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Autologous fat grafting has become more and more popular among plastic surgeons in the last few years due to recent discoveries on the mesenchymal stem cells stored in the harvested fat. These cells have a great regenerative potential and have the ability to restore the damaged tissues. The authors focused their practice on the treatment of the facial scars (derived from burns, trauma, degenerative diseases, and radiotherapy) and confirm that lipofilling is an excellent solution because it is able to improve the quality of the damaged tissues in terms of better scar color, pliability, thickness, relief, itching, pain, scar vascularization, and pigmentation.

INTRODUCTION Cleft lip and/or palate (CL/P) is the most common congenital craniofacial malformation. The severity of the anatomic deformity is highly variable and different techniques can be employed depending on whether the defect is unilateral or bilateral, complete or incomplete. Patients usually undergo multiple steps of reconstruction throughout childhood and adolescence and, for this reason, secondary deformities of the nasolabial region of the midface may ensue. Considering our experience in the treatment of scars, we opted to correct the cleft lip surgery sequelae not only with local flaps/scar revisions, but we decided to add the use of the autologous fat grafting (AFG) to induce a regenerative effect in these young patients. MATERIALS AND METHODS In this study we present the results obtained from a series of 12 consecutive Caucasian patients aged from 23 to 44 years with widened paramedian lip scars secondary to cleft lip reconstruction surgery, treated with a combination of needle-induced lysis of the scar tissue and AFG from January 2013 to December 2018. RESULTS After the procedure we observed an overall improvement in the quality of the scar tissue, in the function of mimic features, in the symmetry and cosmetics of the lower third of the nose. Patients' satisfaction was excellent. Results were long lasting and remained virtually unchanged after 1 year of follow-up. CONCLUSIONS Scar release by needle, AFG and local flaps are excellent tools for the treatment of cleft lip correction sequelae, but the combination of these surgical techniques can lead to even better results. LEVEL OF EVIDENCE Level V.

Background:. 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.

Gynecomastia is the most common form of breast alteration in men, due to proliferation of the gland ducts and stromal components, including fat. In addition to the most obvious indications (weight loss, pharmacotherapy, and drugs suspension), the surgical treatment is needed for long-standing gynecomastia, combining liposuction, adenectomy, partial mammary adenectomy, periareolar skin resection, and round-block suture. A retrospective study was conducted on 148 patients undergoing gynecomastia correction from May 2012 to April 2018. Follow-up ranged from 9 to 14 months. The authors propose a new ultrasound-confirmed classification system, dividing patients into six categories. The authors analyzed immediate complications, revision, recurrence, and minor aesthetic problems (retracted/depressed areas) and introduced a way to correct the irregularities with fat grafting and needles. The total complication rate was 11.5% (17/148). Most of the complications (11) were observed in patients who underwent glandular resection and 3 after liposuction only. Retrospective surveys about patients’ and surgeons’ satisfaction were performed, showing excellent feedbacks regarding the results accomplished. The simple classification helps surgeons choose the most suitable approach, avoiding insufficient or invasive treatments and undesirable scars. Moreover, the analysis of the type of sequelae and their correction allow high patients’ satisfaction. 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 .

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. 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. 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. 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. 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 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.

