Publications by authors named "Marco Innocenti"

100 Publications

Custom-made 3D-printed prosthesis and free vascularised fibula for humeral reconstruction after osteosarcoma resection in a 13-year-old patient.

BMJ Case Rep 2021 May 27;14(5). Epub 2021 May 27.

Department of Plastic Surgery and Microsurgery, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy.

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.
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http://dx.doi.org/10.1136/bcr-2020-240726DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8162075PMC
May 2021

Gynecomastia and Chest Masculinization: An Updated Comprehensive Reconstructive Algorithm.

Aesthetic Plast Surg 2021 May 3. Epub 2021 May 3.

Plastic and Reconstructive Microsurgery, Careggi University Hospital, Viale Giacomo Matteotti 42, 50132, Florence, Italy.

Background: Gynecomastia is a common finding in males. Clinical aspect varies widely in world populations showing peculiar hallmarks according to different body shapes reflecting personal expectations; therefore, a surgical plan must be tailored on individual basis to all type of patients.

Materials And Method: A total of 522 patients, treated for bilateral gynecomastia from January 2007 to January 2019, were included and reviewed in this retrospective study. Considering physical status BMI, muscular trophism, hypertrophy of the mammary region, nipple-areola disorder, gland and skin cover consistency, a four-tier classification system has been used to classify the deformity and to assess a surgical plan. In all cases, a subcutaneous mastectomy was performed under direct vision.

Results: No recurrence of the deformity was observed as well as major complications such as necrosis, and high level of satisfaction was observed in all groups. No breast cancer was found at the histological examinations Operative time ranged from 25 minutes up to 120 minutes and hospitalization time ranged from 1 to 3 days.

Conclusion: Since the physical status is strictly related to the clinical features of the disorder, a comprehensive classification system and a reconstructive algorithm are proposed.

Level Of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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http://dx.doi.org/10.1007/s00266-021-02275-7DOI Listing
May 2021

Custom-Made 3D-Printed Implants as Novel Approach to Reconstructive Surgery after Oncologic Resection in Pediatric Patients.

J Clin Med 2021 Mar 4;10(5). Epub 2021 Mar 4.

Orthopedic Department, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy.

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%. 3D prostheses may yield biological advantages due to possible integration with the host bone and also through the use of vascularized flaps. Further research is warranted.
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http://dx.doi.org/10.3390/jcm10051056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7961419PMC
March 2021

Pediatric Malignant Mandibular Tumors: Personal Experience and Literature Options Discussion.

ORL J Otorhinolaryngol Relat Spec 2021 Mar 31:1-9. Epub 2021 Mar 31.

Maxillo-Facial Surgery Unit, AOU-Careggi, Florence, Italy.

Introduction: Mandibular defects reconstruction could result challenging in childhood, due to facial and mandibular growth patterns. For these reasons, the choice of the most suitable reconstructive option in pediatric patients, affected by mandibular malignancies, still objects of debate.

Objective: The aim of our study was to compare our reconstructive schedules to the existing literature in order to give a personal contribute to the present panorama.

Methods: We performed, in October 2019, a retrospective evaluation of pediatric patients treated for biopsy-proven mandibular malignancies at our Institute between January 2013 and December 2016. All of them received multimodal therapy in accordance with standard guidelines and their demographic, clinical, treatment, and outcome parameters were collected and analyzed.

Results: We observed a shorter duration of surgery, a faster tracheostomy tube and feeding-tube removal, and a minor hospitalization in patients who received grafts transfer compared to those who underwent microsurgical mandibular reconstruction. After a 36-month period of follow-up, osteochondral grafts showed a pattern of growth similar to the mandibular epiphysis (condilylion-gonion linear and vertical ratio ranging to 0.96-1.03 and 1-1.02 at orthopantomogram, respectively). No bone consolidation delays and functional impairment were recorded.

Conclusions: Free flaps mandibular reconstruction in children needs to be better assessed and proximal fibular epiphyseal free flap indication might deserve further studies. Osteochondral grafts find indication for lateral defects, 50-55 mm in maximum length and located in the mandibular ramus, without massive teeth or soft tissue defect. Condyle involvement does not represent an absolute contraindication to rib graft use.
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http://dx.doi.org/10.1159/000513870DOI Listing
March 2021

The Medial Femoral Condyle Flap in the Pediatric Patient.

Plast Reconstr Surg 2021 Apr;147(4):613e-622e

From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine; the Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine; the Division of Plastic Surgery, Department of Surgery, and the Department of Orthopaedic Surgery, University of Pennsylvania Health System; and Plastic and Reconstructive Microsurgery, Careggi University Hospital.

