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Marco PAPPALARDO

Professore Associato
Dipartimento di Scienze Mediche e Chirurgiche Materno-Infantili e dell'Adulto

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Pubblicazioni

2023 - Efficacy of Vascularized Submental Lymph Node Transfer with Decongestive Therapy and Antibiotics for Early-Stage Lower Limb Filarial Lymphedema [Articolo su rivista]
De Santis, G.; Saxena, B.; Starnoni, M.; Pappalardo, M.; Jacob, V.
abstract

Background: Filarial lymphedema (FLE) is the most common cause of secondary lymphedema, with endemic prevalence in developing countries. FLE traditionally has been managed with antibiotics and decongestive therapy (DCT) in the early stage or excisional surgery at the late stage. Results of vascularized lymph node transfer (VLNT) in postoncologic lymphedema have been encouraging, and VLNT is a widely accepted surgical treatment. The authors advocate that the combined treatment of antibiotics, DCT, and vascularized submental lymph node (VSLN) transfer could produce objective and subjective improvement of early-stage lower limb FLE. Methods: Between January of 2019 and January of 2020, patients with early-stage lower-limb FLE who underwent VLNT were retrospectively reviewed. VLNT was harvested from the submental region in all patients. Outcomes were assessed using volume improvement, frequency of cellulitis, and lymphoscintigraphy, along with subjective scoring questionnaire. Results: Three men and one woman with an average age of 27 years (range, 25 to 29 years) were included. Two patients presented bilateral lymphedema. One patient was lost at 3-month follow-up and not included in the analysis. Patients showed an initial decrease in circumferential measurements after antibiotics and DCT of 2074 ± 471 cc (39% ± 9%). At a mean follow-up of 12.3 ± 6.2 months, further improvement of limb volume of 2389 ± 576 cc (45% ± 10%) was achieved following VSLN transfer. Lymphoscintigraphy demonstrated dye uptake by the VLNT with reduced dermal backflow and none of the patients had episodes of postoperative cellulitis. Patients reported excellent outcome on subjective scoring (average score, 9 ± 1) and returned to their daily activities without wearing compression garments. Conclusion: The authors' early experience showed that VSLN transfer may represent an effective treatment option in the multimodal approach to early-stage lower limb FLE.

2023 - Reconstruction of Complex Anterior Chest Wall Defects: The Lasagna Technique [Articolo su rivista]
Baccarani, A.; Filosso, P.; Marra, C.; De Maria, F.; Blessent, C. G. F.; Ruggiero, C.; Pappalardo, M.; Pedone, A.; De Santis, G.
abstract

Background: Sternal tumors are rare, comprising only 0.94% of all bone tumors, with the majority being sarcomas. An extensive composite defect is often the result of surgical resection. Reconstruction of this anatomical area is a challenge for plastic surgeons. Reconstruction must fulfil two different tasks: restoration of soft tissues and stabilization of the chest wall. Both are well defined, and many techniques have been historically proposed. Methods: We present the case of a 66-year-old man affected by sternal metastasis of lung non-small cell carcinoma with sarcomatoid features. After wide tumor resection, a large defect was created. Results: The patient underwent a complex multilayer reconstruction that combined multiple techniques: Gore DualMesh to reconstruct the pericardial plane and protect the heart muscle, omental flap to facilitate integration of the mesh, titanium bars to recreate chest wall stability, and bilateral pectoralis muscle flaps to cover hardware. This multilayer reconstruction was named the "lasagna technique." Conclusions: Due to the rarity of primary malignancies of the sternum, it is difficult to standardize a therapeutic approach. For this reason, it is necessary to customize the surgical treatment by combining several techniques and materials. Our lasagna technique may be considered a valuable option in treating these complex reconstructive cases.

2023 - The Impacts of Lymph on the Adipogenesis of Adipose-Derived Stem Cells [Articolo su rivista]
Hsiao, H. -Y.; Liu, J. -W.; Pappalardo, M.; Cheng, M. -H.
abstract

Background: The pathophysiology of adipose proliferation or differentiation in extremity lymphedema has not been thoroughly studied. This study investigated the impacts of the lymph harvested from lymphedematous limbs on the adipogenesis of adipose-derived stem cells (ASCs). Methods: ASCs were isolated from the adipose tissue of normal extremities and cultured with lymph collected from Cheng lymphedema grade III to IV patients or adipogenic differentiation medium (ADM) and further subjected to differentiation and proliferation assay. The expression of adipogenesis genes was examined by real-time polymerase chain reaction to investigate the effect of lymph on ASCs. The level of adipogenic cytokines in the lymph was also evaluated. Results: The adipocytes were significantly larger in lymphedema fat tissue compared with that in normal fat tissues (P < 0.00). The adipogenesis of ASCs cultured in lymph was significantly enhanced compared with in ADM (P = 0.008) on day 10, suggesting that the adipogenesis of ASCs was promoted under the lymph-cultured environment. The expression of adipogenesis genes, peroxisome proliferator-activated receptor (P = 0.02), CAAT/enhancer-binding protein α (P = 0.008); fatty-acid binding protein (P = 0.004), and lipoprotein lipase (P = 0.003), was statistically elevated when the ASCs were cultured with lymph. The insulin content in lymph was statistically higher in lymph (P < 0.001) than in plasma. Conclusions: The adipogenesis of ASCs was promoted under the lymph-cultured environment with statistically increased adipogenesis genes of peroxisome proliferator-activated receptor, CAAT/enhancer-binding protein α, fatty-acid binding protein, and lipoprotein lipase. The excess lymph accumulated in the lymphedematous extremity contained a greater insulin/insulin-like growth factor-2. These adipogenic factors promoted the expression of early adipogenesis genes and led ASCs to undergo adipogenesis and differentiated into adipocytes. Clinical Relevance Statement: The accumulation of adipose tissue in the lymphedema region was contributed from the content of excess lymph.

