Meshed Dermal Sling for Prepectoral Breast Reconstruction.

The best breast reconstruction solution after mastectomy remains a topic of wide debate. Recently, the focus in the field of implant-based reconstruction has been on the increasing indications for prepectoral reconstruction. This offers undoubted advantages over subpectoral reconstruction, ranging from better aesthetic results and patient comfort to a less invasive procedure that spares the pectoralis major muscle, reducing pain and postoperative recovery time. The dermal sling is a reconstructive variant introduced by Bostwick in the 1990s and is commonly used to complete the subpectoral pocket in one- or two-stage reconstruction, creating a dual-plane reconstruction. This method may be indicated after mastectomy for both therapeutic and prophylactic purposes. It can also be used for unilateral and bilateral reconstructions. We propose a new meshed dermal sling technique that allows complete prepectoral reconstruction without the use of acellular dermal matrix, thus reducing the cost of reconstruction. It also allows the indication for complete prepectoral reconstruction to be extended to patients with medium breast volume and grade 1 or 2 ptosis, without the need to use acellular dermal matrix or the pectoralis major muscle to complete the breast pocket.

Immediate post-mastectomy prepectoral breast reconstruction with animal derived acellular dermal matrices: A systematic review.

BACKGROUND: Animal-derived acellular dermal matrices (ADMs) are increasingly being used in prepectoral direct-to-implant (DTI) breast reconstruction. However, the indications and complication profile associated with this type of reconstruction remain unclear. This study aimed to perform a systematic review of the available literature on the use of animal-derived ADM in prepectoral DTI breast reconstruction. METHODS: Three different literature databases, namely, PubMed, Web of Sciences, and Embase were screened using the following keywords: "immediate" AND "pre-pectoral" OR "prepectoral" AND "ADM breast reconstruction." Animal-derived ADM used (porcine - Braxon® and non-Braxon® - and bovine - Surgimend®) anthropometric information, clinical data, and complications profile were considered. RESULTS: A total of 340 articles were initially identified, of which only 45 articles (5089 patients and 6598 reconstructed breasts) satisfied our inclusion criteria. The most widely used ADM was Braxon® in the context of conservative mastectomies. In most studies, a subcutaneous layer > 1 cm and lack of previous radiotherapy were considered prerequisites for this type of reconstruction. An increased risk of complications was found in smokers, patients who underwent radiation treatment, patients with high breast volumes, and patients with cancers requiring axillary dissection. Data related to the role of diabetes, high body mass index, and breast implant size on surgical outcomes were instead inconcludent. Age was not directly proportional to the complications. CONCLUSION: The complications associated with different animal-derived ADMs are generally comparable. The profile of patients required for eligibility for this type of reconstruction appears to have been identified and is in line with current recommendations.

Sensitive peripheral nerve repair during COVID-19 emergency: does the outpatient surgical setting work as well as the operating theater?

Background: Nerve injuries are a common occurrence among hand injuries, which at the time of the COVID-19 emergency, did not appear to have reduced their incidence. The treatment of these injuries is urgent, but the pandemic has led to a reduction in the availability of resources and a consequent reorganization of activities. Principles about Wide-Awake Local Anesthesia No Tourniquet (WALANT) in hand surgery expressed by LaLonde helped hand surgeons to adapt to this new condition by demonstrating a possible outpatient pathway for the treatment of hand traumatic conditions. In the present study, we bring our experience in nerve repair at time of COVID-19 emergency. Methods: We retrospectively enrolled in this study all patients surgically treated for a peripheral nerve injury (PNI) during the COVID-19 emergency period from March 2020 to March 2022. Demographical, anamnestic, surgical, and postoperative data were recorded and analyzed. Persisting Tinel was set as the primary outcome, while hypoesthesia and other complications as secondary outcomes. Results: Thirty-six patients have been enrolled. Despite some difference in group homogeneity in term of hypertension and multi-digital involvement, we registered no difference in term of outcomes (P > 0.05) between patient operated in surgical theater and in outpatient clinic and between the various techniques of nerve repair employed (P > 0.05). Conclusions: Nerve repair on an outpatient facility is technically feasible and was found in this study to be safe and effective. Compared to hospitalization, the outpatient setting has a more "agile" organization and lower costs, making it preferable in selected cases.Level of evidence: Level IV, Therapeutic.