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, 7 to 18 years) and mean follow-up of 28 months (range, 3 to 120 months). Six were skeletally immature at the time of medial femoral condyle harvest, with the last patient having organic bone disease, putting her at risk for pathologic fracture. All 13 patients achieved bony union, and no patients suffered pathologic fractures or physeal injuries; no patients developed length discrepancies.

Conclusions: The authors present the first series of corticocancellous medial femoral condyle free flaps in the pediatric population along with a novel technique to avoid injury to the physis in skeletally immature patients. This technique is effective for a variety of skeletal defects or nonunions and is safe for growing patients without causing physeal arrest or growth disturbance.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000007778DOI Listing
April 2021

A Safer Way to Harvest a Superthin Perforator Flap.

Plast Reconstr Surg 2021 Mar;147(3):466-469

From the Department of Plastic and Reconstructive Microsurgery, Careggi Universital Hospital.

Summary: The updated knowledge of perforasome anatomy and the evolution of microsurgical techniques have enabled surgeons to safely harvest a thin flap. Recently, the anterolateral thigh perforator flap, the current workhorse in soft-tissue reconstruction, has started to be designed and harvested on the superficial fascia, which divides the deep from the superficial fat. This allows elevation of a very thin flap tailored to the defect. Faithful to the ultrathin concept, in an attempt to make flap dissection simpler and safer, the authors describe a revisited harvesting technique of superthin anterolateral thigh perforator flap. This study presents the outlined technique performed in 16 patients with complex soft-tissue defects after trauma or tumor ablation. All of them underwent primary reconstruction using superthin anterolateral thigh perforator free flaps by superficial fascia elevation harvested according to the described surgical procedure. Complications and functional outcomes were assessed. The authors' series of anterolateral thigh perforator superthin flaps demonstrated an overall 100 percent survival rate. Of 16 anterolateral thigh perforators, 12 (75 percent) had no complications and four (25 percent) had minor complications. No major complications such as total flap loss requiring additional salvage surgery were reported. In no case was secondary debulking performed. The superthin anterolateral thigh perforator flap harvested with the described approach was used successfully in microsurgical reconstruction, providing an excellent outer skin cover tailored to the defect. The dissection procedure was safe, quick, simple, and free of major complications. With minimal donor- and recipient-site morbidity, it provided great aesthetic results, avoiding secondary operations.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000007676DOI Listing
March 2021

A hollow, custom-made prosthesis combined with a vascularized flap and bone graft for skeletal reconstruction after bone tumour resection.

Surg Oncol 2021 Mar 29;36:56-60. Epub 2020 Nov 29.

Department of Plastic Surgery and Microsurgery, Azienda Ospedaliero Universitaria Careggi, Florence, Italy. Electronic address:

Purpose: While limb-sparing surgery is now possible for more than 80% of patients with bone tumours, wide resection is often required, necessitating bone reconstruction. This paper aims to present a surgical technique that combines the advantages of a hollow, titanium, custom-made prosthesis and the biological aspects of microsurgical flaps and bone graft.

Patients And Methods: From June 2016 to September 2017 at our institution, six consecutive patients with skeletal tumours underwent one-stage reconstructive surgery with concomitant implantation of a 3D-printed prosthesis.

Results: At an average follow-up of 30 months (range: 18-45), no early complications were observed, and no implant removals were needed. One patient experienced a delayed haematogenous deep infection, which healed after surgical debridement. Three patients died of their underlying disease 18, 22, and 23 months after surgery, respectively. All flaps and custom reconstructions were successful, with primary osseointegration at a mean of four months (range: 2-7). Patients' average Musculoskeletal Tumour Society score was 23.2 (range: 18-28).

Conclusion: A hollow, custom-made, titanium prosthesis filled with bone graft, used in conjunction with a microsurgical flap, may offer good osseointegration in different anatomic locations among a patient population with a high risk of infection, pseudarthrosis, and long-term mechanical complications. The surgical technique's advantages are preliminarily demonstrated. Further studies with longer follow-up periods and larger sample sizes are required to confirm our findings.
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http://dx.doi.org/10.1016/j.suronc.2020.11.014DOI Listing
March 2021

Reconstruction of upper limb soft-tissue defects after sarcoma resection with free flaps: A systematic review.

J Plast Reconstr Aesthet Surg 2021 Apr 8;74(4):755-767. Epub 2020 Nov 8.

Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy.

Background And Objectives: Upper limb preservation after soft tissue sarcoma (STS) surgical excision is now the accepted gold standard and it often requires reconstruction with free flaps. The purpose of this review is to summarize current literature on upper limb reconstruction with free flaps after STS resection.

Methods: A systematic review was performed in July 2019 in PubMed and MedLine Ovid databases according to the PRISMA guidelines.

