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OBJECTIVE: The purpose of our study was to compare Merocel (Merocel Hemox 10 cm) and BNP (biodegradable nasopore) during a septoturbinoplasty procedure in terms of efficiency and patient comfort. PATIENTS AND METHODS: We carried out a retrospective review of 72 patients who had undergone septoturbinoplasty between January 2015 and January 2016. Each group, packed with BNP or Merocel Hemox 10 cm was composed of 36 patients. A standard visual analogue scale ranging from zero (no symptoms) to 10 (the most severe symptoms) was used to assess subjective symptoms. To compare the usefulness of materials we evaluated the postoperative bleeding, infection and adhesion after the removal of packing with and endoscopic examination using a 5-point scale (zero, absent; 1,mild; 2,moderate; 3, severe; and 4, very severe). Secretions and crusts were evaluated 1 week and 4 weeks after surgery in both groups using a 5-point scale (zero, absent; 1, mild; 2,moderate; 3, severe; and 4, very severe). RESULTS: A total of 72 patients were enrolled in the study, 45 women and 27 men; age range 15-78 with a mean age of 47 years. In the group A (Merocel group), 21 cases showed grade 1 bleeding (58%), 11 cases grade 2 (30%) and 4 patients grade 0 (11.1%). In the group B (BNP group), 29 cases showed grade 0 bleeding (80.56%) and 7 cases showed grade 1 bleeding (19.44%). There was a statistical significant difference between the Merocel group and the BNP group in terms of bleeding after removal of packing material (p < 0.05). In the group A, 16 patients developed mild adhesion (44%), 8 patients moderate adhesion (22.2%), 3 patients severe adhesion (8.33%) and 1 patient very severe adhesion (2.77%). BNP nasal packing didn't cause any adhesion in 25 patients (69.4%), 11 patients developed mild adhesion (30.5%). So there was a European Review for Medical and Pharmacological Sciences Comparative study between biodegradable nasopore (BNP) and Merocel hemox 10 cm after septo-turbinoplasty procedure statistical significant difference between group A and group B regarding the adhesion (p < 0.05). There was a statistically significance reduction of nasal secretions and crusts at a week after surgery in the BNP group vs. Merocel group. The difference is not statistically significant 4 weeks after surgery. About the severity of symptoms related to nasal packing, we found a statistically significant difference (p < 0.05) between Merocel and BNP group regarding the pain during packing removal, the general satisfaction and the pressure. CONCLUSIONS: Biodegradable nasopore reduced pain and patient discomfort during packing removal and causes less bleeding compared to Merocel hemox 10 cm. This type of material can be used after septoturbinolplasty.

Induced Pluripotent Stem Cells (iPSCs) are adult somatic cells genetically reprogrammed to an embryonic stem cell-like state. Fibroblast (FB) is the adult somatic cell most commonly used for reprogramming and is defined by spindle-shape morphology, plastic-adherence and expression of several markers. Nonetheless, such properties also define Mesenchymal Stem Cells (MSCs), that also share with dermal FB the ability to differentiate into osteoblasts, adipocytes and chondroblasts. Moving from the hypothesis that the most striking difference between FBs and MSCs is in the name, we isolated and cultured human dermal and visceral FBs from tissue waste fragments of patients undergoing surgical procedures, and evaluated their morphology and expression of markers typical of MSCs, at gene and protein level. Additionally, we analyzed synthesis and release of specific growth factors in culture medium and, finally, we tested FB ability to differentiate into osteoblasts, adipocytes and chondroblasts. Interestingly, all FBs in culture adhered to plastic culture dishes, expressed markers typical of MSCs, like CD90, CD105, CD146,SSEA-4, ECM2, ID-1, and were morphologically undistinguishable. As reported for MSCs, FBs released EGF, FGF-4, GDNF, HGF, IGF, TGF-b and VEGF, and were capable of differentiating into cells of mesodermal origin. Our findings raise the question of whether FBs and MSCs are not admittedly the same population.We might infer that previously described differences are due to different stages of differentiation, which also account for reports on high variability in both expression of mesenchymal markers by MSCs and efficiency of FB reprogramming to iPSCs.

