Best practices in surgical and nonsurgical management of head and neck Merkel cell carcinoma: An update.

Merkel cell carcinoma (MCC) is a rare, highly aggressive cutaneous neuroendocrine carcinoma. Controversy exists regarding optimal management of MCC as high-quality randomized studies and clinical trials are limited, and physicians are bound to interpret highly heterogeneous, retrospective literature in their clinical practice. Furthermore, the rising incidence and notably poor prognosis of MCC urges the establishment of best practices for optimal management of the primary tumor and its metastases. Herein, we summarized the relevant evidence and provided an algorithm for decision-making in MCC management based on the latest 2021 National Comprehensive Cancer Network guidelines. Additionally, we report current active MCC clinical trials in the United States. The initial management of MCC is dependent upon the pathology of the primary tumor and presence of metastatic disease. Patients with no clinical evidence of regional lymph node involvement generally require sentinel node biopsy (SLNB) while clinically node-positive patients should undergo fine needle aspiration (FNA) or core biopsy and full imaging workup. If SLNB or FNA/core biopsy are positive, a multidisciplinary team should be assembled to discuss if additional node dissection or adjuvant therapy is necessary. Wide local excision is optimal for primary tumor management and SLNB remains the preferred staging and predictive tool in MCC. The management of MCC has progressively improved in the last decade, particularly due to the establishment of immunotherapy as a new treatment option in advanced MCC. Ongoing trials and prospective studies are needed to further establish the best practices for MCC management.

Weight gain is an early indicator of injury in ex vivo normothermic limb perfusion (EVNLP).

PURPOSE: There are no established criteria for discontinuing ex vivo normothermic limb perfusion (EVNLP) before irreversible damage occurs. This study evaluates weight gain as an indicator of injury during EVNLP. METHODS: Sixteen Yorkshire pig forelimbs were procured and preserved using EVNLP with a hemoglobin-based oxygen carrier (HBOC-201) or static cold storage. EVNLP continued until termination criteria were met: arterial pressure ≥ 115 mm Hg, compartment pressure > 30 mm Hg, or 20% reduction of oxygen saturation. Limb weight, contractility, hemodynamics, perfusate electrolytes, metabolites and gases were recorded. Muscles were biopsied 6-h, and muscle injury scores (MIS) calculated. Forearm compartment pressures and indocyanine green (ICG) angiography were recorded at endpoint. Outcomes were compared at 2%, 5%, 10%, and 20% limb weight gain. RESULTS: EVNLP lasted 20 ± 3 h. Weight gain was observed after 13 ± 5 h (2%), 15 ± 6 h (5%), 16 ± 6 h (10%), and 19 ± 4 h (20%). Weight correlated positively with MIS (ρ = 0.92, p < 0.0001), potassium (ρ = -1.00, p < 0.0001), pressure (ρ = 0.78, p < 0.0001), and negatively with contractility (ρ = -0.96, p = 0.011). At 5% weight gain, MIS (p < 0.0001), potassium (p = 0.03), and lactate (p < 0.0001) were significantly higher than baseline. Median muscle contractility was 5 [3-5] at 2% weight gain, 4 [1-5] at 5%, 3 [0-4] and 2 [0-2] at 10% and 20%, respectively. At 20% weight gain, contractility was significantly lower than baseline (p = 0.003). Percent weight gain correlated negatively with endpoint ICG hoof fluorescence (r = -0.712, p = 0.047). CONCLUSIONS: Weight gain correlated with microscopic muscle injury and was the earliest evidence of limb dysfunction. Weight gain may serve as a criterion for discontinuation of EVNLP.

Evaluation of virtual surgical planning and three-dimensional configurations for reconstruction of maxillary defects using the fibula free flap.

