for primary sarcomas.

Bovine Acellular Dermal Matrix-Based Breast Reconstruction in Previously Irradiated Breasts: Complications and Outcomes From a Single-Center Experience

ABSTRACT

Radiation therapy is considered today an integral part of the management of breast cancer. However, radiotherapy significantly increases the incidence of total complications in breast reconstruction. Several procedures have been adopted to reduce complication rates in irradiated fields, including the use of acellular dermal matrices (ADMs). We conducted a retrospective analysis of our single-center experience with ADM-assisted implant-based reconstruction or revision surgeries for capsular contracture treatment in irradiated breasts. We divided our population into 4 groups based on prior surgical history: group A (previous quadrantectomy), group B (previous mastectomy and expander reconstruction), group C (previous mastectomy and implant reconstruction), and group D (prior quadrantectomy followed by mastectomy and implant reconstruction). At the European Oncology Institute in Milan, Italy, between June 2017 and April 2019, we identified 84 patients for a total of 86 irradiated breasts reconstructed with implant and ADM. We observed a total of 12 reconstructive failure, with the highest rate of failure in group B (16.6%) and in group D (15.38%). Overall, we recorded 22 total complications (24.4%): 12 major complications and 10 minor complications. The most common complication was infection, with 9 cases (10.4%), 6 of which were classified as severe and required implant removal. In group B, we observed the highest complication rate, both major and minor, with 7 of 42 patients (16.6%) experiencing each. Before reconstruction with ADM, the Baker grade ranged from 3 to 4, with a mean of 3.25. At the 2-year follow-up, the Baker grade ranged from 1 to 4, with a mean of 1.9. Surgeons were highly satisfied with the aesthetic result in 72.1% of cases, moderately in 8.1% and unsatisfied in 5.81%, and in 13.9%, the outcome was not assessable because of reconstructive failure. The worst aesthetic result was in group B. We observed significant reduction in capsular contracture in revision surgeries despite a moderately high rate of complications in previous quadrantectomy and radiotherapy. In our experience, breast reconstruction with implant and ADM is not the primary surgical indication in case of prior irradiation, but it can be considered as a valid alternative with reasonable safety profile, to be used in selected cases.

Smartphone Dynamic Infrared Thermography for Harvesting AICAP Flap in a Large Breast-conservative Surgery

Flaps based on perforators of the intercostal arteries have been described for the reconstruction of defects resulting from partial mastectomies. Dynamic infrared thermography (DIRT) identifies hot spots that accurately correspond to and evaluate perforator vessels toward the skin. The new generation of portable thermal cameras has become smaller, less expensive, more sensitive, and compatible with common smartphones. One option is the FLIR ONE system (FLIR Systems, Inc., Wilsonville, OR), a smartphone-compatible thermal camera. Despite its lower resolution, compared with the larger infrared camera models, it represents a viable option for thermal skin mapping, and its compact nature allows for easy portable use. The purpose of this article is to report a case of a preoperative study with smartphone DIRT used in the preparation of an anterior intercostal artery perforator-based flap for breast reconstruction after a wide resection at the level of the right infer-internal breast region, including a skin excision. Our study documents how smartphone DIRT is a rapid, sensitive, easily accessible and cost-effective diagnostic method for the topographical identification of intercostal artery perforators. It can be used as a rescue method at any stage of the intervention if it differs from the preoperative planning. It also confirms the proven usefulness of this flap for the reconstruction of partial defects in the breast and thoracic region.

Quantitative Analysis of the Histological Features of Tuberous Breast

INTRODUCTION

Tuberous breast deformity (TB) is a condition mostly characterized by breast stenosis, areolar widening and glandular asymmetry. The most accredited hypothesis describes an abnormal thickening of the fascia corporis that might influence an alteration in the glandular development, limiting the horizontal growth of breast parenchyma. Alterations in the extracellular matrix components (ECM) might be involved in the abnormal breast development.

PATIENTS

The aim of our case control study is to use histological specimens to analyze qualitative and quantitative differences in collagen fibers, elastic fibers and vessel densities in TB and normal breasts of 20 patients using a software for digital pathology.

RESULTS

The quantitative findings showed increasing concentrations of collagen fibers and decreasing elastic fibers in TB, compared to normal breasts. No difference was seen in vessel density among the two groups. The qualitative findings highlighted differences in the distribution of the ECM among the TB specimens. Collagen fibers showed a packed appearance rather a scattered distribution, while elastic fibers visibly presented a reduction and a focal distribution of their concentration.

CONCLUSIONS

The study proposes a correlation between abnormalities in ECM concentrations and TB, resulting in a higher degree of fibrosis and in the characteristic stenotic and less elastic morphology of the deformity.

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 .