A female full term newborn was transferred, immediately after birth, to our Intensive Neonatal Care Unit with diagnosis of collodion baby. On admission the skin surface was covered by a cornified substance of uniform texture, thinner at the joints’ level, which gave the whole body a varnished appearance;1 the newborn showed oedema of upper and lower limbs, ectropion, lip eversion, flattening of the nose and bilateral deformities of ear. Laboratory investigations and urinalysis were normal.

High-resolution (17 MHz) color-Doppler ultrasound (US) is used in the evaluation of normal and pathological skin. To analyze retrospectively the sonographic pattern of healthy skin and of some skin lesions using Doppler US and to compare the results with dermoscopy examination and histology to identify specific patterns of ultrasound for differentiating benign from malignant lesions. To select among them the Melanomas to describe their US pattern, the presence and morphology of vascular signal and to compare their thickness at US with the Breslow index. After signing informed consent in accordance with the ethical standards laid down in the Declaration of Helsinki in 1964 and its subsequent amendments, 104 patients with skin lesions were retrospectively studied. Patients were evaluated with clinical dermatological examination and Doppler US, and underwent surgical excision with subsequent histological analysis. Statistical analysis: the difference between variables was analyzed with statistical Chi square test or Fisher's when appropriate. The strength of the relationship between variables was analyzed with Pearson's r coefficient. The sensitivity and specificity of US tests were also calculated. Sixty-five malignant lesions and 39 benign lesions were identified at Doppler US. In the 34 melanomas, typical US and vascular patterns were identified depending on the thickness of the lesion and a strong correlation between the latter and Breslow index was confirmed. Doppler US is a valuable diagnostic tool for the study of skin and for preexcision characterization of skin lesions.

The introduction of sutures using Polyglecaprone 25 (Monocryl--Ethicon SpA) has facilitated the use of intradermal suture with separate stitches owing to its flexibility and softness, with extremely satisfactory aesthetic results. The authors report their experience regarding the use of this new material from May 1995 to April 1996 in 250 cases of intradermal suture with separate stitches. The paper also describes a few technical details and emphasis their advantages.

Introduction The training to learn how to perform perforator flaps requires practice on a living model to optimize dissection and to evaluate outcome. The purpose of this study was to describe a training model that optimizes the use of animals in order to perform the maximum number of exercises per animal. Material and methods The sequence has been planned and practiced by the first and last author, recorded perfected and implemented in a two-day surgical course. The sequence was then evaluated by the trainers and the trainees by means of a questionnaire. Results All students were able to complete the sequence of exercises before the end of the second day except two (8/10) who could not complete one exercise each. The students considered the Deep Superior Epigastric Artery Perforator flap the most difficult to perform, being the most technically demanding. The sequence of exercises was judged either easily reproducible or reproducible by all the students. Two students suggested to postpone the DSEAP flap to the second day, after some training, to optimize the experience with the most challenging and rewarding flap. Conclusions The training sequence proposed offers a wide range of exercises and allows four trainees, divided in two teams, to work and learn on the same animal. They can perform a wide range of flaps and also harvest the internal mammary vessels. The living model allows for evaluation of the quality of the surgical performance, judged by the difficulties and complications encountered during dissection, and finally through the feedback of flap perfusion.

