Breast amyloidosis: a case report

Amyloidosis is an uncommon disorder characterized by extracellular deposition of abnormal proteins. Breast involvement has rarely been reported and can clinically be misdiagnosed as breast cancer. A 60-year-old woman presented with a 3-mm diameter mass in the right breast close to a silicon implant positioned 20 years before. A core biopsy, performed to rule out breast cancer, showed amyloid deposit. Further exams confirmed a systemic amyloid light chain amyloidosis. After few months the mass increased causing breast volume and shape distortion. Since breast cancer may be the cause of amyloid deposits or be hidden by it, the patient underwent a bilateral skin sparing mastectomy and expander and fat grafting breast reconstruction. The resection specimens showed amyloid deposits only, no evidence of cancer. At 2 years follow-up, no breast amyloidosis recurrence was shown. Breast amyloidosis is rare but can occur in a plastic surgeon\u2019s practice. It is mandatory to rule out a comitant breast cancer or systemic amyloidosis

Aspetti di Chirurgia Rigenerativa della Mammella

L’uso del trapianto di tessuto adiposo auto-logo per riempire difetti e rimodellare i contorni corporei è stato descritto oltre un secolo fa. La prima descrizione sull’uso del trapianto di tessuto adiposo come “filler” venne da Czerny nel 1985 il quale per primo aumentò una mammella con un lipoma rimosso dal dor-so 1. L’innesto di tessuto adiposo è stata una tecnica ben descritta nella prima parte del ven-tesimo secolo 2. Tuttavia entrò in disuso dopo qualche pre-occupazione nata nel 1950 riguardo la perdita di volume in tale tipo di trapianto 3. L’uso corrente del lipofilling risale al 1987, quando Bircoll descrisse un metodo che ac-coppiava la liposuzione con il trapianto nella mammella del tessuto adiposo prelevato 4. Il maggior vantaggio citato di questa tecnica è legato al fatto dell’illimitato sito donatore. Tuttavia ci furono immediatamente preoc-cupazioni riguardo al fatto che questa tecnica potesse provocare cicatrici interne nel tessuto mammario, che potessero interferire o creare dubbi durante lo screening. Questo spinse l’American Society of Plastic and Reconstructive Surgeons ad emanare una dichiarazione nel 1987 che condannava l’uso di questa procedura 5. Più o meno nello stesso periodo, compari-rono numerosi articoli scientifici che suggeriva-no che molte altre procedure sulla mammella, come la mastoplastica riduttiva, portavano a cicatrici mammarie che erano poi visibili duran-te le metodiche di screening mammario e che queste cicatrici erano di gran lunga più volumi-nose rispetto a quelle che ci si poteva aspetta-re in seguito ad un intervento di trapianto di tessuto adiposo autologo 6. In aggiunta, numerosi case reports e case series sono stati pubblicati nel corso degli anni, nessuno supportante alcuna evidenza delle precedenti preoccupazioni in merito alla tecni-ca. Ci sono stati cambiamenti e miglioramenti nella tecnica di esecuzione che hanno portato ad maggiore confidenza soprattutto in ricostru-zione e rimodellamento mammario 7. Così che nel 2009 l’ American Society of Plastic Surgeons nel 2009 rivide la sua prece-dente condanna del 1987 riguardo alla sicu-rezza 8. Attualmente il trapianto adiposo autologo rappresenta la procedura più frequentemente utilizzata in chirurgia mammaria ricostruttiva ed estetica. La procedura è semplice, sicura e ri-producibile. Il tessuto adiposo risulta essere biocompatibile, versatile, naturale, non immu-nogenico, gratuito e facilmente ottenibile. Diverse tecniche sono state descritte sul metodo di prelievo. In tutte queste il tessuto adiposo viene prelevato, processato e innesta-to 7-9. È una procedura sicura che può permettere di: - migliorare e correggere avvallamenti e cica-trici, dopo chirurgia conservativa mammaria e a supporto di altre tecniche ricostruttive - trattare asimmetrie e patologie malformati-ve (mammella tuberosa) - ricostruzione di intere mammelle dopo chi-rurgia demolitiva - supporto a tessuti radiotrattati o che do-vranno subire radioterapia - aumenti di volume mammari