The breast is one of the leading organs treated by plastic surgeons for many purposes, such as correction of malformations (breast asymmetries, stenotic and tuberous breasts, Poland syndrome, etc), postoncological reconstruction (breast reconstruction after mastectomy or lumpectomy) and aesthetic/degenerative corrections (hypotrophy, hypertrophy, age-related problems, and postsurgical deformities). The surgical goals of these procedures are as follows: new pleasant breast cone; nipple–areola complex (NAC) survival and correct positioning at the centre of the breast cone; stable results throughout time; minimal scars. The desire to correct the shape, ptosis, hypo/hypertrophy, and any type of breast malformation using periareolar approach is long-standing. Hollander1 pioneered a technique to lift up the areola with skin excision in the supra-areolar area (“crescent technique”). However, it was Hinderer2 who first described the “doughnut mastopexy” and periareolar dermopexy with retromammary mastopexy (only the periareolar epidermis was removed and not full-thickness skin). These techniques were improved by Andrews3 for small volume breast reduction and Bartels4 for mastopexy in breast augmentation. Erol5 adopted a periareolar breast reshaping by leaving a central pedicle, undermining the superficial fascia, with no detachment of the gland from the muscle. A significant improvement for the evolution of the periareolar technique was the introduction of the purse-string (or round-block suture) by Peled,6 even though Benelli7,8 introduced the modern concept of round-block suture for the correction of small to moderate ptosis, reduction of the areolar diameter, and closure of the two periareolar circles in a concentric fashion. Peixoto,9 Felicio,10 Toledo,11 Goes,12 Spear,13 Ersek,14 Martins,15 and Hinderer16 added interesting contributes by using different breast remodeling and resection. Wilkinson17 proposed the “double Benelli stitch.” Robles18 introduced the concept of periareolar suture with a straight needle and an areolar sizer. Bustos19 suggested the use of a silicone sheet around the gland, anchoring it to the anterior pectoralis muscle fascia for better stabilization, followed by Goes,20 who performed a periareolar access with a polyglactine or mixed mesh as a support. Hammond21,22 described the interlocked suture with particular inferior pedicle. Our group made a significant contribution in 2016, extending the periareolar approach to all breast resections in oncoplastic surgery,23 and subsequently for the treatment of stenotic and tuberous breast.24,25 Despite all the valuable contributions described above, the periareolar approach still presents three main problems: late widening of the areolar diameter due to suture tension and hypertrophic/wide scars; flattening of the breast cone; postoperative ptosis relapse. Today these three issues have almost been solved. The purpose of the present article is to show how the periareolar approach, with a good patient selection, can be applied to different situations, leading to excellent results. Exceptions of the described technique are severe hypertrophies/ptosis or inelastic skin, where a T-inverted or L-scar is preferred. On the basis of previous works and the most recent developments, we think that the treatment of multiple mammary conditions with the periareolar approach can now be judged satisfying.

Dorsal augmentation is of primary importance to shape an ideal nose. Although costal cartilage is still used for this purpose, diced cartilage grafts wrapped in autogenous fascia became more and more popular in recent decades. In this paper, the authors report their experience with a new combination made by diced conchal cartilage wrapped in retroauricular fascia in primary and secondary cases. The clinical records of the first 19 patients to undergo dorsal augmentation with this technique were reviewed. The entire concha has been harvested and, once diced, wrapped in a sleeve of retroauricular fascia obtained using the same incision. Quilting reabsorbable sutures closed the mastoid dead space and prevented the risk of hematoma. The graft has been used in all the cases through a closed approach. The use of diced cartilage is nowadays considered one of the best options among the available procedures for dorsal augmentation. Diced conchal cartilage wrapped in posterior auricular fascial graft is a new, simple and safe procedure that eliminates the necessity of a secondary donor site (temple or thorax), speeds up the operation and leaves a well-concealed scar behind the ear. Its main disadvantages toward costal diced cartilage wrapped in rectus abdominis fascia are the minor quantity of cartilage that can be obtained, even in case of bilateral harvest, and compared to temporal fascia a longer postoperative swelling (6–8 weeks). 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 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. 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). 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. 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. 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 article focuses on the authors' autologous fat grafting technique and its application in regenerative treatment of different scars and ulcers. Although easy to perform, this surgical approach requires some technical procedures and specific management to maximize its effectiveness which are highlighted in the article. In the authors' experience, autologous fat graft has proved to be an efficient and safe procedure to treat scars of different origin demonstrating the capability of lipostructure to achieve an architectural remodeling and loose connective regeneration.

Autologous fat tissue grafting (AFTG) has been successfully used in the treatment of different sclerotic conditions, including localized scleroderma. Patients with advanced systemic sclerosis (SSc)-related perioral thickening and mouth opening limitation are candidates for this therapeutic approach. AFTG of the lips was performed to improve mouth opening in patients with SSc. We enrolled in the study 20 female patients with diffuse SSc (median age 35 ± 15 years and 11 ± 10 years of disease duration). Two-milliliter fractions of autologous fat drawn from trochanteric or periumbilical areas were injected in eight different sites around the mouth. Baseline and after-treatment mouth opening changes were assessed by measuring interincisal distance and oral perimeter, while skin hardness was tested by digital durometer. Pre- and posttreatment modifications of microvascular architecture were assessed by counting capillaries in the inferior lip videocapillaroscopy (VC) images and by scoring the microvascular density (MVD) in anti-CD34/CD31 immunohistochemical (IH) stained perioral skin biopsy sections. Similarly, histological sections were examined to evaluate dermoepidermic junction (DEJ) modifications. Three months after treatment, both the interincisal distance and oral perimeter significantly increased ( p < 0.001). At the same time, a significant skin neovascularization became evident, both considering the VC images ( p< 0.001) and MVD scores in IH sections ( p< 0.0001). Finally, some skin histological aspects also improved, as shown by the significant changes in DEJ flattening scores ( p < 0.0001). The present study suggests that, in patients with SSc, AFTG can improve mouth opening and function, induce a neovascularization, and partially restore the skin structure.

