Correction of Rectus Abdominis Diastasis: A Prospective Comparative Study Between a New Suturable Polypropylene Mesh vs Polypropylene Standard Suture Plication

BACKGROUND

Duramesh (Mesh Suture Inc., Chicago, IL) is a new suturing concept, combining the principles of mesh with the precision, flexibility, and versatility of a suture, suitable also for abdominal rectus diastasis (ARD) correction.

OBJECTIVES

This prospective research aimed to compare mesh with the standard polypropylene suture plication for rectus diastasis repair with regard to safety (infection, seroma, hematoma, surgical wound dehiscence, and fistula rates and hospital stay); effectiveness (ARD recurrence by ultrasound sonography, palpability of the muscular suture, surgical time, and postoperative pain evaluation); and satisfaction of the patients based on the BODY-Q, a patient-reported outcome measure.

METHODS

Sixty-five of the initial 70 patients who underwent rectus diastasis repair with a 6-month follow-up were randomly divided into 2 groups, comprising 33 patients treated with Duramesh and 32 patients treated with standard 0 polypropylene suture plication. Data regarding infection, seroma, hematoma, surgical wound dehiscence, and fistula rates; hospital stay; ARD recurrence; palpability of the muscular suture; surgical time; postoperative pain evaluation (measured by visual analog scale, or VAS); and the BODY-Q were analyzed by Prism 9 (GraphPad Software Inc., San Diego, CA).

RESULTS

No significant differences were reported between the 2 groups with regard to infection, seroma, hematoma, surgical wound dehiscence, and fistula rates and hospital stay. The mesh decreased the time required to perform plication compared with standard polypropylene detached sutures. No statistically significant differences were found with respect to the VAS and BODY-Q data.

CONCLUSIONS

Duramesh 0 application for rectus diastasis repair is safe and effective without compromising aesthetic improvement when compared with standard 0 polypropylene plication.

LEVEL OF EVIDENCE: 2

Cathelicidin LL-37 Expression in Human Breast Implant Capsules

BACKGROUND

Capsular contracture is the most common complication following breast implant placement. Cathelicidin LL-37 is a cationic peptide involved in innate immunity. Initially investigated for its antimicrobial role, it was found to have pleiotropic activities, such as immunomodulation, angiogenesis stimulation, and tissue healing. The aim of the study was to investigate the expression and localization of LL-37 in human breast implant capsules and its relationship with capsular formation, remodeling, and clinical outcomes.

METHODS

The study enrolled 28 women (29 implants) who underwent expander substitution with definitive implant. Contracture severity was evaluated. Specimens were stained with hematoxylin and eosin, Masson trichrome, immunohistochemistry, and immunofluorescence for LL-37, CD68, α-smooth muscle actin, collagen type I and type III, CD31, and Toll-like receptor-4.

RESULTS

LL-37 was expressed in macrophages and myofibroblasts of capsular tissue in 10 (34%) and nine (31%) of the specimens, respectively. In eight cases (27.5%), it was expressed by both macrophages and myofibroblasts of the same specimen. In infected capsules, expression by both cell types was found in all (100%) specimens. LL-37 expression by myofibroblasts positively correlated with its expression by macrophages ( P < 0.001). Moreover, LL-37 expression by macrophages of periexpander capsules negatively correlated with the severity of capsular contracture on definitive implants ( P = 0.04).

CONCLUSIONS

This study demonstrates the expression of LL-37 in macrophages and myofibroblasts of capsular tissue and its negative correlation with the severity of capsular contracture following permanent implant placement. Expression or up-regulation of LL-37 may be involved in myofibroblast and macrophage modulation, thus playing a role in the pathogenic fibrotic process underlying capsular contracture.

CLINICAL RELEVANCE STATEMENT

This is the first study to demonstrate LL37 expression in capsular tissue and to hypothesize its role in contracture and as a prognostic marker for contracture severity. If confirmed, medical strategies or implant coating could be implemented to reduce the risk of contracture for high-risk patients.

Impact of Incisional Access Site in Primary Breast Augmentation: Evaluation of Patient Satisfaction with SCAR-Q

BACKGROUND

Scarring at the incision site represents one of the most impactful outcomes in breast augmentation surgery for both the patient and the surgeon. Few studies exist with the aim of assessing patient perception of scarring outcomes in primary breast augmentation. The aim of this study was to evaluate the impact on quality of life of scars by submitting the SCAR-Q in patients who underwent primary augmentation mammoplasty.

METHODS

The SCAR-Q was administered at one and at 6 months after surgery to 54 consecutive patients underwent primary breast augmentation with inferior hemi-periareolar or inframammary incision. A total of 50 patients were divided into two groups of 21 patients with inferior hemi-periareolar incision and 29 patients with inframammary fold incision, respectively. Statistical analysis was performed with Prism 9.

RESULTS

All mean values of the three SCAR-Q scales tend to decrease at the second administration meaning that the perception of the scar is better at time 6 from the patient perspective. In the "Psychosocial scale," lower values at both 1 month and 6 months for group 2 compared to group 1 were shown. Unpaired T tests with Welch's correction showed significance for delta values variations between the two groups with P values <0.0001.