2023 - The Overwhelming Postsplenectomy Sepsis: Role of Plastic Surgeon [Articolo su rivista]
Starnoni, M.; Pappalardo, M.; Marra, C.; Pinelli, M.; De Santis, G.
abstract

The overwhelming post-splenectomy infection (OPSI) is a feared late complication of splenectomy, with high morbidity and a mortality rate of up to 50%. Although the management of this syndrome is the duty of clinical physicians, the interest of plastic surgeons in OPSI is related to the injury that can occur in tissues with an end circulation, such as the limb extremities, nasal tip, and lips. In the management of OPSI, surgical techniques are not highlighted. The role of the plastic surgeon can be fundamental for the prevention of further extension of the necrotic tissue, improving as much as possible the vascularization around it. Moreover, a critical role in the management of OPSI is avoiding superinfection of the necrotic areas by combining different techniques and methods, such as surgical debridements, negative pressure wound therapy, and conservative treatment. Last but not least, functional and aesthetic restoration of the injured parts is of paramount importance for the final outcome. In this article, we describe the management of two unvaccinated patients with necrosis of the extremities after OPSI.

2022 - Early venous congestion after diep flap breast reconstruction: case report of a successful management [Articolo su rivista]
Baccarani, A.; Starnoni, M.; Pappalardo, M.; Lattanzi, M.; Blessent, C. G. F.; De Maria, F.; De Santis, G.
abstract

BACKGROUND AND AIM: More than 250 000 women estimated to be diagnosed with breast cancer in the USA every year. Mastectomy is primary treatment for more than a third of those with early-stage disease. Most of the patients undergoing mastectomy receive breast reconstruction. A number of. Surgical techniques have been described to reconstruct the breast. With autologous tissue breast reconstruction, the plastic surgeon uses patient's own tissues, taken from a different part of the body where there is an excess of fat and skin. Deep inferior epigastric perforator (DIEP) flap is the autologous breast reconstruction technique of choice in our department due to long lasting results, low donor site morbidity and positive patient reported outcomes have been described.   Case Report: We present the case of a 42-year-old woman who underwent neoadjuvant chemotherapy followed by left breast simple mastectomy, axillary lymph-nodes dissection and later adjuvant radiation therapy (RT). After conclusion of RT a DIEP flap breast reconstruction was performed. Nine-hours after the operation, signs of acute venous congestion were noted. The venous congestion was treated by a combined surgical and medical approach based on pedicle discharge and ICU resuscitation protocol. After take back surgery, the patient was tightly monitored in the intensive care unit where intravenous heparin infusion and leech therapy were performed for 2 days. Flap congestion resolved completely, and the patient was discharged.   Conclusions: Venous congestion is very difficult to treat due to its potential multifactorial nature. The most important step is to recognize this kind of emergency because irreversible microvascular damages will develop in 6-8 hours. Because of multiple causes of venous congestion a timely multidisciplinary approach is mandatory, to maximize flap salvage and success rates.

2022 - Fat Grafting in Facial Palsy: A Secondary Revision Technique to Improve the Facial Aesthetics [Articolo su rivista]
Pappalardo, M.; Davies, K.; Morley, S.
abstract

We report our experience of using autologous fat grafting (AFG) as an adjunct to dynamic and static facial reanimation surgical techniques in patients with facial palsy. A consecutive series of patients with facial palsy (congenital or acquired) treated by AFG between September 2007 and October 2017 were reviewed. Multiple strategies for initial dynamic facial reanimation have been utilized. Indications for AFG included asymmetry, volume deficiency, and visible muscle tethering. Standard AFG technique was used with fat harvested from the lower abdomen or thigh and injected into multiple affected areas. Fat grafting was repeated as necessary. Two-dimensional analysis was performed using standardized pre- and postoperative photographs to assess facial symmetry. Patient, surgeon, and independent evaluator satisfaction was recorded using a five-point Likert scale (0–4). Thirty-two patients with a mean age of 43 ± 15.5 years were treated with AFG following facial reanimation. A mean of 1.7 ± 1.4 secondary procedures were performed following initial dynamic reanimation before fat grafting. The average number of AFG episodes was 2.2 ± 1.4 with a mean volume of 12.9 ± 6.0 ml. Minimal complications were seen in either the donor or the recipient sites. There was significant improvement (P ≤ 0.001) of postoperative quantitative facial symmetry following fat grafting. At one-year follow-up, surgeon, patient, and independent evaluator were mostly satisfied (3.06 ± 0.62, 3.31 ± 0.59, and 3.16 ± 0.57, respectively). We report a positive experience of correction of facial asymmetry, contour abnormality and visible muscle pull with fat transplantation following dynamic facial reanimation. The procedure has been shown to be quick and simple, with few complications.