Results: A total of 17 studies were included in the final analysis, with 132 patients. The most common diagnosis was Malignant Fibrous Histiocytoma. The most frequent timing of flap coverage was immediate. The success rate was almost always 100%. The length of follow-up was reported in 11 studies with a range of 2-187 months. The most commonly reported patient-centered outcome was the MSTS Score. Based on the evidence of the literature collected, we divided the upper limb into four parts (shoulder, elbow and arm, forearm and wrist, and hand) and described the most common and functional free flaps used for reconstruction after STS resection.

Conclusions: Free flaps in the treatment of STS of the upper extremity have a good overall outcome, with a low postoperative complication rate. A wide array of free flaps is available for reconstruction, and the choice of flap is based on defect size, types of tissue required, postoperative functional goal, and surgeon preference. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.
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http://dx.doi.org/10.1016/j.bjps.2020.10.065DOI Listing
April 2021

Propeller Flaps in the Upper Extremity: Arm and Forearm Reconstruction.

Semin Plast Surg 2020 Aug 22;34(3):184-191. Epub 2020 Sep 22.

Unit of Plastic and Reconstructive Microsurgery, Department of Health Sciences, "Careggi" University Hospital, Florence, Italy.

The propeller flap is an island of skin that is raised on its pedicle (most commonly a single perforator) and can rotate 180 degrees to cover a soft tissue defect. Thanks to these features, the propeller flap brings reliable tissue from outside of the zone of injury while sparing the main vessels of the upper extremity. This technique limits the donor site to the same limb, captures skin characterized by having the same color and texture, does not necessarily need a microvascular anastomosis, and overall reduces the operating time and surgical cost. Our intent here is to present 27 cases with different soft tissue defects of the upper arm and forearm that have been successfully reconstructed using propeller flaps. The surgical technique, with emphasis on the anatomy of the upper arm, is described. In particular, use of a freestyle approach to customize a perforator-based propeller flap to cover defects from small to medium size is detailed. In our experience, the use of a perforator propeller flap in the upper extremity for resurfacing represents both a very reliable and aesthetically pleasant option.
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http://dx.doi.org/10.1055/s-0040-1715153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542213PMC
August 2020

Occurrence of the tetracycline resistance gene tetA(P) in Apennine wolves (Canis lupus italicus) from different human-wildlife interfaces.

J Glob Antimicrob Resist 2020 12 3;23:184-185. Epub 2020 Oct 3.

University of Teramo, Faculty of Veterinary Medicine, Loc. Piano D'Accio, Teramo 64100, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.jgar.2020.09.011DOI Listing
December 2020

Vascularized Small-Bone Transfers for Fracture Nonunion and Bony Defects.

Clin Plast Surg 2020 Oct;47(4):501-520

Department of Hand Surgery, Affiliated Hospital of Nantong University, 20 West Temple Road, Nantong 226001, Jiangsu, China. Electronic address:

Vascularized small-bone grafting is an efficient and often necessary surgical approach for nonunion or necrosis of several bones in particular sites of the body, including scaphoid, lunate, distal ulna, and clavicle. The medial femoral condyle is an excellent graft source that can be used in treating scaphoid, ulna, clavicle, or lower-extremity bone defects, including nonunion. Vascularized bone grafting to the small bones, particularly involving reconstruction of damaged cartilage surfaces, should enhance subchondral vascular supply and help prevent cartilage regeneration. Vascularized osteoperiosteal and corticoperiosteal flaps are useful for treating nonunion of long bones.
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http://dx.doi.org/10.1016/j.cps.2020.06.005DOI Listing
October 2020

A Two-Step Immunomagnetic Microbead-Based Method for the Isolation of Human Primary Skin Telocytes/CD34+ Stromal Cells.

Int J Mol Sci 2020 Aug 16;21(16). Epub 2020 Aug 16.

Department of Experimental and Clinical Medicine, Section of Anatomy and Histology, University of Florence, 50134 Florence, Italy.

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 connective tissue-resident cells on the basis of their different immunophenotypic features. Our experiments clearly demonstrated that the proposed method allows a selective purification of cells exhibiting the peculiar TC morphology. Isolated TCs displayed very long cytoplasmic extensions with a moniliform silhouette (telopodes) and presented an immunophenotypic profile (CD31-/CD34+/PDGFRα+/vimentin+) that unequivocally differentiates them from endothelial cells (CD31+/CD34+/PDGFRα-/vimentin+) and fibroblasts (CD31-/CD34-/PDGFRα+/vimentin+). This novel methodology for the isolation of TCs lays the groundwork for further research aimed at elucidating their functional properties and possible translational applications, especially in the field of regenerative medicine.
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http://dx.doi.org/10.3390/ijms21165877DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461544PMC
August 2020

Reverse-flow latissimus dorsi myocutaneous flap in a multi-step approach for complex back defect reconstruction: A case report.