Breast amyloidosis: a case report

Amyloidosis is an uncommon disorder characterized by extracellular deposition of abnormal proteins. Breast involvement has rarely been reported and can clinically be misdiagnosed as breast cancer. A 60-year-old woman presented with a 3-mm diameter mass in the right breast close to a silicon implant positioned 20 years before. A core biopsy, performed to rule out breast cancer, showed amyloid deposit. Further exams confirmed a systemic amyloid light chain amyloidosis. After few months the mass increased causing breast volume and shape distortion. Since breast cancer may be the cause of amyloid deposits or be hidden by it, the patient underwent a bilateral skin sparing mastectomy and expander and fat grafting breast reconstruction. The resection specimens showed amyloid deposits only, no evidence of cancer. At 2 years follow-up, no breast amyloidosis recurrence was shown. Breast amyloidosis is rare but can occur in a plastic surgeon’s practice. It is mandatory to rule out a comitant breast cancer or systemic amyloidosis

Tecnica chirurgica dei lembi perforanti peduncolati (Giorgio De Santis Giulia Boscaini Salvatore D\u2019Arpa Marco Pignatti). CAPITOLO 06

Ilembi perforanti sono lembi vascolarizzati da una arteria (e da una o due vene comitanti) pro- veniente da un vaso dominante profondo che raggiunge e nutre la cute con un percorso pi\uf9 o meno diretto, perpendicolare verso la super cie. Questi vasi sono stati de niti perforanti secondo la classi cazione di Gent.1,2 Questi vasi possono raggiungere la super ce: \u2022 passando attraverso un muscolo (p. indiretta) \u2022 al margine di un muscolo (p. diretta) \u2022 nei setti tra i ventri dei muscoli (p. settocutanea). Basare un lembo su un peduncolo perforante noto permette al chirurgo di non dover obbedi- re alle classiche regole della preparazione dei lembi, come ad esempio la legge lunghezza/ ampiezza peduncolo, ma di isolare un lembo di forme differenti e dimensioni che non sarebbero state possibili coi lembi tradizionali, random o fascio cutanei.3,4 In questo modo l\u2019isola cutanea pu\uf2 essere model- lata sulla forma del difetto, ottimizzando la chiu- sura del sito donatore. Inoltre si possono evitare la restrizione del movimento e l\u2019ingombro di un peduncolo cutaneo o sottocutaneo. Disegnare un\u2019isola cutanea centrata sull\u2019emer- genza di una di queste perforanti crea un lem- bo perforante che ha il vantaggio di essere cer- tamente vascolarizzato ma anche pi\uf9 libero nel movimento, essendo limitato solo da un vaso ab- bastanza essibile e mobile. Su questo si basa il concetto di lembo perforante freestyle.5 Se un vaso perforante pu\uf2 essere identi cato ed isolato, allora un lembo pu\uf2 essere prelevato at- torno ad esso. Lo si potr\ue0 fare ovunque nel corpo ed il lembo potr\ue0 essere di qualunque forma, da bilobato, a V-Y o ad elica, in base alle necessit\ue0 ricostruttive (e di chiusura del sito donatore). 2 3 1 INTRODUZIONE Ilembi perforanti sono lembi vascolarizzati da una arteria (e da una o due vene comitanti) pro- veniente da un vaso dominante profondo che raggiunge e nutre la cute con un percorso pi\uf9 o meno diretto, perpendicolare verso la super cie. Questi vasi sono stati de niti perforanti secondo la classi cazione di Gent.1,2 Questi vasi possono raggiungere la super ce: \u2022 passando attraverso un muscolo (p. indiretta) \u2022 al margine di un muscolo (p. diretta) \u2022 nei setti tra i ventri dei muscoli (p. settocutanea). Basare un lembo su un peduncolo perforante noto permette al chirurgo di non dover obbedi- re alle classiche regole della preparazione dei lembi, come ad esempio la legge lunghezza/ ampiezza peduncolo, ma di isolare un lembo di forme differenti e dimensioni che non sarebbero state possibili coi lembi tradizionali, random o fascio cutanei.3,