2022 - Secondary Autologous Fat Grafting for the Treatment of Chin Necrosis as a Consequence of Prone Position in COVID-19 Patients [Articolo su rivista]
Pappalardo, M.; Starnoni, M.; De Maria, F.; Lolli, F.; Pedone, A.; Baccarani, A.; De Santis, G.
abstract

Summary: Due to the spread of the coronavirus disease 2019 pandemic, an increasing number of ill patients have been admitted to intensive care unit requiring mechanical ventilation. Although prone positioning is considered beneficial, long periods in this position may induce important complications, including pressure ulcers in high-risk and uncommon body areas. We report five cases of pressure ulcer necrosis of the chin in coronavirus disease 2019 patients as a consequence of mechanical ventilation in prone positioning using autologous fat grafting (AFG) as a secondary technique. A series of five patients with secondarily-healed chin necrosis treated by AFG between February and June 2020 were reviewed. All patients had been treated initially with surgical debridement followed by conservative treatment. Secondary AFG was performed to reduce patient's pain, improve chin contour-projection, and minimize cosmetic sequelae and scarring. Patient satisfaction was assessed using a five-point Likert scale (0-4). Vancouver scale was used to evaluate the chin scars clinically. The average amount of fat injected into the chin area was 8.1 ± 2.0 ml. At 6-month follow-up, all patients were mostly satisfied (average Likert-scale 3.2 ± 0.4). Based on the Vancouver scale, improvement of the chin scar from 9.5 ± 0.8 to 4.7 ± 0.8 was found. We report a positive experience with secondary AFG for correction of painful and unaesthetic scarring and contour abnormality following surgical debridement and secondary-intention healing of chin pressure ulcers.

2021 - Breast Cancer-Related Lymphedema: Recent Updates on Diagnosis, Severity and Available Treatments [Articolo su rivista]
Pappalardo, Marco; Starnoni, Marta; Franceschini, Gianluca; Baccarani, Alessio; De Santis, Giorgio
abstract

2021 - Lymphoscintigraphy, Interpretation, Staging, and Lymphedema Grading [Capitolo/Saggio]
Pappalardo, M; Cheng, M-H
abstract

2021 - Systemic sclerosis cutaneous expression: Management of skin fibrosis and digital ulcers [Articolo su rivista]
Starnoni, M.; Pappalardo, M.; Spinella, A.; Testoni, S.; Lattanzi, M.; Femino, R.; De Santis, G.; Salvarani, C.; Giuggioli, D.
abstract

Systemic sclerosis is a connective tissue disease with cutaneous involvement. Clinical manifestations result from the balance of inflammations/autoimmunity process and fibrogenesis. Patients suffer from skin ulcers, non-ulcerative lesions including digital pitting scars, telangiectasias, subungual hyperkeratosis, abrasions, fissures, and subcutaneous calcinosis. A review about the pathophysiology of the disease, the physical examination of the patients, the instrumental assessment, and possible treatments is performed.

2020 - Comparison of 99mTc-Labeled Colloid SPECT/CT and Planar Lymphoscintigraphy in Sentinel Lymph Node Detection in Patients with Melanoma: A Meta-Analysis [Articolo su rivista]
Quartuccio, Natale; Garau, Ludovico Maria; Arnone, Annachiara; Pappalardo, Marco; Rubello, Domenico; Arnone, Gaspare; Manca, Gianpiero
abstract

We compared the detection rate (DR) for sentinel lymph nodes (SLNS), the number of SLNs and the subjects with additional SLNs of single-photon emission computed tomography (SPECT/CT) and planar lymphoscintigraphy (PL) in patients with melanoma. Furthermore, we evaluated the impact of SPECT/CT on surgical plans. Articles containing head-to-head comparisons between SPECT/CT and PL were searched in Pubmed/MEDLINE and Scopus. The literature search was updated until December 31st, 2019. DR was calculated on a per-patient-based analysis; the studies were pooled by their odds ratios (ORs) with a random effects model to assess the significance of difference (p< 0.05). The number of additional SLNs (calculated as the relative risk) and pooled proportion of patients with additional SLNs were investigated. The pooled ratio of surgical procedures influenced by the SPECT/CT findings was calculated. Seventeen studies with 1438 patients were eligible for the calculation of DR of SPECT/CT and PL. The average DR was 98.28% (95% confidence interval (95% CI): 97.94-99.19%) for the SPECT/CT and 95.53% (95% CI: 92.55-97.77%) for the PL; OR of 2.31 (95% CI: 1.66-4.18,p< 0.001) in favor of the SPECT/CT. There was a relative risk of a higher number of SLNs (1.13) for the SPECT/CT and 17.87% of patients with additional SLNs were detected by SPECT/CT. The average impact of SPECT/CT on surgery resulted in 37.43% of cases. This meta-analysis favored SPECT/CT over PL for the identification of SLNs in patients with melanoma due to a higher DR, reproducibility, number of SLNs depicted, proportion of patients with additional SLNs and the impact on the surgical plan. However, PL remains a good option due to the high values of the DR for SLNs.

2020 - Laparoscopically assisted transperineal approach in the management of a giant pelvic lipoma [Articolo su rivista]
Baccarani, A.; Bonetti, E.; Pedone, A.; De Santis, G.; Pappalardo, M.; Romano, A.; Sighinolfi, C.; Rocco, B.
abstract

Giant lipomas affecting the retroperitoneum and pelvis are quite rare. The surgical management of these lesions may be technically demanding and controversies exist with respect to diagnosis, competences being involved, type of surgical approach, radicality, and timing. A unique case presentation of a giant lipoma occupying the whole pelvis and the gluteal region is presented. Due to its size, many anatomical areas are involved, requiring the expertise of multiple specialists to treat. After multidisciplinary counseling, the lesion is radically resected in one stage by using a new videolaparoscopically assisted transperineal access to the pelvis. This type of surgical approach may be of interest for resecting pelvic tumors in women and men.