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. 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. 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. 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. 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 .

Breast reconstructive surgery techniques have increasingly evolved in the last decades both by a surgical and postoperative management point of view.

Autologous fat grafting is a widely adopted surgical technique in both the reconstructive and aesthetic fields. This study aimed to compare centrifuged lipoaspirates harvested and refined by the Coleman technique with noncentrifuged lipoaspirates in terms of cell number and viability, phenotypic profile, and clonogenic and proliferative potential of adipose-derived stem cell (ADSC) populations. For each patient, both a centrifuged sample using the Coleman’s technique and a noncentrifuged sample of adipose tissue were collected. Adipose-derived stem cells from both the centrifuged fraction (CF) and the noncentrifuged fraction (NCF) were isolated. The recovered ADSCs were used to set up flow cytometry analysis, colony-forming units–fibroblast (CFU-F) assays, and ADSC cultures. The number of recovered cells was variable among the different donors but significantly higher in the CF donors. Cell viability, determined by the Trypan Blue dye assay, always exceeded 95 %, in both the CF and NCF fractions. Analysis of the putative ADSC subpopulations showed a significant enrichment of the mesenchymal and endothelial progenitors in CF compared with NCF. No differences in the clonogenic efficiency of the ADSC samples were observed when the same number of cells were plated from each fraction. On the contrary, when equal fat volumes were compared, the colony-forming ability of CF was always significantly higher than that of its NCF counterparts. This is the first study to comprehensively characterize the impact of Coleman’s technique on the quality of lipoaspirates, showing that centrifugation is safe and feasible and does not impair cell viability, can augment the content in ADSC and the frequency of CFU-F, and reduces the number of proinflammatory blood cells. 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 .

Reconstruction of the nipple–areola complex is the last procedure in breast reconstruction after mastectomy. Various techniques have been described, but the creation of a long-lasting projection represents a challenge in plastic surgery causing frequent nipple projection loss. From December 2008 and September 2010, we performed 43 nipple reconstructions using our new technique named “triple-V flap.” This procedure is similar to C-V flap but uses a further V limb area that is de-epithelialized and provides significant support to the new nipple. Clinical assessment was performed with a caliper measuring nipple projection at 1, 6, and 12 months after the surgical procedure. We evaluated the triple-V nipple reconstruction technique in 43 patients. Reconstructed nipple projection ranged between 3.3 and 6.4 mm (mean 4.8 mm). Mean decrease in nipple projection was 0.2 mm at 1 month, 1.4 mm at 6 months, and 1.6 mm at 1 year. After 1 year, mean nipple projection decrease was 34 %. Our triple-V technique allows the maintenance of long-lasting projection of the reconstructed nipple at 12 months after surgery. Ease and speed of execution made our technique usable in all patients who need to complete the breast reconstruction process. Level of Evidence: Level IV, therapeutic study.

Objective.— To test feasibility, safety, and efficacy of local transplant of stromal fraction of adipose tissue in the treatment of chronic headaches of cervical origin. Background.— Chronic headaches of cervical origin (chronic cervicogenic headache and occipital neuralgia) are characterized by persistent pain due to the involvement of the great occipital nerve, with concurrent myofascial spasm and the consequent nerve entrapment within the trapezoid tunnel. Methods.— Tolerability and effectiveness of treatment of chronic cervicogenic headaches refractory to conventional therapies were evaluated in 24 patients. The visual analog scale of pain and the medication use diary were used in the 3 months preceding treatment; moreover, in order to verify the quality of life, patients are required to fill before surgery the Neck Pain Disability Index, the Headache Disability Index, migraine disability assessment scale questionnaire, and the short-form 12 standard v1 questionnaire. Follow-up examination was performed at 3 and 6 months. Results.— In 19 cases (79.2%), a good clinical response was recorded. At 6-month follow-up analysis, recurrence of occipital pain was recorded in 7 cases (29.2%); there is a significant reduction in disability and pain scores, and also a significant reduction of need for pharmacologic treatment and a fast return to previous work capacities. Conclusions.— The key point of our therapeutic strategy might be the regenerative role of stromal fraction of adipose tissue transplanted in the area of the occipital nerve entrapment; the results of the present study are encouraging both in terms of reduction of pain scores and in terms of quality of life improvement. The technique is minimally invasive, and no complications were recorded; indeed, the procedure seems to be safe and effective, and thus, a randomized study with larger follow-up and in a large series will be started.

