Editorial for the Special Issue "Vasorum Lymphaticorum: From the Discovery of the Lymphatic System to the New Perspectives in Microsurgical Reconstruction and Patient Rehabilitation"

Lymphedema is a complex clinical condition that appears as a result of the failure of the lymphatic system function, and it is characterized by edema, fibrosis, and adipose deposition [...].

Mind the Gap: A Questionnaire on the Distance between Diagnostic Advances and Clinical Practice in Skin Cancer Treatment

Background and Objectives: Significant progress has been made in skin cancer diagnosis, with a surge in available technologies in recent years. Despite this, the practical application and integration of these technologies in dermatology and plastic surgery remain uneven. Materials and Methods: A comprehensive 20-question survey was designed and distributed using online survey administration software (Google Forms, 2018, Google, Mountain View, CA, USA) from June 2023 to September 2023. The survey aimed to assess the knowledge and utilization of dermatologic diagnostic advancements among plastic surgeons in various European countries. Results: Data were obtained from 29 plastic surgeons across nine European countries, revealing a notable gap between diagnostic technologies and their routine use in surgical practice. The gap for some technologies was both cognitive and applicative; for electrical impedance spectroscopy (EIS) and multispectral imaging, only 6.9% of the sample knew of the technologies and no surgeons in the sample used them. In the case of other technologies, such as high-frequency ultrasound (HFUS), 72.4% of the sample knew about them but only 34.5% used them, highlighting a more significant application problem. Conclusions: Spotlighting this discrepancy provides a valuable foundation for initiating collaborative efforts between units and facilitating knowledge exchange among diverse specialists. This, in turn, contributes to advancing clinical practice by integrating the innovative opportunities presented by ongoing research.

Orthoplastic limb reconstruction using free fibula flap after trauma: Outcomes from a retrospective European multicenter study

BACKGROUND

Free vascularized fibula flap represents the gold standard vascularized bone graft for the management of segmental long bone defects after traumatic injury. The current study represents the largest retrospective multicenter data collection on the use of free fibula flap (FFF) for extremities' orthoplastic reconstruction after trauma aiming to highlight current surgical practice and to set the basis for updating current surgical indications.

METHODS

The study is designed as a retrospective analysis of prospectively collected data between 2009 and 2021 from six European University hospitals. Patients who underwent fibula flap reconstruction after acute traumatic injury (AF) or as a late reconstruction (LF) after post-traumatic non-union of upper or lower limb were included. Only extra-articular, diaphyseal fracture were included in the study. Surgical data were collected. Time to bone healing and complications were reported as clinical outcomes.

RESULTS

Sixty-two patients were included in the study (27 in the AF group and 35 in the LF group). The average patients' age at the time of the traumatic event was 45.3 ± 2.9 years in the AF group and 41.1 ± 2.1 years in the LF group. Mean bone defect size was 7.7 ± 0.6 cm for upper limb and 11.2 ± 1.1 cm (p = .32) for lower limb. Bone healing was uneventful in 69% of treated patients, reaching 92% after complementary procedures. Bone healing time was 7.6 ± 1.2 months in the acute group and 9.6 ± 1.5 months in the late group. An overall complication rate of 30.6% was observed, with a higher percentage of late bone complications in the LF group (34%), mostly non-union cases.

CONCLUSIONS

FFF reconstruction represents a reliable and definitive solution for long bone defects with bone healing reached in 92% cases with a 8.4 months of average bone healing time.

Medial fascia lata perforator flap: Anatomical basis and clinical application as a pedicled or free flap

Adipofascial flaps have proven to be an excellent tool for multipurpose reconstruction as free or pedicled flaps. The anatomical studies in this field are now focused on improving esthetics in reconstruction while maintaining a minimal donor site morbidity. An anatomical cadaver study has been carried out to investigate the medial thigh region as a potential donor site for adipofascial flaps. Eighteen thighs from fresh cadavers were dissected and a new territory with autonomous vascular supply was defined through vascular injection, anatomical dissection, transillumination, and angiography. Cutaneous access was made in a "T" shape. The fascia harvests had to be centered on the adductor longus and gracilis muscles bearing in mind the position of the flap pedicle. The fascial flap was isolated from adductor longus and gracilis muscles and isolated on his pedicle (medial circumflex femoral artery). After our anatomical study, we used the flap in 2 clinical cases. The results of our anatomical study and clinical cases confirmed the suitability and reliability of a new flap: the "Medial Fascia Lata Flap." Flap size ranged from 20 to 25 cm and has the advantage of preserving the functionality of the thigh muscles. The study showed that the "Medial Fascia Lata Flap" is easy to harvest, and the resulting scar is concealed. In consideration of its suitability, reliability and aesthetical advantages, it could be proposed as a good option in selected cases.

The medial sural artery perforator flap for retromolar trigone reconstruction: A multicenter case series

BACKGROUND

Retromolar trigone (RMT) cancer is a rare malignancy, which develops in a narrow area of the oral cavity. Surgical intervention requires wide excision and appropriate reconstruction usually with a free tissue transfer. Little has been published regarding the ideal microvascular reconstruction, mainly focusing on radial forearm and anterolateral thigh free flap. The medial sural artery perforator flap (MSAP) is not new for head and neck reconstruction but its use for RMT reconstruction has not been previously explored. The purpose of the study is to present a multicentric case series investigating the reliability of MSAP flap for RMT reconstruction.

METHODS

The study is designed as a retrospective case series. All patients diagnosed with RMT cancer and undergone surgical resection and immediate reconstruction with a MSAP flap between February 2016 and March 2020 were identified. Patients' demographics and surgical details were collected. Functional results were evaluated using the Head and Neck Module of the European Organization for Research and Treatment of Cancer at 12 months of follow-up. A total of 34 patients with a mean age of 58 years were included in the study. An average defect size of 31.5 cm2 was observed after RMT tumor resection.

RESULTS

The MSAP flaps' average dimensions were 11 ± 3.1 cm in length and 4.7 ± 1.6 cm in width with a mean thickness of 1.4 ± 0.8 cm. No flap complications were observed in 28 cases; four patients developed an orocutaneous fistula. One patient needed surgical revision for venous congestion while only one case of flap failure was observed. At 12 months of follow-up, 87% of the patient cohort had normal, understandable speech. No patient experienced complete loss of swallowing. Results of the H&N35 module showed a significative postoperative improvement in mouth soreness, mouth opening and social (p < .05*). No patient complained difficulty in motility at the donor site.