Microsurgery 2020 Jul 4;40(5):604-607. Epub 2020 Jun 4.

Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy.

Reconstruction of complex back defects is challenging for reconstructive surgeons, as it should preserve function, provide adequate coverage, and minimize morbidity. We present a case of multiple-step reconstruction after resection of a large squamous cell carcinoma recurrence in a 68-year-old man, with local perforator flaps and a reverse-flow latissimus dorsi myocutaneous flap. After radical excision, four propeller perforator flaps were harvested to cover a 30 × 25 cm defect, based on the dorsal branch of the fifth posterior intercostal arteries (right 20 × 9 cm, left 17 × 9 cm) and on the superior gluteal arteries (right 20 × 11 cm, left 21 × 12 cm) bilaterally. In the second step, bilateral propeller perforator flaps based on the fourth lumbar arteries (right 18 × 13 cm, left 23 × 11 cm) were transposed to cover the residual loss of tissues. After 5 months, a recurrence occurred on the left midback. A wide en bloc excision of the last three ribs and pulmonary pleura was performed, and the synthetic mesh used for thoracic wall reconstruction was covered with an ipsilateral 20 × 10 cm reverse-flow latissimus dorsi myocutaneous flap based on the serratus anterior branch. All the flaps healed uneventfully and there were no donor-site complications. Two years postoperatively, the patient had a cosmetically acceptable result without any functional impairment. The reverse-flow latissimus dorsi myocutaneous flap can represent a salvage procedure in back complex defects reconstruction, especially when other local flaps have already been harvested in previous reconstructive procedures.
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http://dx.doi.org/10.1002/micr.30615DOI Listing
July 2020

Evaluation of Residual Neuro-Muscular Integrity in the Orbicularis Oculi Muscle After Lower Eyelid Transcutaneous Blepharoplasty According to Reidy Adamson-s Flap.

Aesthetic Plast Surg 2020 10 26;44(5):1577-1583. Epub 2020 May 26.

Plastic and Reconstructive Microsurgery, Careggi University Hospital, Viale Giacomo Matteotti 42, 50132, Florence, Italy.

Background: The aging process affects skin, muscle and fat of the eyes in a different manner. Their individual rejuvenation would require specific surgical treatment according to their particular demands during lower eyelid blepharoplasty. This would require the separate management of the skin and the muscle by separating them into two different flaps. Basing on the anatomy, during sub-ciliary myocutaneous incision in conventional lower eyelid transcutaneous blepharoplasty most of innervations of the lower orbicularis oculi muscle are transected and denervation sequelae at the pretarsal orbicularis oculi muscle would be expected. However, sub/ciliary approach is still popular. The absence of signs or symptom of denervation of in our large case series even though injury to the motor innervation of the orbicularis oculi muscle during the operation led the authors to investigate the discrepancy between the anatomical concept and clinical outcomes. The study aimed to investigate the residual functionality of the orbicularis oculi muscle after lower eyelid transcutaneous blepharoplasty according to Reidy Adamson-s flap.

Materials And Methods: Ten patients were enrolled in the study. Orbicularis oculi muscle functionality was investigated with electroneurography before and at least 6 months after the surgical procedure. Investigated parameters are: Compound Muscle Action Potential (CMAP) as expressions of quantity of activated muscular fibers by the electrical stimulation of the facial nerve. Pre- and post-op collected data were compared and statistically analyzed.

Results: The mean age was 52.9; minimum follow-up 6 months; twenty eyes were investigated; 1 patient was excluded. Postoperative data did not show any significant reduction in the CMAP at all.

Conclusion: The study suggests that the buccal branch and medial branch of the zygomatic nerve of the facial nerve supplies efficiently to the orbicularis oculi innervation.

Level Of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-020-01783-2DOI Listing
October 2020

Our 10 Years' Experience in Breast Asymmetry Correction.

Aesthetic Plast Surg 2020 10 14;44(5):1898-1899. Epub 2020 May 14.

Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy.

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http://dx.doi.org/10.1007/s00266-020-01746-7DOI Listing
October 2020

External Quilting: New Technique to Avoid Haematoma in Gynaecomastia Surgery.

Aesthetic Plast Surg 2021 04 24;45(2):831-832. Epub 2020 Apr 24.

Plastic and Reconstructive Microsurgery, Careggi University Hospital, Viale Giacomo Matteotti 42, 50132, Florence, Italy.

