Approach to the correction of drooping tip: common problems and solutions

The drooping tip deformity is both a bothersome aesthetic feature and functional impairment of the nose. Both static and dynamic factors may affect tip appearance and it seems logical to take into account these factors when planning correction of drooping tip. Many studies have examined this topic, but its treatment remains controversial. In order to make nasal tip surgery successful, it is useful to identify the keystone anatomical characteristics of the tip itself. Naso-labial angle, nostril axis, tip rotation angle according to Frankfort plane and columellar-facial angle may be measured to assess nasal tip position. The present study focuses on the authors' personal experience on the key anatomic changes of the nose that deserve correction and on the main surgical steps needed to achieve consistent results when dealing with a drooping tip. Pre- and post-operative nasal tip rotation and projection were studied. Correction of the drooping tip was accomplished by an open or closed septorhinoplasty approach according to patient's needs. The surgical techniques mostly employed for tip repositioning was septum straightening (41/41) and tongue-in-groove (36/41 cases) (87.8%). A columellar strut was used in 8/41 (19.51%) cases. LLC cephalic resection was applied in 29/41 patients (70.73%), LLC re-orienting sutures were made in 18/41 cases (43.9%) and lateral crural overlay was needed in 2/41 (4.8%). The key anatomic changes of the nose that deserve correction and the surgical steps needed to ease the often intriguing pre-operative decision-making process are reviewed.

Traumatic and surgical scars: successful treatment with a 1,565nm erbium-glass NAFL combined with IPL

Scars are a very common condition of the general population and can have a profound impact on the psyche of the patient such as low self-esteem and feelings of psychosocial isolation. Various therapeutic approaches have been proposed for improving the clinical appearance of scars. Fractional mode of ablative and non-ablative lasers has become a novel strategy for the treatment of scars. A total of 43 patients (Fitzpatrick skin type II to IV), clinically diagnosed of surgical and post-traumatic scars from January 2015 to December 2016, were treated. Each treatment comprised of several passes over the scars with different devices, using a 1.565nm scanned erbium-doped fiber NAFL and an IPL. All patients noted subjective improvement in cosmesis and functionality after treatment, also with a decreased pain and an increased mobility on the underlying plans. Numerous therapeutic strategies for traumatic and surgical scars have been suggested to date, but no consistent treatment modality has been established yet. In our study, we have shown that there was a significant collagen remodelling with decrease of scar vascularity and significant improvement of pliability of scar after combined treatment with non-ablative fractional resurfacing and IPL resulting in a remarkable improvement in scar vascularity, pigmentation and height.

Malar region rejuvenation through non-invasive techniques: hyaluronic acid fillers and lipofilling

Contour enhancements of the midface make up a dominant aspect of aesthetic surgery. The goal of midface rejuvenation is to decrease the prominence of grooves and creases as well as to provide volume to atrophied tissue. There are various options, including autologous tissue grafts, allogenic tissue grafts and alloplastic materials. In turn, patients’ needs have led to an increasing trend of less invasive treatments. In the present study, 82 implants were used for midface augmentation in 41 patients (38 women, 3 men) between January 2014 and January 2016. Twenty-five patients were treated with Hyaluronic acid implants while the remaining 16 patients were treated with lipofilling. For both groups and in all cases, good integration of the filled material was observed in the malar region, with no significant treatment complications and the last follow-up visit demonstrated good results and overall satisfaction. Hyaluronic acid fillers and lipofilling are therefore the ideal answer to patients who aim for a natural and immediate result with manageable complications, but, unlike Hyaluronic acid, autologous fat allows us to obtain a long-lasting effect over time, resulting the closest thing to an ideal facial filler.

Non-ablative radio-frequency rejuvenation: a histological and bio-molecular report