Association of Acute Trapeziometacarpal Joint Dislocation and Trapezium Fracture in a 14-Year-Old Boy: A Case Report.

Fracture-dislocation of the trapeziometacarpal (TM) joint in adolescent patients is a rare injury, with only 3 cases reported in literature to our knowledge. Its low incidence, together with the complexity of the anatomy and biomechanics of TM joint, may represent a challenge for surgeons in choosing the best treating option. Here, we report a case of a TM fracture dislocation in a 14-year-old boy treated with percutaneous Kirschner wire pinning. The results we obtained endorsed our choice in patients for whom closed reduction is achievable.

Adaptive proximal scaphoid implant (APSI): a systematic review of the literature.

Scapholunate advanced collapse collapse (SLAC) is a challenging topic for hand surgeons. The adaptative proximal scaphoid implant (APSI) (Bioprofile-Tornier) is a pyrocarbon ovoid shaped interpositional implant, that allows adaptive mobility during motion. The aim of this systematic review is to analyze the clinical and radiological outcomes of APSI implants and possible complications. We performed a literature search combining the following key-words: "APSI", "Scaphoid's proximal pole", "implant", "scaphoid avascular necrosis", "SLAC", "SNAC", "pyrocarbon", "prosthesis", and "spacer" with no limitations for year of publication. We selected seven studies considered relevant to our systematic review. All studies described an improvement in the grip strength and the flexion extension arch compared to pre-operative values. The percentage of patients who reported progression of osteoarthritis (OA) with APSI was 17.3%, and implant's mobilization has a rate 5.1% (8/156). In conclusion the APSI implant is a reliable alternative for the treatment of SNAC wrist and SLAC wrist.

Social Perception of Reconstruction following Orbital Exenteration.

BACKGROUND: Orbital exenteration, the removal of the entire globe, eyelids, and orbital content, is indicated in extensive neoplastic disease involving the orbital region. Although a functional reconstruction of orbital exenteration defects is mandatory, aesthetic concerns need to be considered. Facial disfigurement following reconstructive surgery often leads to great discomfort and social retirement, which can limit social interaction. The aim of this study was to explore how the society perceives the aspect of patients who underwent orbital exenteration and subsequent reconstruction, comparing two different types of reconstruction: standard anterolateral thigh (ALT) or "sandwich" fascial ALT (SALT) free flap. METHODS: An online survey was created based on four questions regarding the perception of reconstruction (discomfort at looking at that patient, perception of unhealthiness, hypothesis of social life impairment, etc); five possible answers were provided, ranging from "completely" to "not at all." The survey was administered to the general population and to medical students. RESULTS: In total, 255 people participated to the survey (130 medical students and 125 people of the general population); a total of 245 surveys were considered eligible (10 were incomplete and then discharged). Statistical significance was found (P < 0.001) regarding the better overall appearance of the SALT group over the ALT one. CONCLUSIONS: After analysis, the surgical outcome after SALT reconstruction has been found to be less disruptive in both groups, due to a reduced scar burden and a more pleasant orbital pocket. Our results encourage more research in the field of postexenteration reconstruction to achieve more aesthetic and social acceptability.

Treatment of a Case of Toe Hair-Thread Tourniquet Syndrome With Hirasè Technique.