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http://dx.doi.org/10.1007/s00266-020-01734-xDOI Listing
April 2021

Mandibular ramus and condyle reconstruction with vascularized proximal fibular epiphyseal transfer in the pediatric patient: A case report.

Microsurgery 2020 Oct 14;40(7):818-822. Epub 2020 Apr 14.

Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy.

Mandibular reconstruction in skeletally immature patients is challenging for the Plastic Surgeon. Indeed, it requires replacement of the bony defect with restoration of the growth capability and joint function, when condyle is involved. Vascularized transfer of the proximal epiphysis of the fibula meets all these reconstructive requirements providing an adequate bone stock which also contains a growth plate and an articular surface. The purpose of this article is to report a case of mandibular reconstruction in a 13-year-old boy who underwent resection of a high-grade osteosarcoma involving mandibular angle, ramus, and condyle. A fibular free flap including proximal epiphysis, with its growth plate and the articular surface, was harvested based on the anterior tibial vessels. The fibular head articular surface was placed facing the articular fossa of the temporal bone. A reverse-flow end-to-end anastomosis was performed with the facial vessels. Postoperatively, no infection nor anastomosis complications occurred. Surgical sites healed uneventfully. At latest follow-up, 1 year after surgery, no signs of recurrence were observed. The transferred bone survived and the growth plate was clearly open. Both functional and aesthetic outcomes were rated as good, with maximal mouth opening of more than 4 cm, neither impairment to mastication, deglutition nor phonation was observed. This technique may be a good option for pediatric reconstruction of large bony and articular mandibular defects, where functional restoration of temporomandibular joint and the growing capacity of the bone should be contemporary.
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http://dx.doi.org/10.1002/micr.30589DOI Listing
October 2020

Why do We Need Anatomical Implants? Science and Rationale for Maintaining Their Availability and Use in Breast Surgery.

Aesthetic Plast Surg 2021 04 2;45(2):822-824. Epub 2020 Apr 2.

Plastic and Reconstructive Microsurgery, Careggi University Hospital, Viale Giacomo Matteotti 42, 50132, Florence, Italy.

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http://dx.doi.org/10.1007/s00266-020-01694-2DOI Listing
April 2021

Characterization of Skeletal Muscle Endocrine Control in an In Vitro Model of Myogenesis.

Calcif Tissue Int 2020 07 27;107(1):18-30. Epub 2020 Feb 27.

Department of Experimental and Clinical Biomedical Sciences, University of Florence, Largo Palagi 1, 50139, Florence, Italy.

Skeletal muscle has remarkable regenerative abilities regulated by a highly orchestrated process involving the activation of cellular and molecular responses, which are dependent on satellite cells. These cells maintain the stem cell population and provide numerous myogenic cells that proliferate, differentiate, fuse and lead to new myofiber formation for a functional contractile tissue. We have isolated and characterized satellite cells obtained from human biopsies and established an in vitro model of myogenesis, evaluating muscle regeneration, monitoring the dynamic increases of the specific myogenic regulatory factors and the final formation of multinucleated myofibers. As the skeletal muscle is an endocrine tissue able of producing many substances that can act on distant organs, and it can be physiologically modulated by a variety of hormones, we embarked in a project of characterization of muscle cell endocrinology machinery. The expression of a large array of hormone receptors was quantified during the process of myogenesis. The results obtained showed a significant and generalized increase of all the tested hormone receptors along the process of differentiation of human cultured cells from myoblasts to myocytes. Interestingly, also the production of the myokine irisin increased in a parallel manner. These findings point to the human cultured myoblasts as an ideal model to characterize the skeletal muscle endocrine machinery and its hormonal regulation.
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http://dx.doi.org/10.1007/s00223-020-00678-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7271047PMC
July 2020

Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases.

Injury 2019 Dec 31;50 Suppl 5:S11-S16. Epub 2019 Oct 31.

Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy. Electronic address:

Purpose: The aim of this report is to compare free perforator flaps and propeller flaps in the coverage of lower limb soft tissue defects.

Patients And Methods: 179 patients (age between 5 and 92 years old), underwent soft tissue reconstruction of the lower limb between January 2009 and January 2015, either by free flap or propeller flap. The two groups were retrospectively evaluated in order to assess the outcome, complications and potential risk factors. Correlations between risk factors and presence/absence of failure or complications have been evaluated with descriptive statistical analysis and a set of logistic regression models. Finally, an economic analysis was conducted to evaluate the different tecniques.

Results: In a simple descriptive statistical analysis, the overall failure rate is 6% for free flaps and 3.7% for propeller flaps; the complication rates are 14% vs 21.5% and it increases as dimension increases. The logistic models relating failure and complications with potential risk factors do not show significant differences, whereas the economic analysis show that the average expense of free flaps is 5077.5€ per patient, 1595.6€ per patient for propeller flaps.