2020 - Lymphoscintigraphy for the diagnosis of extremity lymphedema: Current controversies regarding protocol, interpretation, and clinical application [Articolo su rivista]
Pappalardo, M.; Cheng, M. -H.
abstract

Appropriate diagnosis, staging and a further selection of the best treatment are fundamental for the management of patients with extremity lymphedema. Several clinical and imaging tools have been described for these purposes. Lymphoscintigraphy is still considered the gold standard imaging modality for diagnosing lymphedema. However, protocol variability and poor image resolution can make the interpretation challenging. Here, we reviewed technical aspects of lymphoscintigraphy, interpretation of the lymphoscintigraphy findings, staging, and its clinical application.

2020 - Management of Personal Protective Equipment in Plastic Surgery in the Era of Coronavirus Disease [Articolo su rivista]
Starnoni, M.; Baccarani, A.; Pappalardo, M.; De Santis, G.
abstract

2020 - MicroRNAs in solid organ and vascularized composite allotransplantation: Potential biomarkers for diagnosis and therapeutic use [Articolo su rivista]
Di Stefano, A. B.; Pappalardo, M.; Moschella, F.; Cordova, A.; Toia, F.
abstract

Nowadays, solid organ transplantation (SOT) is an established treatment for patients with end-organ dysfunction, which dramatically improves the quality-of-life. Vascularized composite allotransplants (VCAs) including hand and face have been reported worldwide over the last 20 years. However, VCAs, differently to SOT, are life-enhancing instead of life-saving and are not routinely performed due to the risk of immune rejection and the adverse effects of immunosuppression. Over the past decade, although considerable improvements in short-term outcomes after allotransplantation have been registered, these results have not been translated into major progress in long-term allograft acceptance and patient survival. Recently active researches in the field of biomarker discovery have been conducted to develop individualized therapies for allograft recipients. MicroRNAs (miRNAs) are a small noncoding RNAs functioning as critical regulators of gene and protein expression by RNA interference. They have been connected in numerous biological processes and diseases. Due to their immunomodulatory functions, miRNAs have been amended as potential diagnostic and prognostic biomarker for the detection of rejection in allotransplantation. Due to their specific circulating expression profile, they could act as noninvasive predictive tools for rejection that may help clinicians in an early adjustment of the immunosuppression protocol during acute rejections episodes. Indeed, specific anti-sense oligonucleotides suppressing miRNAs expressed in rejection could reduce the rejection rate in allografts and decrease the use of immunosuppressants. We present a literature review of the immunomodulatory properties and characteristics of miRNAs. We will summarize the current knowledge on miRNAs as potential biomarkers for allograft rejection and possible application in allotransplantation monitoring. Finally, we will discuss the advances in preclinical miRNA-based therapies for immunosuppression.

2020 - Necrobiosis Lipoidica Affecting the Leg: What Is the Best Treatment in a Patient with Very High Aesthetic Demand? [Articolo su rivista]
Baccarani, A.; De Maria, F.; Pappalardo, M.; Pedone, A.; De Santis, G.
abstract

Summary: Necrobiosis Lipoidica (NL) is a rare necrotising disorder of the skin characterized by collagen degeneration, thickening of blood vessels, and granulomatous inflammatory process. Its main clinical features are brownish-red papules and yellowish plaques with atrophic central areas. NL affects 0.3% -1.2% of the diabetic population, mostly women (female/male ratio is 3:1). Management of NL is challenging, especially for large lesions refractory to medical therapy, thus requiring surgical excision as an alternative option. Due to the rare occurrence of this condition no treatment guidelines exist and individualized treatment mostly depends on the severity of the lesion, location and patient's expectations. A case of a 30-year-old diabetic woman with very high aesthetic expectations was succesfully treated with staged resections of a giant NL to the leg and reconstruction with dermal template and full thickness skin grafts. Grafts were taken from the groin region bilaterally and from the lower abdomen after a cosmetic mini-abdominoplasty procedure. This approach allowed for a stable and very satisfactory aesthetic result with no donor site exposed scars.

2020 - Plastic Surgeons in the middle of the Coronavirus Disease 2019 Pandemic Storm in Italy [Articolo su rivista]
Baccarani, A.; Pappalardo, M.; Starnoni, M.; De Santis, G.
abstract

2020 - Sentinel node identification in melanoma: Current clinical impact, new emerging SPECT radiotracers and technological advancements. an update of the last decade [Articolo su rivista]
Quartuccio, N.; Siracusa, M.; Pappalardo, M.; Arnone, A.; Arnone, G.
abstract

Background: Melanoma is the most lethal skin cancer with a mortality rate of 262 cases per 100.000 cases. The sentinel lymph node (SLN) is the first lymph node draining the tumor. SLN biopsy is a widely accepted procedure in the clinical setting since it provides important prognostic informa-tion, which helps patient management, and avoids the side effects of complete lymph node dissection. The rationale of identifying and removing the SLN relies on the low probability of subsequent metas-tatic nodes in case of a negative histological exam performed in the SLN. Discussion: Recently, new analytical approaches, based on the evaluation of scintigraphic images are also exploring the possibility to predict the metastatic involvement of the SLN.99mTc-labeled colloids are still the most commonly used radiotracers but new promising radiotracers, such as99mTc-Tilmanocept, are now on the market. In the last decades, single photon emission computed tomogra-phy-computerized tomography (SPECT/CT) has gained wider diffusion in clinical departments and there is large evidence about its superior diagnostic accuracy over planar lymphoscintigraphy (PL) in the detection of SLN in patients with melanoma. Scientists are also investigating new hybrid techniques combining functional and anatomical images for the depiction of SLN but further evidence about their value is needed. Conclusion: This review examined the predictive and prognostic factors of lymphoscintigraphy for metastatic involvement of SLN, the currently available and emerging radiotracers and the evidence of the additional value of SPECT/CT over PL for the identification of SLN in patients with melanoma. Finally, the review discussed the most recent technical advances in the field.