CONCLUSIONS

The MSAP flap appears to be appropriate for RMT reconstruction and could be considered the workhorse for small to medium size defect of RTM region. It has a long pedicle of matching caliber and provides adequate tissue volume with minimal donor site morbidity.

The breast cancer-related lymphedema multidisciplinary approach: Algorithm for conservative and multimodal surgical treatment

BACKGROUND

Multiple surgical alternatives are available to treat breast cancer-related lymphedema (BCRL) providing a variable spectrum of outcomes. This study aimed to present the breast cancer-related lymphedema multidisciplinary approach (B-LYMA) to systematically treat BCRL.

METHODS

Seventy-eight patients presenting with BCRL between 2017 and 2021 were included. The average age and BMI were 49.4 ± 7.8 years and 28.1 ± 3.5 kg/m2 , respectively. Forty patients had lymphedema ISL stage II (51.3%) and 38 had stage III (48.7%). The mean follow-up was 26.4 months. Treatment was selected according to the B-LYMA algorithm, which aims to combine physiologic and excisional procedures according to the preoperative evaluation of patients. All patients had pre- and postoperative complex decongestive therapy (CDT).

RESULTS

Stage II patients were treated with lymphaticovenous anastomosis (LVA) (n = 18), vascularized lymph node transfer (VLNT) (n = 12), and combined DIEP flap and VLNT (n = 10). Stage III patients underwent combined suction-assisted lipectomy (SAL) and LVA (n = 36) or combined SAL and VLNT (n = 2). Circumferential reduction rates (CRR) were comparable between patients treated with LVA (56.5 ± 8.4%), VLNT (54.4 ± 10.2%), and combined VLNT-DIEP flap (56.5 ± 3.9%) (p > .05). In comparison to LVA, VLNT, and combined VLNT-DIEP flap, combined SAL-LVA exhibited higher CRRs (85 ± 10.5%, p < .001). The CRR for combined SAL-VLNT was 75 ± 8.5%. One VLNT failed and minor complications occurred in the combined DIEP-VLNT group.

CONCLUSION

The B-LYMA protocol directs the treatment of BCRL according to the lymphatic system's condition. In advanced stages where a single physiologic procedure is not sufficient, additional excisional surgery is implemented. Preoperative and postoperative CDT is mandatory to improve the outcomes.

Combined lymph node transfer and suction-assisted lipectomy in lymphedema treatment: A prospective study

BACKGROUND

Recent studies have analyzed the combination of suction-assisted lipectomy (SAL) and vascularized lymph node transfer (VLNT) in lymphedema treatment, reporting positive outcomes. However, it is difficult to draw conclusions due to the heterogeneity of the studies. Aim of this prospective study is to evaluate the effectiveness of the combination of VLNT and SAL in lymphedema treatment.

PATIENTS AND METHODS

Between January 2016 and May 2019, 94 patients with upper or lower limb stage IIb-III lymphedema were enrolled and treated with the gastroepiploic VLNT followed by SAL. Patients were prospectively evaluated through circumference measurement and clinical examination, including number of episodes of cellulitis.

RESULTS

Among patients enrolled in the study 83 were affected by lower limb lymphedema (LLL) and 11 were affected by upper limb lymphedema (ULL). Average follow-up was 3 ± 0.8 years. In the LLL group, the mean circumference reduction rates (CRR) were 60.4, 56.9, 29.6, and 55.4% above and below the knee, above the ankle, and at the foot level, respectively. A statistically significant difference was noted at all the levels (p < .05), but above the ankle (p = .059). Regarding the ULL group, the mean CRR were 80.7, 60.7, 65.0 and 49.6% above and below the elbow, at wrist and at mid-hand, respectively. CRR were reported at all the levels but no statistical difference was noted. The number of episodes of cellulitis dropped significantly (p < .05).

CONCLUSION

This study supports the use of VLNT+SAL in lymphedema grades IIb-III, with important implications for the clinical practice.

Partition of Pectoralis Major Musculocutaneous Flap as a Salvage Procedure for Simultaneous Coverage of the Exposed Carotid Artery and Reconstruction of Cervical Esophagus

BACKGROUND

In advanced pharyngoesophageal cancer patients, a critical event is represented by the failure of primary reconstruction with exposure of the carotid artery and partial or total defect of the cervical esophagus. For these high-risk patients, a partitioned pectoralis major musculocutaneous (PMMC) flap can prevent carotid blowout and provide skin for simultaneous esophageal reconstruction.

METHODS

Twenty-six patients needing pharyngoesophageal reconstruction together with coverage of carotid artery exposure were included in this retrospective case series. The patients were treated with a partitioned PMMC flap, based on the branching pattern of the pectoral branch of the thoracoacromial artery and the perforators of the pectoralis major muscle, to simultaneously reconstruct the defect and provide coverage for the carotid artery.

RESULTS

In 25 patients, the partitioned PMMC flap reconstructions resulted in complete wound healing without occurrence of carotid blowout syndrome or fistula formation. Minor complications as partial flap necrosis (7.7%) and strictures formation (7.7%) were recorded but did not compromise reconstruction. Twenty-two patients were able to adopt a semisolid diet, and 4 had recurrence of cancer.

CONCLUSIONS

The partitioned PMMC flap reconstruction represents a useful salvage solution to simultaneously restore the continuity of the alimentary tract and provide reliable coverage for the exposed carotid artery.

Quantitative Analysis of Nipple to Inframammary Fold Distance Variation in Tuberous Breast Augmentation: Is there a Progressive Lower Pole Expansion?

INTRODUCTION

In patients with short nipple to inframammary fold (N-IMF) distance, as in tuberous breast, the cohesivity and gel distribution of shaped implants work as a controlled tissue expander, progressively adapting the tissues to the implant's shape. This phenomenon translates into a gradual increase of the N-IMF distance over time, but the true extent to which this occurs has not been quantified to date. This study aims to quantify the postoperative variation of the N-IMF distance in tuberous breast treated with shaped cohesive silicone breast implants.

METHODS

We did a retrospective review of a prospective maintained database of all consecutive patients with bilateral Groulleau I and II tuberous breasts who underwent primary breast augmentation between April 2017 and May 2018 at our institution. To quantify the lower mammary pole's morphological changes, we evaluated the N-IMF distance under maximal stretch as an endpoint. We recorded this value at time 0 (preoperative), immediate post-op (equivalent to the distance planned preoperatively) and at month 1, month 6 and 1-year post-op. Then we calculated the average N-IMF distance variation of our sample of patients with a 99% interval of confidence for each breast obtained. Comparisons were performed using the Sign test and the Mann-Whitney U test.

