Research Interests:
Research Interests:
Head and neck reconstruction poses unique challenges in rehabilitating surgical defects in terms of integrity, function, and form. The radial forearm free flap (RFFF) has been widely used for defect coverage, especially in the head and... more
Head and neck reconstruction poses unique challenges in rehabilitating surgical defects in terms of integrity, function, and form. The radial forearm free flap (RFFF) has been widely used for defect coverage, especially in the head and neck area, but its versatility allows it to be used for soft-tissue reconstruction in various parts of the body. The vascular features of the flap are quite constant and reliable. Nevertheless, abnormalities of the forearm vascular tree have been described over the decades. We report a case of intraoral reconstruction after verrucous carcinoma recurrence in a 74-year-old woman with an unusual forearm flap, which we called the median forearm free flap, based on a median branch of the radial artery that was preoperatively detected using handheld Doppler ultrasonography. The distally located skin paddle was predominantly supplied by the aberrant median vessel with its perforators. The flap was thus safely harvested with this atypical pedicle. Successful ...
Research Interests:
Background: The use of free flaps from the medial femoral condyle has grown in popularity and is now a workhorse in the reconstruction of skeletal defects. The utility of this technique has not yet been described for the pediatric patient... more
Background: The use of free flaps from the medial femoral condyle has grown in popularity and is now a workhorse in the reconstruction of skeletal defects. The utility of this technique has not yet been described for the pediatric patient population. The authors present their series of pediatric patients who underwent surgery using a medial femoral condyle free flap or a variant thereof in skeletal reconstruction and demonstrate the efficacy of this technique in this population. Methods: A multi-institutional retrospective review of patients aged 18 years or younger who required a medial femoral condyle flap for skeletal reconstruction was undertaken. Operative technique, radiographs, and clinical outcomes were recorded. A novel technique (Innocenti) was used to avoid the distal femoral physis in which a Kirschner wire was placed under fluoroscopic guidance just proximal to the growth plate. Results: Thirteen patients met inclusion criteria, with an average age of 14.7 years (range,...
Research Interests:
Research Interests: Surgery, Microsurgery, Tendon, Medicine, Fascia, and 3 moreClinical Sciences, Thigh, and Fascia Lata
AimsAfter intercalary resection of a bone tumour from the femur, reconstruction with a vascularized fibular graft (VFG) and massive allograft is considered a reliable method of treatment. However, little is known about the long-term... more
AimsAfter intercalary resection of a bone tumour from the femur, reconstruction with a vascularized fibular graft (VFG) and massive allograft is considered a reliable method of treatment. However, little is known about the long-term outcome of this procedure. The aims of this study were to determine whether the morbidity of this procedure was comparable to that of other reconstructive techniques, if it was possible to achieve a satisfactory functional result, and whether biological reconstruction with a VFG and massive allograft could achieve a durable, long-lasting reconstruction.Patients and MethodsA total of 23 patients with a mean age of 16 years (five to 40) who had undergone resection of an intercalary bone tumour of the femur and reconstruction with a VFG and allograft were reviewed clinically and radiologically. The mean follow-up was 141 months (24 to 313). The mean length of the fibular graft was 18 cm (12 to 29). Full weight-bearing without a brace was allowed after a mea...
Research Interests:
The quality of reconstruction of soft tissue defects in the upper extremity, resulting either from traumatic injury or tumor excision, has relevant implications both from functional and aesthetic standpoints. Various local and free flaps... more
The quality of reconstruction of soft tissue defects in the upper extremity, resulting either from traumatic injury or tumor excision, has relevant implications both from functional and aesthetic standpoints. Various local and free flaps with more or less consistent donor-site morbidity have been described in the past. The recent introduction of the perforator-based flap concept, has led to an evolution in upper extremity reconstruction, optimizing results at the recipient site whilst minimizing damage to the donor site and, performing this in the simplest way possible. In this study between 2001 and 2008, 31 patients having post-traumatic or post-tumor excision soft tissue defects of the upper limb, were treated using local perforator flaps raised according to two different modalities: "pedicled fasciocutaneous" and "transposition fasciocutaneous/cutaneous". Complete and stable coverage of the soft tissue losses was obtained in all cases with an inconspicuous, only aesthetic, donor-site defect. Superficial or partial necrosis of the tip of the flap, due to venous congestion, was observed in 2 cases of "pedicled fasciocutaneous flap". An additional surgical procedure was required in only one of these cases. In our series all 9 patients who had a transposition flap, underwent routinely a preoperative echo color Doppler investigation to identify the main perforators. In only one case did the Doppler investigation fail to accurately locate the perforator. Local perforator flaps allow the coverage of medium size defects in the upper extremity, can be raised with a relatively simple surgical technique, have a high success rate and good aesthetic results without functional impairment. In the light of this they can be considered among the surgical choices to resurface complex soft tissue defects of the upper extremity. Preoperative identification of the perforators in case of "transposition flaps" greatly facilitates the operation. In our experience echo color Doppler investigations provided reliable results.