2020 - Simultaneous Ipsilateral Vascularized Lymph Node Transplantation and Contralateral Lymphovenous Anastomosis in Bilateral Extremity Lymphedema with Different Severities [Articolo su rivista]
Cheng, M. -H.; Tee, R.; Chen, C.; Lin, C. -Y.; Pappalardo, M.
abstract

Background: Extremity lymphedema can occur bilaterally with different severities on each side. The aim of this study is to investigate the treatment outcomes of such patients with bilateral extremity lymphedema of different severities. Patients and Methods: Between 2013 and 2017, patients with bilateral extremity lymphedema of different severities according to the Taiwan Lymphoscintigraphy Staging (TLS) system were retrospectively reviewed. Ipsilateral vascularized lymph node transplantation (VLNT) was indicated in TLS total obstruction and contralateral lymphovenous anastomosis (LVA) in TLS partial obstruction with patent lymphatic vessels on indocyanine green lymphography. Outcomes were assessed using circumference improvement, frequency of cellulitis, and lymphedema-specific quality of life (LYMQoL) questionnaires. Results: A total of 10 patients with bilateral extremity lymphedema with median age of 63 (range 12–75) years were included. The median symptom duration of the lymphedematous limb was 60 (range 36–168) months and 12 (range 1–60) months in the VLNT and LVA group, respectively (p < 0.05). At average follow-up of 37.5 (range 14–58) months, the average limb circumference improvement was 2.4 (range − 3.3 to 7.8) cm in the VLNT group and 2.3 (range 0.3–7) cm in the LVA group (p = 1). The median episodes of cellulitis decreased significantly from 4 to 0.5 and 1 to 0 times/year in the VLNT and LVA group, respectively (p = 0.02, p = 0.06). The overall LYMQoL score improved from 4.5 preoperatively to 7.5 postoperatively (p < 0.01). Conclusions: Limb-specific VLNT and LVA selected by TLS effectively treated bilateral extremity lymphedema with different severities.

2020 - Staging and clinical correlations of lymphoscintigraphy for unilateral gynecological cancer–related lymphedema [Articolo su rivista]
Pappalardo, M.; Lin, C.; Ho, O. A.; Kuo, C. -F.; Lin, C. -Y.; Cheng, M. -H.
abstract

Background: This study was to investigate the lymphoscintigraphy findings for the diagnosis and severity in unilateral gynecological cancer–related lymphedema (GCRL) and to correlate lymphoscintigraphy stages with the clinical findings. Methods: Patients with unilateral GCRL who underwent lymphoscintigraphy were staged using the presence of ileo-inguinal lymph nodes, distal-lymphatic ducts, and dermal backflow findings. Taiwan Lymphoscintigraphy Staging (TLS) was divided into three patterns and seven stages: normal drainage (L-0); partial obstruction (P-1, P-2, and P-3); and total obstruction (T4, T-5, and T-6). Correlations between clinical lymphedema severity and TLS were evaluated using analysis of variance and multivariable linear regression analyses. Results: A total of 141 patients with unilateral GCRL were divided as follows: 6 (4.3%) in normal drainage, 56 (39.7%) in partial-obstruction, and 79 (56%) in total obstruction. Cellulitis episodes, circumferential difference, and computed tomography (CT) volumetric difference were shown to be statistically different between TLS stages (P <.001 for all). Total obstruction stages were the most significant factors associated with the severity of circumferential difference (β = 19.72, 25.54, 32.42, respectively; P <.05) and CT volumetric difference (β = 36.04, 45.12, 52.78, respectively; P <.01). Conclusions: Total lymphatic obstruction was present in 56% of unilateral GCGL. Lymphoscintigraphy stages were statistically correlated with episodes of cellulitis, circumferential difference and CT volumetric difference in unilateral GCRL.

2020 - Summary of hands-on supermicrosurgery course and live surgeries at 8th world symposium for lymphedema surgery [Articolo su rivista]
Pappalardo, M.; Chang, D. W.; Masia, J.; Koshima, I.; Cheng, M. -H.
abstract

The hands-on supermicrosurgery course provided participants a valuable learning experience of in-depth practices of supermicrosurgical skills with experts. Seven live surgeries were successfully demonstrated at 8th World Symposium for Lymphedema Surgery. Variable donor sites for vascularized lymph node transfer were the submental, supraclavicular, groin, and omental; while the recipient sites included the wrist and axilla in upper limb; and popliteal and groin in the lower limb. The therapeutic and preventive lymphovenous anastomosis was also satisfactorily performed.

2020 - Traumi da agenti chimico-fisici [Capitolo/Saggio]
Zagra, Michele; Pappalardo, Marco
abstract

2019 - A Modified Delta-Inset Anterolateral Thigh Flap for Reconstruction of Circumferential Pharyngoesophageal Defects: Comparison Regarding Postoperative Complications Among Three Different Flap design” [Abstract in Atti di Convegno]
Pappalardo, M
abstract

2019 - Immunomodulation in Vascularized Composite Allotransplantation: What Is the Role for Adipose-Derived Stem Cells? [Articolo su rivista]
Pappalardo, M; Montesano, L; Toia, F; Russo, A; Di Lorenzo, S; Dieli, F; Moschella, F; Leto Barone, Aa; Meraviglia, S; Di Stefano, Ab.
abstract