ABSTRACT: Hair-thread tourniquet syndrome (HTTS) is an uncommon condition that affects mostly babies, usually a few months old. It happens when a strand of hair or cloth fiber encircles an appendage causing a condition of total or subtotal ischemia (West J Med 1976;125:335-336). This condition has been described several times in the recent literature. Appendages involved include toes, fingers, genitalia, uvula, and neck (N Engl J Med 1965;273:866-867). The mechanism of injury usually involves the fiber cutting the skin deeply through soft tissues, veins, and arteries. As HTTS occurs in small babies and hidden parts of the body, sometimes this event can be very difficult to detect and irritability may be the only symptom. The treatment consists of releasing the circumferential constriction and restoring the arteriovenous flow also with microsurgical techniques if vessel interruption is present. Unfortunately, the fiber or the thread often penetrates so deep that, once an HTTS is recognized, it may be very challenging to identify and trim. The authors present a case of HTTS of the second toe of the right foot in a 2-month-old baby treated with surgical release and Hirasè technique. After the thread was successfully cut and removed, the forefoot was covered with aluminum foil, and a bag with ice was immediately put all around. After 3 days, we observed a complete survival of the toe without any sign of necrosis. Later control at 6 months showed complete restitutio ad integrum of the affected digit with a normal perfusion and absence of any onychopathy. Hirasè technique represents a simple, safe, and low-cost option of treatment for HTTS.

Chronic exertional compartment syndrome of the forearm: a systematic review.

The aim of this systematic review is to understand which surgical procedure provides better results in terms of pain relief and function in the treatment of chronic exertional compartment syndrome (CECS) of the forearm.We searched Medline (PubMed), Web of Science, Embase and Scopus databases on 8 July 2020. Twelve studies were included in this review.We assessed the quality of the studies using the Coleman Methodological Score.Data on demographic features, operative readings, diagnostic methods, follow-up periods, type and rates of complications, survivorship of the procedure, return to sport activity, and outcome measures were recorded.In conclusion, compared to the other techniques, endoscopic fasciotomy delivers similar success rates and lower incidence of complications. Cite this article: EFORT Open Rev 2021;6:101-106. DOI: 10.1302/2058-5241.6.200107.

Complete testicular remission after chemotherapy in a patient with advanced seminoma: is the testicle a real 'sanctuary'? A case report and review of the literature.

Testicular cancer is relatively uncommon, but at the same time, it is the most common solid tumor in men between the ages of 20 and 34 years. Seminoma represents the most frequently encountered germ cell tumors. Because orchiectomy is usually performed before chemotherapy, little is known about the effect of systemic chemotherapy on primary testicular tumors. Furthermore, the testis has always been considered a sanctuary site, an immune-privileged site in which inadequate exposure of the tumor to chemotherapy may occur. We report the case of a young patient with advanced seminoma with a complete testicular response after four cycles of cisplatin-based chemotherapy. Then, we performed a systematic review of the literature reporting the studies published to date on the topic.

The Adipo-Fascial ALT Flap in Lower Extremities Reconstruction Gustillo IIIC-B Fractures. An Osteogenic Inducer?

RESULTS: Mean time from injury to flap coverage was 72 hours. The mean size of bone defects was 4-7,6 cm. All flaps were Antero Lateral Tight flaps, and the fracture sites did not have any evidence of infection. None of the patients was a smoker. A solid bone union was reached, and full wearing was in a mean of 11 (4-20) weeks after the injury. The lower limb was saved in 100% of the cases. CONCLUSION: Despite the goods results, further studies applied on a large number of patients are needed to confirm authors theory, however, we can consider the fascial ALT flap as a valid help for bone healing in 3B-C open tibial fractures.

Chronic Exertional Compartment Syndrome of the Forearm: Mini-invasive Technique Using an Endoscopic Soft Tissue Release System.

Chronic exertional compartment syndrome of the forearm is a rare disease characterized by the recurrent onset of forearm pain and progressive weakness during exertion. Over the years many surgical techniques have been reported in literature: wide-open fasciotomy, mini-open fasciotomy, fasciotomy associated with fasciectomy, and mini-invasive endoscopic fasciotomy. Compared with traditional open techniques, mini-invasive techniques are characterized by minimal tissue trauma, less postoperative pain, faster recovery to normal activity and better esthetical result. We describe a mini-invasive endoscopic technique for the treatment of forearm chronic exertional compartment syndrome using the SmartRelease endoscopic tissue release system (MicroAire).