Research Interests:
The concept of limb salvage led to increased demand for more complex and sophisticated reconstructive options to achieve better functional and cosmetic outcome. Reconstruction of the total or partial loss of quadriceps muscle after soft... more
The concept of limb salvage led to increased demand for more complex and sophisticated reconstructive options to achieve better functional and cosmetic outcome. Reconstruction of the total or partial loss of quadriceps muscle after soft tissue sarcomas excision with free functioning latissimus dorsi muscle transfer had become more popular in the last years. Between November 1993 and October 2004, 11 patients with average age 45.5 years underwent excision of quadriceps muscle followed by simultaneous reconstruction with free functioning latissimus dorsi muscle. There were six men and five women. The tumors were high grade in 90.9% of patients and were >10 cm in 81.8% of patients. The tumor extension required the resection of the entire quadriceps in four cases, of three heads in six cases, of only two heads in one case. The average follow up was 69 months. The average time of recovery of the contractile activity of the muscle was 8.3 months after operation. The musculoskeletal tumor society rating score (MTSRS) scored excellent or good in 73% of patients. Three patients (27.3%) died of metastatic disease. Local recurrence occurred in one patient (9.1%). Limb salvage was achieved in all the patients (100%). This method of reconstruction is a reliable technique not only to fill the defect resulting from oncological resection but also to provide better function. Microsurgical reconstruction of soft tissue sarcoma helps to expand the indications of limb salvage by allowing better local control and achieving adequate function and coverage.
Research Interests:
Research Interests:
Research Interests:
Research Interests: Microsurgery and Medicine
Research Interests:
BACKGROUND The submental artery island flap is widely used in head and neck reconstruction, since it is easy and quick to harvest, and it can be successfully used for the coverage of perioral, intraoral and facial defects. We used this... more
BACKGROUND The submental artery island flap is widely used in head and neck reconstruction, since it is easy and quick to harvest, and it can be successfully used for the coverage of perioral, intraoral and facial defects. We used this technique for the reconstruction of a complex soft-tissue and bony defect of rhino-oropharinx. CASE REPORT Osteoradionecrosis of rhino-oropharingeal posterior wall with C2 necrotic body exposure occurred in a 77-year-old woman. After the failure of reconstruction with a Hadad-Bassagasteguy flap, a submental island flap with cervical spine stabilization was planned to be performed in a one-stage operation. The anterior arc of C1 and odontoid process of C2 were removed and, according to the defect size, a submental island flap was designed in an elliptical fashion. The flap was rotated 180° and tunnelized under the left parapharingeal-prevertebral space, then it was positioned in the rhino-oropharinx and fixed with reabsorbable sutures. The donor site w...