CONCLUSION

Data show that patients undergoing primary breast augmentation have a scar that has no significant impact. Patients with inframammary fold scar have less psychosocial impact than those with inferior hemi-periareolar scar. There were no statistically significant differences in scar-related symptoms and scar appearance between scar along the inframammary groove and inferior hemi-periareolar scar.

LEVEL OF EVIDENCE IV

Case series study. 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 .

Main Factors Influencing Patient Satisfaction After Primary Breast Augmentation: A Prospective Study Based on Patient-Reported Outcome Measures

BACKGROUND

Primary breast augmentation is one of the most sought-after procedures in cosmetic surgery. It is generally related to a high degree of patient satisfaction, but it is not always obvious which factors have greater influence on patient satisfaction.

OBJECTIVES

The aim of this prospective study was to evaluate how anthropometric, psychological, and social parameters, in association with the main surgical variables, influenced patients' satisfaction with their breasts after surgery.

METHODS

Patients undergoing primary breast augmentation between October 2018 and February 2022, who completed a 12-month follow-up without complications, were enrolled in the study. For each patient we recorded: BMI, pinch test (upper pole of the breast), surgical access, implant pocket, implant volume, bra size increase, age, smoking habit, civil status, education level, pregnancies, and psychiatric disorders. Each variable was statistically correlated with patient's satisfaction, assessed by BREAST-Q questionnaire preoperatively and 12 months postoperatively.

RESULTS

Analyzing the data of the 131 patients, we found 3 factors affecting their satisfaction (P<.05); BMI: underweight patients were less satisfied than normal and overweight patients; pinch test: patients with a pinch test >2 cm were more satisfied; volume of the implant and bra size increase: patients with implant volume <300 cc and a less than 2 bra size increase were less satisfied than patients with larger augmentation.

CONCLUSIONS

BMI, pinch test, implant volume, and extent of volumetric enhancement should be taken into careful consideration by the surgeon during preoperative consultation and surgical planning, because they can be critical to patient satisfaction.

LEVEL OF EVIDENCE: 3

Switching from Galenic to Advanced Dressings or Vacuum Assisted Closure Therapy Can Improve Quality of Life of Patients with Chronic Non-Responsive Pressure Skin Ulcers: Preliminary Data with Italian Translation of WOUND-Q

Objective: A few studies have focused on the quality of life (QoL) of patients with chronic non-responsive pressure skin ulcers. The aim of this study was to assess how correct treatment (advanced wound care [AWC] dressings alone or vacuum assisted closure [VAC] therapy alone) changes the QoL of these patients. Approach: One hundred six patients with chronic non-responsive pressure skin ulcers, who had previously used galenic dressings, applied without proper therapeutic indication, were included in this study. We administered the WOUND-Q, at time 0 and after 1 month of appropriate therapy, to assess patient-reported outcome measures. Group 1 consisted of 30 patients treated with advanced dressings, Group 2: 22 patients treated with VAC therapy, and Group 3: 30 patients continuing conventional galenic dressings (Control group). Statistical analysis allowed us to analyze QoL changes over time and to compare WOUND-Q Group 1 and 2 deltas with those of Group 3. The study followed the STROBE statement. Results and Innovation: In all the scales evaluated (Assessment, Drainage, Smell, Life impact, Psychological, Social, Sleep and Dressing), there were significant improvements in mean values for Groups 1 and 2. Kruskal-Wallis tests with Dunn's multiple-comparisons tests and Brown-Forsythe and Welch Analysis of Variance tests demonstrated significant differences between deltas of Group 1 and Group 2 compared with those of Group 3 for most scales analyzed. Conclusions: Administration of the WOUND-Q demonstrated that the application of advanced dressings alone or VAC therapy alone positively affects the QoL of patients with chronic nonresponsive pressure wounds, in comparison with galenic dressings alone. The WOUND-Q has been shown to be a valid tool in studying changes in QoL of these patients.

Relevance of Self-Consciousness of Appearance on Patient Satisfaction in Primary Rhinoplasty: a 12-Month Follow-up Prospective Study

BACKGROUND

Rhinoplasty procedure has a strong impact on patient quality of life. Plastic surgery patients show a degree of appearance-related distress higher than general population, especially patients undergoing rhinoplasty. Relationship between patient-reported outcome after rhinoplasty and self-consciousness of appearance needs further studies. The aim of this study is to investigate this correlation, considering the surgeon external evaluation as well.

MATERIALS AND METHODS

A total of 50 consecutive patients underwent primary cosmetofunctional rhinoseptoplasty. Appearance-related distress and surgical outcome were assessed by DAS59 (Derriford Appearance Scale 59) and SCHNOS (Standardised Cosmesis and Health Nasal Outcomes Survey), administered before and after surgery. Follow-up period was 12 months. Third-party clinical outcome was evaluated by three plastic surgeons by a scale ranging from 1 (poor outcome) to 5 (excellent outcome).

RESULTS

A first division in Group 1 (satisfied) and Group 2 (unsatisfied) was done. DAS59 mean score in Group 1 showed to be statistically lower than Group 2 (p value < 0.05). Spearman's test showed a large strong positive correlation between preoperative and postoperative DAS59 and SCHNOS-C score variations (Delta 0-12 months) (r = 0.7514, p<0.001), as well as between DAS59 and SCHNOS-O (r = 0.5117, p<0.001) and between SCHNOS-C and SCHNOS-O (r = 0.6928, p<0.001).

