The two-stage breast reconstruction with tissue expander and prosthesis is nowadays a common method for achieving a satisfactory appearance in selected patients who had a mastectomy, but its most common aesthetic drawback is represented by an excessive volumetric increment of the superior half of the reconstructed breast, with a convexity of the profile in that area. A possible solution to limit this effect, and to fulfil the inferior pole, may be obtained by reducing the inferior tissue resistance by means of capsulotomies. This study reports the effects of various types of capsulotomies, performed in 72 patients after removal of the mammary expander, with the aim of emphasising the convexity of the inferior mammary aspect in the expanded breast. According to each kind of desired modification, possible solutions are described. On the basis of subjective and objective evaluations, an overall high degree of satisfaction has been evidenced. The described selective capsulotomies, when properly carried out, may significantly improve the aesthetic results in two-stage reconstructed breasts, with no additional scars, with minimal risks, and with little lengthening of the surgical time.

Sir: The removal of a breast implant is a relatively frequent operation in both plastic surgery and reconstructive surgery. As for the implant also, the removal occurs through rather small skin incisions with respect to the dimensions of the prosthesis. In general, the implant to remove is eliminated from its pocket manually by the operator who, to be able to proceed in such an operation, is forced to pinch the implant with his or her fingers to ensure optimal take, and to put it in traction with a force directly proportional to the dimensions of the prosthesis and inversely proportional to the dimensions of the skin incision. This solution exposes the prosthesis and in particular its external coating to two forces: one of compression (because of the initial pinching) and one of traction (the amount of which greatly increases the possibility of rupture of the prosthesis). Despite the high frequency of this action during surgical procedures with the use of prostheses in mammary areas, only a few solutions have been proposed.1,2 To reduce the mechanical stress on the prosthesis as much as possible, in our clinic practice, we developed a simple system based on the use of negative pressure applied on a unique surface reduced by the coating of the implant, allowing simple removal, by avoiding manual contact of the operator and reducing the possibility of rupture of the implant. In particular, a syringe of 60 ml is used, without the plunger, which is connected with the beak of the flask to the aspiration system (Fig. 1).Fig. 1.: A 60-ml syringe, without the plunger, connected with the beak of the flask to the aspiration system.The back part of the syringe is then made to adhere to the implant's surface, creating a vacuum system that allows the implant to be removed through a soft traction toward the outside. The advantages of such a system are many and represented (1) by the absence of the pressure and back-pressure exercised by the digital pinching with mechanical stress limited to a sole surface of the shell (Fig. 2), allowing safer removal, especially in case of a ruptured silicone gel implant; and (2) by greater control of the force of traction exercised by the operator through the comfortable grip offered by the length of the syringe cylinder.Fig. 2.: The back part of the syringe is made to adhere to the implant's surface, creating a vacuum system that allows the implant to be removed through soft traction toward the outside.Giuseppe Nisi, M.D. Matteo Campana, M.D. Massimiliano Calabrò, M.D. Anna Brafa, M.D., Ph.D. Carlo D'Aniello, M.D. Department of General and Specialistic Surgery Plastic and Reconstructive Surgery Unit “S. Maria alle Scotte” Hospital University of Siena Siena, Italy

Mesenchymal stem cells (MSCs) from human adult adipose tissue (A-MSCs) have a better differentiative ability than MSCs derived from the derma (D-MSCs). To test whether this difference is associated with differences in the content of multi-potent progenitors in A-MSCs, the number and the differentiative properties of multi-potent progenitors have been analyzed in various preparations of A-MSCs and D-MSCs. Adipogenic and osteogenic differentiation performed on colony-forming units have revealed that adipogenic and osteogenic progenitors are similar in the two populations, with only a slighty better performance of A-MSCs over D-MSCs from passages p0 to p15. An analysis of the presence of tri-, bi-, uni- and nulli-potent progenitors isolated immediately after isolation from tissues (p0) has shown comparable numbers of tri-potent and bi-potent progenitors in MSCs from the two tissues, whereas a higher content in uni-potent cells committed to adipocytes and a lower content in nulli-potent cells has been observed in A-MSCs. Furthermore, we have characterized the progenitors present in A-MSCs after six passages in vitro to verify the way in which in vitro culture can affect content in progenitor cells. We have observed that the percentage of tri-potent cells in A-MSCs at p6 remains similar to that observed at p0, although bi-potent and uni-potent progenitors committed to osteogenic differentiation increase at p6, whereas nulli-potent cells decrease at p6. These data indicate that the greater differentiative ability of A-MSC populations does not correlate directly with the number of multi-potent progenitors, suggesting that other factors influence the differentiation of bulk populations of A-MSCs.

In our patient, the size of the lesion required reconstruction with a transposition flap, as direct closure was not possible without modification of the skin of the scalp.