Management of complications caused by permanent fillers in the face: A treatment algorithm

Background: Nonresorbable substances are still injected to enhance soft-tissue volumes and fill subcutaneous defects. Inflammatory reactions (often termed granulomas) to these materials can be functionally and socially disabling. Most therapeutic options used until now are nonspecific antiinflammatory treatments, targeting an ill-defined immune reaction of undefined cause. The minimally invasive intralesional laser treatment can remove the foreign substance and the inflammatory reaction with an 808-nm diode laser. Methods: Two hundred nineteen consecutive patients referred from September of 2006 until June of 2013 for inflammatory reactions to permanent facial fillers and treated with this technique at the authors' institution with a minimum 6-month follow-up were studied. All patients were screened with an ultrasound soft-tissue examination and the lesions were classified as either cystic (implants inserted by bolus injections) or infiltrating (as in microdeposit injection). The authors' therapeutic approach is summarized in an algorithm: infiltrating patterns were treated with intralesional laser treatment alone, whereas cystic distribution cases were also drained through stab wound incisions. The mean patient age was 49 years (range, 23 to 72 years); 204 patients were women. Results: Partial improvement was obtained in 30 percent of patients, whereas 8 percent discontinued the treatment because of a lack of satisfaction. Lesions disappeared completely in 62 percent. Complications included transient swelling in all cases, hematoma in 2 percent, secondary sterile abscess in 9.5 percent, and minimal scarring in 10 percent. Conclusion: A problem-oriented systematic approach to inflammatory complications from permanent fillers is proposed, based on the comprehensive work from the past 7 years, with an overall improvement rate of 92 percent

Composite orbital reconstruction using the vascularized segmentalized osteo-fascio-cutaneous fibula flap

Reconstruction of composite orbital defects must address the orbit and an exposed skull base and/or maxillary region. The orbit should not only be covered but also reshaped to accommodate the orbital contents or an epithesis when warranted. This study presents a rationale for a near-anatomical reconstruction of the orbit, together with adjacent dead space obliteration, using the segmentalized osteo-fascia-cutaneous fibula flap. Before the flap transfer, a cutting template for the fibula is made according to the measures and requirements of the facial defect. The segmentalized bone is then osteosynthesized to the facial skeleton and revascularized. Thus, an orbital depth is created by the bony fibula, whereas the fascio-cutaneous part of the flap may be used for lining the orbit and obliteration of the skull base or the maxillary region, or resurface the palate and/or the nasal cavity

Composite scalp replacement and negative pressure therapy for successful graft take and hair regrowth

Microvascular scalp replantation is the procedure of choice after devastating scalp avulsion injuries. When replantation is not possible, alternative procedures should be considered to provide 1) wound closure and, possibly, 2) acceptable cosmetic results. A number of elective procedures including local and microsurgical flaps have historically been described. None of those procedures allow for obtaining superior cosmetic results in one single stage, as tissues being replaced are not "like with like". The use of spare parts from the avulsed scalp as a non vascularized composite hair bearing graft is reported herein, in association to negative pressure therapy. Despite very low success rate of composite scalp grafts reported into the literature, our patient had a 100% graft take and a favourable cosmetic result in terms of hair re-growth. At 6 months follow-up the graft is stable, pliable, and covered by a considerable amount of hair. The patient is very satisfied with the result. We think negative pressure device as the key factor in enhancing non-vascularized composite tissue survival including follicles. This is to our knowledge the first case of successful non-vascularized scalp replacement associated to negative pressure therapy. We think this approach should be considered when microsurgical replantation is not possible, still being available the use of spare parts, before attempting further elective procedures