CONCLUSION

Rhinoseptoplasty has a significant impact on the patient self-consciousness of appearance, in both negative and positive terms. We emphasize the surgeon's burden, who need to carefully assess and address the patient's expectations during the first evaluation. This distinction is crucial since unrealistic expectations may lead to dissatisfaction even after a properly performed procedure.

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.

The Correlation Between the Improvement in Patient's Quality of Life and Surgeon's Satisfaction Following Primary Breast Augmentation: A Prospective Study

BACKGROUND

Patient satisfaction are the primary goal in breast augmentation, but in a few cases patient and surgeon satisfaction are in disagreement.

OBJECTIVES

The authors try to explain the reasons associated with disparity between patient and surgeons' satisfaction.

METHODS

Seventy-one patients underwent primary breast augmentation with dual plane technique with inframammary or inferior hemi-periareolar incision were enrolled in this prospective study. Quality of Life using BREAST-Q pre- and post-operative was evaluated. A pre and post photographic analysis was performed by a heterogeneous group of experts whom completed the Validated Breast Aesthetic Scale. Satisfaction with breast score was compared with overall appearance of VBRAS; a difference in score ≥ 1 was considered as discordant judgement. Statistical analysis was performed using SPSS version 18.0, with values of p<0.01 considered statistically significant.

RESULTS

BREAST-Q analysis, showed a significative improvement of QoL in Psychosocial Well-Being, Sexual Well-being, Physical Well-Being Chest scale and Satisfaction with Breast (p<0.01). Of the 71 pairs, 60 had a concordant judgment between patient and surgeon and 11 discordant. The score expressed by the patients (4.35±0.69) was on average higher than that of the third-party observers (3.88±0.58) with p<0.001.

CONCLUSIONS

Patient satisfaction is the main goal following the success of a surgical or medical procedure. BREAST-Q and photographic support are 2 important tools in the preoperative visit to understand the patient's real expectations.

Melasma treatment: a systematic review

Melasma is a common chronic refractory disorder of pigmentation affecting people with darker skin types. Overall prevalence varies between 8.8% and 40%, depending on the ethnicity of the population and the geographical area. Therapeutic management of melasma is challenging, with high recurrence rates which significant impacts on the quality of life. No single treatment is universally efficacious. Systemic treatments with tranexamic acid and polypodium leucotmatous had promising results, although the former was related to systemic side effects. Microneedling and peeling were also efficacious, although their superiority to topical hydroquinone, the gold standard in melasma treatment, remains to be established. Similarly, laser and light devices have been beneficial. However, recurrence rates remain high in all treatment groups. Combination therapies, either in double or triple combinations yielded the best results when compared to single terapies. Treatment choice should be made after Wood's lamp examination, as well as dermatoscopic evaluation, in order to select the best treatment option, targeted at each melasma subtype.

Neoadjuvant Therapy for Non-melanoma Skin Cancer: Updated Therapeutic Approaches for Basal, Squamous, and Merkel Cell Carcinoma

OPINION STATEMENT

Recently introduced systemic therapies for locally advanced and metastatic non-melanoma skin cancers (NMSCs) are paving the way for neoadjuvant approach. Although none of the therapeutic options has currently gained indication in this setting, neoadjuvant approach for NMSCs is an open field and we are likely to see huge developments in the near future. Targeted therapy with sonic hedgehog pathway inhibitors is very effective in locally advanced or multiple basal cell carcinomas while immunotherapy with immune checkpoint inhibitors appears to be promising for advanced cutaneous squamous cell carcinoma and Merkel cell carcinoma. To date, targeted therapy and immunotherapy represent the frontiers in NMSC therapeutic management and, according to recent studies, good results can be achieved.

Effectiveness and tolerability of treatment for isolated actinic keratoses: A retrospective comparison between cryotherapy, CO2 laser and 5-fluorouracil 0.5%/salicylic acid 10

Actinic keratoses (AK) have been described as either intraepithelial keratinocytic dysplasia that can evolve into invasive squamous cell carcinoma (SCC) or as in situ SCC that can progress into an invasive form. A retrospective study was conducted to compare outcomes of three different topical therapies for patients with single AK (<4): cryotherapy, CO₂ laser and 5-fluorouracil 0.5%/salicylic acid 10%. We included 72 patients who presented at the Dermatology Clinic of Maggiore Hospital of Trieste between 1 November 2019 and 31 January 2020 for the treatment of AKs. All treatments led to a significant reduction in the average diameter of AK. Pain felt by patients was significantly lower after 5-FU 0.5%/SA 10%. Side effects appeared similarly distributed among the three groups, with erythema and crusts being the most frequent. Aesthetic outcomes were highest in the 5-FU 5%/SA 10% group, as evaluated by both the patient and the operator. Cryotherapy, CO₂ laser and 5-FU 5%/SA 10% were all effective, with no significant efficacy differences among them. Additionally, 5-FU 5%/SA 10% was proved to have the best aesthetic result and to cause the least pain, while necessitating long-term administration. This should be taken into account for patients with low pain tolerance and low treatment adherence. Cryotherapy and CO₂ laser have the advantage of requiring a single session, which might be more suitable for uncooperative patients.