Conclusions: Our results do not demonstrate significant differences between the two groups about correlation of risk factors or flap size with complication or failure. The surgical option choice should be taken only after accurate evaluation of the soft tissue surrounding the defect. Propeller flaps should be preferred in case of small/medium size defects in otherwise healthy extremities. Free perforator flaps should be the choice in large defects due to trauma or vascular diseases. The economic analysis suggests that propeller flap should be considered when possible.
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http://dx.doi.org/10.1016/j.injury.2019.10.039DOI Listing
December 2019

Perforator-based Reverse Radial Teno-Adipo-Fascial Flap: Surgical Technique and Case-report for the Functional Reconstruction of the Dorsum of the Hand.

Handchir Mikrochir Plast Chir 2019 Dec 7;51(6):464-468. Epub 2019 Nov 7.

University Hospital Careggi CTO, Plastic reconstructive surgery and microsurgery - Oncology.

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 vascularization of the tissues used for the reconstruction.

Results: The hand healed well with containment of the infection. The dorsal healed skin appeared elastic and pliable enough. Passive and active motion of interphalangeal and metacarpofalangeal joints were very satisfying. The donor site was well healed, with almost no morbidity.

Conclusions: This reconstructive strategy provides a quick and straightforward single-stage option for the reconstruction of complex cutaneotendinous defects of the dorsum of the hand. Such a reconstruction, with a completely vascularized procedure, is particularly indicated in cases of high contamination or infection of the recipient site.
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http://dx.doi.org/10.1055/a-0881-9835DOI Listing
December 2019

Extensor hallucis longus tendon and soft-tissue reconstruction with palmaris longus tendon included in a radial forearm free flap: A case report.

Microsurgery 2020 Mar 12;40(3):391-394. Epub 2019 Oct 12.

C.O.O., Azienda Socio Sanitaria Territoriale Gaetano Pini, Milan, Italy.

Reconstruction of foot structures is challenging because of the need to restore both anatomy and function. Extensor hallucis longus (EHL) excision without reconstruction could result in a flexion deformity of the toe at the interphalangeal joint. In this report, we present a case of the use of a palmaris longus tendon included in a fasciocutaneous radial forearm free flap to reconstruct EHL tendon and soft tissues of the distal foot dorsum. A 41-year-old woman presented with a recurrence of myxoinflammatory fibroblastic sarcoma on the medial part of the left foot dorsum. The EHL tendon was sacrificed, leaving a soft-tissue defect of 14 × 5 cm and 14-cm tendon gap. A 14 × 5 cm radial forearm flap with a 16-cm section of palmaris longus tendon was harvested from the left forearm. Radial artery and its comitant vein were anastomosed with dorsalis pedis artery and vein. EHL tendon repair was performed from the composite mass to the proximal and distal stumps. No complication in the postoperative period occurred. At latest follow-up, 12 months postoperatively, the patient showed a normal joint function and was satisfied with the treatment. Palmaris longus tendon included in a radial forearm free flap could be recommended for combined soft tissue and tendon defects, particularly on the foot dorsum.
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http://dx.doi.org/10.1002/micr.30523DOI Listing
March 2020

Long-Term Functional Outcome After Surgical Treatment of Peroneal Intraneural Ganglion Cyst.

World Neurosurg 2019 Dec 5;132:e217-e222. Epub 2019 Sep 5.

Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy.

Background: Intraneural ganglia are benign mucinous cystic formations that originate within the epineurium of peripheral nerves. Different treatments have been recommended, with an overall satisfactory outcome. In this paper, we aim to evaluate the long-term outcomes of surgical treatment of peroneal intraneural ganglia by reviewing our local institutional experience.

Methods: We performed a case series review of peroneal intraneural ganglia surgical treatment performed by the senior author. Demographic and surgical details were abstracted from the medical record for each patient. Electrodiagnostic studies and magnetic resonance imaging (MRI) were performed in all patients pre- and postoperatively.

Results: Eight men were enrolled, with an average age at time of surgery of 47.5 years (range 28-68 years). Motor testing revealed a preoperative deficit of dorsiflexion, eversion, and toe extension in 7 patients, with a median preoperative Medical Research Council (MRC) score of 0/5. Sensory loss in the distribution of the common peroneal nerve was present in 7 patients. Mean clinical follow-up time was 113 months (range 32-189 months). Significant pain relief was achieved in all patients. Overall neurologic function was improved, more so for motor function. The median postoperative dorsiflexion, eversion, and toe extension at last follow-up were MRC score of 5/5. No complications occurred postoperatively. There was no clinical evidence of intraneural recurrence, as confirmed in postoperative MRI. In 2 patients, an extraneural cystic formation was visible in the anterior muscular compartment.