RESULTS

The average implant weight was 353g (range 290-450; SD ±46.147). Of the 54 breasts analyzed, the immediate post-op N-IMF distance was on average 2.43 cm longer than the preop IMF with a 99% confidence interval between 2.01 and 2.86 and SD of ±1.22. The mean difference between the preop N-IMF distance and after 1, 6 and 12 months was respectively 2.78 cm (SD,1.56) (99% CI, 2.24-3.34), 3.08 cm (SD, 1.57) (99% CI, 2.53-3.64), and 3.36 (1.55) (99% CI, 2.82-3.91) Comparing immediate postoperative nipple to inframammary fold distance (N-IMF) to the 1, 6 and 12 months N-IMF values, an average of 4.23% (CI 1.3-7.16), 7.74% (CI 4.25-11.23) and 10.84% (CI 7.21-14.49) of skin length, was gained respectively. According to implants' weight, subgroup analysis showed that implants > 400 g were associated with significantly higher N-IMF distance increase (p <0.05) compared to implants < 400 g.

CONCLUSIONS

Our findings suggest that a significant progressive postoperative increase in N-IMF distance should be expected in all cases of tuberous breast augmentation with anatomical implants over a 1 year period. This aspect may have an important implication on the IMF incision and the new fold position preoperative planning. LEVEL OF EVIDENCE IV.

The Keystone Flap: A Multi-centric Experience in Elderly Patients Treatment

Soft tissue reconstruction in elderly patients must be rapid and reliable. The keystone island flap (KF) offers an effective solution, with low complication rates and quick recovery. This multi-centric study aims to show authors' experience with KFs in treating soft tissue defects of trunk and limbs. Patients with soft tissue defects suitable for KF reconstruction were recruited from March 2019 to December 2019. Active inflammation and previous surgeries in the same region were considered exclusion criteria. Complications that occurred during follow-up were recorded, and their incidence pattern was assessed with the Fisher test. Seventy-two patients with mean age of 76.2 years old were selected. They presented lesions in torso (46; 63.9%) or in upper (4; 5.6%) or lower (22; 30.6%) limb regions. Fifteen (20.8%) wounds were non-oncologic lesions, and the others were oncologic lesions, mostly non-melanoma skin cancers. KF type I was carried out in 42 (58.3%) cases, KF type II-A in 13 (18%) cases, double opposed type III KF in 16 (22.2%) patients, and 1 (1.4%) case required partial flap's undermining (IV KF). Mean post-operative recovery period was 4.3 days (range, 1-9 days). Post-surgical complications occurred in 15 (20.8%) cases, 7 (9.7%) of them were considered major complications. No statistically significant difference in complications' incidence, nor among different surgical sites nor among KF types, was registered. Reconstructive surgeons have to adapt their work to elderly patients. The KF allows rapid operative times, low morbidity rates, and short post-operative recovery time, thus appearing as a feasible solution.

Safety of Reconstructive Microsurgery in the Elderly Population: a Multicentric Prospective Study

BACKGROUND

Safety of reconstructive microsurgery in elderly patients is still a topic of debate, because no conclusive evidence exists that provides indications and risk evaluation in elderly patients. The purpose of this study, which the Italian Society for Plastic, Reconstructive, and Aesthetic Surgery (SICPRE) has promoted, is to evaluate the safety and the complication risk of elective reconstructive microsurgery in elderly patients as well as to identify patient- or procedure-related risk factors. The secondary aim is to evaluate the predictive role for complications of the Geriatric 8 score (G8).

METHODS

A total of 194 consecutive patients from 18 centers, aged 65 or older, who received an elective microsurgical flap between April 2018 and April 2019 were prospectively evaluated. Patient-related, treatment-related, and outcomes data were recorded and statistically analyzed through multiple-adjusted logistic regression models.

RESULTS

Our study showed an increased risk of complications and a longer hospitalization in patients aged ≥75 years with the American Society of Anesthesiologists (ASA) score ≥3 (or G8 score ≤11) as compared to patients >65 years of age and <75 years of age who undergo reconstruction with a microsurgical flap. Instead, flap survival did not significantly vary with age, but was associated only with ASA score ≥3 (or G8 score ≤11) and surgeries that last longer than 480 min; however, flap survival (92.3%) was slightly lower than that commonly reported for in the general population.

CONCLUSIONS

Reconstructive microsurgery in the elderly is generally safe. The ASA score is easier and quicker than the G8 score and equally useful for risk stratification.

Quality of Life Interventions in Breast Cancer Survivors: State of the Art in Targeted Rehabilitation Strategies

Breast cancer is the most common malignant tumor and the most prevalent cause of mortality in women. Advances in early diagnosis and more effective adjuvant therapies have improved the long-term survival of these patients. Pharmacotherapies and intrinsic tumor-related factors may lead to a wide spectrum of treatment-related disabling complications, such as breast cancer-related lymphedema, axillary web syndrome, persistent pain, bone loss, arthralgia, and fatigue. These conditions have a detrimental impact on the health-related quality of life of survivors. Here, we sought to provide a portrait of the role that rehabilitation plays in breast cancer survivors. Particular emphasis has been placed on recovering function, improving independence in activities of daily living, and reducing disability. This complex scenario requires a precision medicine approach to provide more effective decision-making and adequate treatment compliance.

Helix Thigh Lift. A Novel Approach to Severe Deformities in Massive Weight Loss Patients

BACKGROUND

After massive weight loss, the severe gynoid body contour deformities are not always faceable with optimal results. The thigh is one of the most demanding area to address; therefore, the approach should be virtually individualized. The authors describe the helix thigh lift: A novel technique that combines vertical with horizontal axis of pull. The goal of this ultimate customization is to dramatically impact physical functioning and esthetics of this patient population.

METHODS

Thigh lift patients from 2016 to 2019 were assessed retrospectively; fourteen patients were selected for helix thigh lift procedure. Preoperative markings, surgical technique and outcomes were described. The mean follow-up time was 14.8 ± 3.2 months. A questionnaire was administered to evaluate the results.

RESULTS

Fourteen female patients (mean age, 42 ± 4.8 years) underwent helix thigh lift after massive weight loss. The overall complication rate was 36 percent. They were all minor complications and were treated in an outpatient setting. Seroma formation was the most frequent, at 29 percent. No skin necrosis was reported. Complication development was straight related to the age of the patient (p = 0.0455). The patients were very satisfied with the overall outcome.