An overview on the role of CO2 laser in general dermatology

Among different laser types, the carbon dioxide (CO₂ ) laser remains one of the most used by dermatologists. Its usefulness has been demonstrated both for therapeutic and cosmetic purposes. This review aims to provide an overview of the applications of CO₂ laser in dermatology, focusing on the treatment of infective, neoplastic, and antiaesthetic lesions.

Cutaneous Manifestations in Confirmed COVID-19 Patients: A Systematic Review

There have been increasing reports of skin manifestations in COVID-19 patients. We conducted a systematic review and included manuscripts describing patients with positive RT-PCR coronavirus testing from nasopharyngeal swabs who also developed cutaneous manifestations. A total of 655 patients were selected, with different types of skin rashes: Erythematous maculopapular (n = 250), vascular (n = 146), vesicular (n = 99), urticarial (n = 98), erythema multiforme/generalized pustular figurate erythema/Stevens-Johnson syndrome (n = 22), ocular/periocular (n = 14), polymorphic pattern (n = 9), generalized pruritus (n = 8), Kawasaki disease (n = 5), atypical erythema nodosum (n = 3), and atypical Sweet syndrome (n = 1). Chilblain-like lesions were more frequent in the younger population and were linked to a milder disease course, while fixed livedo racemosa and retiform purpura appeared in older patients and seemed to predict a more severe prognosis. For vesicular rashes, PCR determined the presence of herpesviruses in the vesicle fluid, which raised the possibility of herpesvirus co-infections. The erythema-multiforme-like pattern, generalized pustular figurate erythema and Stevens-Johnson syndrome were most frequently linked to hydroxychloroquine intake. A positive PCR determination of SARS-COV-2 from conjunctival swabs suggest that eye discharge can also be contagious. These cutaneous manifestations may aid in identifying otherwise asymptomatic COVID-19 carriers in some cases or predict a more severe evolution in others.

The use of acellular porcine dermis, hyaluronic acid and polynucleotides in the treatment of cutaneous ulcers: Single blind randomised clinical trial

Reconstruction of chronic ulcers is often hampered by lack of local tissues and poor general conditions. Conservative approaches with debridement and advanced medications, such as polyurethane foam, stand as mainstays. However, the healing process is often slow, thus increasing the risk for infection or other complications. In such cases, porcine dermis (PD) and polynucleotides-added hyaluronic acid (PAHA) were previously reported to accelerate healing. The aim of the study was to compare the efficacy of PD, PAHA and polyurethane foam in chronic ulcers. Thirty patients were randomly divided into 3 groups: group 1 was treated with advanced medications, group 2 with PD, group 3 with PAHA. Standardised photographs and biopsies were taken before treatment and at 30-day follow-up. Photographs were processed to calculate the wound area. Specimens were stained with Haematoxylin/Eosin, Masson trichrome, and immunohistochemically for CD34, alpha-Smooth Muscle Actin (α-SMA), Collagen types I and III, Ki67. The re-epithelialized area was larger in patients treated with PD and PAHA compared with those treated with polyurethane foam (P < .05 and P < .01, respectively). Specimens from patients treated with PD and PAHA showed a higher number of myofibroblasts (α-SMA+, P < .01), neo-angiogenesis (CD34+, P < .01), proliferating dermal cells (Ki67+, P < .01), proliferating keratinocytes (Ki67+, P < .01) and collagen type 1 deposition (P < .05). No difference was found between PD and PAHA. PD and PAHA proved to be more effective than polyurethane foam in the treatment of chronic ulcers. These approaches are a versatile and reliable option to address such cases.

The Use of Botulinum Toxin in Flap Surgery: A Review of the Literature

Botulinum neurotoxin-A and botulinum neurotoxin-B have been shown to play a potential role in improving flap survival in animal models. The aim of this study is to review indications as well as to study injection timing, technique, and doses of botulinum neurotoxin-A and botulinum neurotoxin-B in animal models. Seventeen articles describe a total of 266 animals that underwent botulinum toxin injections before or during flap harvesting or vascular anastomosis procedure. All the studies demonstrated a beneficial effect of botulinum toxin administration in flap surgery or vascular anastomosis. Botulinum neurotoxin-A injection was shown to be a reliable approach in reducing vascular complications rate and increasing survival of flaps in animal models. The main conclusions drawn from the study include the following: perivascular injections targeting each vascular pedicle are preferred in cases of free flaps or axial flaps; subdermal injections are favorable in cases of random pattern skin flaps; and injections should be performed 7 days before flap elevation.

Foreign Body Reaction Mimicking Sarcoma

Foreign body reaction can sometimes mimic the features of sarcoma. A 42-year-old patient was referred to our department for a rapidly growing subcutaneous mass in the posteromedial aspect of the lower leg. Ultrasonography and magnetic resonance imaging were highly suggestive for soft tissue sarcoma. The patient underwent surgical resection. The histho-pathologic diagnosis found that the supposed sarcoma was an inflammatory pseudo-tumor, also referred to as "gossypiboms". Surgeons must be aware that, in some cases, the imaging cannot reliably distinguish between sarcoma and foreign body reaction.