Immediate direct-to-implant breast reconstruction: A single center comparison between different procedures

Background

The increased incidence of conservative mastectomy operations (nipple- and skin- sparing) has increased the frequency of immediate breast reconstructions (IBR). In order to guarantee patients the best possible aesthetic outcome, the least chance of complications and moreover, the least postoperative pain, the technique with prepectoral prosthetic pocket was recently reconsidered with the use of ADM. This is the first study using Fortiva® in prepectoral breast reconstruction, and it compares the outcomes of three different patient populations (undergoing retromuscular, prepectoral and prepectoral reconstruction with ADM). The authors suggest that prepectoral breast reconstruction with ADM may bring benefits compared to the current standard technique (retromuscular) as well as compared to the prepectoral reconstruction without ADM.

Methods

Retrospective data analysis of patients who underwent mastectomy followed by immediate breast reconstruction with silicone implants (DTI), performed by a team of breast surgeons and plastic surgeons. Logistic factor regressions were performed in order to investigate the effects of the three different intervention techniques on the incidence of complications. Fisher's exact test was used to analyze the differences in the occurrence of each complication. Mann Whitney test was used to compare the averages of referred pain. A p value <0.05 was considered significant.

Results

A total of 67 patients underwent DTI reconstruction, of which 43 with retromuscular prosthesis, 13 prepectoral and 11 prepectoral with ADM. We found a significantly lower incidence of surgical complications with ADM, exclusively in comparison with retromuscular reconstruction (p = 0.028). It emerges prepectoral reconstruction with ADM involves significantly less visibility of the implant than both the prepectoral surgery without ADM (p = 0.013) and the retromuscular technique (p = 0.029). Finally, postoperative pain referred at twelfth month is significantly less relevant in the group with prepectoral prosthesis and ADM, both in the group with retromuscular (p < 0.001) and prepectoral without ADM (p = 0.001).

Conclusions

This study demonstrates that immediate prepectoral breast reconstruction with ADM is a safe and reliable technique, able to exceed some type of limits imposed by prepectoral reconstruction. Moreover, it provides benefits if compared to the current standard technique. In the future, this technique could also be added to it, after a proper selection of patients in pre- and intraoperative time.

Algorithm-Assisted Decision Making in Otoplasty

INTRODUCTION

Ear congenital deformities represent an aesthetical concern in adult patients and a social matter in children. An accurate assessment of ear defects should be made preoperatively in order to plan surgery adequately.

MATERIALS AND METHODS

In order to correctly assess the ear preoperatively the authors have considered four different subunits: helical and scaphal region (A), antihelical region (B), conchal region (C) and lobule region (D). Surgical planning should start from sub-unit A evaluation, ending with sub-unit D, in a concentric fashion. When sub-unit A defects have to be corrected, an anterior approach is preferred.

DISCUSSION

A correct evaluation of ear defects prior to surgery is of dramatic importance. Sub-unit A ear defects are often disregarded, and surgical techniques for their correction are rarely considered. Correcting helical and scaphal defects requires an anterior approach, influencing the technique employed for the correction of subunits B and C defects. Sub-unit B defects should be evaluated and corrected before sub-unit C defects in order to avoid overcorrection of ear protrusion.

CONCLUSION

Several surgical techniques have been described in the literature for correcting ear defects. After many years of experience, we outlined a schematic flowchart that prevents from leaving areas of the ear untreated, providing the best possible result for the patient.

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 .

Upper eyelid blepharoplasty following hyaluronic acid injection with improved facial aesthetics and eye symptoms: a case report

BACKGROUND

Dermatochalasis of the upper eyelids (blepharochalasis) is a typical age-related change in the upper third of the face and a major concern for facial aesthetics. Nowadays both surgical and nonsurgical interventions are available for patients complaining of upper eyelid dermatochalasis. Although nonsurgical treatments are often easier to perform, if they are not performed correctly, complications may ensue and worsen the condition.

CASE PRESENTATION

We describe the case of a Caucasian patient presenting with bilateral upper eyelid dermatochalasis, previously treated with multiple injections of hyaluronic acid filler. Following these procedures, the patient reported nonspecific eye symptoms (such as a sense of heaviness and asthenopia) and cosmetic concerns. We decided to perform an upper eyelid blepharoplasty. During the procedure we found a ribbon of hard, fibrous material, which was carefully removed. The patient reported resolution of functional eye symptoms owing to the reduction of upper lid heaviness, which also resulted in subjective improvement of the visual field. Patient satisfaction was assessed preoperatively and 3 months postoperatively using the Blepharoplasty Outcomes Evaluation (BOE), which showed an overall satisfaction rate of 95.8 %.

CONCLUSIONS

Blepharoplasty not only treated the patient's blepharochalasis but also allowed us to correct the previous nonsurgical intervention by removing the excessive amount of injected hyaluronic acid. Both aesthetic and functional results were successfully achieved.

Study of Inflammatory and Infection Markers in Periprosthetic Fluid: Correlation with Blood Analysis in Retrospective and Prospective Studies

BACKGROUND

Surgical site infection represents the most severe complication in prosthetic breast reconstruction. Risk profiling represents a useful tool for both clinicians and patients.