CONCLUSIONS

Helix thigh lift effectively addresses the severe gynoid body contour deformities. The high satisfaction and the reasonable complication rate suggest that this is a safe and effective technique. The age of the patient was significantly associated to complication development. A dramatic improvement of ease in performing activities of daily living along with reduction of the skin problems leads to significant improvement of the quality of life.

Muscle-Sparing Skin-Reducing Breast Reconstruction with Pre-Pectoral Implants in Breast Cancer Patients: Long-Term Assessment of Patients' Satisfaction and Quality of Life

INTRODUCTION

Breast cancer is the most frequently diagnosed tumor in women; globally, it accounts 23% of all cancer deaths. Breast reconstruction after oncologic surgery has become crucial to enhance patients' quality of life and alleviate the psychological distress related to the disease. The aim of this study was to assess quality of life and esthetic satisfaction of breast cancer patients undergoing muscle-sparing skin-reducing breast reconstruction (MS-SR) with pre-pectoral implants.

METHODS

Sixty-three patients who met definite oncological and reconstructive criteria were enrolled in the study. Specific questionnaires (EORTC QLQ-C30, QLQ-BR23) were administered preoperatively, 1, and 12 months after MS-SR breast reconstruction to evaluate patients' QoL. Satisfaction with procedure and related Quality of Life were assessed through BREAST-Q questionnaire preoperatively and 12 months after surgery.

RESULTS

Sixty-three breast cancer patients underwent MS-SR. Seventy-eight procedures were carried out; in 15 patients a bilateral reconstruction was performed. One month after surgery, both EORTC QLQ-C30 and QLQ-BR23 average scores demonstrated a slight drop since preoperative values, but a significant improvement in QoL was documented 12 months after BR (p < 0.05). BREAST-Q test showed significant psychophysical and esthetic satisfaction 12 months postoperatively.

CONCLUSIONS

Muscle-sparing skin-reducing breast reconstruction is an established and reliable technique. EORTC QLQ-C30, QLQ-BR23 and BREAST-Q scores showed an improvement of patients' QoL and esthetic satisfaction. Reduction of pain and other surgery-related symptoms are cornerstones of patient well-being. Both physicians and patients should build a thorough awareness of the silver lining of muscle-sparing skin-reducing breast reconstruction based on the high safety profile and highly satisfactory patient-reported results.

Lymphatico-venous anastomosis in chronic ulcer with venous insufficiency: A case report

Patients presenting with chronic wounds in venous insufficiency often represent a challenge, like other conditions, like lymphatic impairment, may complicate the wound healing process. The purpose of this report is to highlight how the treatment of lymphatic impairment may be beneficial in patients affected by chronic ulcers with concomitant venous insufficiency. We present the case of a 78-year-old woman affected by chronic venous insufficiency (CVI) with long-lasting ulcers secondary to sclerosing agents treatment for varicose veins. The patient's condition was refractory to both conservative and surgical treatment. Since the patient also presented with severe lymphorrhea, with a significant amount of daily secretion, ICG-lymphography was performed subcutaneously, to visualize the pathway of lymphatic drainage and leakage. It also allowed marking on the skin the exact location of lymphatic vessels distally to the wound area. Hence, two lymphatico-venous anastomoses were performed between the two major collecting lymphatic vessels and two subcutaneous veins of adequate size. The postoperative course was uneventful and the procedure allowed for immediate resolution of lymphatic leakage and complete wound healing within 2 weeks with no recurrence in the follow-up time of 1.5 years. Based on the outcomes of this case, it is possible to consider the use of CVI treatment and lymphedema surgery as a combined approach to complicated cases of long-standing venous ulcers with lymphorrhea.

Management of skin damage of health workers' face: the role of plastic surgery in the time of Pandemic

Background and aim:

The Sars-Cov-2 virus is characterized by a being highly contagiousness, and this is the reason why massive use of personal protective equipment is required by medical and paramedical staff of the COVID-19 dedicated departments. The aim of this manuscript is to describe and share our experience in the prevention and treatment of the personal protective equipment related pressure sores and other skin alterations in the medical and paramedical staff.

Methods:

All healthcare workers with PPE-related skin damages were registered at time 0. Age, sex, profession, type of skin damage, diseases and possible drugs were registered.

Results:

Two strategies were employed: the first strategy was to immediately treat the skin and the second one was to prevent pressure wounds formation both in already affected healthcare workers and the recurrence in healed staff. Three weeks after the two strategies were used, the incidence rate PPE-related skin damage was reduced in a statistically significant way.

Conclusions:

Proper management helps in reducing the incidence of pressure ulcers related to personal protective devices in Covid-19 Units. Skin prevention and hydration, have been obtained achieved by using products applied at home, autonomously.

Axillary web syndrome in women after breast cancer surgery referred to an Oncological Rehabilitation Unit: which are the main risk factors? A retrospective case-control study

OBJECTIVE

Axillary web syndrome (AWS) is a complication of surgical procedures in breast cancer (BC) patients. This condition with poorly understood incidence and etiology is characterized by the locoregional development of scar tissue, leading to subcutaneous cording, motion impairment and pain. The early identification of patients at risk for AWS would improve their clinical management. Here, we sought to characterize the prevalence of and the risk factors associated with AWS in BC women after surgery.

PATIENTS AND METHODS

All patients with BC that underwent axillary surgery referred to an Outpatient Service for Oncological Rehabilitation were retrospectively collected. These women were assessed two weeks after the surgical procedure for their clinicopathologic features, type of therapeutic interventions, and AWS presence, laterality, pain, localization, cords type, and number of cords.

RESULTS

Altogether, 177 patients (mean aged 60.65 ± 12.26 years) were included and divided into two groups: AWSPOS (n=52; 29.4%) and AWSNEG (n=125; 70.6%). Patients with tumor N ≥1 (OR=3.7; p<0.001), subjected to mastectomy, axillary lymph node dissection (ALND) and chemotherapy showed significant correlations with AWS onset (p<0.05). The range of shoulder motion limitation (OR=11.2; p<0.001) and the presence of breast cancer related lymphedema (OR=3.5; p=0.020) were associated with AWS.

CONCLUSIONS

Mastectomy, ALND, chemotherapy, low staging tumors, shoulder range of motion limitations, and BCRL represent risk factors for AWS onset. Realizing new strategies for assessing the individual risk of AWS is a crucial clinical need to improve the health-related quality of life of BC survivors.

Three-dimensional laser scanning as a reliable and reproducible diagnostic tool in breast cancer related lymphedema rehabilitation: a proof-of-principle study

OBJECTIVE

In this study, we aimed to assess the reproducibility and reliability of a three-dimensional laser scanner (3DLS) in measuring the upper limb volume of BRCL women undergoing a 2-week complete decongestive therapy (CDT).