Research Interests:
Research Interests: Microsurgery and Medicine
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
To the Editor: We read with great interest the article entitled “Blepharoplasty Effect on a Described Algorithmic Approach to External Ptosis Repair: Is It Time for Unbundling?” by Rubinstein et al. The authors, referring to as previously... more
To the Editor: We read with great interest the article entitled “Blepharoplasty Effect on a Described Algorithmic Approach to External Ptosis Repair: Is It Time for Unbundling?” by Rubinstein et al. The authors, referring to as previously described algorithm technique “small-incision external levator resection” for treatment of involutional ptosis, highlighted that the addition of upper blepharoplasty to the ptosis procedure repair alone provides good but less predictable results comparing to the ptosis repair technique alone. Aponeurotic ptosis is the most common type of acquired ptosis resulting from an involutional dehiscence, stretching, or thinning of the aponeurotic fibers of the levator aponeurosis. We congratulate for the authors’ algorithmic surgical technique and for the device proposed to hold the aponeurosis; it seems to be useful to standardize the amount of stress placed on aponeurosis between different patients, minimizing the variable depending on the operator, standardizing the method to calculate the amount of tissue resection and surgical correction. We retain that the function of superior levator system must be evaluated preoperatively, but also the asymmetry between the 2 eyes must be carefully assessed. As stated by Hering law, both levator muscles are innervated from a single nucleus producing equal neural output from both sides, and so the less affected eyelid may be capable of maintaining a normal level of elevation due to an excessive nerve stimulation determined by the more ptotic eyelid. The compensatory retraction of the less affected eye make it difficult to adjust the balance between the 2 eyes. Furthermore, an assessment of compensation for the superior visual field loss by the recruitment of the frontalis muscle and a long-term functional evaluation of results is important. We recently published an article to evaluate long-term follow-up results after ptosis correction by external levator advancement with or without blepharoplasty, considering both functional and aesthetic results. The former was evaluated basing on postoperative upper eyelid margin reflex distance and the second one on symmetry. According to the British Oculoplastic Surgery Society National Ptosis Survey, a successful outcome can be considered when upper eyelid margin reflex distance was between 3 mm and 5 mm. Symmetry was achieved when all the following 3 different criteria were met:
Research Interests:
Research Interests: Medicine, Humans, Ultrasonography, Male, Liposuction, and 4 moreGynecomastia, Clinical Sciences, Lipectomy, and Nipples
Research Interests:
Replacement of osseous defect, restoration of joint function, and restoration of longitudinal growth are the 3 main reconstructive issues that need to be addressed when the physis and epiphysis are damaged in a skeletally immature... more
Replacement of osseous defect, restoration of joint function, and restoration of longitudinal growth are the 3 main reconstructive issues that need to be addressed when the physis and epiphysis are damaged in a skeletally immature individual. Failure in achieving these objectives leads to severe deformity and functional impairment, which significantly compromises the quality of life of young patients. Because of its biological and morphological characteristics, the proximal fibula epiphyseal transfer has proven to be an excellent option in limb salvage surgery in pediatric oncologic cases meeting all the reconstructive requirements. Between 1992-2006, 8 children with a mean age of 7.3 years (range 4-11 years old) diagnosed with malignant bone tumor of the distal radius underwent tumor resection and immediate microsurgical reconstruction of the distal part of the radius with vascularized proximal fibular transfer, which included the physis and a variable length of the diaphysis. The ...
Research Interests:
Giant-cell tumor (GCT) is locally aggressive bone neoplasm, with an unpredictable pattern of biological aggressiveness. The optimal treatment had to achieve a negligible local recurrence rate while maximizing musculoskeletal function.... more
Giant-cell tumor (GCT) is locally aggressive bone neoplasm, with an unpredictable pattern of biological aggressiveness. The optimal treatment had to achieve a negligible local recurrence rate while maximizing musculoskeletal function. Numerous options for reconstruction are available, but in the literature there is a lack of salvage surgery data. We present a case of a 67-year-old woman who underwent complete wrist arthrodesis with vascularized fibular graft as salvage procedure for allograft necrosis, after excision of a distal radius GCT. The patient did not complain of any impairment in daily use, and the functional score was 22 points (73%) at latest follow-up of 14 months. Despite joint salvage remains the most favorable treatment with regard to functional outcome for aggressive tumors of the distal radius, vascularized fibular grafts is a valuable alternative especially in salvage procedures, where the use of another allograft could lead to higher complications rate. Keywords:...
Research Interests:
Skeletal muscle has an outstanding capacity for regeneration in response to injuries, but there are disorders in which this process is seriously impaired, such as sarcopenia. Pharmacological treatments to restore muscle trophism are not... more
Skeletal muscle has an outstanding capacity for regeneration in response to injuries, but there are disorders in which this process is seriously impaired, such as sarcopenia. Pharmacological treatments to restore muscle trophism are not available, therefore, the identification of suitable therapeutic targets that could be useful for the treatment of skeletal reduced myogenesis is highly desirable. In this in vitro study, we explored the expression and function of the calcium-sensing receptor (CaSR) in human skeletal muscle tissues and their derived satellite cells. The results obtained from analyses with various techniques of gene and protein CaSR expression and of its secondary messengers in response to calcium (Ca2+) and CaSR drugs have demonstrated that this receptor is not present in human skeletal muscle tissues, neither in the established satellite cells, nor during in vitro myogenic differentiation. Taken together, our data suggest that, although CaSR is a very important drug...
