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Background Do plastic surgeons really know what happens to the breast after surgery? We often think that we do, but we have very few measurements to show whether we are on the right track. Objectives Only when the surgeon can predict the changes can she or he achieve consistent outcomes. Measurements lead to understanding; understanding what the measurements show allows us to refine our approach. Methods Consecutive patients in 4 categories were analyzed: breast reduction, mastopexy, augmentation, and mastopexy-augmentation. All procedures were performed by a single surgeon and all measurements were performed by the same surgeon. A standard measuring tape was utilized, and data were collected immediately preoperatively and at each follow-up visit. Only those patients with preoperative and complete 1-year postoperative measurements were included in this review. The parameters measured were clavicle to upper breast border (UBB), UBB to nipple, suprasternal notch (SSN) to nipple, SSN to inframammary fold (IMF), and chest midline to nipple. Results The changes were consistent. The borders of the breast footprint were expanded with the addition of an implant (UBB and IMF) and reduced with the removal of parenchyma (IMF). The existing SSN to nipple position was stretched when volume was added to the breast mound and it remained unchanged from the preoperatively marked position in a breast reduction. Conclusions Although measurements are not necessary to achieve good aesthetic results in breast surgery, surgeons should understand what the measurements show and what happens to the different breast parameters. Level of Evidence: 3

Split-thickness skin graft is one of the most used procedures in plastic surgery. This procedure involves numerous painful dressings at the donor site. α-Tocopherol acetate has anti-oxidative and anti-inflammatory properties and it can reduce the local bacterial growth, thereby promoting wound healing. We designed a prospective study to evaluate the effects of two different kinds of dressings at skin graft donor sites. A total of 30 patients were subjected to daily dressings with α-tocopherol acetate oil and traditional moist gauzes (group 1). Another 30 patients were subjected to dressings every 4 days with α-tocopherol acetate oil and silicone-vitamin E gauzes (group 2). Healing time, infection rate, patient's pain perception and costs were evaluated in both the groups. No statistically significant difference was found in terms of healing time. The infection rate was slightly different in the two groups. Significant reduction of pain perception was detected in group 2. In the same group, significant reduction in the total cost of the treatment was also observed. α-Tocopherol acetate oil and silicone-vitamin E gauzes may represent a safe, simple, painless and inexpensive method for improving skin graft donor site healing.

Gorlin-Goltz syndrome is mainly characterised by the development of numerous multicentric and relapsing cutaneous basal cell carcinomas (BCCs). A major problem for patients with Gorlin-Goltz syndrome is the large amount of BCCs that can invade the deep underlying structures, especially the face. Here, we describe the case of a 23-year-old male affected by Gorlin-Goltz syndrome. He had recurrent BCCs on a hairless scalp and dorsum since he was 17 years old and underwent four surgical procedures to excise BCCs, including a reconstruction with anteromedial thigh perforator flap. For each of the surgical procedures, a phenotypic study on peripheral blood mononuclear cells using flow cytometry was performed on the same day of surgery, and on days 7, 14 and 21 after surgery. The role of the tumour-specific cytolytic immune response as a potential future treatment of syndromic BCCs and its trend in relation to surgical ablation of large portions of tumour tissue was examined, and the cosmetic and therapeutic results are shown.

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical-related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high-risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re-operation and re-hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero-haematoma formation and on the re-operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

According to the literature, incisional closure complications may range from postoperative surgical site infections, representing 17-22% of health care-associated infections, surgical wound dehiscence and formation of haematomas or seromas, and can lead to delayed or impaired incision healing. These kinds of situations are more common when wounds are closed under tension or in specific patient morbidities. Obesity, in particular, is associated with an impaired blood flow to tissues, predisposing the patient to increased risk of wound complications by various mechanisms. Incisional complications can become relevant economic burdens for health care systems because of an increase in the average length of hospital stay and readmissions, and additional medical and surgical procedures. Thus, a preventive therapy may have a critical role in the management of healing. Negative pressure wound therapy (NPWT) technology as delivered by Prevena™ Customizable™ (Kinetic Concepts Inc., San Antonio, TX) has recently been the focus of a new investigation, as a prophylactic measure to prevent complications via immediate postoperative application in high-risk, clean, closed surgical incisions. The authors present a 62-year-old class II obese female, who underwent bilateral inguinal dermolipectomy. Prophylactic NPWT as delivered by Prevena™ was performed successfully over surgical incisions. Cosmetic and therapeutic results are shown.