PATIENTS AND METHODS

3DLS and CM were used to measure the upper limb volume in a cohort of BCRL women before (T0) and after (T1) a 2-week CDT. We evaluated: a) correlation between 3DLS and CM at both time points; b) level of agreement and the consistency of the different measurements at both time points; c) correlation between the inter-rater operator analysis in terms of total limb volume differences before and after rehabilitative treatment of both circumferential method and laser scanning 3D in breast cancer related lymphedema patients.

RESULTS

Taken together, 43 BCRL women (age 51.1 ± 5.4 years) were included. Both 3DLS and CM showed a significant inter and intra-operator correlation in the arm volume measurement at both time-points (T0: r2=0.99, p<0.0001; T1: r2=0.99, p<0.0001). 3DLS showed a strong correlation with CM (r2=0.99, p<0.0001) in terms of volume measurement and provided greater intra-operator correlation (r2=0.92 vs. 0.62) in detecting volume variations after the treatment (T1-T0).

CONCLUSIONS

3DLS confirmed to be highly sensitive, cheap and easy-to-use in the evaluation of the upper limb volume in BCRL women before and after a rehabilitative treatment. These findings suggest that augmented reality technologies might be very useful in oncological rehabilitation.

A prospective study on combined lymphedema surgery: Gastroepiploic vascularized lymph nodes transfer and lymphaticovenous anastomosis followed by suction lipectomy

BACKGROUND

There is no consensus on the appropriate treatment of lymphedema. Proposed techniques include lymphaticovenous anastomosis (LVA), vascularized lymph nodes transfer (VLNT), and suction lipectomy (SL). The benefit of combined procedures has also been postulated. In this prospective study, a combined protocol is proposed as an alternative to single-procedure strategies.

METHODS

Between January 2016 and October 2018, we enrolled patients with secondary lymphedema of lower limbs, stage II-III according to the International Society of Lymphology, progressive swelling and skin tonicity >60. Thirty-seven consecutive patients were dichotomized into group I, undergoing VLNT, and group II undergoing VLNT and LVA. Gastroepiploic lymphnode flap was harvested through laparoscopy, and in the same operation, LVAs were performed in group II on the basis of indocyanine green lymphography and patent blue findings. Two weeks later, SL was performed in all the patients. Patients were prospectively evaluated through clinical examination, circumference measurement, and skin tonicity.

RESULTS

The average follow-up was 2 ± 0.8 years. The first consecutive 21 patients were treated with VLNT followed by SL. The next 16 patients underwent combined VLNT and LVA, followed by SL. A mean of 2.4 LVAs were performed. A significant difference in the postoperative circumference measurements was found overall (p < .05): 52.6 ± 18.9 above the knee, 42.9 ± 25 below the knee, 36.2 ± 37 at foot. The postoperative tonicity dropped by 12.7 ± 6.3% (p < .05). The episodes of cellulitis significantly decreased to 0.1 ± 0.3 (p < .05).

CONCLUSIONS

LVA, VLNT, and SL can be integrated together in a combined approach, in synergy to enhance the outcomes.

Breast surgeons updating on the thresholds of COVID-19 era: results of a multicenter collaborative study evaluating the role of online videos and multimedia sources on breast surgeons education and training

OBJECTIVE

Current trends show a rise of attention given to breast cancer patients' quality of life and the surgical reconstructive result. Along with this trend, surgical training quality and efficacy are gaining importance and innovative training methods such as online videos shared on social media portals, are becoming main updating tools. In hazardous times like COVID-19 pandemic nowadays, online communication becomes of vital importance and adaptation and innovation are fundamental to keep research and education alive. The authors aimed to investigate the role of video and multimedia sources on the daily activity and surgical training of a representative group of surgeons specifically dedicated to oncologic, oncoplastic and reconstructive breast surgeries.

MATERIALS AND METHODS

A survey was produced and administered to 20 major Italian Breast Centers. Collected data were analyzed with Fisher's Exact Test.

RESULTS

From October 2019 to March 2020, a total of 320 surveys were collected. Among the responders, there were 188 trainees (intern medical doctors and residents) and 110 faculty, 72% of them belonged to a plastic surgery environment, while 28% to general surgery environment. Almost all respondents have ever watched videos concerning breast surgery.

CONCLUSIONS

The results of the study show how breast surgeons rely on videos and web platforms, mostly YouTube, when searching for training info about surgical procedures. Social media offer great opportunities for sharing knowledge and diffusion of new ideas but greater attention to their reliability is mandatory.

Quality Assessment of Online Information on Body Contouring Surgery in Postbariatric Patient

BACKGROUND

Nowadays, we have to face the fact that the Web represents one of the most important sources of information for patients. Postbariatric patients in particular are usually very motivated, and they are enthusiastic users of the Web as a source of information on the different types of surgery they could undergo after their weight loss in order to reshape and remodel their body thus regaining physical and functional wellness and dignity. The aim of the study was to assess information on the four most commonly performed postbariatric procedures worldwide, tummy tuck, breast, arm and thigh lift, with the same scale.

METHODS

Google and Yahoo have been probed for the keywords "Post bariatric Mastopexy OR breast lift" and "Post bariatric abdominoplasty OR tummy tuck" and "Post bariatric brachioplasty OR arm lift" and "post bariatric thigh lift". The first 50 hits were included, and the quality of information was evaluated with the expanded EQIP scale.

RESULTS

There was a critical lack of information about qualitative risks and side-effect description, treatment of potential complications, alert signs for the patient and precautions that the patient may take. Moreover, there was poor information about the sequence of the medical procedure, quantitative benefits and risks and quality of life issues after the procedure, and often, there were no other sources of information.

CONCLUSIONS

Due to the poor and not reliable information offered by the Web, health professionals should seek for a good communication practice with their patients.

LEVEL OF EVIDENCE V

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.

Lower Body Lift After Bariatric Surgery: 323 Consecutive Cases Over 10-Year Experience

BACKGROUND

Lower body lift is a widespread procedure for massive weight loss patients aimed to improve the contour of the lower trunk, gluteal region and proximal lower extremity. The data about complications are confusing, and there is a lack of uniform studies for massive weight loss patients. A simple formula to carry out a reliable procedure in a short time with a low complication rate should be advocated.