Breast cancer represents the most frequent cancer in female population. Nowadays breast conservative surgery (BCS) is an accepted option for breast malignancies, and its indications has been extended thanks to the advent of oncoplastic surgery, reducing both mastectomy and re-excision rate, avoiding at the same time breast deformities. From January 2008 to November 2011, 84 women underwent BCS with periareolar approach for oncoplastic volume replacement. We divided patients into four groups analyzing breast size and resection volume (Group 1: small-moderate sized breast with resection20%; Group 2: small-moderate sized breast with resection20%; Group 3: big sized breast with resection20%; Group 4: big sized breast with resection20%). We evaluated patients' satisfaction regarding final esthetic outcome using the specific module "Satisfaction with outcome" of the Breast-Q questionnaire 1 year after surgery. The mean age was 52.1 years, and the mean follow-up was 11.2 months. During the follow-up, 12 patients have been lost. We obtained high satisfaction mean value with Breast-Q questionnaire in each group: 75.8 in group 1, 63.4 in group 2, 81.1 in group 3, 69.7 in group 4. Periareolar approach as oncoplastic volume replacement technique is useful in correction of breast deformity after BCS: it is a versatile technique that can be easily adapted for any breast tumor location and for wide glandular resection.

Introduction. Pain syndromes affect women after conservative and radical breast oncological procedures. Radiation therapy influences their development. We report autologous fat grafting therapeutical role in treating chronic pain in irradiated patients.Materials and Methods. From February 2006 to November 2014, we collect a total of 209 patients who meet the definition of “Postmastectomy Pain Syndrome” (PMPS) and had undergone mastectomy with axillary dissection (113 patients) or quadrantectomy (96 patients). Both procedures were followed by radiotherapy. We performed fat grafting following Coleman’s procedure. Mean amount of adipose tissue injected was 52 cc (±8.9 cc) per breast. Seventy-eight in 209 patients were not treated surgically and were considered as control group. Data were gathered through preoperative and postoperative VAS questionnaires; analgesic drug intake was recorded.Results. The follow-up was at 12 months (range 11.7–13.5 months). In 120 treated patients we detected pain decrease (mean ± SD point reduction, 3.19 ± 2.86). Forty-eight in 59 patients stopped their analgesic drug therapy. Controls reported a mean ± SD decrease of pain of 1.14 ± 2.72. Results showed that pain decreased significantly in patients treated (p<0.005,Wilcoxon rank-sum test).Conclusion. Our 8-year experience confirms fat grafting effectiveness in decreasing neuropathic pain.

We describe the case of a 45-year-old male patient who presented a retractile and painful scar in the nasolabial fold due to trauma which determined partial motor impairment of the mouth movements. We subsequently treated him with autologous fat grafting according to Coleman’s technique. Clinical assessments were performed at 5 and 14 days and 1, 3, and 6 months after surgical procedure and we observed a progressive release of scar retraction together with an important improvement of pain symptoms. A second procedure was performed 6 months after the previous one. We observed total restoration of mimic movements within one-year follow-up. The case described confirms autologous fat grafting regenerative effect on scar tissue enlightening a possible therapeutic effect on peripheral nerve activity, hypothesizing that its entrapment into scar tissue can determine a partial loss of function.

A rare case of isolated congenital bone agenesis in a young woman referred to the authors for aesthetic correction of the dorsum profile is described. There are no descriptions of surgical treatment for this isolated facial defect in the literature. After a complete and accurate diagnostic study, a rhinoplasty was performed with a good result and without complications during a 2-year follow-up period. To explain this congenital malformation, several hypotheses were examined, such as bony resorption and embryologic bony development syndromes. This report describes the possibility of intervention in the case of nasal bone absence and shows how risks of structural instability can be avoided with an accurate preoperative study and a careful surgical approach.