BACKGROUND: Maxillary reconstructive surgery with fibula free flaps (FFFs) is a challenging procedure for head and neck surgeons. However, virtual surgical planning (VSP) and three-dimensional (3D) printing technologies have contributed to improved functional and aesthetic outcomes. The objective of this report is to demonstrate VSP/3D application in reconstruction of maxillary defects using the FFF by describing the different configurations available. We reviewed a series of consecutive cases operated at our institution and considered the management strategy of in-house planning in VSP/3D application. METHODS: In total, 11 cases were included from November 2016 to December 2021. Eight male and three female were included, with a mean age of 55.4 years old (range: 34-74 years old). Maxillary defects were classified according to Brown's Classification: two cases with IIB, one case with IIC, four cases with IID, three cases with III, and one case with IV. Preoperatively, facial computed tomography (CT) and lower extremity computed tomography angiogram (CTA) were performed in all patients. Osteocutaneous FFFs were planned, harvested, and customized according to the VSP/3D guide configuration. VSP and 3D printed cutting guides were performed by an external company in nine cases and were self-planned in three of them. Titanium 3D-printed fixation plates were used in four cases. RESULTS: All flaps survived, and the main reconstructive goals were achieved in 9 cases out of 11. Mean FFF length before osteotomy was 20.0 cm (17.5-22.5 cm). None of the cases experienced flap ischemia or venous congestion. At least one complication occurred in four cases: Prefabricated titanium plate exposure (two cases), loss of donor site skin grafts (one case), and ectropion (one case). One patient underwent a second FFF reconstruction. Two titanium printed plates became exposed after radiotherapy and needed to be removed. Mean follow-up time was 23.5 months (range 6-63 months). Dental rehabilitation was completed in eight of the 11 cases. Regarding functional recovery, five cases underwent delayed osseo-integrated dental implants (ODI), and two cases had immediate ODI procedures. One case was treated with removal dentition. CONCLUSION: VSP/3D printing technology is a new and helpful tool to successful restoration of craniofacial function and aesthetics. It can be used in the broad range of configurations offered by FFFs considering our suggested management strategy.

Recurrence of breast ptosis after mastopexy - a prospective pilot study.

BACKGROUND: Breast ptosis is characterized by severe volumetric deficiency of the upper pole, excess of skin in the lower pole and descent of the nipple-areola complex (NAC). Mastopexy, also known as breast lifting, is the surgical operation aimed to reshape the ptotic breast. Recurrence of breast ptosis after mastopexy is common but to the best of our knowledge no study before has measured it. PURPOSE: The aim of this study was to measure the recurrence of breast ptosis after mastopexy in a prospective study. MATERIALS AND METHODS: Female patients affected by unilateral or bilateral moderate or severe breast ptosis were enrolled in the study. All the patients underwent mastopexy performed only with the removal of skin excess following a Wise pattern. The jugular notch-nipple distance was measured before surgery, immediately after surgery and after 1, 3, 6 and 12 months. RESULTS: Ten patients were included in the study, four underwent unilateral mastopexy and six underwent bilateral mastopexy. The lifting of the NAC, measured in the immediate post-operative period, ranged from 3 to 8.5 cm, with an average value of 6.3 cm. This lifting, one year after surgery, ranged from 2 to 7 cm, with an average value of 4.6 cm. The percentage loss of the NAC lifting one year after surgery compared to the immediate post-operative time ranged from 12.5 to 41.7%, with an average value of 27.5%. CONCLUSION: In our case series, the lifting of the NAC obtained immediately after surgery showed an average loss of 27.5% one year after surgery. Even if limited by the low number of patients included, this pilot study is eye-opening on a very common phenomenon that occurs after mastopexy. The patients should be informed about the possible recurrence of the breast ptosis.

Pre-Pectoral One-Stage Breast Reconstruction with Anterior Coverage Using Superior Anterior Biological Acellular Dermal Matrix (ADM) and Inferior Anterior Dermal Sling Support.

The use of acellular dermal matrix (ADM) implants has enhanced breast reconstruction. ADM is a biotechnologically designed human tissue of bovine or porcine origin in which tissue processing removes cellular antigens. In this case report, we describe the use of ADM in one-stage prepectoral breast reconstruction. Skin-reduction breast reconstruction with a prepectoral implant was performed. We created a combined dermal pocket using the inferior dermal flap, sutured with a patch of acellular dermal matrix to continue its extension until the upper pole, to cover the implant. This technique offers single-stage immediate reconstruction, with a decreased requirement for ADM and increased use of vascularized tissue and implant support. Additionally, in the pre-pectoral space, decreased pain postoperatively and less anatomic disruption is offered.

What is Beauty?