Conclusions: The data from our series support excellent long-term postoperative motor outcomes with a low recurrence rate. To avoid extraneural recurrence, resection of the superior tibiofibular joint is necessary.
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http://dx.doi.org/10.1016/j.wneu.2019.08.195DOI Listing
December 2019

New Paradigms in Reconstructive Microsurgery Education.

Ann Plast Surg 2019 09;83(3):243-246

Reconstructive Microsurgery Unit, Careggi University Hospital, Florence, Italy.

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http://dx.doi.org/10.1097/SAP.0000000000001825DOI Listing
September 2019

Re: A novel method to insert drain atraumatically after liposuction in gynecomastia.

Indian J Plast Surg 2018 Sep-Dec;51(3):342-343

Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy.

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http://dx.doi.org/10.4103/ijps.IJPS_106_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6440363PMC
April 2019

Calcaneal reconstruction after total calcanectomy with iliac crest free flap.

Microsurgery 2019 Nov 22;39(8):704-709. Epub 2019 Mar 22.

Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy.

Introduction: Calcaneal tumors being a rare occurrence, surgical options and outcomes are not well-known. Extensive defects following wide resection, especially in weight-bearing areas, still remain a challenge and different reconstructive techniques have been proposed. The aim of this report was to analyze the clinical and functional long-term outcomes of heel reconstruction using an iliac crest free flap.

Patients And Methods: Four patients who underwent calcaneal reconstruction between 1999 and 2012 were included. Two were females and mean age was 27 years, ranging 18-42 years. Each patient underwent total calcanectomy, for two osteoblastomas, one osteosarcoma, and one Ewing's sarcoma. An iliac crest flap was harvested and shaped to fit the residual space. After the articular cartilage at recipient site was debrided, the flap was fixed to the talus and the cuboid.

Results: The average size of the flaps was 2 x 7 x 5 cm. Postoperatively wound dehiscence, screw breaking, and graft fracture healed conservatively. All the arthrodesis healed successfully and no donor site complication occurred. At an average follow-up of 13 years (range 6-19 years) any patient claimed pain, evident limp or limitation of daily activities. Computerized pedobarographic examination and gait analysis revealed a satisfactory result and an acceptable weight-bearing area in the reconstructed limb in each patient.

Conclusions: Calcaneal reconstruction with iliac crest free flap is likely to provide good chances of a long-lasting result, especially in young patients. Particularly, it provides the possibility to adequately shape the graft to fit the bone loss while using the crest as the weight-bearing surface.
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http://dx.doi.org/10.1002/micr.30452DOI Listing
November 2019

Quadriceps tendon reconstruction using a fascia lata included in a reverse-flow anterolateral thigh flap.

Microsurgery 2019 Oct 21;39(7):642-646. Epub 2019 Jan 21.

Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy.

Quadriceps tendon re-rupture after surgical repair is an overall estimated 2% complication. We report a case of reconstruction in a large tendon and soft tissue defect using a reverse-flow anterolateral thigh (ALT) perforator flap including fascia lata in a 75-year-old man presented with septic necrosis of a reconstructed quadriceps tendon. A reverse-flow ALT flap was transferred to the knee defect; the fascia lata was sutured to the residual tendon. Post-operative flap congestion and infection were successfully treated with debridement and conservative treatment. One year after surgery, the patient was able to fully and actively extend the knee, with an acceptable aesthetic appearance. The reverse-flow anterolateral thigh flap including fascia lata may be a good option for coverage of soft-tissue defects around the knee and contemporary quadriceps tendon reconstruction, particularly in case of septic tendon necrosis, where the use of non-vascularised tissues is contraindicated.
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http://dx.doi.org/10.1002/micr.30420DOI Listing
October 2019

Detection of selected pathogens in Apennine wolf () by a non-invasive GPS-based telemetry sampling of two packs from Majella National Park, Italy.

Eur J Wildl Res 2019 25;65(6):84. Epub 2019 Oct 25.

1Faculty of Veterinary Medicine, University of Teramo, Loc. Piano D'Accio, 64100 Teramo, Italy.