MATERIALS AND METHODS

In our hospital, 534 breast reconstructions with tissue expander implants, in 500 patients, were performed. Several clinical variables were collected. In our study, we evaluated the different inflammatory markers present in the periprosthetic fluid and we compared them with the ones present in plasma.

RESULTS

The surgical site infection rate resulted to be 10.5%, and reconstruction failed in 4.5% of the cases. The hazard ratio for complications was 2.3 in women over 60 (CI: 1.3-4.07; p = 0.004), 2.57 in patients with expander volume ≥ 500 cc (CI: 1.51-4.38; p < 0.001), 2.14 in patients submitted to previous radiotherapy (CI: 1.05-4.36; p < 0.037), and 1.05 in prolonged drain use (CI: 1.03-1.07; p < 0.001). 25-OH, PCT, and total protein were less concentrated, and ferritin and LDH were more concentrated in the periprosthetic fluid than in plasma (p < 0.001). CRP (p = 0.190) and β-2 microglobulin (p = 0.344) did not change in the two fluids analyzed. PCT initial value is higher in patients who underwent radiotherapy, and it could be related to the higher rate of their postoperative complications. Patients with a tissue expander with a volume ≥ 500 cc show an increasing trend for CRP in time (p = 0.009).

CONCLUSIONS

Several risk factors (prolonged time of drains, age older than 60 years, and radiotherapy) have been confirmed by our study. The study of markers in the periprosthetic fluid with respect to their study in plasma could point toward earlier infection detection and support early management.

Superior Pedicle Breast Reduction with Prefiguration of Final Shape: A 10-year Retrospective Study

Breast reduction, also defined as reduction mammaplasty, is one of the most common procedures performed in aesthetic surgery. Multiple techniques have been proposed throughout the years and several classification systems have been adopted according to: type of incision, pedicle blood supply (cutaneous, glandular, dermoglandular), extent of undermining, excision area, simultaneous or separate tissue excision (fat/gland, skin, or both), and combination of the aforementioned. In the present article, we share our 10 years' experience with reduction mammaplasty and we describe our personal technique, a modified superior pedicle breast reduction.

METHODS

We performed a retrospective analysis on 823 consecutive patients undergoing either aesthetic or functional reduction mammaplasty at Humanitas Research Hospital between 2009 and 2018. For each patient, we evaluated the mean resection volume and complication rate. We also assessed patients' satisfaction (VAS scale) and aesthetic outcome (assessed by independent surgeons, scale from 1 to 5).

RESULTS

The average patient age was 48, ranging from 17 to 77 years. The average operative time was 77 minutes, ranging from 62 to 123 minutes. After a thorough follow-up of these patients, we can conclude that our technique has a low complication rate, patients' satisfaction is excellent, and the result is stable over time in terms of shape and symmetry (the mean VAS score was 8.1). Postoperative surgeon's photographs evaluation scores were 4.5 ± 0.5. Average resected volume was 860gr.

CONCLUSION

The proposed technique is safe, fast, and simple with a relatively short learning curve, making it didactic and intuitive for young surgeons.

The evolution of autologous breast reconstruction

With breast cancer (BC) becoming more treatable, breast reconstruction has become an integral part of BC treatment. Nowadays, implant-based breast reconstruction is more common. However, there is a growing interest in autologous breast reconstruction due to the increasing awareness of implant-related complications. This work provides a comprehensive overview of the evolution of autologous reconstruction techniques of the breast and the nipple-areolar complex (NAC).

Breast Reconstruction in a Coronavirus Disease 2019 Hub

The coronavirus disease 2019 (COVID-19) pandemic presented a dramatic challenge to healthcare systems. Humanitas Clinical and Research Hospital (Rozzano, MI, Italy) was declared a regional hub for the treatment of COVID-19 patients. Our plastic surgery team, in consultation with our breast surgery colleagues, decided to perform immediate implant-based breast reconstruction for patients undergoing mastectomy for cancer. In this report, we present our experience performing breast reconstruction with a new protocol in the first month following the COVID-19 pandemic in the most affected region in Italy.

METHODS

We adopted a new protocol to treat patients with breast cancer during the COVID-19 pandemic. The main goals of our protocol were to reduce the risk of COVID-19 spread for both patients and clinicians, postpone nononcologic and more advanced surgery, develop rapid recovery for early patient discharge (within 24 hours from surgery) through pain management, and finally reduce postoperative consultations.

RESULTS

The protocol was applied to 51 patients between early March and early April 2020. After 1 month, we decided to retrospectively review our experience. We found no significant differences in terms of postoperative pain and complication rate compared with our data in the pre-COVID period.

CONCLUSION

Our new protocol is safe and effective, enabling tumor resection and immediate implant-based breast reconstruction, without increasing risks to the patient or staff.

AUtologous fat graft in foot calcaneal postsurgical chronic ulcer

INTRODUCTION

Post-traumatic injury of talus's posterior area and ankle joint with consequent scar formation is often complicated by an unhealing trophic ulcer. Aim of this paper is to evaluate the autologous fat graft effectiveness in treating Achilles tendon area wounds.