Background Breast implants are widely used and at times might cause inflammation as a foreign body, followed by fibrous capsule formation around the implant. In cancer, the inflamed stroma is essential for preservation of the tumor. Mesenchymal stem cells can be recruited to sites of inflammation, and their role in cancer development is debated. The authors assessed the effects of inflammation caused by breast implants' effects on tumor. Methods Mesenchymal stem cells were isolated from the fibrous capsules of women who underwent a second operation after 1 year (presenting inflammation) or after 20 years (not presenting inflammation) since initial surgery. After characterization, cells were co-cultured with MCF7, a breast cancer cell line. The expression of genes involved in oncogenesis, proliferation, and epithelial-to-mesenchymal transition was investigated, followed by Western blot analyses. Results After co-culture with mesenchymal stem cells from the inflamed capsule, MCF7 induced a dose- and time-dependent increase in proliferation. Polymerase chain reaction analyses revealed a dysregulation of genes involved in oncogenesis, proliferation, and epithelial-to-mesenchymal transition. The subsequent evaluation by Western blot did not confirm these results, showing only a modest decrease in the expression of E-cadherin after co-culture with mesenchymal stem cells (both derived from inflamed or control capsules). Conclusion These data indicate that inflammation caused by breast implants partially affects proliferation of MCF7 but does not influence key mechanisms of tumor development.

Wound healing is a systemic response to injury that impacts the entire body and not just the site of tissue damage; it represents one of the most complex biological processes. Our knowledge of wound healing continues to evolve and it is now clear that the wound microenvironment plays a crucial role. The interactions between cells and the surface microenvironment, referred to as the "biofilm," contributes to skin homeostasis and healing. Understanding the functional complexity of the wound microenvironment informs how various factors such as age, ischemia, or bacterial infections can impair or arrest the normal healing processes, and it also allows for the possibility of acting therapeutically on healing defects with microenvironment manipulation. Microbes represent a particularly important factor for influencing the wound microenvironment and therefore wound healing. Moreover, the role of infections, particularly those that are sustained by biofilm-forming bacteria, is mutually related to other microenvironment aspects, such as humidity, pH, metalloproteinases, and reactive oxygen species, on which the modern research of new therapeutic strategies is focused. Today, chronic wounds are a rapidly growing health care burden and it is progressively understood that many non-healing wounds might benefit from therapies that target microorganisms and their biofilm communities. There is no doubt that host factors like perfusion impairments, venous insufficiency, pressure issues, malnutrition, and comorbidities strongly impact the healing processes and therefore must be targeted in the therapeutic management, but this approach might be not enough. In this article, we detail how bacterial biofilms and related factors impair wound healing, the reasons they must be considered a treatment target that is as important as the host's local and systemic pathologic conditions, and the latest therapeutic strategies derived from the comprehension of the wound microenvironment.

Background/Objective: This study aims at the evaluation of the efficacy and safety of a combination therapy based on pidobenzone 4% and fractional CO2 laser or cryotherapy in the treatment of solar lentigines and the prevention of eventual posttreatment hyperchromia. Methods: Efficacy was clinically evaluated by grading the pigmentation level with the Skin Tone Color Scale (STCS), and by grading patients' impression through a Visual Analog Scale (VAS). Results: Our study shows that the associated treatment was safe and that it improves the therapeutic results on solar lentigines and prevents postiatrogenic hyperpigmentation compared with physical therapy alone. Conclusion: The combination of cryotherapy and pidobenzone 4% has been found to be the most useful treatment.