Research Interests:
Research Interests: Medicine and Haemophilia
Research Interests:
Telocytes (TCs), commonly referred to as TCs/CD34+ stromal cells, are a peculiar type of interstitial cells with distinctive morphologic traits that are supposed to exert several biological functions, including tissue homeostasis... more
Telocytes (TCs), commonly referred to as TCs/CD34+ stromal cells, are a peculiar type of interstitial cells with distinctive morphologic traits that are supposed to exert several biological functions, including tissue homeostasis regulation, cell-to-cell signaling, immune surveillance, and reparative/regenerative effects. At present, the majority of studies investigating these cells are mainly descriptive and focus only on their morphology, with a consequent paucity of functional data. To gain relevant insight into the possible functions of TCs, in vitro analyses are clearly required, but currently, the protocols for TC isolation are only at the early stages and not fully standardized. In the present in vitro study, we describe a novel methodology for the purification of human primary skin TCs through a two-step immunomagnetic microbead-based cell separation (i.e., negative selection for CD31 followed by positive selection for CD34) capable of discriminating these cells from other c...
Research Interests: Genetics, Chemistry, Biology, Cell Biology, Medicine, and 3 moreCD, Molecular sciences, and Vimentin
Reconstruction after maxillofacial trauma is extremely challenging. During the past several decades, the chimeric fibular-free flap has emerged as a leading reconstructive option for head and neck compound defects. This report describes a... more
Reconstruction after maxillofacial trauma is extremely challenging. During the past several decades, the chimeric fibular-free flap has emerged as a leading reconstructive option for head and neck compound defects. This report describes a unique case of total mandibular reconstruction using a double-paddle osteocutaneous fibular free flap after facial traumatic injury. A 45-year-old man presented a severe maxillofacial trauma with complete mandibular avulsion. The shortest segment of a 24-cm fibular flap was used to reconstruct the symphysis while the longest segments were placed to rebuild the mandibular body. Microvascular anastomoses were performed with the external jugular vein and facial artery. The distal skin island (10 × 5 cm) was sutured to cover the endo-oral defect while the proximal one (12 × 6 cm) to restore the external tissues continuity of the facial lower third. The postoperative course was uneventful. One year after flap reconstruction, a first commissuroplasty was performed. After 3 months, secondary commissuroplasty was performed with an Estlander flap to rebuild the right lower lip. At latest follow-up, 60 months postoperatively, the patient was able to tolerate soft diet with maximal mouth opening of more than 4 cm; no impairment to mastication, deglutition, or phonation was observed. Speech was normal and the aesthetic outcome was judged good. Double-paddle fibular free flap allows reconstruction of extremely challenging defects, such in case of complete mandibular avulsion. The proximal perforator can provide extended soft-tissue coverage and greater volume than traditional osteocutaneous flaps, avoiding two flaps simultaneous harvest.