MATERIAL AND METHODS

From October 2011 to March 2014 we treated with fat graft a total of 7 patients with post-surgical painful chronic ulcer of calcaneal area. Mean age was 38.6 years (range 22-64 years). One patient was a professional football player who was presenting a post-injury ulcer not respondant to advanced dressings.

RESULTS

Wound rehepitelization was observed in all cases treated within one month and fat grafting resolved pain related to the wound. All patient returned to their daily normal activities. In all cases treated we observed an increased softness of perilesional post-surgical scars. Our professional football player came back able to perform an usual training 5 days post-operation obtaining complete rehepitelization within 3 weeks.

DISCUSSION

Our surgical approach showed a therapeutic effect that relies on biological properties of adipose tissue; those properties are clear in both procedures of chronic ulcer's rehepitelization stimulation and perilesional tissue's enhancement obtaining pain control. The procedure is safe, with low rate of complication.

Optimising aesthetic outcome after nipple-areola complex-sparing mastectomy and immediate one-stage prosthetic reconstruction: A simple surgical trick to fix nipple-areola complex position

Background:

Nipple-areola complex (NAC) sparing mastectomy (NSM) is mostly indicated in patients with small-/medium-sized and non-ptotic breasts, while skin-reducing mastectomy is used in patients with medium or large breasts with severe ptosis. NAC location on the reconstructed breast is one of the major factors in determining the final aesthetic result and patients’ satisfaction. An optimum result obtained at the end of surgical procedure may be altered and compromised by skin redistribution and consequently NAC depositioning during the post-operative period in patients with medium-sized breasts and a moderate degree of ptosis.

Aims:

In the present study, we propose a simple surgical trick to fix the NAC in the desired position with a long-lasting result.

Methods:

We selected 35 patients undergoing NAC sparing mastectomy for breast cancer and immediate one-stage prosthetic reconstruction and we performed a single suture to fix NAC in the desired position before closing the skin envelope. We evaluated NAC complex position stability overtime comparing pre-operative standard photographs with early (3 weeks after surgery) and late (1 year after surgery).

Results:

In all patients, we were able to place the NAC complex on the desired position, and the result was stable at 1 year follow-up. The aesthetic outcome was satisfactory in all patients with no change in the complication rate.

Conclusions:

This simple surgical trick has been shown to be safe and effective in optimising the aesthetic outcome in a patient undergoing NAC sparing mastectomy and immediate one-stage prosthetic reconstruction. Level IV: evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Fat Graft in Composite Breast Augmentation with Round Implants: A New Concept for Breast Reshaping

BACKGROUND

Breast augmentation surgery with implants is one of the most common aesthetic surgical procedures. Round and anatomical textured implants are employed very often, and fat grafting has proven to be a very useful complementary procedure in breast augmentation. Many authors report a more natural result with anatomical compared to round implants. Nevertheless, anatomical implants can be associated with complications such as implant rotation with subsequent shape distortion. In this article, we propose a combination of high-profile round implants and fat grafting to obtain a natural result analyzing its impact on the aesthetic outcome and patient satisfaction.

METHODS

In this study, we report our personal approach on 31 consecutive patients undergoing primary aesthetic breast augmentation with high-profile round implants and fat grafting. We describe our personal technique of breast augmentation via the periareolar approach and fat grafting. We evaluated short- and medium-term aesthetic outcomes and patient satisfaction using a 10-point VAS scale.

RESULTS

We achieved in all cases high patient satisfaction and good aesthetic outcomes with a "natural" breast shape and a "smoothened" upper pole with low complication rates. The technique is safe, simple, fast, and it leads to high levels of patient satisfaction.

CONCLUSIONS

Our observations show that the combination of high-profile round implants and fat grafting in aesthetic breast augmentation can improve the aesthetic outcome and patient satisfaction as with anatomical implants eliminating the risk of implant rotation.

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 .

Autologous fat graft in irradiated orbit postenucleation for retinoblastoma

Autologous fat grafting has been extensively and successfully adopted in a number of pathologic conditions in regenerative surgery especially on irradiated fields in order to improve pain symptoms and tissue trophism promoting scar release. In the present study, we report our experience with autologous fat grafting for the treatment of postirradiation fibrosis and pain on three consecutive patients undergoing orbital enucleation for locally advanced retinoblastoma (RB) and subsequent radiotherapy. We selected three consecutive patients who underwent orbital enucleation for locally advanced RB and subsequent local radiotherapy showing severe reduction in orbital volume and eyelid length and retraction due to fibrosis, spontaneous local pain exacerbated after digital pressure with no possibility to place an ocular implant. They underwent autologous fat grafting in the orbital cavity and results were evaluated by clinical examination at 5 and 14 days, and 1, 3, 6 months, and 1 year after surgery. A significant release of scar retraction, reduction of fibrosis and orbital rim contraction together with an important improvement of pain symptoms was observed in all patients. The local changes observed enabled an ease placement of an ocular prosthetic implant (implant). No local or systemic complication occurred. Fat grafting is a promising treatment for patients showing radiotherapy related complication in the orbital area and it should be adopted by all oculoplastic surgeon in order to improve pain syndrome creating the ideal local conditions for the placement of an ocular prosthetic implant.