PURPOSE: In the current study, the authors attempt to thoroughly investigate the concept of beauty from different perspectives in different historical periods and offer their personal thoughts about it. METHODS: The authors performed a comprehensive and across-the-board literature review about 'beauty', including beauty from a philosophical perspective, beauty perception by human mind, beauty from a biopsychological perspective, beauty of the face, body and breast, models of beauty and beauty in cosmetic surgery. RESULTS: From Plato to modern neuro-psychological studies, the concept of beauty has always been a theme for adamant debates and passionate thoughts. Different aspects of beauty, from intellectual to pure physical, have received a tremendous amount of attention. The true definition of the concept of beauty is still ambiguous, and there is not a unanimous explanation for it. It seems that the definition of beauty differs in every individual's mind and over the history of humankind. CONCLUSION: Although beauty is a very important concept and the seek for achieving it is a very natural behavior, one must remember that the importance of beauty should not overshadow the fact that every human being is made up of similar internal organs. We strongly encourage the reader to look beyond the hedge, to be aware that each of us is made up of internal organs, beyond the external appearance. 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 Table of Contents or online Instructions to Authors www.springer.com/00266.

Efficacy of virtual plastic surgery encounters in establishment of care and surgical conversion.

BACKGROUND: The efficacy of virtual visits in converting new patients into established patients undergoing surgical treatment has not been demonstrated. The aim of this study was to evaluate patient retention and surgical conversion rate after an initial virtual plastic surgery consultation. METHODS: An IRB-approved retrospective review of all new plastic surgery patients seen between May and August 2020 at a single institution was conducted. The initial encounter type, chief complaint, demographics, treatment recommendation, insurance approval rate, number and modality of pre- and postoperative visits, time to procedure, follow up, and complications were recorded. Patient retention and surgery conversion rate were calculated. Statistical analysis was performed with Chi-squared test, Fisher's exact test, and unpaired t-test. RESULTS: In total, the records of 1889 new patients were reviewed (1635 in-person, 254 virtual). Virtual patients were younger (44.5 ±â€¯19.0 versus 49.5 ±â€¯20.7 years, p < 0.001), and nearly half resided greater than 50 miles away (42% versus 16%, p < 0.001). Virtual patients more frequently presented for cosmetic surgery (14% versus 7%, p < 0.001), lymphedema (15% versus 3%, p < 0.001), and gender dysphoria (11% versus 2%, p < 0.001). In-person patients presented more often for trauma (18% versus 5%, p < 0.001), elective hand complaints (16% versus 3%, p < 0.001), and breast reconstruction (9% versus 4%, p < 0.01). There were no differences in patient retention (p = 0.45) and procedure conversion rate (p = 0.21) between the groups. CONCLUSION: Telemedicine provides an opportunity to increase the practice catchment area and is as effective as in-person first encounters for establishing care and transition to surgery.

Jump Technique versus Seton Method for Anal Fistula Repair: A Randomized Controlled Trial.

BACKGROUND: The treatment of anal fistula has been a conundrum for surgeons over the years. Various methods such as fistulotomy, fistulectomy, seton, ligation of the intersphincteric fistula tract (LIFT), advancement flaps, fibrin glue, and plugs are well-known techniques. Yet, they may be followed by several considerable complications, including incontinency and recurrence. METHODS: In this study, the outcomes of the "Jump" and "Seton" techniques are compared. A randomized controlled trial consisting of 130 cases with cryptoglandular anal fistula randomly sorted into two groups was conducted. Group A underwent the "Jump technique" while group B underwent the "Seton technique." Outcomes, incontinency and recurrences in particular, were evaluated after a year of treatment. Data were analyzed by Fisher Exact, Chi-Square and Mann Whitney Tests. RESULTS: Group A with 65 cases underwent the "Jump technique" while group B with 65 cases underwent the "Seton Method." Recurrence was reported in 12 (20%) cases in group A and 10 (15.6%) cases in group B (p=0.687). Overall incontinence was reported in 3 (4.6%) cases in group A and 18 (27.7%) cases in group B (P=0.001). The total St. Mark's scores for incontinency of group A (0.092±0.52) and group B (1.8±02.47) significantly differed (p<0.001). CONCLUSIONS: The "Jump technique", named after a runner who jumped over hurdles, has obviated these complications. The "Jump technique" had satisfactory results and can be utilized as a first-line approach for all types of fistulas. Moreover, it can be redone for cases with recurrences without affecting the continence, paving the way to change the technique during operations.

Post-Bariatric Plastic Surgery: Abdominoplasty, the State of the Art in Body Contouring.