Composite orbital reconstruction using the vascularized segmentalized osteo-fascio-cutaneous fibula flap

Reconstruction of composite orbital defects must address the orbit and an exposed skull base and/or maxillary region. The orbit should not only be covered but also reshaped to accommodate the orbital contents or an epithesis when warranted. This study presents a rationale for a near-anatomical reconstruction of the orbit, together with adjacent dead space obliteration, using the segmentalized osteo-fascia-cutaneous fibula flap. Before the flap transfer, a cutting template for the fibula is made according to the measures and requirements of the facial defect. The segmentalized bone is then osteosynthesized to the facial skeleton and revascularized. Thus, an orbital depth is created by the bony fibula, whereas the fascio-cutaneous part of the flap may be used for lining the orbit and obliteration of the skull base or the maxillary region, or resurface the palate and/or the nasal cavity

Invited Response on: Comments on \u201cAutologous Fat Grafting for the Oral and Digital Complications of Systemic Sclerosis: Results of a Prospective Study\u201d

Background Systemic sclerosis is a connective tissue disease. Skin involvement of the mouth and hand may compromise function and quality of life. Autologous fat grafting has been described as a specific treatment of these clinical features. We report the results of our prospective study designed to treat and prevent skin complications in systemic sclerosis. Materials and Methods We treated 25 patients with mouth and/or hand involvement (microstomia, xerostomia, skin sclerosis, Raynaud\u2019s phenomenon and long-lasting digital ulcers) with autologous fat grafting, according to the Coleman\u2019s technique, around the mouth and/or at the base of each finger. The surgical procedures were repeated in each patient every 6 months for a total of two or three times. Clinical data were collected before the first surgery and again 6 months after each surgical procedure. Pain, skin thickness, saliva production and disability were assessed with validated tests. Results Overall we performed 63 autologous fat grafting sessions (either on the mouth, on the hands or on both anatomical areas). Results at 6 moths after the last session included improvement of xerostomia evaluated with a sialogram, reduction of the skin tension around the mouth and, in the hands, reduction of the Raynaud phenomenon as well as skin thickness. Pain was reduced while theperception of disability improved. Digital ulcers healed completely in 8/9 patients. Conclusions Our results confirm the efficacy and safety of autologous fat grafting for the treatment of skin complications and digital ulcers due to systemic sclerosis. In addition, the patients\u2019 subjective well-being improved

A challenging study to address the complexity of extreme and threatened habitats: the BioAlpEC project (Biodiversity of Alpine Ecosystems in a Changing world)

Alpine ecosystems are unique in their extreme heterogeneity due to topography, geomorphology, geophysics, and microclimatic conditions. They are particularly exposed to climate change, with the regression of the snowline and thawing of glaciers inducing profound modifications to all habitats. While the timber line shifts upslope, freshwater bodies undergo radical changes in water regime and persistence. Forests exposed to extreme climatic events experience outbreaks of plant or animal invasive species and parasites, taking advantage of weakened communities. This scenario is made additionally complex by other forms of anthropogenic pressure; for example, although the abandonment of traditional landuse has made habitats available to an expanding large mammal community, the denser network of roads and trails and their increased used for outdoor activities have enhanced the potential for human-wildlife conflict. Here we used a multiscale, multi-level approach to assess how these cascading effects have impacted biodiversity, pooling an ensemble of techniques and methodologies. From metagenomics of bioaerosol, ecto- and endo- microbial communities, and freshwater protists and metazoans to comparative genomics of flora and population genomics of endemic vertebrate species; from population demography of invertebrates and mammals to remote sensing of forest, grassland, and mammals’ occurrence, and bio-logging of free-ranging ungulates, the BioAlpEC project is unravelling a gradient of biodiversity threats, but also of species’ resilience and responses that are rapidly re-shaping the dynamics and functions of Alpine ecosystems