Stenotic Breast Malformation and Its Reconstructive Surgical Correction: A New Concept From Minor Deformity to Tuberous Breast

BACKGROUND

Several classification systems have been reported to define the spectrum of tuberous breast deformity, and a range of surgical techniques has been described. In this paper, we proposed a new classification including tuberous breast and minor deformity based on stenosis type, glandular trophism and ptosis adapting surgical planning to different breast types.

METHODS

A total of 246 patients meeting our definition for stenotic breasts asking for surgery were analyzed in this study. We considered eight different types of stenotic breasts analyzing anatomical presentations, and we then proposed eight key-point maneuvers, finalized to the correction of different breast deformities and their possible association according to the stenotic breast type. Results have been evaluated by a group of three surgeons and by patients. In addition, we evaluated the complication incidence in terms of re-intervention rate.

RESULTS

Following our classification eight different groups were distinguished. For each one we reported the prevalence and the surgical procedure adopted. Results evaluated by the surgeon group reported a mean aesthetic outcome of 8.2 (range 5-10), whereas patients reported a mean value of 7.9 (range 6-10). During a follow-up period with a mean of 16 months we observed a 4.9% re-intervention rate.

CONCLUSIONS

We believe this new classification to be very complete in evaluating breast shape, including most of the breast evaluable features. Our results confirmed the suitability of the approach for appropriate preoperative planning, thus improving the global surgical outcome.

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 .

MRI anatomical preoperative evaluation of distally based peroneus brevis muscle flap in reconstructive surgery of the lower limb

BACKGROUND

The distally based peroneus brevis muscle flap has proved to be a simple solution for small- to moderate-sized wounds of the lower limb. The length of the muscle belly suitable for coverage is a crucial parameter. In this study, we evaluated the capability of 3D MRI of the lower limb to measure it preoperatively.

METHODS

Between 2008 and 2017, 32 patients with lower limb defects underwent preoperative MRI to measure the peroneus brevis muscle length. All patients underwent reconstruction, and the muscle was measured again intraoperatively during surgical dissection. Surgical measurements were then compared to the MRI ones.

RESULTS

MRI measures of the peroneus brevis muscle belly ranged from 9 to 21 cm (μ = 14.44 ± 3.43 cm), and intraoperative measures ranged from 9 to 20 cm (μ = 14.2 ± 2.3 cm). Thirty of 32 intraoperative measures corresponded to the MRI ones (variation = ± 1 cm, r = 0.92, p = 0.002). One patient showed an intraoperative muscle length 3 cm shorter than the MRI measure, and another patient had intraoperative muscle length 3 cm longer than the MRI one. All flaps survived, and no secondary local flap coverage was required, with no flap-related complication, limited donor site morbidity, and acceptable patient discomfort.

CONCLUSIONS

The reverse peroneus brevis muscle flap is a versatile alternative to free flap reconstruction in small- to moderate-sized defects of the lower limb. Preoperative 3D MRI is accurate to evaluate the anatomy of the muscle when performed by an expert radiologist. In our experience, it should become part of preoperative workup before performing a peroneus brevis flap procedure.

The Prevalence of Tuberous/Constricted Breast Deformity in Population and in Breast Augmentation and Reduction Mammaplasty Patients

BACKGROUND

The exact prevalence of tuberous breast deformity (TBD) has not been properly investigated and still remains undetermined. We report our data about TBD prevalence with the aim of demonstrating its high prevalence.

MATERIALS AND METHODS

A retrospective analysis was performed on preoperative photographs of 1600 Caucasian female patients admitted to our department from January 2009 to July 2014 for augmentation or reduction mammaplasty and other breast clinical conditions. The main features of TBD included a contracted skin envelope, a reduction in breast parenchyma of the lower medial and lateral quadrants, a constricted breast base, abnormal elevation of the inframammary fold, herniation of the breast into the areola with a constricted breast base, and nipple areola complex herniation with a normal breast base. Patients were classified into three groups: breast augmentation group (AUG group), breast reduction group (RED group), and general population group (POP group).

RESULTS

Four hundred patients were analyzed for each group (AUG and RED group); 194 patients (48.5 %) and 189 cases (47.3 %), respectively, demonstrated at least one tuberous breast deformity; in 800 patients of the POP group, we found 221 patients (27.6 %) with at least one tuberous breast deformity.

CONCLUSIONS

Retrospective analysis reveals a high prevalence of TBD in the general population and in particular in women seeking breast augmentation or breast reduction (about 50 %). TBD is characterized by a wide range of clinical features with a spectrum of degrees. Preoperative evaluation is crucial to achieve an optimum outcome and patient 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 .