In 2002, a 41-year-old woman had been treated for severe buttock lipodystrophy resulting from highly active anti-retroviral (HAART) therapy medication. During a single session the loss of subcutaneous fatty tissue had been compensated by injections of an undefined quantity of polyalkylimide 4% (Bio-Alcamid™, Polymekon Biotech Industry, Milan, Italy). The post-treatment course had been uneventful and the patient had initially been satisfied with the result of this treatment. Seven years later, the patient presented with a redness and swelling of the area (Figure 1) by our unit. The area was hard and extremely painful on touch. All previous antibiotic therapies led only to temporary relief of these symptoms. A bedside drainage of the abscess was performed through a 20-gauge intravenous cannula that was inserted in the thin collagen capsule surrounding the gel (Figure 2). The patient underwent bedside irrigations with 10% povidone-iodine solution three times daily. Large spectrum antibiotics were continued intravenously. Microbiologic culture demonstrated the growth of Escherichia coli susceptible to the first line antibiotic treatment Levofluoxacina (intravenous Levoxacin®, a vial/24 h for three days). The inflammation subsided, and the infection had resolved 3 days after admission. The patient was discharged from our department with a 7-day regimen of oral Levoxacin® (500 mg/24 h). Re-examination of the patient after 1, 3, 10 and 18 weeks yielded no signs of granuloma formation or local findings of inflammation or irritation. No further treatment was required. Figure 2Bedside drainage of the abscess by puncturing the membrane formed around the filler. View Large Image Figure Viewer Download Hi-res image

A wound is defined as chronic when it does not heal according to the normal repair times and mechanisms. This particular condition may be principally due to local hypoxia. Carbon dioxide (CO(2)) therapy refers to the transcutaneous or subcutaneous administration of CO(2) for therapeutical effects on both microcirculation and tissue oxygenation. In this study, we report the clinical and instrumental results of the application of CO(2) in the therapy of chronic wounds. The study included 70 patients affected by chronic ulcers. The patients were selected by aetiology and wound extension and equally divided into two homogeneous groups. In group A, CO(2) therapy was used in addition to the routine methods of treatment for such lesions (surgical and/or chemical debridement, advanced dressings according to the features of each lesion). In group B, patients were treated using routine methods alone. Both groups underwent to instrumental (laser doppler flow, measurement of TcPO(2)), clinical and photographic evaluation. In the group that underwent subcutaneous treatment with CO(2) therapy, the results highlighted a significant increase in tissue oxygenation values, which was confirmed by greater progress of the lesions in terms of both healing and reduction of the injured area. Considering the safety, efficacy and reliability of this method, even if further studies are necessary, we believe that it is useful to include subcutaneous carbon dioxide therapy in the treatment of wounds involving hypoxia-related damage.

In April 2008, a 37-year-old white woman was referred to our Plastic Surgery Unit with a history of red-violet, painful, bilateral pretibial nodosities that had become ulcerated for 3 years. The medical history of these patient was considerable despite her young age, revealing recurrent Erythema Nodosum (EN) since 1992, and the diagnosis of ileo-colo-rectal Crohn's Disease in 1996, complicated by sacroileitis and symmetric polyarthritis of the knees, ankles and wrists. The patient was placed on immunomodulating drug therapy through cycles of oral corticosteroids and immunosuppressive drugs and, moreover, oral sulfasalazyn. The disease was sufficiently treated and under controlled, so as cutaneous manifestation resolved (re-appearing sporadically during rare exacerbation of Crohn's disease). Unfortunately, in 1998 the patient contracted pulmonary tuberculosis for which, subsequently, patient clinical situation slowly worsened since immunosuppressive therapy was stopped.

BACKGROUND:Digital epiluminescence dermoscopy is a relatively recent tool, based on the acquisition of high-definition digital images, for the diagnosis of pigmented cutaneous lesions.PURPOSE:To verify the usefulness of digital dermoscopy in detecting pigmented lesions with features which may lead to suspicion of malignancy, when the examination is carried out by primary care physicians (PCP), not expert in that kind of diagnosis. Another target was an appraisal of the effectiveness and safety of telediagnosis based on epiluminescence digital dermoscopy on pigmented lesions.METHODS:Digital images from some peripheral centres (235 lesions) have been forwarded in real time to the reference centre (Unit of Plastic Surgery, University of Siena, Italy), with a double judgement by each primary care physician ('benign' or 'suspicious of malignancy') on the basis of anamnesis and clinical examination at first step, and dermoscopy as second step. The image analysis carried out from the reference centre identified every lesion examined as 'to be controlled' (219 lesions) or 'to be removed' (16 lesions).RESULTS:Regarding the patients with dermoscopic examination (197 subjects, 235 lesions), the investigation reduced the number of lesions suspected of malignancy from 68 to 29 after the first dermoscopy, and from 29 to 16 after the re-examination of the image by the central unit researchers. Fourteen lesions suspected of malignancy when examined in the peripheral centres were then evaluated as benign by the central unit researchers, while one lesion, judged as benign at first (always labelled as 'benign' by the PCP), was then revealed as a dysplastic naevus.CONCLUSION:Digital dermoscopy can be enhanced by telediagnosis, which provides a better control of cutaneous pigmented lesions in the peripheral areas, thus reducing the number of consultations in specialised centres.