Radiofrequency machines for medical use are known to produce moderate clinical improvement of skin laxity without invasive procedures. Numerous equipment with different characteristics have been proposed after the introduction in 2002 of the first FDA approved device. This report is aimed to test if RF treatment is effective when performed at low frequency and low energy level. Two RF treatments were performed unilaterally 7 and 2 days before a planned eyebrow lifting surgery, with a radiofrequency device with 0.52 to 0.7 MHz frequencies, maximum energy of 200 W, used at 40% of its power. A bipolar handpiece with a diameter of 30 mm and a maximum power of 9-9.5 W was massaged along the temporal area for 10 min. Skin samples of treated and untreated sides were collected during surgery and processed for histologic examination and RT-PCR analysis, to test differences in gene activation in a panel of proteins that are relevant in extracellular matrix of dermal connective tissue. The histological examination of the samples showed that the treatment induced a loss of the typical oriented structure in the reticular dermis. The study through RT-PCR evidenced that ELN, the gene codifying for Elastine was strongly enhanced. Some collagen-tested genes (COL1A1, COL3A1 and COL9A1) were inhibited by the treatment, whereas COL2A1 and COL11 were activated. The genes responsible for Metallo-proteases (MMP) 2, 3 and 13 were depressed, while the MMP9 was stimulated. Gene codifying for Hyaluronic synthase 1 (HAS1), Hyluronidase 1 (HYAL1), Neutrophyl elastase (Elane), Desmoplakin (DSP) and GDF6 were inhibited. Insulin like growth factor (IGF1) gene activity was enhanced. RF treatment, with the tested non-ablative equipment, produced histological effects and change in DNA expression of some extracellular matrix related genes, confirming the biostimulatory role of this procedure.

Bio-Revitalization: Effects of NASHA on Genes Involving Tissue Remodeling

BACKGROUND

The "non-animal stabilized hyaluronic acid" (NASHA) is a widely used product in bio-revitalization injective procedures in esthetic medicine. The present research aimed to quantitatively evaluate the therapeutic effect of one of the more used bio-revitalization products on cultured dermal fibroblasts. RT-PCR was used for gene expression profiling of some proteins known to be relevant in skin homeostasis.

METHODS

Human dermal fibroblasts were seeded on a culture medium enriched with a product for dermal bio-revitalization, consisting of stabilized hyaluronic acid gel 20 mg/ml. After 24, 48, and 72 h of exposure, the cDNA was amplified by real-time PCR. Gene expression was quantified with the delta/delta calculation method.

RESULTS

In this study, the gene of metalloproteinase (MMP)-13 is strongly expressed after NASHA incubation. The MMP-2 encoding gene instead is less expressed, but both evidence the same temporal trend, being progressively up-regulated after 24 and 48 h, thereafter the expression decreases, whereas MMP-3 maintains the same up-regulation at 72 h. Hyaluronan synthase 1 and desmoplakin are progressively up-regulated and increase at 24, 48, and 72 h. Hyaluronidase 1 and neutrophil elastase genes are overexpressed, but at 72 h they both exhibit the same behavior as the other degradative enzymes MMP-13 and MMP-2.

CONCLUSIONS

Skin bio-revitalization by injecting the tested NASHA gel produces an enhancement in the expression of some genes involved in extracellular matrix degradation and organization. In this study, a time-dependent behavior, different for genes encoding degradative compared to synthesis proteins, was demonstrated.

HYALURONIC ACID IN DERMAL REJUVENATION: AN IN VITRO STUDY

The purpose of this paper is to evaluate the role of hyaluronic acid in bio-revitalization by testing several extracellular matrix biological parameters in cultured dermal fibroblasts. To this aim, fibroblastic expressed genes after exposition to three hyaluronic acid medical devices were evaluated. Cells were seeded on a layer of three different medical devices containing 6.2, 10 and 20 mg/ml of hyaluronic acid for 24 h. Real Time Polymerase Chain Reaction was performed to investigate gene expressions. Genes encoding hyaluronic acid synthesis and degradation, Metalloproteinases 2 and 3 and Desmoplakin production as well as GDF6, and IGF1 were activated by hyaluronic acid products. The in vitro study showed similar effects on tested genes despite a different concentration of hyaluronic acid contained in the medical devices and the simultaneous presence of other additives. Based on the reported data, gene activations are an aspect of metabolic modulation of signalling pathways rather than the proportional production of a specific connective tissue molecule. Indeed different hyaluronic acid concentration and the presence of other additives did not change the overall effect on the studied genes. We believe that the optimization of extracellular matrix micro-environment, obtained by enhanced structural support with hyaluronic acid, leads to functional and metabolic improvement.

THE THEORIES OF AGING: REACTIVE OXYGEN SPECIES AND WHAT ELSE?