BACKGROUND Microsurgical training on rats before starting with clinical practice is a well-established routine. Animal model training is less widespread for perforator flaps, although these flaps represent a technical challenge. Unlike other flaps, they require specific technical skills that need to be adequately trained on a living model 1 : a cadaver is not enough because no bleeding, vessel damage, or vasospasm can be simulated. 2 The purpose of this study was to assess the suitability of the porcine abdomen as a training model for the deep inferior epigastric artery perforator (DIEAP) flap, commonly used in human breast reconstruction. METHODS A female swine (Sus scrofa domesticus, ssp; weight 25kg) was used. The procedure was performed with the pig under general anesthesia and in the supine position. A deep superior epigastric artery perforator (DSEAP) flap was harvested on the left side of the abdomen, including the 3 cranial nipples and stopping in the midline to spare the contralateral flap for another dissection (as in bilateral breast reconstructions in humans; Fig. 1). All steps of a DIEAP harvest were simulated: superficial vein harvest, suprafascial perforator dissection, intramuscular perforator harvest with preservation of the nerves, and flap isolation. Observation of capillary refill was used to confirm flap viability at the end of the dissection. The procedure was recorded by means of a GoPro camera and simultaneously with a head mounted (4× magnification) Loupecam system. Photographs were taken using 2 cameras during surgery at relevant time points. RESULTS At the end of the dissection, the flap was viable. The subcutaneous adipose tissue of the pig is less represented than in human and pigs have an additional muscular layer, the panniculus carnosus, which is the analogue of the human Scarpa's fascia. The rectus fascia is thinner. The perforators are lined in 2 rows: 1 lateral and 1 medial, as in the DIEAP, and the intercostal nerves cross the vessels, as happens in humans. The porcine rectus abdominis muscle is thinner than the human one, but vessels' branching faithfully reproduces the human model. 1 We identified 5 perforating vessels of more than 1mm in diameter (2 lateral and 3 medial). We isolated a lateral perforator first and a medial one last: the latter was eventually used to nourish the flap (Fig. 2). CONCLUSIONS The DSEAP flap allows one to closely reproduce all the steps of DIEAP flap harvesting and also to carry out the intramuscular dissection of 2 perforators for each side (up to 4 for each animal), confirming the adequacy of this pig model for microsurgical training. The deep superior epigastric artery is dominant in pigs. 3 Despite this anatomical difference, the DSEAP allows one to reproduce the main steps of DIEAP flap harvesting, providing an excellent training model. Moreover, the presence of double perforating rows allows simulating the dissection twice on each side.

Background Ear defect reconstruction still remains a surgical challenge today. Proper reconstruction should result in correction of the deformity with minimum morbidity with the aim of achieving the most esthetically pleasing outcome possible. Herein, we present our clinical experience with propeller flap reconstruction of external ear defects with a focus on indications and surgical technique. Methods Fourteen patients underwent surgery at our Plastic Surgery Unit between January 2015 and October 2019. After identifying perforators with a handheld Doppler ultrasound, a tailor-made flap was designed for each patient. Following tumor excision, dissection of the pedicle and of the remaining flap was performed with the aid of surgical loops. Flap in-setting and donor site closure were final steps. Results Flaps have survived in their entirety in almost all our patients (13/14) maintaining optimal color and elasticity and showing no complications. In one case, a superficial distal necrosis was observed and, in another patient, tumor recurrence took place. Conclusions Propeller flaps offer great advantages when used in ear reconstruction ensuring excellent esthetic results with a one-stage technique. Nevertheless, it must be kept in mind that good dissection skills are required in order to avoid complications. Level of evidence: Level IV, Therapeutic study.

Arteriovenous malformations (AVMs) are rare congenital errors of vascular morphogenesis, characterised by abnormal direct communications between arteries and veins, bypassing the normal capillary bed. Apart from the central nervous system, typical locations include the head and neck, and less frequently limbs, trunk or internal organs. AVMs of the head and neck often become clinically evident and symptomatic only in later childhood and are characterised by a history of variable growth, sometimes leading to large, deforming, pulsating masses with a propensity to massive haemorrhage. Therapeutic strategy is based on selective embolisation, surgical excision, or a combination of both. Radical surgical excision of local AVMs is the only effective treatment but it may be mutilating, especially for AVMs of the head and neck. Laser therapy represents a good option to treat the cutaneous aspects of AVMs nevertheless, its efficacy is limited. To the date, pharmacological therapy for AVMs is still on debate due to its controversial outcomes as it seems not as effective as other treatments and usually requires a longer course of application. However, pharmacological therapy could be useful in selected patients and for AVMs nonresponsive to traditional treatment, allowing them to obtain acceptable results without serious complications. This paper reports the case of a serious laser complication of extensive intraorbital AVM successfully treated by local reconstruction and topical pharmacological treatment.