2019 - Lymphatic Microsurgery versus Complex Decongestive Therapy in Unilateral Extremity Lymphedema: Outcome Based on Objective Clinical Findings and Lymphoscintigraphy’ [Abstract in Atti di Convegno]
Pappalardo, M; Lin, Cy; Cheng, Mh.
abstract

2019 - Patterns, Staging and Clinical Application of Lymphoscintigraphy for Gynecologic Cancer-Related Lymphedema [Abstract in Atti di Convegno]
Pappalardo, M; Lin, Cy; Cheng, Mh
abstract

2019 - Surgical Versus Non-Surgical Treatment in Unilateral Extremity Lymphedema: Outcome Based on Objective Clinical Findings and Lymphoscintigraphy”, [Abstract in Atti di Convegno]
Pappalardo, M; Lin, Cy; Cheng, Mh.
abstract

2018 - A New Lymphoscintigraphy Staging for Unilateral Extremity Lymphedema Validation and Correlation between Nuclear Images and Clinical Findings [Abstract in Rivista]
Pappalardo, M
abstract

2018 - Abstract: The Submental Versus Groin Vascularized Lymph Node Transfer Flaps: A Head-to-Head Comparison of Surgical Outcomes for Breast Cancer Related Lymphedema. Plast Reconstr Surg Glob Open. [Abstract in Rivista]
Pappalardo, M
abstract

2018 - Chimeric Free Vascularized Metatarsophalangeal Joint With Toe Fillet Flap: A Technique for Reconstruction of the Posttraumatic Metacarpophalangeal Joint With Concomitant Soft Tissue Defect [Articolo su rivista]
Pappalardo, M.; Laurence, V. G.; Lin, Y. -T.
abstract

For painful, dysfunctional, posttraumatic metacarpophalangeal (MCP) joints, the free vascularized toe joint transfer may represent a good solution. Successful reconstruction is potentially limited, however, by 2 features of the traditional vascularized metatarsophalangeal (MTP) transfer: inadequate arc of flexion and insufficient soft tissue coverage. The solution to both of these dilemmas lies in the manner of utilizing the donor site. Because of its innate hyperextensibility, rotating the MTP 180° volar to dorsal provides the greatest arc of flexion in the reconstructed MCP. Excellent soft tissue coverage can be provided by elevating the skin paddle of the transferred second toe as a chimeric fillet flap, based on the tibial plantar digital artery.

2018 - Comparisons of submental and groin vascularized lymph node flaps transfer for breast cancer-related lymphedema [Articolo su rivista]
Ho, O. A.; Lin, C. -Y.; Pappalardo, M.; Cheng, M. -H.
abstract

Background: The vascularized groin and submental lymph node (VGLN and VSLN) flaps are valuable options in the treatment of lymphedema. This study was to compare outcomes between VGLN and VSLN transfers for breast cancer-related lymphedema. Methods: Between January 2008 and December 2016, VGLN and VSLN transfers for upper limb lymphedema were compared including flap characteristics, flap elevation time, complications, and limb circumference changes. Results: All flaps survived. Similar vein (2.6 versus 3.2 mm; P = 0.3) and artery diameter (2.1 versus 2.8 mm; P = 0.3) and number of lymph nodes (3 versus 4; P = 0.4) were found between VGLN and VSLN groups, respectively. Circumferential reduction rate was higher in VSLN than VGLN (P = 0.04) group. Vascular complication rate with salvage rate was not statistically different between the 2 groups. Donor-site complication and total complication rates were statistically higher in VGLN than VSLN flaps (7.7% versus 0%, P = 0.004; 46.2% versus 23.3%, P = 0.002). At a mean 39.8 ± 22.4 months, the circumferential reduction rate was statistically higher in VSLN than in the VGLN group (55.5 ± 14.3% versus 48.4 ± 23.9%, P = 0.04). Both flaps were effectively decreased in the episodes of cellulitis. Conclusions: Both VGLN and VSLN flaps are valuable surgical options in treating breast cancer-related lymphedema. However, the VSLN flap for breast cancer-related lymphedema is better in providing more significant improvements in limb circumference, a faster flap harvest time, decreased complication rates, and minimal donor-site iatrogenic lymphedema.

2018 - Free Vascularized Metatarsophalangeal Joint for Reconstruction of the Post-Traumatic Metacarpophalangeal Joint with Concomitant Soft-Tissue Defect: Strategies to Improve Outcomes [Abstract in Atti di Convegno]
Pappalardo, M
abstract

2018 - Long-term outcome of patients with or without osseointegrated implants after resection of mandibular ameloblastoma and reconstruction with vascularized bone graft: Functional assessment and quality of life [Articolo su rivista]
Pappalardo, M.; Tsao, C. -K.; Tsang, M. L.; Zheng, J.; Chang, Y. -M.; Tsai, C. -Y.
abstract