This manuscript is a short review on the theories of aging, focusing mainly on the balance between the nutrient and the oxygen intake necessary for energy metabolism and the processes for neutralizing the negative consequences of energy production. The first section entitled “Why” provides brief historical details regarding the main group of aging theories, firstly the evolutionary theories and secondly the theories of aging related to humans, cells and biomolecules are discussed. The second section entitled ‘Where’ includes brief summaries of the many cellular levels at which aging damage can occur: replicative senescence with its genetic and epigenetic implications, cytoplasmic accumulation, mitochondrial respiratory chain dysfunction, peroxisome and membrane activity. In the third section entitled ‘How’ the linking mechanisms between the caloric restriction and the antioxidant intake on lifespan and aging in experimental models are discussed. The role of ROS is evaluated in relation to the mitochondria, the AMPK activated sirtuins, the hormesis, the target of rapamicin and the balance autophagy/apoptosis.

HYALURONIC ACID: THE USE OF ITS PRECURSOR IN SKIN BIO-STIMULATION

Bio-stimulation is an injective therapy aimed to boost the anabolic functions of dermal fibroblasts to obtain skin improvement. It can be achieved with multiple intradermal injections (0.05–0.1 ml each) of a solution of 400 mg (3 ml) of injectable glucosamine sulphate, plus 5.623 mg (3 ml) of polideoxyribonucleotide, 1 ml of lidocaine and 0.5–1 ml of sodium bicarbonate, to repeat every 7, 14, 21, and 28 days. The administration of glucosamine sulphate to skin fibroblasts is believed to lead to its incorporation in glycosaminoglycans, and thereby to the stimulation of extracellular matrix synthesis, whereas polideoxyribonucleotide possesses anti-inflammatory and regenerative capability. This study aims to elucidate the in-vitro effects of this treatment by studying what happens to several genes related to connective tissue integrity. Human dermal fibroblasts were seeded in a culture medium enriched with either two drugs alone or combined: glucosamine sulphate and/or polideoxyribonucleotide. After the end of the exposure time of 24 h, 48 h, and 72 h, the cells were trypsinized and lysed for RNA extraction. Reverse transcription to cDNA was performed directly from cultured cell lysate. Finally, the cDNA was amplified by real-time PCR and a panel of genes involved in dermal integrity was tested. Gene expression of Hyaluronan synthase 1 (HAS1), Elastine (ELN), Insulin like growth factor 1 (IGF1), Growth differentiation factor 6 (GDF6) and of a series of catabolic enzymes, such as Metalloproteases (MMP) 2, 3 and 13, the neutrophyl expressed Elastase (ELANE) and the Hyaluronidase 1 (HYAL1) were tested after 24, 48 and 72 hours of exposure to glucosamine sulphate and polideoxyribonucleotide alone or combined. All the tested genes but one were up-regulated. A negative synergism on several enzymes (particularly appreciable for Insulin-like growth factor 1 and metalloprotease 13) was observed when the two drugs were delivered together. Glucosamine sulphate acts not only as building block in the biosynthesis of glycosaminoglycan chains, but also as a booster of hyaluronan synthase 1. The association of glucosamine sulphate and polideoxyribonucleotide, used in bio-stimulation therapy protocol, has a negative synergism on catabolic genes in dermal fibroblast cultures. The present observations produce further insight into the effects of glucosamine sulphate in the biosynthesis of glycosaminoglycan chains.

RECONSTRUCTION OF THE ZYGOMATIC BONE WITH SMARTBONE®: CASE REPORT

The repair of complex craniofacial bone defects is challenging and a successful result depends on the defect size, the quality of the soft tissue covering the defect and the choice of reconstructive method. Autologous bone grafts are the gold standard for bone replacement. Tissue engineered constructs are temporary substitutes developed to treat damaged or lost tissue. Recent advances in materials science have provided an abundance of innovations, underlining the increasing importance of polymer in this field. The Galeazzi Orthopedical institute of Milan received a Serbian soldier who reported a deep wound, due to the explosion of a grenade, during former-Yugoslavia’s war. His left cheekbone was completely lost, together with the floor of the left eye. SmartBone® technology allowed the realization of custom-made grafts which perfectly fitted the bone defect thanks to mechanical strength, also at small thicknesses, and the ability to be shaped without powder formation or unpredicted fractures. Tissue engineering approaches to regeneration utilize 3-dimensional (3D) biomaterial matrices that interact favorably with cells. The potential benefits of using a tissue engineering approach include reduced donor site morbidity, shortened operative time, decreased technical difficulty of the repair, ability to closely mimic the in vivo microenvironment in an attempt to recapitulate normal craniofacial development: this 36-month case study allowed to prove that SmartBone® custom-made bone grafts are an effective solution, gathering such benefits and being available now for daily routine.