Comparisons of fascio-cutaneous anterolateral thigh and sandwich fascial ALT free flap in the distal extremity reconstruction.

INTRODUCTION: The anterolateral thigh (ALT) flap is considered a workhorse reconstructive option; however, it is encumbered by its bulkiness that can result in poor final outcome and need for revision surgery. The aim of the present study was to compare the standard cutaneous ALT free flap and sandwich fascial ALT (SALT) free flap, raised harvesting between the Scarpa's fascia and the crural fascia, for distal extremity soft tissue reconstruction, including pre- intra- and post-operative considerations and outcomes. PATIENTS AND METHODS: A retrospective review of medical records from 2013 to 2018 of 24 patients who underwent distal extremity reconstruction with standard fascio-cutaneous ALT flap (13 patients) and SALT flap (11 patients) was performed. The mean defect dimensions were 12 × 6.5 cm in group 1 and 12 × 6 in group 2. Surgical outcomes and quality of life were assessed (through the upper extremity functional scale and the lower extremity functional scale questionnaires. RESULTS: The mean flap dimensions were 13.1 × 7.1 in group 1 and 14.1 × 7.8 in group 2, the overall flap success rate was 100% (one microvascular venous thrombosis occurred in group 1), no statistically significant difference was recorded regarding microvascular thrombosis (one patient in group p = .369) and infections (one patient in group 1, p = .36) while a statistically significant difference was presence regarding the number of secondary/debulking procedures (6 patients vs. 0) (p = .0076) and the quality of life perception showed an overall better perception in group 2 with statistical significant difference (p = .03). CONCLUSION: The SALT flap represents a valid option, as showed through our preliminary data, when a thin and robust reconstruction is required when dealing with distal extremities soft tissue reconstruction.

Medial femoral condyle free flap in combination with paramedian forehead flap for total/subtotal nasal reconstruction: Level of evidence: IV (therapeutic studies): Level of evidence: IV (therapeutic studies).

BACKGROUND: The nose is a functionally complex organ with also a critical role in aesthetics. For reconstruction of full thickness nasal defects, multiple stages are needed and there is risk for resorption resulting in residual deformity. The aim of this report was to develop and evaluate a new method for full thickness total/subtotal nose reconstruction using the medial femoral condyle free flap (MFCFF) in combination with a paramedian forehead flap. METHODS: Between November 2015 and January 2018, eight patients (four males, four females) mean age 52 years (range 40-73 years) undergoing a total/subtotal nasal excision and subsequential reconstruction with MFCFF plus paramedian forehead flap were enrolled. Six cases were squamous cell carcinomas while two were basal cell carcinomas. The MFCFF was stabilized, with the periosteum as inner layer, with plates and a paramedian forehead flap was used as external skin coverage. All patients were evaluated for with postoperative nasal endoscopy and CT scan. A postoperative questionnaire was given 6 months after surgery. RESULTS: The mean MFCFF size was 2-3.8 cm × 2.25-2.5 cm with a mean pedicle length of 6.3 cm (range 4.1-9.4 cm). The postoperative period was uneventful. The mean follow-up was 16 months, no bone displacement or resorption was observed at the CT scan, no evidence of nasal stenosis occurred. All patients had a satisfying aesthetic evaluation and a good subjective nasal function. CONCLUSIONS: In this series, the MFCFF in combination with the paramedian forehead flap appeared to provide a valid subtotal nose reconstruction, allowing for the recreation of all the three nasal layers and maintaining the nose projection and airway patency in the long term.

FRAIL scale as a predictor of complications and mortality in older patients undergoing reconstructive surgery for non-melanoma skin cancer.