Background: The optimal management after the resection of mandibular ameloblastoma has been very challenging to surgeons. The aim of this study is to evaluate the functional, aesthetic, and quality of life outcomes of patients who had a segmental mandibular resection and immediate reconstruction with or without osseointegrated implants. Method: Patients’ demographics, tumor characteristics, treatment, and complications were retrieved. Patients were divided into two groups: dental rehabilitated vs. nondental rehabilitated depending on the placement of osseointegrated implants followed by an implanted-retained prosthesis. Functional outcomes and quality of life were assessed using the Performance Status Scale, the University of Washington Quality of Life (UW-QOL) scale, and the 14-item Oral Health Impact Profile (OHIP-14). Aesthetic outcome was evaluated by patients using a Visual Analog Scale. Results: Thirty-four patients were reviewed. Twenty-two patients were included in the dental rehabilitated group and 12 in the nondental rehabilitated group. No recurrence of the tumor was found during the average follow-up period of 7.4 years. Although both groups reported a similar satisfaction in appearance, patients in the dental rehabilitated group scored significantly higher in masticatory function and “eating in public” (p < 0.01). There were significant differences (p < 0.05) regarding “chewing,” “activity,” and “anxiety” when assessed using the UW-QOL scale. Indeed, patients in the dental rehabilitated group showed a definitively better outcome in “physical disability” and “psychological discomfort” dimensions when assessed using the OHIP-14. Conclusion: Vascularized bone graft reconstruction followed by immediate or delayed placement of osseointegrated implants showed as an ideal and predictable treatment modality for patients with ameloblastoma. The results suggested that patients with osseointegrated implants had a significantly better masticatory function, improved quality of life, and less psychological consequences.

2018 - Modified Lymphoscintigraphy Staging as a Tool for Assessment of Lymphatic Obstruction in Lymphedema Patients and Correlation with Clinical Findings [Poster]
Pappalardo, M
abstract

2018 - Nipple-sparing mastectomy and breast reconstruction with a deep inferior epigastric perforator flap using thoracodorsal recipient vessels and a low lateral incision [Articolo su rivista]
Ho, O. A.; Lin, Y. -L.; Pappalardo, M.; Cheng, M. -H.
abstract

Background: Nipple-sparing mastectomy poses challenges in providing esthetically-pleasing immediate autologous breast reconstruction. This study was to investigate the outcomes of nipple-sparing mastectomy with breast reconstruction using free abdominal flaps between two different recipient sites. Methods: Between 2010 and 2016, 79 patients who underwent nipple-sparing mastectomy with autologous breast reconstruction using thoracodorsal (TD) vessels in 30 cases or internal mammary (IM) vessels in 49 cases were investigated. Demographics, intraoperative findings, complications, and quality of life using Breast-Q questionnaire were compared between two groups. Results: All flap survived. There was no statistical difference in age, BMI, ischemia time, and flap-used percentage. The TD artery had a statistically smaller diameter 1.8 ± 0.4 mm than the IM artery 2.7 ± 0.43 mm (p = 0.02). At a mean follow-up of 44.4 ± 35.2 months, there was no statistical difference in total complication rates between TD and IM groups (23.3% and 36.7%, respectively, p > 0.05). The “psychosocial well-being” of Breast-Q in TD group 83.9 ± 14.6 was statistically greater than IM group 72.8 ± 17.6 (p = 0.04). Conclusions: Nipple-sparing mastectomy with immediate breast reconstruction using TD vessels with a low lateral scar is a safe procedure that provides an inconspicuous scar with better cosmesis and minimal complication rate.

2018 - Validity in the Application of the Novel Taiwan Lymphoscintigraphy Staging and Clinical Grading Systems for Unilateral Extremity Lymphedema [Abstract in Atti di Convegno]
Pappalardo, M; Cheng, Mh; Lin, C; Kuo, Cf; Lin, Cy; Chung, Kc.
abstract

2018 - Validity of the Novel Taiwan Lymphoscintigraphy Staging and Correlation of Cheng Lymphedema Grading for Unilateral Extremity Lymphedema [Articolo su rivista]
Cheng, M. -H.; Pappalardo, M.; Lin, C.; Kuo, C. -F.; Lin, C. -Y.; Chung, K. C.
abstract

OBJECTIVE: The aim was to validate the new Taiwan Lymphoscintigraphy Staging, correlate it with Cheng Lymphedema Grading (CLG) and evaluate the treatment outcomes of unilateral extremity lymphedema. BACKGROUND: No consensus has been reached for diagnosis and staging for patients with lymphedema among medical specialties. METHODS: We included 285 patients with unilateral extremity lymphedema using lymphoscintigraphy. Lymphoscintigraphy was correlated to clinical symptoms and signs, and classified into normal lymphatic drainage, partial obstruction, and total obstruction. Inter- and intraobserver reliability of Taiwan Lymphoscintigraphy Staging, correlation between Taiwan Lymphoscintigraphy Staging and clinical findings were conducted. Patients were categorized in "surgical" (n = 154) or "nonsurgical" (n = 131) groups for outcome evaluation. RESULTS: Lymphoscintigraphy found 11 patients (3.9%) with normal lymphatic drainage, 128 (44.9%) with partial obstruction, and 146 (51.2%) with total obstruction. Taiwan Lymphoscintigraphy Staging showed high interobserver agreement [intraclass correlation coefficient: 0.89 (95% confidence interval, 0.82-0.94)], and significantly correlated to computed tomography volumetric difference (r = 0.66, P < 0.001) and CLG [intraclass correlation coefficient: 0.79 (95% confidence interval 0.72-0.84)]. At a mean follow-up of 31.2 ± 2.9 months, significant improvement in the circumferential difference (from 23.9% ± 17.6% to 14.6% ± 11.1%; P = 0.03) with a mean circumferential reduction rate of 40.4% ± 4.5% was found in surgical group. At a mean follow-up of 26.6 ± 8.7 months, the nonsurgical group had increase of mean circumferential difference from 24.0% ± 17.2% to 25.3% ± 19.0% (P = 0.09), with a mean circumferential reduction rate was -1.9% ± 13.0%. CONCLUSIONS: The Taiwan Lymphoscintigraphy Staging is a reliable diagnostic tool, correlated with clinical findings and CLG, aiding in the selection of the appropriate treatment to achieve favorable long-term outcomes in unilateral extremity lymphedema.