METHODS

This retrospective study analyzed data of 323 patients undergoing lower body lift after bariatric surgery over a 10-year period. Selection criteria, careful preoperative marking, reliable intra- and postoperative care and a few surgical tips are discussed. All the complications (both major and minor) and the aesthetic satisfaction were evaluated. Risk factors assessed were patient age, tobacco consumption, current BMI, operative time and combined surgery.

RESULTS

The overall complication rate was 42%. We recorded a lower rate of major complications and skin dehiscence; no infection and no skin necrosis were observed. The most frequent complication was seroma (35%). A complication development was straight related to age (p = 0.0177) and tobacco use (p = 0.0336). Patients' satisfaction about overall aesthetic was high.

CONCLUSIONS

We present our case load and describe an easy recipe to perform a safe surgery without undermining and liposuction in short operative times. The reasonable overall complication rate and the surprisingly lower rate of dehiscence and skin necrosis combined with a pleasant aesthetic result make the lower body lift an easy and safe procedure, when applied to the appropriate patient population.

LEVEL OF EVIDENCE IV

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Postsurgical antithrombotic therapy in microsurgery: our protocol and literature review

OBJECTIVE

Despite the improvements reached by microsurgeons in the last 30 years, postoperative complications still occur and most of them are the result of venous thrombosis at the pedicle anastomosis. Primary prevention of thrombosis is mandatory and anticoagulant therapy in the preoperative and postoperative period is widely used. Still, there is a lack of consensus in the literature about the best postoperative protocol for microsurgical reconstruction. The authors aimed to review the postoperative antithrombotic regimens described in literature focusing on their effects and risks, and moreover, share their experience.

MATERIALS AND METHODS

The authors performed a literature review of postsurgical antithrombotic protocols applied in reconstructive microsurgery. Research on PubMed server was performed typing the terms "antithrombotic", "postoperative", "microsurgery", "free flap pedicle", "anticlotting", "anticoagulant".

RESULTS

The authors described the postoperative standardized pro-weight pharmacological protocol applied in their unit: a combination of dextran and heparin. They inhibit more than one pattern of coagulation in order to stop platelet aggregation and thrombin action and, in the meantime, contending fluid loss with plasma expansion.

CONCLUSIONS

Nowadays, a non-standardized practice, based on experience, is applied by microsurgeons in postsurgical care; the authors performed a review of the combined antithrombotic therapies described in the literature. A standardized pro-weight pharmacological protocol is proposed; it allows to increase blood flow by volume expander action (Dextran) and thrombin inhibition (Heparin). Still, coagulation cascade and platelet function have a wide variability among humans, as well as the effect of drugs. Achieving an optimal antithrombotic effect and minimizing adverse reactions meantime remains a challenge.

Outcomes following head neck free flap reconstruction requiring interposition vein graft or vascular bridge flap

BACKGROUND

Interposition vein grafts (IVG) and vascular bridge flaps (VBF) have been exploited as vascular conduit in challenging head and neck reconstructions.

METHODS

A retrospective review was conducted on 6025 flaps. The effect of patients' characteristics and length of IVG on flap compromise and loss were analyzed. Comparison between IVG and VBF was performed.

RESULTS

The flap compromise and loss rates for the overall group were 8.2% and 3.2%, respectively. An IVG was used in 309 free flaps. The average length of the vein grafts was 6.9 ± 4.2 cm. An unplanned return to the operation room occurred in 32 cases (10.4%) and failure of the flap in 12 patients (3.9%). Binary logistic regression found a significant association between flap compromise and loss rates and length of IVG, hypertension, prior radiation, and neck dissection. In the multiple regression model, length of IVG and prior radiation significantly influenced the outcomes. Thirty-nine patients underwent reconstruction with a long IVG (>10 cm). Twenty-six patients underwent surgical reconstruction with radial forearm flap as a VBF. The rate of flap compromise was higher in the group with a long IVG (P = .01).

CONCLUSIONS

In head and neck free flap reconstruction, the length of IVGs and history of radiotherapy are associated with flap compromise and loss. In case of long distance between the pedicle and the recipient site, the use of a VBF bridge should be considered as a safe alternative.

Modified single pedicle reverse adipofascial flap for fingertip reconstruction

BACKGROUND

Homodigital adipofascial flap is a well-established method for treating a distal fingertip defect; nonetheless, its use has some limitations. Reconstruction of fingertip injuries, with radial or ulnar tissue loss, may lead to some difficulties in providing an adequate bone coverage. The standard bipedicled technique did not allow the flap to cover the bone exposure without excessive tension. In our series, the reverse adipofascial flap had a single pedicle. The modified technique, because of its improved degree of rotation, granted the flap to reach either radial or ulnar tissue losses.

PATIENTS AND METHODS

We treated 15 fingertip amputations distal to the lunula (9 Allen's type II and 6 type III), the mean size of defects was 2.7 cm² (range, 1.8-3.2 cm² ), the mean age of patients was 44 years (range, 22-63 years). Quick Disabilities of the Arm, Shoulder, and Hand score and Visual Analogue Scale were evaluated along with a 2-point discrimination test; the aesthetic satisfaction of the patients was estimated subjectively using a 5-point Likert scale.

RESULTS

Mean flap size was 3.6 cm² (range, 2.5-4.2 cm² ), primary flap survival was observed in 14 out of 15 cases, partial flap necrosis was observed in 1 case, the nail grew in all fingers in about 6 months. Mean proximal and distal interphalangeal joint motion was 89° (range, 80°-100°) and 71° (range, 65°-80°), respectively. No complications were observed at the donor site. The median static 2-point discrimination was 4.5 mm (range, 3-8 mm), the mean quick DASH score was 2.6 (range, 0-9.1). All patients returned to work within a mean of 4.4 weeks (range, 4-5 weeks). The follow-up was 12 months.

CONCLUSIONS

Single pedicle reverse adipofascial flap is an effective technique. This modified procedure allows a wider degree of flap rotation; it represents the ultimate arrow in our bow to address some particular defect geometry.

New application of purse string suture in skin cancer surgery

Closure of large wounds may require full-thickness skin grafts, but their use is burdened by donor tissue availability and morbidity; the use of the purse string technique is an elegant way to overcome this problem. The study highlights the gain in terms of graft donor site morbidity and oncological radicality. The study included a group of 47 patients who underwent surgical excision for skin cancer and whose wounds were covered using a purse string suture and a skin graft. Radius of the defect left was measured after the lesion's excision and after the purse string suture. Thereafter, the difference between the initial defect area and the area after purse string suture was calculated. Initial defects ranged from 3.85 to 61.5 cm² . After skin graft, the purse string suture ranged between 2.2 and 40 cm² (mean area = 14 cm² ). Gained area before the graft measured from 1.3 to 21.5 cm² (mean gained area = 7.1 cm² ). Average reduction was 33%. The technique allows a reduction of the size of the area to be grafted and the skin graft donor area, thus increasing the possibility of the feasibility of full-thickness grafts. In addition, it allows an optimal observation both of the area of tumour excision and margins during follow-up controls.