Research Interests:
Dear Sir, We read with great interest the article titled: ‘‘Our 10 Years’ experience in Breast asymmetry correction’’ by Patlazhan G. et al. The authors presented their personal experience with breast asymmetry correction, reporting a... more
Dear Sir, We read with great interest the article titled: ‘‘Our 10 Years’ experience in Breast asymmetry correction’’ by Patlazhan G. et al. The authors presented their personal experience with breast asymmetry correction, reporting a very large case series including different types of clinical findings. We completely agree with the authors that correction of asymmetry is a common problem in breast surgery, representing a difficult challenge for plastic surgeons, including preservation of the long-term results. Breast surgery includes a wide range of clinical aspects, and therefore, every single case should be carefully evaluated. We congratulate the authors for the significant number of presented cases and results, but we have some elements to discuss. According to the authors, simple augmentation mammoplasty with different implants in patients with native breast asymmetry could not be sufficient and breast glands should be remodelled to achieve a long-term satisfactory symmetry. The authors’ personal classification of asymmetry includes shape, volume, presence and severity of ptosis and nipple–areola complex aspects, but we believe that also the difference in consistency between the breasts, including gland and soft tissue coverage, should be considered and included as parameter in the classification of breast asymmetry. This parameter is a very sensitive finding, especially in some congenital breast malformations such as tuberous breasts because different consistencies strictly reflect in maintaining long-term symmetry [1–3]. Authors proposed the Volume Shift Test (VST) to assess breast asymmetry preoperatively as well as during the surgical procedure. While intraoperative VST is a real objective evaluation of asymmetry, preoperative VST is very subjective and affected by personal sensibility based on a great experience and therefore it could be useful for experienced surgeons. We cannot agree with the authors that in size 1-mammary glands-Grade 1-asymmetry patients, different implants alone could be sufficient to maintain long-term results. Forty ml in difference could be considered a very low difference in larger breasts, but it could represent a very sensitive issue producing an evident asymmetry over time for size 1 mammary glands-Grade 1-asymmetry patients, strongly reflecting in conserving long-term stability of surgical correction [1]. In fact, this relatively small amount of breast in this type of patient could be considerably modified during the woman’s life and therefore gland reduction of the bigger breast should be considered also in size 1-mammary glands-Grade 1-asymmetry patients. Moreover, breast reduction of size 1-mammary glands-Grade 1-asymmetry patients represents a non-invasive surgical step without particular morbidities [4, 5].
Research Interests:
Research Interests:
Background Dorsal complex cutaneotendinous lesions of the hand represent a reconstructive challenge. The use of composite microvascular flaps and vascularized tendon grafts represent the gold-standard. The radial anti-brachial region can... more
Background Dorsal complex cutaneotendinous lesions of the hand represent a reconstructive challenge. The use of composite microvascular flaps and vascularized tendon grafts represent the gold-standard. The radial anti-brachial region can still represent an excellent donor site, to the detriment of the possible sacrifice of the radial artery. The reverse radial anti-brachial flap can be either perforator-based, thus saving the radial artery or raised as an adipo-fascial flap, to spare the skin. Patients and Methods A case of post-traumatic highly contaminated dorsal cutaneotendinous defect of the second ray of the hand was reported. An original surgical reconstructive technique with a Revers Radial Teno-Adipo-Fascial Flap (RRTAFF) plus vascularized Palmaris Longus was described, preserving the radial artery. A simple partial thickness skin graft was performed a second time to complete dorsal cutaneous coverage. A subsequent infection was managed by trusting the complete vascularizati...
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
ment of Gynecomastia” by Shirol. The author described a new interesting technique, comparing it with the most popular surgical procedures described in the literature to correct the malformation. Congratulations on the brilliant idea and... more
ment of Gynecomastia” by Shirol. The author described a new interesting technique, comparing it with the most popular surgical procedures described in the literature to correct the malformation. Congratulations on the brilliant idea and the excellent results achieved by the author, and we would like to expose elements for discussion. We totally agree with the author to consider gynecomastia as a psychological stress in men with feminine-looking breasts, but, even when affected by minor forms, patients are very upset with the disorder and require treatment for aesthetic purposes with different expectations according to their lifestyle, physical appearance, and personal perception of the malformation. In 2016, we published an article about our experience in the treatment of gynecomastia in 312 consecutive patients, comparing their dissimilar needs related to the different body types thus to optimizing the management of the same disorder according to different patients' expectations. Unlike the author, we performed 309 surgical procedures under local anesthesiawith sedation. Because the author used tumescent infiltration, we believe that local anesthesia could be considered in main procedure, thus to reduce costs, hospitalization, and aggressiveness of the procedure. Furthermore, the use of long-lasting anesthetics could increase postoperative comfort, reducing the need of medical therapy for pain control. We really appreciate the author's effort to minimize the scars as much as possible because postoperative scaring may represent a very sensitive issue for patients and may cause permanent embarrassment. In all our cases, the excision of the gland was performed using an emiperiareolar incision ranging from 2 up to 4 cm in length. Although our skin incision resulted longer than the one proposed by Shirol, it offers a good surgical visibility and we never reported unpleasant scar. Because complete excision of the gland seems to be the most appropriate treatment of gynecomastia to avoid recurrence, we be-
Research Interests: Medicine, Humans, Male, Gynecomastia, Clinical Sciences, and 4 moreAxilla, Lipectomy, Odorants, and Subcutaneous fat
A cutaneous horn could be defined as a conical projection on the surface of skin made of cornified material and resembling an animal horn. These lesions most commonly affect light-skinned men aged between 50 to 89 years and usually appear... more
A cutaneous horn could be defined as a conical projection on the surface of skin made of cornified material and resembling an animal horn. These lesions most commonly affect light-skinned men aged between 50 to 89 years and usually appear in sun exposed areas. Radiation, chronic irritation and even human papilloma virus-2 infection may be precipitating factors. More than half of the cases originate from either malignant or premalignant lesions, therefore the base of the lesion must be carefully examined histologically. Long standing presence of the lesion, conspicuous protrusion of the horn and pain are positive predictive factors for malignancy and invasivity. In these cases an invasive surgical approach is needed. Basal cell carcinoma, Cancer, Clow foot, Non melanoma skin cancer, Skin cancer.