The aim of the present study was to determine the association between preoperative frailty and the onset of surgical complications in patients diagnosed with massive non-melanoma skin cancer subjected to plastic and reconstructive surgery. A retrospective analysis was performed on a cohort of 587 patients with non-melanoma skin cancer, selected on the basis of specific inclusion criteria, who were subjected to plastic and reconstructive surgery between 2005 and 2014. Frailty was scored using the FRAIL index, whereas postoperative complications were classified according to Clavien-Dindo criteria. By binary logistic regression, the odds and probabilities of complications were calculated as a function of increasing values of the FRAIL index. Two different logistic models were created, comparing absent/mild (Clavien grades 1st and 2nd) vs. moderate/severe complications or mortality (Clavien grades 3rd-5th; model A), or absent/mild/moderate complications (Clavien grades 1st-3rd) vs. severe complications or mortality (Clavien grades 4th and 5th; model B). The FRAIL index was an accurate predictor of surgical complications or mortality, with significant odds ratios and goodness of fit. In model A, FRAIL scores 4 and 5 were the most critical predictors of moderate/severe complications or mortality (37 and 94% probability, 0.6 and 17.3 odds, respectively), compared to score 3 (2% probability, 0.02 odds) or lower. In model B, FRAIL score 5 was the most critical predictor of severe complications or mortality, as it was associated with a 74.6% probability and 2.93 odds for these events. In conclusion, increasing FRAIL scores were associated with worsening surgical outcomes for patients with non-melanoma skin cancer undergoing plastic/reconstructive surgery. A low rate of surgical complications was observed in pre-frail and frail patients up to FRAIL score 3.

Sandwich Fascial Anterolateral Thigh Flap in Head and Neck Reconstruction: Evolution or Revolution?

INTRODUCTION: The anterolateral thigh perforator flap (ALT) represents the workhorse for most reconstructive efforts in the head and neck regions. The main advantages of this flap are its versatility, the length of the pedicle, and the low morbidity of the donor site. The major drawback is the bulkiness of this flap with the frequent need for secondary revisions. To overcome this, we have developed a novel way to harvest and inset the ALT, called the sandwich fascial ALT flap (SALT). METHODS: All patients undergoing head and neck reconstruction using the SALT flap from January 2013 to March 2016 were included in this retrospective analysis. The SALT flap was harvested as a composite flap including the superficial fascia, the subscarpal fat, and the deep fascia. At the recipient site, the flap was inset with the deep fascia facing out. A split thickness skin graft (± dermal substitute) was used to cover the deep fascia and the pedicle. RESULTS: Eleven patients were included: 8 cases of orbital exenteration, 1 case of forehead reconstruction, and 2 cases of palatal reconstruction after radical maxillectomy. Flap survival was 100%. One patient required an early take back for venous thrombosis. The reconstruction was effective in all cases, allowing a prosthetic rehabilitation when required. Donor-site morbidity was minimal. CONCLUSIONS: The reconstruction of head and neck defects with a bulky fasciocutaneous ALT flap might not be the best option in every case. The SALT flap could represent a valid alternative for selected cases, with encouraging functional and cosmetic outcomes.

Chimeric anterolateral thigh free flap for reconstruction of complex cranio-orbito-facial defects after skull base cancers resection.