Due to the increased prevalence of obesity in the last decades, bariatric surgery has been on the rise in recent years. Bariatric surgery is a compelling option for weight loss in obese patients with severe obesity-related comorbidities or for whom lifestyle modifications have proven ineffective. Redundant skin following significant weight loss is a common occurrence affecting up to 96% of patients who undergo bariatric surgery, negatively impacting physical and psychosocial health and detracting from activities of daily living. Statistics of the American Society of Plastic Surgeons show that 46,577 body contouring procedures were performed after massive weight loss in the USA in a 2020 report. Abdominoplasty, a well-established cosmetic surgery procedure for improving body contour, is performed by removing excess skin and fat from the abdominal wall and thereby restoring musculofascial integrity and skin elasticity, resulting in a more ideal body shape and increasing quality of life. Although abdominoplasty is a safe procedure, it has been associated with a higher complication rate compared with other body-contouring procedures. Technologic advances over the past decade have been developed as non-invasive alternatives or adjunctive tools to surgery to enhance cosmetic results and minimize complications. New energy-based technologies may supplant invasive surgery for mild to moderate skin laxity and/or diminish the extent of surgery and resulting scars. Plastic surgeons play a significant role in improving the quality of life of patients who suffer from obesity and underwent bariatric surgery. We are deeply convinced, however, that the advancement of knowledge and research in this field will determine the introduction of new technologies and custom-made techniques. This advancement will reduce the complication rate with a rapid reintegration of the patient into the world of work and resumption of daily activities.

Treatment of Axillary hyperhidrosis.

BACKGROUND: Axillary hyperhidrosis characterized by excessive sweating in the axillary regions is a frustrating chronic autonomic disorder leading to social embarrassment, impaired quality of life and usually associated with palmoplantar hyperhidrosis. Identifying the condition and its cause is central to the management. AIM: The aim of this article is to discuss treatment options for axillary hyperhidrosis. METHODS: Comprehensive literature search using PubMed and Google Scholar was performed to review relevant published articles related to diagnosis and treatment of axillary hyperhidrosis. RESULTS: Treatment modalities for axillary hyperhydrosis vary from topical and systemic agents to injectables, newer devices and surgical measures. None except for physical measures using devices or surgery, which destroys the sweat glands to remove them, is possibly permanent and most are associated with attendant side effects. CONCLUSION: Several treatments including medical and surgical option are available for the treatment of axillary hyperhydrosis. Patient education is important component of its management. Individualized approach of management is necessary for optimal outcome of treatment.

Leonardo da Vinci: the Lady with an Ermine enigma.

"Lady with an Ermine" (1489-1490) is an oil on walnut portrait by the Italian artist Leonardo da Vinci. The portrait's subject is Cecilia Gallerani, the favorite mistress of Ludovico Sforza, known as "il Moro", Duke of Milan. It was painted around the time of Cecilia's pregnancy with Ludovico's illegitimate son. Leonardo's paintings are famous for hiding mysteries; thus, the truth about the "Lady with an Ermine" is still unclear. However, the solution to this enigma could be more evident than expected. Our hypothesis is that Cecilia might have suffered from pregnancy-induced Cushing syndrome.

PEGylated superparamagnetic iron oxide nanoparticles (SPIONs) ameliorate learning and memory deficit in a rat model of Alzheimer's disease: Potential participation of STIMs.

The amyloid-beta (Aß) fibrillation process seems to execute a principal role in the neuropathology of Alzheimer's disease (AD). Accordingly, novel therapeutic plans have concentrated on the inhibition or degradation of Aß oligomers and fibrils. Biocompatible nanoparticles (NPs), e.g., gold and iron oxide NPs, take a unique capacity in redirecting Aß fibrillation kinetics; nevertheless, their impacts on AD-related memory impairment have not been adequately evaluated in vivo. Here, we examined the effect of commercial PEGylated superparamagnetic iron oxide nanoparticles (SPIONs) on the learning and memory of an AD-animal model. The outcomes demonstrated the dose-dependent effect of SPIONs on Aß fibrillation and learning and memory processes. In vitro and in vivo findings revealed that Low doses of SPIONs inhibited Aß aggregation and ameliorated learning and memory deficit in the AD model, respectively. Enhanced level of hippocampal proteins, including brain-derived neurotrophic factor, BDNF, phosphorylated-cAMP response element-binding protein, p-CREB, and stromal interaction molecules, e.g., STIM1 and STIM2, were also observed. However, at high doses, SPIONs did not improve the detrimental impacts of Aß fibrillation on spatial memory and hippocampal proteins expression. Overall, we revealed the potential capacity of SPIONs on retrieval of behavioral and molecular manifestations of AD in vivo, which needs further investigations to determine the mechanistic effect of SPIONs in the AD conundrum.