Role of antioxidants in dermal aging: an in vitro study by q-RT-PCR

BACKGROUND

Reactive oxygen species production is the final step in skin aging. These unstable molecules can damage and destroy DNA, proteins, and membrane phospholipids. The aim of this study was to test the in vitro effect of an antioxidant precursor, N-acetylcysteine (NAC), on human dermal fibroblasts. NAC alone and a solution of NAC and amino acids together, used in aesthetic medicine as intradermal injection treatment, were tested.

METHODS

The expression levels of some connective related genes (HAS1, HYAL1, ELN, ELANE, DSP, GDF6, and IGF1) were analyzed on cultures of dermal fibroblasts using real-time reverse-transcription polymerase chain reaction (real time RT-PCR).

RESULTS

All genes were upregulated after 24 h of treatment.

CONCLUSIONS

An interesting effect of gene induction by administration of NAC and amino acids in vitro was demonstrated. Upregulation of elastin-, hyaluronic acid-, and GDF6-encoding genes supports the evidence of clinical improvement induced by NAC biostimulation in the prevention and correction of skin aging.

Medial thighplasty: horizontal and vertical procedures after massive weight loss

Background:

The ‘medial thigh lift’ was first described by Lewis in 1957, but did not receive the widespread acceptance because of the various postoperative complications, such as scar migration with vulvar deformities and early recurrence of ptosis. For this reason, Lockwood developed a technique of anchoring the dermis to the Colles’ fascia, to make the surgical outcome more stable over time and to prevent scar migration. In this article, we describe our approaches to the medial thigh lift in post-bariatric surgery patients.

Materials and Methods:

A total of 45 females underwent medial thigh reduction. In 15 patients with Grade 2 on Pittsburgh Scale (PS), we performed a thigh lift with a horizontal scar; in 15 patients with Grade 2 on PS, we used a technique with a vertical scar; in 15 patients with Grade 3 on PS, the above-mentioned two procedures were combined. When it was really necessary, we also did the liposuction of the medial thigh. The patients were observed every 6 months with a 60-month median follow-up (range: 12–108 months).

Results:

In six patients was observed scar enlargement due to poor wound healing (one patient with a horizontal scar, three patients with a vertical scar and two with the combined procedure). In two patients with a horizontal scar, minimal scar migration was observed. In three patients, the recurrence of ptosis was evident (one patient with a horizontal scar and two patients with the combined procedure). No skin necrosis was observed.

Conclusion:

The medial thigh lift surgery is remarkably simple and free of major complications, if the basic anatomy of this region is understood, in order to preserve important structures such as the great saphenous vein and femoral vessels. The only complication is the presence of extensive and visible scars along the thigh, in the case of vertical procedure, and along the inguinal canal, with a possible distortion of the labia major, in the case of horizontal procedure.

Surgical treatment of frontoethmoidal encephalocele: a case report

This study reports a patient affected by congenital frontoethmoidal encephalocele. The cause of this malformation is unknown. A preoperative selective diagnosis evaluation is necessary. The workup should include an accurate clinical examination associated with radiological study (two- and three-dimensional computed tomography, magnetic resonance imaging, etc). The aim of the surgical treatment is to restore the functional brain tissue in the cranial cavity, perform dural repair, correct bone lack and other associated facial malformations (hypertelorism, orbital dystopia, etc.). A multidisciplinary team approach is necessary to resolve the brain herniation and to correct splanchnocranium malformations frequently associated with encephalocele. Cranial flap with orbital osteotomies has been performed; this operation permits correction of the hypertelorism and of the orbital dystopia associated with this malformation. In bone reconstructions, miniplates have been used as fixation devices. In adults we generally use titanium, but resorbable devices are required in children because of growing tissues. A restoration of craniofacial malformations with good aesthetic and functional results is achieved with early surgery.

Obstructive sleep apnea in a growing patient

Sleep apnea syndrome (SAS) is a complex respiratory disorder that is very difficult to diagnose and to treat surgically as well as medically. SAS can affect growing patients as well as adults. SAS shows a central, an obstructive, and a mixed form. Diagnosis is based on clinical examination of the patient and instrumental examinations such as teleradiography, nuclear magnetic resonance imaging (NMR), three-dimensional computed tomography, polysomnography, rhinomanometry, and spirometry. The patient presented has an obstructive form of SAS in addition to Crouzon's disease. He underwent a Le Fort III osteotomy to obtain an advancement of the orbitomaxillary complex, allowing an increase in volume of posterior airway space at the level of the hypopharynx.