The role of angiogenesis, inflammation and estrogen receptors in breast implant capsules development and remodeling

BACKGROUND

Capsular contracture is the most common complication following breast implant placement. The multiple factors unbalancing the physiological response to the foreign body have not been fully elucidated. The aim of this study was to investigate the role of neo-angiogenesis, inflammation and estrogen receptors in peri-prosthetic tissue development and remodeling.

METHODS

The study enrolled 31 women who underwent expander substitution with definitive implant. Specimens were stained with hematoxylin/eosin, Masson trichrome, immunohistochemistry and immunofluorescence for alpha-smooth muscle actin, estrogen receptor-α (ER-α), estrogen receptor-β (ER-β), Collagen type I and III, CD31 (as a marker of neo-angiogenesis) and vascular endothelial growth factor (VEGF). Inflammatory infiltration was quantified and analyzed. Transmission electron microscopy was performed for ultrastructural evaluation.

RESULTS

Myofibroblasts, mainly localized in the middle layer of capsular tissue, expressed VEGF, ER-α and ER-β. ER-β expression positively correlated with Collagen type I deposition (p= 0.025). Neo-angiogenesis was predominant in the middle layer. CD31 expression positively correlated with Collagen type I expression (p=0.009) and inflammatory infiltration grade (p= 0.004). The degree of inflammatory infiltration negatively correlated with the time from implantation (p = 0.022).

DISCUSSION

The middle layer is key in the development and remodeling of capsular tissue. Myofibroblasts produce VEGF, that induces neo-angiogenesis. New vessels formation is also correlated to the inflammatory response. Collagen deposition is associated with ER-β expression and neo-angiogenesis. These findings may prelude to targeted pharmacologic therapies able to control such interactions, thus hampering the self-sustaining loop promoting the progression of physiologic fibrosis toward pathologic contracture.

Iloprost administration in acrodermatitis of Hallopeau complicated by acquired toes syndactyly: a case report and review of the literature

OBJECTIVE

Acrodermatitis Continua of Hallopeau (ACH) is a variant of pustular psoriasis often very difficult to treat. Secondary syndactyly, also called "pseudosyndactyly", is rare and can be a complication of burns, dystrophic epidermolysis bullosa or trauma. If left untreated, joint complications and definitive functional impairments may occur.

CASE REPORT

We report a case of a 74-year-old man with acrodermatitis continua of Hallopeau involving the toes and complicated by syndactyly. ACH regression following Iloprost administration was also observed.

DISCUSSION

Published studies are mainly limited to case reports only, due to the rarity of the disease. Therefore, there are no clear-cut therapeutic management guidelines available for this chronic and sometimes debilitating disease. ACH is often recalcitrant to the available therapies. Topical and systemic treatments have been described in literature with no long-lasting results.

CONCLUSIONS

To our knowledge, this is the first report of foot syndactyly associated to ACH. In our patient, ACH symptoms regressed with Iloprost administration: this finding has never been previously described in literature. If confirmed by other clinical experiences, Iloprost could be a further therapeutic option in ACH.

Breast implant capsule flaps and grafts: a review of the literature

BACKGROUND

A breast implant capsule forms as a physiological response to the foreign material. Over the past decades, authors started to consider the breast implant capsule as a new source of tissue, thus describing several capsular flaps and grafts. The aim of this article is to provide an overview of the applications and indications for the use of capsular tissue flaps and grafts in reconstructive and aesthetic surgery.

METHODS

A review of the literature on breast implant capsule grafts and flaps was conducted. The reported surgical techniques were described and compared for indications and complications. The studies were evaluated and compared for number of patients and follow-up.

RESULTS

The search yielded a total of 21 citations. Patient population was reported in 11 studies for capsular flaps and 2 articles for capsular grafts. Between 1997 and 2012, a total of 74 patients underwent surgery with the use of capsular tissue. Among these, 60 patients had a capsular flap (81 %) and 14 (19 %) had a capsular graft. Complications were experienced in 5 patients (6.7 %).

CONCLUSIONS

Capsular flaps and grafts are indicated mainly to address breast implant-related problems. The breast implant capsule represents a versatile and reliable source of tissue for both aesthetic and reconstructive surgery.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Oestrogen receptor-alpha and -beta expression in breast implant capsules: experimental findings and clinical correlates