Autologous fat graft is becoming a widely used procedure in plastic surgery. Its indications are progressively increasing, ranging from functional to aesthetic surgery. The procedure has now entered in the field of regenerative medicine. Although many have commented on the long-term safety implications of fat grafting, especially to the breast, there is no body of information in the literature that analyzes near-term complications associated with this procedure. We performed a retrospective study of 1000 consecutive fat transplantation cases in our hospital since 2005. Complications were divided between donor-site complications and recipient-site complications. Of 1000 procedures, there were 2 donor-site hematomas and 83 local deformities caused by liposuction. In treated patients, the recipient site, there were 4 infections. One patient reported implant rupture at 1 month after fat graft. There was no skin necrosis in the grafted areas and no systemic complications such as pulmonary embolism, cardiac arrest, or deep venous thrombosis. The complications in fat transplantation are dominated by complications of the liposuction-the donor harvesting phase of the procedure. The relatively low complication rates in the recipient site suggest that fat transplantation, especially considering the recipient, is characterized by a high safety level and our device is simple to use.

To evaluate the technical feasibility of real-time elastography (RTE) to assess the stiffness of the skin of the peri-oral region in patients affected by systemic sclerosis (SSc).Six female patients affected by SSc (median age = 52 years) presenting with microstomia and six healthy controls matched for age and sex underwent RTE evaluation of the peri-oral region. Two operators with different experience evaluated the stiffness of the peri-oral region placing the probe in four different positions: parasagittal left (PL), parasagittal right (PR), upper axial (UA), lower axial (LA). Color map was converted into a semi-quantitative scale in which blue = 1, green = 2 and red = 3. Thus, each subject had a variable score ranging from 4 (four positions × value = 1) and 12 (four positions × value = 3). Mann-Whitney U and k statistics were used.RTE demonstrated that the skin of the peri-oral region of patients affected by SSc was stiffer than that of controls, both overall (6;4-6 [median; 25-75th percentile] vs. 11;9-11, p 0.001) and for each probe position (PL = 1;1-2 vs. 2;2-3, PR = 1;1-2 vs. 2;2-3, UA = 1;1-2 vs. 2;2-3; LA = 1;1-1 vs. 3;3-3, p ≤ 0.011 for all). Interobserver reproducibility was excellent both overall and for each probe position (k = 1).RTE is a feasible modality to assess peri-oral region skin stiffness with excellent interobserver reproducibility. Further studies on a larger cohort of patients including more clinical data and measures are warranted to confirm our initial results.Valutare la fattibilità dell’utilizzo dell’elastosonografia per studiare la rigidità della cute della regione periorale in pazienti affetti da sclerosi sistemica.Sei pazienti affette da sclerosi sistemica (età mediana = 52 anni) con microstomia e sei controlli sani appaiati per sesso ed età sono state sottoposte ad elastosonografia della regione periorale. Due operatori con differente esperienza hanno valutato l’elasticità della regione periorale con la sonda in quattro posizioni parasagittale sinistra (SX), parasagittale destra (DX), assiale superiore (AS), assiale inferiore (AI). La mappa colore è stata convertita in una scala semi-quantitativa in cui blu = 1, verde = 2 e rosso = 3. Pertanto, ogni soggetto ha avuto un punteggio totale variabile tra 4 (quattro posizioni × valore = 1) e 12 (quattro posizioni × valore = 3). Sono stati utilizzati i test U di Mann–Whitney e k di Cohen.L’elastosonografia ha dimostrato che la cute della regione periorale delle pazienti affette da sclerodermia è più rigida di quella dei controlli, sia globalmente (6;4–6 [mediana; 25–75th percentile] vs. 11;9–11,L’elastosonografia può essere eseguita nella regione periorale per valutare il grado di rigidità della cute, con eccellente riproducibilità interosservatore. Ulteriori studi che includano un campione maggiore di pazienti con dati clinici sono necessari per confermare i nostri risultati preliminari.

Reconstruction of open abdominal defects is a clinical problem which general and plastic surgeons have to address in cooperation. We report the case of a 66-year-old man who presented an abdominal dehiscence after multiple laparotomies for a sigmoid-rectal adenocarcinoma that infiltrated into the abdominal wall, subsequently complicated by peritonitis and enteric fistula. A cutaneous dehiscence and an incontinent abdominal wall resulted after the last surgery. The abdominal wall was reconstructed using a biological porcine cross-linked mesh Permacol (Covidien Inc., Norwalk, CT). Negative Pressure Wound Therapy (NPWT), instead, was used on the mesh in order to reduce wound dimensions, promote granulation tissue formation, and obtain secondary closure of cutaneous dehiscence which was finally achieved with a split-thickness skin graft. Biological mesh behaved like a scaffold for the granulation tissue that was stimulated by the negative pressure. The biological mesh was rapidly integrated in the abdominal wall restoring abdominal wall continence, while the small dehiscence, still present in the central area, was subsequently covered with a split-thickness skin graft. The combination of these different procedures led us to solve this complicated case obtaining complete wound closure after less than 2 months.