Complex cranio-orbito-facial defects after skull base cancers resection entail a functional and esthetic reconstruction. The introduction of endoscopic assisted techniques for excision surgery with the advances in reconstructive surgery and anesthesiology allowed to improve the management of such critical patients. We report a series of chimeric anterolateral thigh (ALT) flaps used to reconstruct complex cranio-orbital-facial defects after skull base surgery. A retrospective review of patients that underwent cranio-orbito-facial reconstruction using a chimeric ALT flap from March 2013 to October 2015 at a single tertiary care referral Institute was performed. All patients were affected by locally-advanced malignant tumor and the resulting defects involved the skull base in all cases. The ALT flaps were perforator-based flaps with different components: fascia, skin and muscle. The different flap territories had independent vascular supply and were independent of any physical interconnection except where linked by a common source vessel. Ten patients were included in the study. Three patients underwent adjuvant radiotherapy and to chemotherapy. The mean hospitalization time was 21 days (range, 8-24 days). One failure was observed. After a mean follow-up of 12.4 months, 3 patients died of the disease, 2 are alive with disease, while 5 patients (50%) are currently alive without evidence of disease. Chimeric ALT flap is a reliable and versatile reconstructive option for complex cranio-orbito-facial defects resulting from skull base surgery. The chimeric flap composed of different territories proved to be adequate for a patient-tailored three-dimensional reconstruction of the defects as well as able to resist to the postoperative adjuvant treatments.

Medial Femoral Condyle Free Flap for Nasal Reconstruction: New Technique for Full-Thickness Nasal Defects.

The nose is a functionally complex organ implicated in breathing, olfaction, and phonation, with a critical role also in the aesthetic appearance of a person. This latter aspect should be carefully considered whenever a total or subtotal rhinectomy is performed for resection of locally advanced nasal cancer. To reconstruct large nasal defects, several techniques were described, including the use of cartilaginous grafts, bony grafts, local flaps, and free flaps. In cases of extensive full-thickness resections, free flaps probably represent the most adequate option. The aim of this report is to present the functional and aesthetical outcomes of a reconstruction of the nose after rhinectomy, using the medial femoral condyle free flap associated with the forehead flap.

Evaluation of lymphangiogenesis in acellular dermal matrix.

INTRODUCTION: Much attention has been directed towards understanding the phenomena of angiogenesis and lymphangiogenesis in wound healing. Thanks to the manifold dermal substitute available nowadays, wound treatment has improved greatly. Many studies have been published about angiogenesis and cell invasion in INTEGRA(®). On the other hand, the development of the lymphatic network in acellular dermal matrix (ADM) is a more obscure matter. In this article, we aim to characterize the different phases of host cell invasion in ADM. Special attention was given to lymphangiogenic aspects. MATERIALS AND METHODS: Among 57 rats selected to analyse the role of ADM in lymphangiogenesis, we created four groups. We performed an excision procedure on both thighs of these rats: On the left one we did not perform any action except repairing the borders of the wound; while on the right one we used INTEGRA(®) implant. The excision biopsy was performed at four different times: First group after 7 days, second after 14 days, third after 21 days and fourth after 28 days. For our microscopic evaluation, we used the classical staining technique of haematoxylin and eosin and a semi-quantitative method in order to evaluate cellularity counts. To assess angiogenesis and lymphangiogenesis development we employed PROX-1 Ab and CD31/PECAM for immunohistochemical analysis. RESULTS: We found remarkable wound contraction in defects that healed by secondary intention while minor wound contraction was observed in defects treated with ADM. At day 7, optical microscopy revealed a more plentiful cellularity in the granulation tissue compared with the dermal regeneration matrix. The immunohistochemical process highlighted vascular and lymphatic cells in both groups. After 14 days a high grade of fibrosis was noticeable in the non-treated group. At day 21, both lymphatic and vascular endothelial cells were better developed in the group with a dermal matrix application. At day 28, lymphatic endothelial cells had organized themselves, engineering the pseudocylindrical structure better disposed in the ADM group than in the control group, and the lymphatic cells were detectable inside the vessels' lumen in this group. CONCLUSION: This study has made it possible to demonstrate the absolute importance of an ADM in proper wound healing and has shown better definition of both the qualitative and quantitative aspects of lymphangiogenesis compared to the second intention healing. A major grade of organization of the extracellular matrix and a minor grade of fibrosclerosis in ADM allowed a well-structured morphologic and functional development of the endothelial and lymphatic vascular structures. This study hopes to represent a clinical basis for a wider use of ADM in lesions where lymphatic complications are common.