Myofibroblasts provide a force to decrease the surface area of breast implant capsules as the collagen matrix matures. 17-β-Oestradiol promotes myofibroblast differentiation and contraction. The aim of the study was to investigate the expression of oestrogen receptors α and β in capsular tissue. The study enrolled 70 women (80 capsules) who underwent expander or implant removal, following breast reconstruction. Specimens were stained with haematoxylin/eosin, Masson trichrome and immunohistochemistry and immunofluorescence stainings for alpha-smooth muscle actin (α-SMA), oestrogen receptor-alpha (ER-α) and oestrogen receptor-beta (ER-β). The relationship between anti-oestrogenic therapy and capsular severity was evaluated. A retrospective analysis of 233 cases of breast reconstruction was conducted. Myofibroblasts expressed ER-α, ER-β or both. In the whole sample, α-SMA score positively correlated with ER-α (p = 0.022) and ER-β expression (p < 0.004). ER-β expression negatively correlated with capsular thickness (p < 0.019). In capsules surrounding expanders α-SMA and ER-α, expressions negatively correlated with time from implantation (p = 0.002 and p = 0.016, respectively). The incidence of grade III-IV contracture was higher in patients who did not have anti-oestrogenic therapy (p < 0.036); retrospective analysis of 233 cases confirmed this finding (p < 0.0001). This study demonstrates the expression of oestrogen receptors in myofibroblasts of capsular tissue. A lower contracture severity was found in patients who underwent anti-oestrogenic therapy.

Abstract 664: Aberrant KEAP1 promoter methylation is associated with disease progression in breast cancer patients treated with epirubicin/cyclophosfamide and docetaxel chemotherapy

The KEAP1 (Kelch-like ECH-Associated Protein 1) is an adaptor protein that mediates the ubiquitination/degradation of genes regulating cell survival and apoptosis under oxidative stress conditions. We investigated the possible contribution of KEAP1 genetic and epigenetic abnormalities to development and progression of breast cancer. Methylation status of the KEAP1 promoter was evaluated in 102 primary breast cancers, 14 pre-invasive lesions, 38 paired normal breast tissues and 6 normal breast from reductive mammoplasty by Quantitative Methylation Specific PCR (QMSP). Aberrant promoter methylation was detected in 52 out of the 102 primary breast cancer cases (51%) and 10 out of 14 pre-invasive lesions (71%). No mutations of the KEAP1 gene were identified in the 20 breast cancer cases analyzed by fluorescence based direct sequencing. Methylation was more frequent in the subgroup of patients identified as ER positive-HER2 negative tumors (66.7%) as compared with triple negative breast cancers (35%) (p=0.02, Mann Whitney U-test). Interactions between ER, PR, HER2 expression and KEAP1 methylation on the mortality were investigated by RECPAM multivariable statistical analysis, identifying four prognostic classes at different mortality risks. Triple negative breast cancer patients with KEAP1 methylation had higher mortality risk than patients without triple negative breast cancer (HR=14.73, 95% CI: 3.65-59.37). Both univariable and multivariable COX regression analyses showed that KEAP1 methylation was associated with a better progression free survival in patients treated with epirubicin/cyclophosfamide and docetaxel as sequential chemotherapy (HR=0.096; 95%CI: 0.011-0.832 p=0.03 and HR=0.082 95%CI: 0.007-0.934 P=0.04 respectively). Our data indicate that aberrant promoter methylation of the KEAP1 gene promoter is involved in breast cancerogenesis. In addition identifying patients with KEAP1 epigenetic abnormalities may contribute to disease progression prediction in breast cancer patients.

Citation Format: Raffaela Barbano, Lucia Anna Muscarella, Barbara Pasculli, Vanna Maria Valori, Andrea Fontana, Michelina Coco, Annamaria la Torre, Teresa Balsamo, Maria Luana Poeta, Giovanni Francesco Marangi, Evaristo Maiello, Marina Castelvetere, Fabio Pellegrini, Roberto Murgo, Vito Michele Fazio, Paola Parrella. Aberrant KEAP1 promoter methylation is associated with disease progression in breast cancer patients treated with epirubicin/cyclophosfamide and docetaxel chemotherapy. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 664. doi:10.1158/1538-7445.AM2013-664

Aberrant Keap1 methylation in breast cancer and association with clinicopathological features

Keap1 (Kelch-like ECH-associated protein 1) is an adaptor protein that mediates the ubiquitination/degradation of genes regulating cell survival and apoptosis under oxidative stress conditions. We determined methylation status of the KEAP1 promoter in 102 primary breast cancers, 14 pre-invasive lesions, 38 paired normal breast tissues and 6 normal breast from reductive mammoplasty by quantitative methylation specific PCR (QMSP). Aberrant promoter methylation was detected in 52 out of the 102 primary breast cancer cases (51%) and 10 out of 14 pre-invasive lesions (71%). No mutations of the KEAP1 gene were identified in the 20 breast cancer cases analyzed by fluorescence based direct sequencing. Methylation was more frequent in the subgroup of patients identified as ER positive-HER2 negative tumors (66.7%) as compared with triple-negative breast cancers (35%) (p = 0.05, Chi-square test). The impact of the interactions between Er, PgR, Her2 expression and KEAP1 methylation on mortality was investigated by RECPAM multivariable statistical analysis, identifying four prognostic classes at different mortality risks. Triple-negative breast cancer patients with KEAP1 methylation had higher mortality risk than patients without triple-negative breast cancer (HR = 14.73, 95%CI: 3.65-59.37). Both univariable and multivariable COX regressions analyses showed that KEAP1 methylation was associated with a better progression free survival in patients treated with epirubicin/cyclophosfamide and docetaxel as sequential chemotherapy (HR = 0.082; 95%CI: 0.007-0.934). These results indicate that aberrant promoter methylation of the KEAP1 gene is involved in breast cancerogenesis. In addition, identifying patients with KEAP1 epigenetic abnormalities may contribute to disease progression prediction in breast cancer patients.