Background Basal cell carcinoma is the most common non-melanoma skin cancer of the nose. Defects of the nasal ala and tip region are among the most difficult to repair due to their intrinsic characteristics. Objective To present our experience with the extended rotation flap for reconstruction of nasal ala defects and evaluate the outcome using the Patient and Observer Scar Assessment Scale (POSAS). Methods and Materials Twenty-two patients with partial thickness nasal ala defects reconstructed using the extended rotation flap were assessed. Final cosmetic and functional outcomes were evaluated using the POSAS. Results Flaps survived in all the reported cases and no major complication was recorded. Histology showed complete excision of the tumour in all cases. Using the POSAS, the mean overall evaluation for patients was 1.8/10, while the mean overall evaluation for the evaluation panel was 2.2/ 10. Conclusion Although similar flaps have been previously described, the extended rotation flap for nasal ala and tip reconstruction represents a functionally and cosmetically appealing wound closure option, respecting and avoiding any distortion of the alar crease.

Adiposity and diabetes affect breast cancer (BC) progression. We addressed whether glucose may affect the interaction between mammary adipose tissue-derived mesenchymal stromal/stem cells (MAT-MSCs) and BC cells. Two-dimensional co-cultures and spheroids were established in 25 mM or 5.5 mM glucose (High Glucose-HG or Low Glucose-LG) by using MAT-MSCs and MCF7 or MDA-MB231 BC cells. Gene expression was measured by qPCR, while protein levels were measured by cytofluorimetry and ELISA. CD44high/CD24low BC stem-like sub-population was quantified by cytofluorimetry. An in vivo zebrafish model was assessed by injecting spheroid-derived labeled cells. MAT-MSCs co-cultured with BC cells showed an inflammatory/senescent phenotype with increased abundance of IL-6, IL-8, VEGF and p16INK4a, accompanied by altered levels of CDKN2A and LMNB1. BC cells reduced multipotency and increased fibrotic features modulating OCT4, SOX2, NANOG, αSMA and FAP in MAT-MSCs. Of note, these co-culture-mediated changes in MAT-MSCs were partially reverted in LG. Only in HG, MAT-MSCs increased CD44high/CD24low MCF7 sub-population and promoted their ability to form mammospheres. Injection in zebrafish embryos of HG spheroid-derived MCF7 and MAT-MSCs was followed by a significant cellular migration and caudal dissemination. Thus, MAT-MSCs enhance the aggressiveness of BC cells in a HG environment.

Introduction Skin tags are benign lesions, that often represent only an aesthetic problem; if subjected to trauma, they can occasionally bleed with possible infection and pain. When they occur in the preauricular region, attention should be paid to the diagnosis and approach; in fact, controversy exists in the differential diagnosis between hair follicle nevi, accessory tragus, and skin tag. Misdiagnosis and failure of treatment can lead to serious consequences, such as chondritis. Materials and Methods In our retrospective study, we evaluated 19 newborns affected by single, unilateral skin tag in the preauricular region. Each patient underwent a careful clinical examination; lesions without a pilosebaceous unit and with a thin, soft pedicle were treated in the nursery with Ligaclip (Johnson & Johnson). Results Skin tag falls between day 7 and 10. We had no cases of edema, cellulitis, clip loss, or bleeding. Scarring results were extremely satisfactory at 3-month follow-up. Conclusion We believe that after a careful clinical examination, cases of skin tags in the preauricular area can be selected and treated with Ligaclip. This procedure can be considered rapid, safe, economical, and simple in the newborn patients.

Skin grafting is a reliable and commonly used technique to cover skin defects due to multiple etiologies. The most common and used skin-graft dressing is the well known “tie-over dressing”, made of sterile gauzes or sterile sponge, on the top of a tulle gras sheet, stabilized with loop sutures. The use of surgical sponge provides homogenous pressure over the graft reducing the risk of complications such as hematoma or seroma formation between the skin-graft and the recipient bed. Furthermore, the residual povidone-iodine in the sponge is an anti-infection agent, so it may protect the skin graft from bacterial colonization. The use of this technique provides many advantages: low cost, appropriate protection of the graft and the pressure is evenly distributed. Furthermore it gives an antibacterial shield thanks to the residual povidone-iodine in the sponge. Lastly it is a fast tecnique and reduce the patient post-operative discomfort. This method, although effective, has disadvantages: once the tie-over dressing is in place, the surgeon cannot easily visualize the graft site to check for complications that may lead to partial or total graft loss. In conclusion, the combination of sterile scrubbing sponges with skin surgical staples can be an affordable, time saving and reliable alternative to the commonly used sterilized rubber foam fixed by suture for skin graft tie over dressing.