Recent studies tried to identify new indicators of risk in the development of insulin resistance, cardiovascular disease, and metabolic syndrome; recently, breast size has been proposed as a new measure of risk for type 2 diabetes mellitus in women. To understand the role of breast adipose tissue and subcutaneous adipose tissue in lipidic and glucose metabolism, we decided to evaluate the variation on levels of adiponectin in plasma and other well-known metabolic markers before and after surgical fat reduction.We formed 2 groups: breast reduction group (M-) and abdominoplasty group (ADD). For all patients enrolled in the study, we recorded anthropometric measurements 1 hour before surgery (that we considered as time zero). At time zero, we always performed a blood sample to observe the assay of glucose, total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, CRP, TNF-α, IL-1, IL-6, and adiponectin. The dosage of the above parameters was repeated 40 days after the surgical intervention with the aim of assessing whether they showed a statistically significant change after surgery.Adiponectin levels increased significantly in both groups of patients after surgery: in patients undergoing reduction mammaplasty and abdominoplasty, the mean increase was equal to 1.68 (P = 0.007) and 4.28 (P = 0.019), respectively. The variation in increase was not statistically different between the 2 groups (P = 0.254).Moreover, in the M- group, we observed that HDL levels increased and glycemia decreased significantly.Our study shows that reduction mammaplasty is a surgical procedure associated with a significant improvement in adiponectin level, HDL cholesterol level, and a significant decrease in glycemia level.The effective correlation between the role of breast adipose tissue and appearance of disease is still to be determined.

Breast cancer is the most common cancer in women worldwide, affecting one in eight women. Breast-conserving surgery (BCS) has become a well-established alternative to mastectomy in the treatment of breast cancer, providing a less invasive treatment. Just as life expectancy after breast cancer has improved, so has morbidity increased. One of the most relevant and debilitating consequences of oncological breast surgery is postmastectomy pain syndrome (PMPS). Our results published in 2011 on the treatment of PMPS in patients who had undergone mastectomy and radiotherapy and our experience in scar treatment with fat grafts were the theoretical bases for this prospective study. From April 2011 to April 2012 a total of 96 patients, who had undergone lumpectomy and radiation therapy, with the diagnosis of PMPS were considered for fat grafts. We performed autologous fat grafting in 59 patients (study group), whereas 37 patients did not receive any further surgical procedure (control group). Pain assessment was performed using the visual analog scale (VAS) before and after treatment in the treated group and in the control group at the first visit and the control visit, with a mean follow-up of 10 months. Results were analyzed using the Wilcoxon rank sum test. Four patients were lost to follow-up (two patients in the control group and two patients in the treated group). A significant VAS pain decrease was detected in patients treated with autologous fat grafting (3.1 point reduction, p ≤ 0.005). Because of the safety, efficacy, and optimal tolerability of the procedure, we believe that fat grafting can be considered useful in treating PMPS in patients who have undergone BCS and radiotherapy. 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 .

Regenerative medicine is an emerging and rapidly evolving field of research and therapy, thanks to new discoveries on stem cells. Adipose tissue is a connective tissue which contains a reserve of mesenchymal stem cells. Clinical improvements in trophic characteristics of teguments after autologous fat graft are well described in literature. In this paper, we present our observation after 6 years of autologous fat graft experience in scar remodeling.All patients recruited had retractile and painful scars compromising the normal daily activity/mobility of the joint involved. We performed surgical procedure with Coleman technique. In 20 patients, we performed a clinical assessment using Patient and Observer Scar Assessment Scale (POSAS) and Durometer measurements.In all treated scars, a qualitative improvement was shown both from an aesthetic and functional point of view. Most importantly, reduction or complete resolution of pain and increases in scar elasticity were objectively assessable in all cases. In patients studied using Durometer and POSAS score, areas treated with autologous fat graft showed statistically significant reduction in hardness measurements in comparison with areas infiltrated with saline solution. POSAS scores showed a statistically significant reduction of a great deal of POSAS parameters as a result of an improvement of both clinical evaluation and patient perception.Injection of processed autologous fat seems to be a promising and effective therapeutic approach for scars with different origin such as burns and other trauma scars, and post-surgery and radiotherapy outcomes. In general, we can affirm that treated areas regain characteristics similar to normal skin, which are clinically objectivable, leading not only to aesthetic but also functional results.