Three cases of embolia cutis medicamentosa (Nicolau's syndrome)

Embolia cutis medicamentosa, also known as Nicolau's syndrome, is a rare complication due to i.m. injections. Its real incidence is actually underestimated. Many drugs have been associated with it, but at the time only a few studies showed a related pathogenetic mechanism. Symptoms consist of immediate local pain, edema and cutaneous, subcutaneous and even muscular necrosis occurring in the first 48 h. The type of treatment depends mostly on time of diagnosis. A medical resolution can be achieved through heparin and cortisone injections within the first 48 h. Surgical debridement has to be considered as the main treatment in case of late diagnosis. We present three cases of Nicolau's syndrome presenting to us in a short period of time that we treated with surgical debridement.

Multiple localization of granular cell tumour: a case report

INTRODUCTION

Granular cell tumour, also known as Abrikossoff's tumour, is a rare entity occurring in the skin as well as in internal organs, more common among the third to fifth decade of life. It has often been described as a peripheral neuroectodermal tumour and its clinical behaviour is usually benign although malignant and multifocal forms are also known to occur.

CASE PRESENTATION

We report a case of multiple granular cell tumour in a 17-year-old Caucasian woman who presented with a nodular lesion in the popliteal cave, diagnosed as an Abrikossoff's Tumour, followed 2 years later by another soft tissue mass in the neck.

CONCLUSION

This case is quite rare: only a few cases were presented in literature with an extended period of time before the clinical presentation of subsequent disease.

Surgical treatment of locally advanced anal cancer after male-to-female sex reassignment surgery

We present a case of a transsexual patient who underwent a partial pelvectomy and genital reconstruction for anal cancer after chemoradiation. This is the first case in literature reporting on the occurrence of anal cancer after male-to-female sex reassignment surgery. We describe the surgical approach presenting our technique to avoid postoperative complications and preserve the sexual reassignment.

Digital photography in plastic surgery: how to achieve reasonable standardization outside a photographic studio

Accurate photographic documentation has become essential in reconstructive and cosmetic plastic surgery both for clinical and scientific purposes. Digital imaging systems currently are popular, being reasonably affordable and much improved in quality. They offer multiple advantages in terms of quality, easy image storage and retrieval. Nevertheless, obtaining standardized, consistent, and relevant digital images is not easy outside a photographic studio. The purpose of this report is to define guidelines for accurate image capture in different anatomic areas, following elementary general criteria based on practical issues beyond the purely theoretical, to obtain reasonable standardization, consistency, and reproducibility.

Expression and heterodimer-binding activity of Ku70 and Ku80 in human non-melanoma skin cancer

BACKGROUND

Experimental data suggest that exposure to ultraviolet radiation may indirectly induce DNA double-strand breaks.

AIM

To investigate the contribution of the non-homologous end-joining repair pathway in basal and squamous cell carcinomas.

METHODS

Levels of Ku70 and Ku80 proteins were determined by immunohistochemical analysis and Ku70-Ku80 heterodimer-binding activity by electrophoretic mobility shift assay. Matched pathological normal margins and skin from healthy people were used as controls.

RESULTS

A significant increase in Ku70 and Ku80 protein levels was found for both tumour types as compared with normal skin (p<0.001). Squamous cell carcinoma showed increased immunostaining as compared with basal cell tumours (p<0.02). A direct correlation was found between Ku70 and Ku80 protein levels and expression of the proliferation markers Ki-67/MIB-1 (p<0.02 and p<0.002, respectively) in basal cell carcinoma. DNA binding activity was increased in basal cell carcinoma samples as compared with matched skin histopathologically negative for cancer (p<0.006). In squamous cell carcinomas, however, the difference was significant only with normal skin (p<0.02) and not with matched pathologically normal margins.

CONCLUSIONS

Overall, an up regulation of the Ku70 and Ku80 protein levels seems to correlate only with tumour proliferation rate. As non-homologous end joining is an error-prone mechanism, its up regulation may ultimately increase genomic instability, contributing to tumour progression.

Decision making in the treatment of tuberous and tubular breasts: volume adjustment as a crucial stage in the surgical strategy

Tuberous and tubular breasts, two distinct deformities based on the same anatomic anomaly, are characterized by several morphologic alterations with a wide spectrum of expression. The classifications reported in the literature are based primarily on deformity of shape, but other parameters such as breast volume and symmetry often are underrated. This study aimed to define tuberous and tubular breasts and their management accurately on the basis of multiple anatomic alterations involving breast volume and symmetry as well as shape. The records of 30 patients affected by tubular and tuberous breast were reviewed. Surgical strategy included correction of breast shape through areola and gland alterations, correction of volume asymmetry through parenchyma resection, and volume augmentation through permanent expandable breast implant insertion. All the patients were treated bilaterally. Evaluation using a visual analogic scale confirmed high patient satisfaction with a mean value of 92.6% in the assessment of shape, volume, and symmetry. Correct diagnosis, careful preoperative evaluation, and a comprehensive surgical strategy can achieve, in one surgical procedure, good and long-lasting outcomes in terms of breast shape and volume symmetry.