Autologous fat graft as treatment of post short stature surgical correction scars

INTRODUCTION

Surgical limb lengthening is undertaken to correct pathological short stature. Among the possible complications related to this procedure, painful and retractile scars are a cause for both functional and cosmetic concern. Our team has already shown the efficacy of autologous fat grafting in the treatment of scars with varying aetiology, so we decided to apply this technique to scars related to surgical correction of dwarfism. A prospective study was conducted to evaluate the efficacy of autologous fat grafting in the treatment of post-surgical scars in patients with short-limb dwarfism using durometer measurements and a modified patient and observer scar assessment scale (POSAS), to which was added a parameter to evaluate movement impairment.

PATIENTS AND METHODS

Between January 2009 and September 2012, 36 children (28 female and 8 male) who presented retractile and painful post-surgical scars came to our unit and were treated with autologous fat grafting. Preoperative and postoperative mean durometer measurements were analysed using the analysis of variance (ANOVA) test and POSAS parameters were studied using the Wilcoxon rank sum test.

RESULTS

There was a statistically significant reduction in all durometer measurements (p-value <0.05) and in all but one of the POSAS parameters (p-value <0.05) following treatment with autologous fat grafting.

DISCUSSION

Surgical procedures to camouflage scars on lower limbs are not often used as a first approach and non-surgical treatments often lead to unsatisfactory results. In contrast, our autologous fat grafting technique in the treatment of post-surgical scars has been shown to be a valuable option in patients with short-limb dwarfism.

CONCLUSION

There was a reduction of skin hardness and a clinical improvement of all POSAS parameters in all patients treated. Moreover, the newly introduced POSAS parameter appears to be reliable and we recommend that it is included to give a more complete evaluation of patient perception.

Autosomal microsatellite and mtDNA genetic analysis in Sicily (Italy)

DNA samples from 465 blood donors living in 7 towns of Sicily, the largest island of Italy, have been collected according to well defined criteria, and their genetic heterogeneity tested on the basis of 9 autosomal microsatellite and mitochondrial DNA polymorphisms for a total of 85 microsatellite allele and 10 mtDNA haplogroup frequencies. A preliminary account of the results shows that: a) the samples are genetically heterogeneous; b) the first principal coordinates of the samples are correlated more with their longitude than with their latitude, and this result is even more remarkable when one outlier sample (Butera) is not considered; c) distances among samples calculated from allele and haplogroup frequencies and from the isonymy matrix are weakly correlated (r = 0.43, P = 0.06) but such correlation disappears (r = 0.16) if the mtDNA haplogroups alone are taken into account; d) mtDNA haplogroups and microsatellite distances suggest settlements of people occurred at different times: divergence times inferred from microsatellite data seem to describe a genetic composition of the town of Sciacca mainly derived from settlements after the Roman conquest of Sicily (First Punic war, 246 BC), while all other divergence times take root from the second to the first millennium BC, and therefore seem to backdate to the pre-Hellenistic period. A more reliable association of these diachronic genetic strata to different historical populations (e.g. Sicani, Elymi, Siculi), if possible, must be postponed to the analysis of more samples and hopefully more informative uniparental DNA markers such as the recently available DHPLC-SNP polymorphisms of the Y chromosome.

Antibody responses to hepatitis C virus hypervariable region 1: evidence for cross-reactivity and immune-mediated sequence variation

Sequence heterogeneity of hepatitis C virus (HCV) is unevenly distributed along the genome, and maximal variation is confined to a short sequence of the HCV second envelope glycoprotein (E2), designated hypervariable region 1 (HVR1), whose biological function is still undefined. We prospectively studied serological responses to synthetic oligopeptides derived from HVR1 sequences of patients with acute and chronic HCV infection obtained at baseline and after a defined follow-up period. Extensive serological cross-reactivity for unrelated HVR1 peptides was observed in the majority of the patients. Antibody response was restricted to the IgG1 isotype and was focused on the carboxyterminal end of the HVR1 region. Cross-reactive antibodies could be readily elicited following immunization of mice with multiple antigenic peptides carrying HVR1 sequences derived from our patients. The vigor and heterogeneity of cross-reactive antibody responses were significantly higher in patients with chronic hepatitis compared with those with acute hepatitis and in patients infected with HCV type 2 compared with patients infected with other viral genotypes (predominantly type 1), which suggest that higher time-related HVR1 sequence diversification previously described for type 2 may result from immune selection. The finding of a statistically significant correlation between HVR1 sequence variation, and intensity, and cross-reactivity of humoral immune responses provided stronger evidence in support of the contention that HCV variant selection is driven by the host's immune pressure.

Past malaria, thalassemia and woman fertility in southern Italy

The role of natural selection in maintaining the thalassemia polymorphism is examined in a southern Italy district, in the past affected by malaria endemia. The Haldane's hypothesis that the thalassemia heterozygotes enjoy more protection than the normal homozygotes against the risk of malaria infection, seems to be confirmed by this indirect study at population level. The higher number of children born of the women who lived in the highly endemic villages, where the highest proportion of heterozygotes occurs, supports the hypothesis that the woman fertility contributes to the thalassemia maintenance. The joint effects of the acquired and inherited immunities and of the reproductive compensation are assumed as the mechanisms through which malaria and thalassemia influence fertility.