Morbidity of Selective Lymph Node Biopsy for Melanoma: Meta-Analysis of Complications

Background and Aim

Intraoperative lymphatic mapping and selective lymph node biopsy is accepted worldwide as the standard procedure for staging regional lymph nodes of 1–4 mm thick melanomas, as well as for other neoplasms. Although it is often stated that selective lymph node biopsy is a minimally invasive procedure associated with few complications, few data exist concerning the morbidity associated with the procedure. The present analysis was performed to evaluate the morbidity associated with selective lymph node biopsy in a long-term follow-up.

Materials and Methods

The study provides a review of 437 selective lymph node biopsies on 269 patients, operated on between the 1994 and the 2009, for the lymph node biopsy of head and neck, groin, axilla, upper and lower limbs and nodal basins. Patients’ history and follow-up were reviewed for 2 weeks after surgery, every 3 months for the first 2 years, every 4 months during the third year, and every 6 months subsequently, and postoperative morbidity was evaluated.

Results

After sentinel node biopsy, 14 patients developed one of the following complications: hematoma, 1 case (0.30%); lymphedema, 1 case (0.30%); seroma, 2 cases (0.61%); wound infection, 6 cases (1.83%); keloid scar, 2 cases (0.61%); and postoperative pain, 2 cases (0.61%). The total complication rate was 4.26%.

Conclusions

Selective lymph node biopsy for melanoma, as for other tumors, in respect to radical lymphadenectomy, is not a complications-free procedure but is usually not severe.

Is the prognosis and course of acral melanoma related to site-specific clinicopathological features?

OBJECTIVE

Acral melanoma is an uncommon type of melanoma in Caucasian patients. However, acral melanoma is the most common type of melanoma in African and Asian patients. Comparison analyses between hand-acral melanoma and foot-acral melanoma have been rarely reported in the literature. Acral melanoma is an uncommon melanocytic tumor characterized by an intrinsic aggressiveness, with specific histological and clinicopathological features. Acral melanoma involves the palms, soles and sub-ungueal sites.

PATIENTS AND METHODS

A total of 244 patients with acral melanoma were included in our analysis. The current study was performed in three different medical centers: Sapienza University of Rome, San Gallicano Institute of Rome and University of Magna Graecia (Italy). The Kaplan-Meier product was used to estimate survival curves for disease-free survival and overall survival. The log-rank test was used to evaluate differences between the survival curves. Assuming that the effects of the predictor variables are constant over time, the independent predictive factors were assessed by Spearman's test and subsequently data were analyzed performing Cox proportional-hazard regression.

RESULTS

In both univariate and multivariate analyses Breslow thickness (p < 0.0001) and ulceration (p = 0.003) remained the main predictors. General BRAF mutation was detected in 13.8% of cases. We found that median Breslow value and the percentage of recurrences were similar in hand-acral melanoma and foot-acral melanoma, as well as there were no differences in both short and long-term.

CONCLUSIONS

The absence of differences in survival between hand-acral melanoma and foot-acral melanoma shows that the aggressiveness of the disease is related to distinct mutational rate, as well as to anatomical site-specific features, rather than to the visibility of the primary lesion.

Extracorporeal Shock Wave Therapy: An Emerging Treatment Modality for Retracting Scars of the Hands

Prolonged and abnormal scarring after trauma, burns and surgical procedures often results in a pathologic scar. We evaluated the efficacy of unfocused shock wave treatment, alone or in combination with manual therapy, on retracting scars on the hands. Scar appearance was assessed by means of the modified Vancouver Scar Scale; functional hand mobility was evaluated using a range-of-motion scale, whereas a visual analogue score was implemented for detecting any improvements in referred pain. Additionally, biopsy specimens were collected for clinico-pathologic correlation. For each active treatment group, statistically significant improvements in modified Vancouver Scar Scale were recorded as early as five treatment sessions and confirmed 2 wk after the last treatment session. Analogous results were observed when assessing pain and range of movement. Histopathological examination revealed significant increases in dermal fibroblasts in each active treatment group, as well as in neoangiogenetic response and type-I collagen concentration.

Coverage of exposed hardware after lower leg fractures with free flaps or pedicled flaps

OBJECTIVE

The placement of osteosynthetic materials in the leg may be complicated by hardware exposure. Successful soft tissue reconstruction often provides a critical means for limb salvage in patients with hardware exposure in the leg. Free flaps are currently considered the standard surgical procedure for soft tissue coverage of the wounds with internal hardware exposure. However, to date, no conclusive literature shows the superiority of a specific type of flap.

MATERIALS AND METHODS

The current review compares data from the literature concerning outcomes and complications of free and pedicled flaps for exposed osteosynthetic material preservation in the leg.

RESULTS

A total of 81 cases from twelve different articles presenting internal hardware exposure of the leg were analyzed in our study. Thirty-two patients underwent immediate reconstructive surgery with pedicled flaps, while forty-nine patients underwent free flap reconstruction. The overall survival rate for pedicled flaps was 96.77%, while for free flaps it was 97.77%. The overall implant preservation rate was 78.12% for pedicled flaps and 53.33% for free flaps. With reference to postoperative complications, the overall complication rate was 46.87% for pedicled flaps and 10.20% for free flaps.

CONCLUSIONS

No significant difference was found in terms of overall flap survival. However, a significant difference was found regarding successful implant preservation (78.12% in the pedicled flap group vs. 53.33% in the free flap group). In particular, the first observation appears to be in contrast with the current trend of considering the free flaps the first choice procedure for soft tissue coverage of the wounds with internal hardware exposure. Nevertheless, a higher occurrence of postoperative complications was observed in the pedicled flap group (46.87% vs. 10.20%). The choice of the most appropriate reconstructive procedure should take into account several issues including the size of the wounds with internal hardware exposure, the possibility of soft tissue coverage with pedicled flaps, the availability of recipient vessels, general conditions of the patients (such as age, diabetes, smoking history), patients' preference and presence of a microsurgical team. However, according to the results of this review, we believe that pedicled flap reconstruction should be reconsidered as a valid alternative procedure for skin tissue loss with hardware exposure whenever it is possible.