Various reconstructive procedures have the common goal of improving the appearance of the breast in order to make it conform to what the patient considers more aesthetically pleasing. Breast secondary asymmetry may be due to the shape, the volume, the position of the implant and the nipple-areola complex. Post-reconstruction breast asymmetry is often associated with dimensional problem, retraction of the peri-prosthetic breast fibrous capsule, persistent mammary ptosis. The authors discuss the use of the GID svf-1, a new device for fat grafting.

In performing abdominal repair, the surgeon should have good knowledge of the abdominal wall anatomy. The author discusses in detail the anatomy of the abdominal wall and the surgical approaches to reconstruct the abdominal wall with a large hernia with mesh with open surgery, laparoscopic method, component separation technique, and the various meshes available. Clinical cases are described.

Capsular contracture is one of the most frequent complications following breast augmentation where the capsule begins to squeeze or contract upon itself. The incidence of this phenomenon varies between 0.5 and 30 %, according to the experience of the plastic surgeon. The authors discuss the use of periprosthetic fat transfer in capsule contracture following breast reconstruction. Lipofilling fits well with the breast tissue over time and it adapts to the patient in a very natural way following weight and structural changes. There is still a lack of standardization in the techniques used, but trends towards time management and simplification of technique are appearing. Two cases are described.

Summary: We report the case of a 50-year-old paraplegic man with a complicated grade III/IV ischiatic pressure sore treated with a propeller flap based on the first perforator of the profunda femoris artery. Our aim was to surgically reconstruct an ischiatic pressure sore in a patient with ankylosis using a fasciocutaneous perforator propeller flap obtained from the posterior region of the thigh. Our decision to perform a profunda femoris artery perforator propeller flap reconstruction was mainly due to the anatomical contiguity of the flap with the site of the lesion and the good quality of the skin harvested from the posterior region of the thigh. The use of the perforator fasciocutaneous flap represents a muscle-sparing technique, providing a better long-term result in surgical reconstruction. The choice of the 180-degree propeller flap was due to its ability to provide a good repair of the pressure ulcer and to pass over the ischiatic prominence in the patient in the forced decubitus position. The operatory course did not present any kind of complication. Using this reconstructive treatment, we have obtained complete coverage of the ischiatic pressure sore.

Chronic wounds cause morbidity due to local infections, sepsis, osteomyelitis, but also increase mortality in the most severe cases and in patients with multiple comorbidities. Their increasing prevalence, associated disabilities and relevant health costs make chronic wounds a real social disease. At a time in which we hear more and more about spending reviews and reduction of health care costs, the natural evolution of Medicine and Health Care is increasingly directed towards the achievement of high quality standards while at the same time, reducing costs. It is in this framework that a hub and spoke model was used for organizing Plastic Surgery services in Ancona (Italy). In order to ensure appropriate clinical and organizational management of services, the activities of reference centres need to be widely integrated, by functional interconnections with activities of peripheral hospitals and local centres. Through a careful analysis of the Regional Reference Center for non - healing wounds in Ancona, the authors make some considerations regarding appropriate diagnostic-therapeutic-healthcare pathways and the correct use of human, material and technological resources in the area of wound healing.

Skin extender is a very useful method to repair wounds when oedema and skin retraction make a direct suture impossible. We have developed a new, simple and cheap way to prepare skin extenders based only on elastic vessel loops and metal clips stapler commonly used for skin suture and available in any operating room. This simple method can be performed both in the operating room and at the patient bedside, even under local anaesthesia, causes no bleeding and appears to be inexpensive and rapidly usable and should be made readily available in any hospital.