Dynamics of hypervariable region 1 variation in hepatitis C virus infection and correlation with clinical and virological features of liver disease

Hepatitis C virus (HCV) infection is a dynamic process during which molecular variants are continuously selected as the result of virus adaptation to the host. Understanding the nature of HCV genetic variation is central to current theories of pathogenesis and immune response. We prospectively studied hypervariable region 1 (HVR1) variation in the E2 gene of 36 hepatitis C patients, including 10 asymptomatic carriers, followed up for 1 to 2 years. Sequence changes in single and consecutive serum samples were assessed and correlated with clinical and virological parameters of liver disease. A region of the E1 gene was sequenced for comparison in 3 subjects. HVR1 heterogeneity at single time points widely varied in individual patients, did not increase cumulatively over the follow-up period, and did not correlate with HVR1 evolutionary rates. Conversely, the process of HVR1 sequence diversification, although differed considerably among patients, was stable over time and directly correlated with infections by HCV type 2, lower alanine aminotransferase (ALT) levels, and absence of cirrhosis. HCV carriers showed the highest HVR1 variation rates. Our findings indicate that HVR1 variation has an adaptive significance and is associated with favorable features of liver disease and suggest that prospective, rather than static, observations are required to model the process of HCV variation.

Evidence that amyloidogenic light chains undergo antigen-driven selection

AL amyloidosis is characterized by fibrillar tissue deposits (amyloid) composed of monoclonal light chains secreted by small numbers of indolent bone marrow plasma cells whose ontogenesis is unknown. To address this issue and to provide insights into the processes that accompanied pathogenic light chain formation, we isolated the complete variable (V) regions of 14 light (VL) and 3 heavy (VH) chains secreted by amyloid clones at diagnosis (10 Bence Jones and 4 with complete Igs, 9 lambda and 5 kappa) by using an inverse polymerase chain reaction-based approach free of primer-induced biases. Amyloid V regions were found to be highly mutated compared with the closest germline genes in the databases or those isolated from the patients' DNA, and mutations were not associated with intraclonal diversification. Apparently high usage of the lambdaIII family germline gene V lambdaIII.1 was observed (4 of 9 lambda light chains). Analysis of the nature and distribution of somatic mutations in amyloid V regions showed that there was statistical evidence of antigen selection in 8 of 14 clones (7 in VL and 1 in VH). These results indicate that a substantial proportion of the amyloid clones developed from B cells selected for improved antigen binding properties and that pathogenic light chains show evidence of this selection.

A family of rapidly evolving genes from the sex reversal critical region in Xp21

Patients with an intact SRY gene and duplications of portions of Xp21 develop as phenotypic females. We have recently mapped this sex reversal locus, DSS, to a 160-kb region of Xp21 that includes the adrenal hypoplasia congenita locus. To clone the gene(s) underlying DSS and AHC, we isolated expressed sequences from the region. Here we describe the characterization of two related genes. DAM10 and DAM6, expressed in adult testis and lung tumors. The predicted DAM10 and DAM6 proteins are 66% identical and are both highly similar to the MAGE family of tumor-associated antigens and to mouse necdin. Genes belonging to the MAGE superfamily, DAMs, MAGEs, and necdin, are likely to have originated from a common ancestor and to be subject to an unusually rapid evolution. The tumor-restricted expression of DAM proteins and their structural similarity to MAGE genes suggest that DAM peptides may be targets for active immunotherapy in lung cancer patients.

Prognostic value of adenosine deaminase compared to other markers for progression to acquired immunodeficiency syndrome among intravenous drug users

This study was designed to determine the prognostic value of erythrocyte adenosine deaminase (ADA) as a possible indicator of progression to AIDS, and compare this with other known cellular and serological markers. At the end of a 3-year study, a cohort of 114 human immunodeficiency virus-1 (HIV-1) seropositive intravenous drug users (IVDUs) from the five different Center for Disease Control (CDC) groups was examined in order to estimate the prognostic relevance with respect to the progression to acquired immunodeficiency syndrome (AIDS) of each of the following markers at baseline value: number and percentage of CD4+ T cells, number of CD8+ T cells, CD4+/CD8+ ratio, IgA and beta 2 microglobulin and ADA levels, and the presence of HIV antigens. Moreover, 57 IVDUs belonging to II and III CDC groups were analyzed in a follow-up study at 6-month intervals, in order to evaluate and compare the behavior of each marker over time. The prognostic significance of each marker was assessed by computing the survival distribution and the Cox analysis in a multivariate model providing the set of markers with greatest predictive value. The levels of ADA and the CD4+/CD8+ ratio showed a linear association with disease staging, whereas beta 2 microglobulin and CD4+/CD8+ ratio were the best predictors for AIDS progression. A highly significant increase in ADA and beta 2 microglobulin was observed during follow-up. The results obtained among HIV-positive IVDUs clearly indicate that the erythrocyte ADA may be considered a reliable marker of the development of HIV infection from the intermediate stages of the disease onwards.(ABSTRACT TRUNCATED AT 250 WORDS)