In this study, a multi-pathogens survey was conducted to verify the sanitary status of two Italian wolf packs of Majella National Park. Twenty fecal samples (10/pack) were collected using a sampling protocol, based on the combining data from radio-collared wolves with geographic information system (GIS) analysis, allowing to mark off the home range of packs and to recover group-specific and high-quality specimens. Virological screening against the most prevalent canine viruses (protoparvovirus, distemper virus, adenoviruses, and coronaviruses) was carried out by molecular methods, while parasites were detected by means of copromicroscopic and molecular analysis. Canine parvovirus type 2b (CPV-2b) is the most prevalent virus in both packs (7/20), followed by canine adenovirus type 2 (CAdV-2), while no sequences of canine distemper virus and coronaviruses were detected. The sequence analysis of the viruses demonstrated the domestic origin of the infection, highlighting the importance of vaccination of local dogs in order to reduce the risk of exposure of wildlife to these pathogens. Fourteen samples resulted positive for parasites. (sin. ), , eggs, spp., , and larvae were identified sensu stricto (ovine genotype G1) and (canid-specific Assemblage C) were also characterized, providing insights into the wolves' diet and their effects on environmental contamination. The sampling protocol applied in this study, based on a multidisciplinary approach, represents an innovative tool for the survey of Apennine wolf, able to integrate sanitary data with the ecological and demographic features of this population.
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http://dx.doi.org/10.1007/s10344-019-1326-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7088344PMC
October 2019

Latissimus dorsi rotational flap combined with a custom-made scapular prosthesis after oncological surgical resection: a report of two patients.

BMC Cancer 2018 Oct 20;18(1):1003. Epub 2018 Oct 20.

Department of Plastic Surgery and Microsurgery, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.

Background: Sarcomas that arise from the scapula or periscapular soft tissues often require a total scapulectomy. This often implies a large complex tissue defect that needs adequate reconstruction of both bone and soft tissue. Although various methods have been developed, no optimal procedure has emerged. Postoperative complications are common and functional recovery is not always satisfactory. This study aims to present a new surgical technique that combines a custom-made scapular prosthesis with a functional latissimus dorsi flap.

Case Presentation: Two patients diagnosed with malignant tumour of the scapular region were surgically treated after proper multidisciplinary evaluation. The first patient underwent the procedure as a first surgery, the second as revision surgery. The new technique comprises three surgical stages: excisional surgery with soft tissue resection and scapulectomy, bone reconstruction with custom-made prosthesis, and soft tissue reconstruction using a latissimus dorsi rotational flap overturned on the prosthesis. The goal is to set up a new functional unit combining an anatomically shaped implant (manufactured using latest three-dimensional printing technology) and a muscular flap, and to maintain the neurovascular supply. The patients were followed up to evaluate functional outcome and complications. Both patients were alive with no evidence of disease. Functional results were satisfactory and the Musculoskeletal Tumor Society scores were 87% and 63%, respectively. No surgical complications such as implant breakage, joint collapse, wound dehiscence, or infection were observed.

Conclusions: This new technique upgrades the role of the latissimus dorsi flap to a functional tool in combination with an anatomical, three-dimensionally printed, custom-made prosthesis, and provides adequate well-vascularized and healthy tissue to maximize the likelihood of successful limb salvage.
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http://dx.doi.org/10.1186/s12885-018-4883-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6196007PMC
October 2018

Refinements in Tear Trough Deformity Correction: Intraoral Release of Tear Trough Ligaments: Anatomical Consideration and Clinical Approach.

Aesthetic Plast Surg 2018 Dec 8;42(6):1576-1581. Epub 2018 Oct 8.

Department of Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy.

Background: Correction of tear trough (TT) deformity is a crucial aspect of facial rejuvenation. Because the anatomical origins of TT deformity lie in the TT ligaments, which firmly attach the dermis to the periosteum, the release of TT ligaments should be considered when performing an etiological correction. The aim of this paper is to propose an alternative method for TT deformity correction, comprising use of filler together with the release of TT ligaments. This technique was compared to the procedure of only percutaneous filler.

Methods: From January 2014 to December 2015, 10 patients were enrolled in the study for recurrence of TT deformity. All the patients underwent TT ligament release and filler injections; all had been previously treated with percutaneous hyaluronic acid injection without ligament release. Under local anesthesia, the TT ligaments were detached using a blunt cannula introduced directly in the supra periosteal plane through an intraoral access. Once the ligament was released, the TT depression was evenly recontoured with a very small amount of filler. The clinical data, digital images, evaluations of outcomes, including patient satisfaction rates were collected and compared.

Results: Adding the procedure of TT ligament release to filler injections showed satisfactory results, avoiding an unnatural puffy appearance. The comparison between the two different methods showed improved outcomes and increased patient satisfaction with minor patient discomfort among those who underwent TT ligament release.

Conclusion: Because TT ligaments are among the etiologic factors of TT deformity, they have a strong impact on procedures that are designed to improve TT deformity; therefore, TT ligament release should always be considered to obtain satisfactory, natural results.

Level Of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-018-1245-4DOI Listing
December 2018