Cutaneous lymphoadenoma: a rare clinicopathological entity

Cutaneous Lymphadenoma (Benign Lymphoepithelial tumour of the skin) is a rare tumour, with distinctive clinical and histological features. To date, very few cases of this entity have been reported. We present a case of cutaneous lymphoadenoma in a 52-year-old man and a short review of the literature, summarizing the principal clinical and morphological characteristics of this rare tumour.

Wedge Excision of the Nail Fold in the Treatment of Ingrown Toenail

Many treatment modalities of ingrown toenail are reported in the literature, often associated with unacceptably high recurrence rate. The authors present their technique, which aims at reducing the convexity of the nail fold. After complete removal of the nail plate and accurate debridement of the granulomatous tissue, a wedge-shaped ellipsis of skin and subcutaneous tissue, lateral to the affected nail fold, is removed. Approximation of the margins of the resulting defect determines eversion of the nail fold. One hundred twenty ingrown toenails were treated with the wedge excision of the nail fold at the outpatient clinic of the department of plastic surgery, Campus Bio-Medico University, Rome, Italy, between January 1998 and January 2002. Six recurrences were observed. In addition to the high cure rate, short postoperative pain duration, and morbidity as well as low risk of postoperative infection, the remarkable esthetic results achievable with this method are indicated.

Differential modulation of Ku70/80 DNA-binding activity in a patient with multiple basal cell carcinomas

Ku70/80 nonhomologous end-joining activity is essential for resolving random DNA double-strand breaks, and the Ku70/80 protein complex has been proposed as "caretaker" of genomic stability. We studied the Ku70/80 heterodimer activity in a patient affected by multiple basal cell carcinomas with a personal history of moderate exposure to ionizing radiation. The Ku70/80 DNA-binding activity was analyzed, by electrophoretic mobility shift assay, in five tumor biopsies from different sites and at distinct clinical stages, and in three matched normal skin samples from the same patient. As control normal tissues from healthy individuals were also tested. The five basal cell carcinomas were classified as "non aggressive" and "aggressive" on the basis of morphologic parameters and expression of the molecular markers bcl-2, Ki67/MIB1, and p53. A 62% increase in the Ku70/80 DNA-binding activity was found in normal skin from the patient, compared to unexposed individuals (p<0.0001). The nuclear activity of the heterodimer was further increased in nonaggressive basal cell carcinomas compared to both matched normal skin from the patient (31%, p=0.0001) and tissues from healthy controls (73%, p=0.0001). Strikingly, the two aggressive basal cell carcinomas tested showed very low Ku70/80 DNA-binding activity with a reduction of 87% compared to normal skin from the patient (p<0.0001) and 64% compared to controls (p=0.001). Although these results are limited to only one patient, together with other recent studies they support the hypothesis that downregulation of the nonhomologous end-joining pathway may be associated with tumor progression.

Vulvo-perineal reconstruction: medial thigh septo-fascio-cutaneous island flap

From 1996 through 2001, the authors performed 26 vulvo-perineal reconstructions after vulvar cancer resection. A unilateral or bilateral medial thigh septo-fascio-cutaneous island flap was used in all cases. The vascular supply to this flap is guaranteed by the underlying fascial plexus that arises from the convergence of three longitudinal rows of vessels (anterior, medial, and posterior). The flap is fashioned in a triangle shape and incorporates the underlying muscular fascia, sparing the intermuscular septal perforators. It is advanced in a V-Y fashion and is easily adapted and secured to the recipient site. Competent urethral and anal meati are reconstructed with multiple intercalated flaps. Scarring at the donor site is limited and acceptable. The nerve supply guarantees acceptable sensation at the reconstructed area. The medial thigh septo-fascio-cutaneous flap allows a valid one-stage vulvo-perineal reconstruction with a simple surgical execution process after superficial soft tissue resections.

Gynecomastia and the complete circumareolar approach in the surgical management of skin redundancy

Gynecomastia is a benign enlargement of the male breast due to a physiological or pathological factor that interferes with the balance between estrogens and androgens in the serum. Gynecomastia itself requires no treatment unless the persistent enlargement of the male breast is a source of embarrassment and/or distress for the adolescent or adult man. The indications for the surgical treatment of gynecomastia are founded on two main objectives: (1) the restoration of male chest shape and (2) diagnostic evaluation of suspected breast lesions. The diagnostic evaluation begins with an adequate history and a thorough breast examination helped by laboratory tests and instrumental research. Several approaches for surgical treatment have been described in the literature. Some problems arise in patients who have significant enlargement and ptosis of the breast that will require skin reduction and in some patients requiring nipple-areola complex reduction. The authors believe that the complete circumareolar technique with purse-string suture creates the best aesthetic results, with fewer complications, in patients with moderate and severe ptotic glandular breast enlargements that have skin redundancy combined with areolar enlargement. From 1995 through 1999, a total of 10 male patients with moderate to severe gynecomastia were treated surgically using a complete circumareolar approach. All patients achieved a good aesthetic contour of the chest. Only two patients required a revision of the circumareolar scar to correct postoperative enlargement.