2018 - Vascularized lymph node transfer for treatment of extremity lymphedema: An overview of current controversies regarding donor sites, recipient sites and outcomes [Articolo su rivista]
Pappalardo, M.; Patel, K.; Cheng, M. -H.
abstract

As lymphatic microsurgery has become more common, vascularized lymph node transfer ascended to the forefront in many centers for the surgical management of advanced stages of lymphedema showing substantial clinical improvement. However, no consensus has been reached among experts regarding many details of the procedures, including patient selection criteria, type of treatment, donor, and recipient sites and postoperative evaluation of the outcome. Here, we will review these issues and provide the current results of this procedure.

2017 - Free Vascularized Toe Joint Transfer to the Metacarpal phalangeal Joint: new surgical techniques to improve the functional outcome [Abstract in Atti di Convegno]
Pappalardo, M
abstract

Free Vascularized Toe Joint Transfer to the Metacarpal phalangeal Joint: new surgical techniques to improve the functional outcome. Objectve: Reconstruction of dysfunctional or painful damaged metacarpophalangeal joints (MCPJs) is challenging. The current treatment of choice remains controversial, including arthrodesis, implant arthroplasty or vascularized joint transfer (VJT). Although previous studies showed that implant arthroplasty provide superior range of motion (ROM) than VJTs, in young or high-demand patients for whom either potential growth or maintenance of a good ROM is required, VJTs provide a good solution to their needs. Furthermore in case of tendon and skin defects, VJTs can also provide specific soft tissue replacement, in a one-stage procedure. Since the toe metacarpal phalangeal joint (MTPJ) and finger MCPJ have similar anatomical structure, vascularized MTPJ transfer is an ideal transplant for reconstructing the damaged MCPJ, except for having dorsal extension as its main function. The aim of this study, is to provide new anatomical knowledge and reconstructive techniques in a clinical series for the reconstruction of the MCPJ using toe joint transfers. Methods: Nine patents (eight male and one female) with ankylosed MCPJ underwent reconstruction with vascularized second-toe MTPJ transfer over a five-year period. All cases suffered from posttraumatic arthritis. The average age of the patients was 42.3 years. The follow-up period ranged from 8 to 37.5 months and outcomes were assessed by grip strength and ROM of the reconstructed joints. Results: All of the joints survived without any microvascular compromise. At an average period of 4.5 weeks bony union was achieved in all patients. Constant and sizable articular branch originated from the first plantar metatarsal artery was intentionally included to achieve reliable blood supply to the MTPJ. Indeed, to overcome the problem of excessive dorsal extension of MTPJs in four cases we adopted the Turnover Technique in which the joint is turned upside-down around its longitudinal axis and in two MTPJ we used the 45o Oblique Osteotomy technique of the metatarsal head. In addition, in two cases an innovative modification of the skin paddle design was performed. A fillet flap from the same toe based on the distal run off of the tibial plantar digital artery provided additional skin for coverage the neo-MCPJ. No evidence of postoperative arthritis was noted and a total ROM of 57.8o (mean flexion, 72.2o ) was achieved over the follow-up period Conclusion: Vascularized second-toe MTPJ allows for restoration of powerful pinch/grasp and ROM of a MCPJ in the hand. Improvement of the surgical techniques can result in very favorable functional outcomes enabling more patients to benefit from VJTs.

2016 - 18F-FDG PET/CT, cytoreductive surgery and intraperitoneal chemohyperthermia for the therapeutic management in peritoneal carcinomatosis: A pilot study | 18F-FDG PET/TC, cirugía citorreductora y quimiohipertermia intraperitoneal para el tratamiento terapéutico de la carcinomatosis peritoneal: estudio piloto [Articolo su rivista]
Cistaro, A.; Cucinotta, M.; Cassalia, L.; Priola, A.; Priola, S.; Pappalardo, M.; Coppolino, P.; De Simone, M.; Quartuccio, N
abstract

2016 - Versatility of the Free Anterolateral Thigh Flap in the Reconstruction of Large Defects of the Weight-Bearing Foot: A Single-Center Experience with 20 Consecutive Cases [Articolo su rivista]
Pappalardo, M.; Jeng, S. -F.; Sadigh, P. L.; Shih, H. -S.
abstract

Background Reconstruction of the weight-bearing surface of the foot represents a challenging task. With very little scope to borrow glabrous tissue from adjacent areas means that achieving a like for like reconstruction is rarely possible. In this setting, alternative approaches need to be considered. In this article we present our experience with various differing designs of the anterolateral thigh flap (ALT) in the reconstruction of 20 large defects of the weight-bearing sole. Methods Twenty patients with complex soft tissue defects of the weight-bearing sole underwent reconstruction over a 5-year period. Five cases were complicated by osteomyelitis resulting in significant calcaneal defects. The follow-up period ranged from 8 to 48 months and outcomes were assessed by two-point discrimination and protective sensation, observation of gait, and the ability of the patient to return to wearing normal footwear. Results All flaps survived with the exception of two partial skin necrosis. Sensory nerve coaptation was performed in 12/20 cases. One patient underwent second-stage total calcaneal reconstruction with a fibula osteocutaneous flap. Five large defects were reconstructed with the split skin paddle technique to allow for direct donor-site closure. No evidence of postoperative ulceration was noted in any of the patients over the follow-up period and all were satisfied regarding the functional and aesthetic results achieved. Conclusion Complex defects of the weight-bearing sole can be successfully reconstructed using the free ALT flap resulting in very favorable functional outcomes. Even when calcaneal osteomyelitis has set in, excellent outcomes can be achieved.