Deep gluteal grounding pad burn after abdominal aortic aneurysm repair

Although skin burns at the site of grounding pad are a known risk of surgery, their exact incidence is unknown. We first report the case of a patient who presented a deep gluteal burn at the site of the grounding pad after an abdominal aortic aneurism repair, the etiology and the challenging treatment required to overcome this complication.

An improved method of supercharged transposed latissimus dorsi flap with the skin paddle for the management of a complicated lumbosacral defect

OBJECTIVE

Treatment of non-healing wounds of lower back often poses a powerful challenge. We present one of the first report of treatment of a lumbosacral defect with a supercharged latissimus dorsi flap with the skin paddle.

CASE REPORT

We report a case of a 59 year-old man with myeloma of the sacral spine who underwent radiotherapy and chemotherapy and subsequently, laminectomies and placement of hardware for ongoing paresis and spine instability. Then, he developed an open wound and osteomyelitis of the spine with culture positive tuberculous granulomas. After multiple surgical debridement, he presented to our service and was treated with a single stage debridement followed by the performance of a latissimus dorsi musculocutaneous flap based on paraspinal perforators and supercharged.

RESULTS

This solution, allowed for augmentation of blood flow to the muscle with the inferior gluteal artery, provided coverage of the defect resistant to the pressure, and simplified post-operative management of the patient.

CONCLUSIONS

Alternative treatment options, including free tissue transfer, posed difficulties in finding suitable recipient vessels near the defect, in inserting the flap so as to restore its original length without compromising blood flow, and in postoperative care of the patient. Treatment of a lumbosacral defect with a supercharged latissimus dorsi flap with the skin paddle may represent a milestone procedure for complicated lower spine wounds.

Management of microanastomosis in patients affected by vessel diseases

OBJECTIVE

In the last 10 years with the advances in microsurgery of techniques and materials the indications for free tissue transfer have considerably been increased. But, there are still some limitations and drawbacks. Among risk factors associated with flap failure, atherosclerosis can affect both the flap and the recipient vessels of free microvascular tissue transfers. The purpose of this paper is to discuss about the pathogenesis of Monckeberg's sclerosis, and the topics that must be taken into consideration when performing microsurgery in these patients.

METHODS

PubMed database was searched using Mesh. The following terms was added to the search builder: Monckeberg's sclerosis, free flap. The Boolean operator "AND" was selected. All the selectable Mesh headings for "Monckeberg's sclerosis" and "free flap" were included.

RESULTS

Almost all the literature works about microsurgery in Monckeberg's sclerosis patient show the importance of an accurate preoperative and postoperative evaluation and of a proper surgical technique.

CONCLUSIONS

When adequate preoperative evaluation, surgical technique and postoperative monitoring are performed, even severe atherosclerosis should not be considered an absolute contraindication for microvascular surgery.

Retromolar trigone reconstructive surgery: prospective comparative analysis between free flaps

PURPOSE

Retromolar trigone (RMT) tumours are rare and aggressive malignancies, which require an aggressive surgical approach. The reconstruction oral cavity defects represent a challenge because of the critical role of this area both aesthetically and functionally. Free radial forearm (RF) or anterolateral thigh (ALT) flap are the first choice for the repair of intraoral defects. In reviewing the literature, there is lack of evidence pertaining to the differences between RF and ALT flaps in the reconstruction of patients with RMT tumours. This study evaluates the better microvascular reconstruction after RMT cancer resection.

METHODS

Thirty patients with RMT cancer underwent oropharingectomy and microvascular reconstruction using the free RF flap (RF group) and the ALT perforator flap (ALT group). The two groups were homogeneous for sex, age, anatomic area, body mass index, and clinicopathologic profile. Viability, complications, scarring, cosmetic appearance, disorder of sensations, ROM, disease-specific items and satisfaction rate were analyzed, and statistical analysis was performed.

STUDY DESIGN

Prospective study.

RESULTS

There were differences between the RF and ALT groups in the morphofunctional outcomes, both short-term and long-term follow-up. These differences were statistically significant (p < 0.05) for donor site complications, cosmetic appearance, and scar evaluations. Manual dexterity was slower on the operated donor side than on the nonoperated side in the 33.3 % in the RF group.

CONCLUSIONS

The study showed that the free ALT perforator flap provides better results in appearance and scarring than the RF flap for intraoral reconstruction after RMT cancer resection.

The use of botulinum toxin in the treatment of plunging nose: cosmetic results and a functional serendipity

INTRODUCTION

Muscles of the nose are active in facial movements both with the other facial muscles. An active depressor septi muscle (DSN) can accentuate a drooping nasal tip and shorten the upper lip on animation, especially during smiling. Paralysis of the DSN allows the tip of the nose to be lifted up.

MATERIALS AND METHODS

Between January and June 2011 a double blinded, randomized study was performed on 40 patients for nasal defects as "plunging" tip. 20 patients underwent to Botulinum toxin injection (B), 20 patients were treated with placebo such as saline solution (S). Both aesthetic and functional results were evaluated using objective and subjective parameters at time 0, after 7, 15 and 30 days and values were compared using t Student test.

RESULTS

S group results were not significant from an objective point of view. In botulinum group, patients showed an increase in columellar-lip distance. Satisfaction of the Group B patients was an average of 6.3 on VAS (range from 4 to 9). VAS mean values were studied with t-Student test and were found significant.

DISCUSSION

Several authors recommend the incision of DSN muscle during rhinoplasty to correct the plunging tip. In patients with no needs for rhinoplasty this procedure is unnecessary and a quick and targeted injection of Botulinum toxin is the most convenient choice to improve aesthetic of the plunging tip.

Diabetic foot infection treatment and care

Foot infections in diabetic patients are a common, complex and costly problem. They are potentially adverse with progression to deeper spaces and tissues and are associated with severe complications. The management of diabetic foot infection (DFI) requires a prompt and systematic approach to achieve more successful outcomes and to ultimately avoid amputations. This study reviews a multi-step treatment for DFIs. Between September 2010 and September 2012, a total of about 37 patients were consulted for DFI. The treatment algorithm included four steps, that is, several types of debridement according to the type of wound, the application of negative pressure therapy (NPT), other advanced dressings, a targeted antibiotic therapy local or systemic as the case may, and, if necessary, reconstructive surgery. This treatment protocol showed excellent outcomes, allowing us to avoid amputation in most difficult cases. Only about 8% of patients require amputation. This treatment protocol and a multidisciplinary approach with a specialised team produced excellent results in the treatment of DFI and in the management of diabetic foot in general, allowing us to improve the quality of life of diabetic patients and also to ensure cost savings.