Introduction: Kidney transplant recipients and patients on the waiting list for kidney transplant who acquire SARS-CoV-2 infection are at serious risk of developing severe COVID-19, with an increased risk of mortality for the their immunosuppressive state; other risk factors for mortality have been identified in some comorbidities such as obesity, diabetes, asthma and chronic lung disease. Materials and methods: The COVID-19 pandemic has led to a sharp reduction in kidney transplants in most countries, mainly due to the concern of patients on the waiting list for their potential increased susceptibility to acquire SARS-CoV-2 infection in healthcare facilities and for the difficulties of transplant centers to ensure full activity as hospitals have had to focus most of their attention on COVID-19 patients. Indeed, while the infection curve continued its exponential rise, there was a vertical decline in kidney donation/transplant activity. Conclusion: This review article focuses on the damage induced by SARS-CoV-2 infection on kidney and on the adverse effect of this pandemic on the entire kidney transplant sector.

Elective localization at the upper left chest of Dermatofibrosarcoma Protuberans

Summary Introduction Among the few methods available, none is able to determine accurately the volume of a DIEP flap. Specimen weight is commonly used to assess the amount of flap needed to reconstruct a breast, but the density of breast is different from that of abdominal tissues; therefore, the volume should be used as a unique unit of measure. The purpose of this study was to provide a simple method to calculate the predicted volume of a DIEP flap in order to match the volume of the breast being reconstructed. Material and Method We hypothesised that the shape best resembling a DIEP flap was a truncated pyramid. Based on this shape, we tailored 30 DIEP flap models using the discarded tissue after unilateral DIEP flap breast reconstructions. The awaited volume (AV) of the models was calculated with a free online calculator measuring the length and height with a ruler, and width (fat thickness) with Ultrasound (US). The real volume (RV) of the models was calculated using water displacement method. AV and RV were compared and statistical analysis was performed. Results The mean difference between the AV and the RV was not statistically significant with a mean estimation error of 6.75%. When the AVs were plotted against the RVs, the two data sets were highly statistically correlated (correlation coefficient (r = 0.997). Conclusions The proposed tool can be a useful, precise, easy and accessible tool to improve the current DIEP flap size assessment improving outcomes for both surgeons and patients.

Syringe plunger: An alternative sterile skin-marker in plastic surgery

Alar base surgery has been widely studied in modern rhinoplasty. After the equalization of the dorsum-tip relationship and the improvement of the nasolabial, nasocolumellar and nasofrontal angle, also alar base, needs to be harmonized also. Several classifications of alar base deformities have been described, as well as many techniques for correcting them. This work aims to demonstrate that alar base symmetrization suture (abss) is effective in keeping the nasal wings symmetrical immediately after alar wedges resection and also permits maintenance of the symmetrization during time. It is a simple technique to perform with long-lasting esthetic results. Level of evidence: Level V, therapeutic study.

Reconstruction of scalp defects can be performed with local flaps for medium to large defects (2–25 cm2) and microvascular free flaps for extensive full-thickness scalp reconstruction greater than 25 cm2. Doppler flowmetry with its ability to exactly mark the course of arteries on the overlying skin, is a useful tool for the surgical planning of large local flaps. In our retrospective study conducted on 38 patients (all patients had malignancies or post-traumatic scalp defects), consisting of 39 total surgical procedures, we studied the impact of doppler ultrasonic flowmetry in the surgical planning for pedicled flaps in extensive full-thickness scalp reconstruction (>25 cm2) by evaluating overall flap survival rate. Nine different types of local flaps were employed in the scalp reconstruction: Superficial temporal artery (STA) pedicled rotation flap, STA pedicled transposition flap, STA islanded flap, bipedicled STA flap, bipedicled fronto-occipital flap, Supraorbital/Supratrochlear artery rotation flap, Supraorbital/Supratrochlear artery transposition flap, Occipital artery (OA) pedicled rotation flap, OA pedicled transposition flap. Before each surgical procedure a hand held doppler Huntleigh Diagnostic flowmeter with a 8 MHz probe was used to identify and follow the course of the arteries. Flap survival rate was 100%. No postoperative complications related to the flap were reported, while in two patients a partial skin graft failure occurred.