Marjolin’s ulcer is a squamous cell carcinoma that develops in posttraumatic scars and chronic wounds. Suspicion of such lesions should be raised in chronic wounds demonstrating characteristic changes. We have reported the peculiar phenomenon of malignant transformation of chronic pressure sores that occurred in a paraplegic patient. The aim of this study was to cover the extensive defects by a last resort reconstructive option. Department of Plastic and Reconstructive Surgery, Universita Politecnica delle Marche, Ancona, Italy. A 40-year-old paraplegic man, with multiple hemangioblastomas of the brain and spinal cord due to Von Hippel Lindau syndrome developed pressure ulcers with unstable healing over the sacral, trochanteric, bilateral, and ischiatic areas after 15 years from neurosurgery. The biopsy result showed an invasive squamous carcinoma. Carcinomas in pressure sores are highly aggressive, and they need to be treated more radically. In our case we opted for a demolitive surgical treatment including musculocutaneous rotational flap harvested from total left thigh to cover the extensive defects. The limb was previously disarticulated. In Marjolin’s ulcer, multiple biopsies are the first-line modality for the early diagnosis as they are a safe method with high rate of accuracy. First-line treatment is surgery consisting of radical excision with lymph node dissection, if they are involved. Adjuvant radiation therapy may be used in selected patients. Management of massive pelvic defects can be a challenging problem. The pedicled lower limb flap offers a technique that can be considered as a last resort procedure for extensive defects where other options are insufficient or not available anymore. In our case the patient is disease-free after 2 years of follow-up.

Breast implants, and more generally any foreign body, promote the formation of a fibrous capsule that surrounds them completely. It is a real chronic inflammatory reaction with the production of fibrous tissue rich in collagen fibers and cells of chronic inflammation at the interface between the implant and the host. The capsule seems to be rich in MSCs, particularly active for the presence of a microenvironment characterized by high stress and inflammation. The author discusses mesenchymal stem cells and breast cancer as a paradigmatic model. The authors conclude that the preliminary data describe a reassuring scenario, where paracrine effect exerted by MSCs does not affect the aggressiveness of breast cancer cells.

The authors describe how we age, the history of autologous fat grafting, the future of adipose stem cells (ADSCs), stem cell niche therapy, using adipose tissue, benefits of stem cells in fat transfer, research directions, aging and rejuvenation, and structural fat grafting including harvesting, refinement, and transfer; influence of local anesthesia on adipose tissue; and preoperative care. Potential areas for facial fat transfer, postoperative care, unfavorable points to fat grafting, graft survival, and complications are discussed.

The authors discuss the history of fat transfer to the face; how we age; adipose-derived stem cells (ADSCs); stem cell niche therapy, using adipose tissue; benefits of stem cells in a fat transfer; and aging and rejuvenation. Described are structural fat grafting with harvesting refinement and transfer, the influence of local anesthesia on adipose tissue, preoperative care, and postoperative care. The potential areas for facial fat transfer include nasolabial folds, marionette lines, cheeks, infraorbital regions, trough area, chin, glabellar area, temple, forehead, inferior orbital rim, and lips. Graft survival is discussed with unfavorable points to fat grafting and future perspectives for fat harvesting.

Skin extender is a very useful method to repair wounds when oedema and skin retraction make a direct suture impossible. We have developed a new, simple and cheap way to prepare skin extenders based only on elastic vessel loops and metal clips stapler commonly used for skin suture and available in any operating room. This simple method can be performed both in the operating room and at the patient bedside, even under local anaesthesia, causes no bleeding and appears to be inexpensive and rapidly usable and should be made readily available in any hospital.

Primary angiosarcoma (AS) of the breast is a rare neoplasia that is not related to radiation exposure. It represents less than 0.05% of all malignant breast tumors. This lesion is characterized by aggressive patterns and poor prognosis and by the absence of typical features at radiologic examination.Currently there are not evidence-based guidelines regarding surgical and adjuvant treatment for this tumor even though wide surgical resection followed by chemo- radiotherapy appears to improve both disease free survival and overall survival.The aim of this study was to analyze the available series of AS patients suggesting the most reliable treatment options for this rare neoplasia.