Ataxia-telangiectasia in Italy: genetic analysis

Genetic analysis was performed on 72 Italian A-T families ascertained through 91 probands. The frequency of the A-T gene was estimated through Dahlberg's formula, which uses the frequencies of first cousin marriages among the patients' parents and in the general population were obtained from the collection of Catholic Church dispensations for the period 1910-1964. Accurate estimates of the disease frequency were made by subdividing data into 5-year periods and between provinces, in order to take into account temporal (decrease over time) and spatial (higher frequency in Southern Italy) heterogeneity. The estimate of the gene frequency for the whole sample was q = 0.012 +/- 0.0065, corresponding to a heterozygote frequency of 2.34% and to a disease frequency of 1 in 7090. When considering q before and after 1970, there was an apparent increase of heterozygote frequency from 1.69 to 3.43%, perhaps due to a better ascertainment of the disease in the latter period. A segregation ratio of 0.249 +/- 0.043 was obtained by analyzing the offspring of the 72 families under the model of incomplete multiple selection. This value is not significantly different from 0.25, as expected for an autosomal recessive disease.

Differential fertility as a mechanism maintaining balanced polymorphisms in Sardinia

Women's fertility, gathered from the 1961 Italian population census, and estimates of heterozygote frequencies for thalassemia and G6PD deficiency (Siniscalco et al. 1961, 1966) in 52 Sardinian villages were examined to study at the population level the mechanisms that have maintained the stability of these polymorphisms over long periods. Sardinian villages were classified according to low or high frequency of heterozygotes, and the reproductive behavior of the women living in these areas was analyzed. A high mean number of children per woman and a low percentage of women without children with a high heterozygote frequency was demonstrated. The observed differential fertility and sterility were interpreted as being the result of different numeric ratios within each area between normal homozygous and heterozygous women, who were less and more resistant, respectively, to malarial infection, according to Haldane's theory. The effect of differing degrees of malaria on fertility rates has been demonstrated previously (Zei et al. 1990). To account for the effect of the genetic and epidemiological composition of an area on reproductive behavior, we classified data on women's fertility and sterility by heterozygote frequency level and malarial morbidity level. A combined and direct effect of inherited and acquired immunities on fertility and sterility rates was shown. The level of endemicity in an area may contribute to decreasing or increasing fitness, which is already influenced by the stable balanced polymorphisms.

Barriers to gene flow estimated by surname distribution in Italy

Surname distributions were studied in order to reconstruct human migration patterns. Zones of sharp change in surname frequencies--presumably barriers to gene flow--were detected by the statistical technique of wombling (Barbujani et al. 1989), using data from consanguineous marriages (1910-64) collected from 280 Italian dioceses which we grouped into 80 provinces. The 28 observed surname boundaries were compared with physical (geographical) and cultural (linguistic) barriers, and with boundaries detected from distributions of 57 alleles in the same territorial subdivisions. Genetic and surname boundaries had similar locations, as expected given the analogy in the inheritance mechanism of genes and surnames. Physical barriers seemed to be the main cause of gene flow reduction. However, cultural factors alone (e.g. linguistic ones) also determined barriers that delimited areas of homogeneous gene (and surname) frequency probably due to increased endogamy. The observed similarity between spatial patterns of surnames, genes and languages supports the hypothesis of the co-evolution of genetic and linguistic variation.

Fertility and malaria in Sardinia

Using data from the 1961 Italian census, the study of fertility in Sardinia when malaria was endemic shows differential fertility between women living in areas with differing degrees of malaria. Cultural factors measured by women's level of education are negatively correlated with fertility, just as the 'urban' character of the area in which the women lived has a lowering effect on the fertility rate. The hypothesis of differential mortality according to social class, affecting lower-class women and in particular the more prolific among them, seems to be supported by data analysed through time. The subdivision of Sardinian towns and villages into those with a 'low' and a 'high' malaria rate was made on the basis of the classification given by Fermi in a period corresponding to the overall period of fertility of the women considered. Hypotheses about a greater acquired immunity and a higher frequency of heterozygotes for malarial genes, like thalassaemia and G-6-PD deficiency, in the area where malaria was more intense, are proposed to explain the higher fitness of women living in this area. The comparison between frequencies of heterozygotes for thalassaemia and G-6-PD deficiency, obtained by Siniscalco et al. for Sardinian villages in the two different malaria-infested areas, shows a significant difference when the areas are examined as a whole, but a great variability (principally for G-6-PD deficiency) between villages. Changes in ecological factors could have modified the geographical distribution of malaria today, compared with the distribution that may have determined the frequencies of heterozygotes many years ago.