Research Interests:
Surgical reconstruction after humeral resection represents a challenging issue in orthopaedic oncology. Particularly in paediatric patients, the main concerns are maintaining limb function and reconstruction longevity. We describe a novel... more
Surgical reconstruction after humeral resection represents a challenging issue in orthopaedic oncology. Particularly in paediatric patients, the main concerns are maintaining limb function and reconstruction longevity. We describe a novel strategy of humeral reconstruction based on the use of a three-dimensional-printed custom-made prosthesis in a 13-year-old patient diagnosed with osteosarcoma. The implant was specifically designed to sustain the native head, which was spared, as it was not involved by the neoplastic tissue. The mechanical support the prosthesis provided was associated with the biological stimulus of a free vascularised fibular graft to obtain an anatomic, functional and stable construct. This solution has had good longevity, and after 3 years of follow-up, the patient still shows excellent limb function and personal satisfaction.
Research Interests: Surgery, Prosthesis, Medicine, Fibula, Osteosarcoma, and 3 moreCase reports, Implant, and BMJ Case Reports
After studying this article, the participant should be able to: 1. Define the anatomy of the lower eyelid tarsoligamentous framework and the related periorbital retaining ligaments, and cite their surgical relevance. 2. Perform a... more
After studying this article, the participant should be able to: 1. Define the anatomy of the lower eyelid tarsoligamentous framework and the related periorbital retaining ligaments, and cite their surgical relevance. 2. Perform a systematic functional and aesthetic evaluation of the lower eyelid focusing on the lid-cheek junction, and clinical tests that predict the need for lateral canthal tightening. 3. Enumerate the different approaches to lower eyelid rejuvenation and discuss their merits/limitations. 4. Describe surgical strategies to blend the lid-cheek junction and tighten the lateral canthal retinaculum. Modern lower lid blepharoplasty requires a thorough understanding of periorbital anatomy, age-related changes of the lid-cheek junction, and the variables controlling lower lid tone and position. The surgical strategies are best used in a graded fashion. The patient with isolated lower lid bags may be treated by transconjunctival fat resection alone. Additional mild skin lax...
Research Interests:
Recently, custom-made 3D-printed prostheses have been introduced for limb salvage surgery in adult patients, but their use has not been described in pediatric patients. A series of 11 pediatric patients (mean age 10.8 years; range 2–13)... more
Recently, custom-made 3D-printed prostheses have been introduced for limb salvage surgery in adult patients, but their use has not been described in pediatric patients. A series of 11 pediatric patients (mean age 10.8 years; range 2–13) with skeletal tumors treated with custom-made implants for the reconstruction of bony defects is described. Patients were followed up every 3 months. Functional results were evaluated by the Musculoskeletal Tumor Society Score (MSTS) for upper and lower limbs. The mean follow-up was 25.7 months (range 14–44). Three patients died after a mean of 19.3 months postoperatively—two because of disease progression and the other from a previous malignancy. Three patients experienced complications related to soft tissues. One patient required device removal, debridement, and antibiotic pearls for postoperative infection. Partial osseointegration between grafts and host bone was observed within a mean of 4 months. At the final follow-up, mean MSTS score was 75%...