Prophylactic Venous Supercharging in Deep Inferior Epigastric Artery Perforator Flap Surgery: A Retrospective Dual-Center Study.

BACKGROUND: Deep inferior epigastric artery perforator (DIEP) flap is nowadays considered the gold standard in breast reconstruction. However, venous congestion is still a leading cause of free flap failure. Despite the conspicuous articles regarding the use of a secondary venous anastomosis, there is a lack in the literature regarding the prophylactic use of a secondary venous route to reduce the incidence of complications during breast reconstruction. METHODS: A double-center retrospective study based on women undergoing DIEP breast reconstruction was conducted, dividing patients into case group (DIEP flaps with double venous anastomosis) and control group (DIEP flaps with single venous anastomosis). Demographic and surgical data and complications were compared and statistically analyzed, and a reconstructive algorithm was proposed to improve the flap insetting. RESULTS: In total, 154 patients were included in the study, divided into case group (74 patients) and control group (80 patients). The median age at the time of surgery was 49.09 years (range: 29-68 years), slightly lower in group 1 when compared with group 2. The mean body mass index (BMI) was 25.52 kg/m2 (range: 21.09-29.37 kg/m2), in particular 25.47 kg/m2 (range: 23.44-28.63 kg/m2) in group 1 and 25.58 kg/m2 (range: 21.09-29.37 kg/m2) in group 2. No statistical differences were found between groups in terms of BMI and smoking and comorbidities history. The average operative times were 272.16 minutes (range: 221-328 minutes) in group 1 and 272.34 minutes (range: 221-327 minutes) in group 2, with no significant difference between groups, as well as ischemia time (44.4 minutes in group 1 [range: 38-56 minutes] and 49.12 minutes in group 2 [range: 41-67 minutes]). Statistical analysis showed a reduction in short-term complications and a statistically significant reduction for take-backs in the two groups. CONCLUSIONS: Our study suggests that venous supercharging of DIEP flap by performing dual venous anastomosis can be routinely and safely done prophylactically, and thus not only after intraoperative assessment of venous congestion, to avoid flap venous congestion and decrease the rates of re-exploration.

A Single Center's Clinical Experience With Ergonomix Breast Implants.

BACKGROUND: This retrospective study reports on the early experience of a private surgical center with Motiva Ergonomix SilkSurface breast implants. OBJECTIVES: The aim of this study was to examine the incidence of complications and satisfaction levels in women who received primary and revision breast augmentation or augmentation-mastopexy with Ergonomix SilkSurface breast implants. METHODS: A total of 356 consecutive patients received Ergonomix SilkSurface breast implants between April 2014 and October 2018 by 3 different surgeons and were followed-up for a minimum of 12 months. Complications were assessed by measuring the rate of rupture, capsular contracture, malposition, late seroma, double capsule, reoperation, symmastia, ptosis, extrusion, and infection. Satisfaction with aesthetic results was assessed on a Likert scale by both surgeon and patient. RESULTS: Only 6 major complications were observed in these 356 patients (712 implants): 1 unilateral implant ptosis ("bottoming out") at 12 months (0.14%) and 2 capsular contractures (0.28%), 1 at 14 months and 1 at 2 years. At all time points, 98% of the patients were "extremely satisfied or very satisfied" with the aesthetic results, and the surgeons categorized the outcomes as "very important or important improvement" in 96% of the cases. CONCLUSIONS: Motiva Ergonomix SilkSurface devices provided high patient satisfaction up to more than 5 years postoperatively with very few complications. These data are consistent with other reports in the literature. The observed favorable outcomes might be attributed, at least in part, to the bioengineered "cell-friendly" surface of these implants.

The Application of the Divine Proportion for the Construction of the Visualized Treatment Objective in Craniofacial Surgery.

ABSTRACT: Aesthetics and function of maxillofacial district are closely related and could interfere with patient psychological conditions. The aim of this paper is to describe and to analyze the procedures necessary for a proper surgical visualized treatment objective (VTO) realization through the use of the tracing on lateral head film, applying the divine proportion (or golden ratio) in certain steps. The method described is easy to realize, cheap and help both orthodontist and maxillo-facial surgeon to communicate each other and to the patients.For the following article, digital research and handheld research on surgical VTO planning for patients with skeletal or dentoalveolar severe deformities managed by surgeons and orthodontics were used. The research included articles in English published on dental and maxillofacial surgery journals.The surgical VTO consists of a "previsualization" of the objectives in order to make the desired changes for the individual patient. The result can thus be visualized and pre-evaluated rather than just imagined by the mind's eye. To simplify the procedure, the surgical VTO has been divided into 11 steps. The accurate model of the surgical result is fundamental in the treatment of dentofacial deformities. These predictions are intended to guide the treatment towards the desired result, to give the patient a reasonable preview of the outcome, and to ensure communication between the orthodontist and the surgeon.This technique proves to be effective in planning surgical treatment and it allows the clinician to view changes before, during, and after orthognathic surgery. The skeletal, dental, and aesthetic complete cephalometric evaluation is the key point to the long-term success of the results.

Tuberous Breast: Past, Present, and Future: Personal Classification, Treatment, and Surgical Outcomes.

BACKGROUND: Tuberous breast (TB) is a rare congenital deformity, which may appear in different clinical forms representing various degrees of a single pathological entity. The worst cases are characterized by severe hypoplasia. Following a detailed analysis of the available relevant literature and a significant number of treated cases, in this article, the authors propose a new classification, with the aim of summarizing and simplifying a more intuitive categorization of the malformation, considering all the clinical aspects and including all types of TBs, even the minor ones, thus allowing a more immediate diagnosis and surgical planning. METHODS: Between September 2006 and December 2015, 78 patients with TBs underwent surgical procedures to correct the deformity. The patients' mean age was 18.6 years, ranging between 17 and 26 years. There being 11 monolateral deformities, the treated TBs amounted to 145. A periareolar approach, adipo-glandular flaps, and dual plane breast implant placements were performed. Postoperative follow-up include photos collected 12 months after operation. The authors present a personal classification including all the forms of the deformity, plus the minor forms based on the following 2 principal categories: hypoplastic and normoplastic TBs, taking into account all the clinical aspects of the malformation including the morphology and the consistency of the breast. CONCLUSIONS: Preoperative identification of the type of the deformity is essential to obtain satisfactory results and a complete and intuitive classification including all the possible variants of the deformity, even the minor forms, and fundamental in diagnosing and resolving the problem. In this article, the authors propose a personal classification and surgical procedure to resolve the malformation.

Management of Gynecomastia in Patients With Different Body Types: Considerations on 312 Consecutive Treated Cases.

BACKGROUND: Gynecomastia is a common finding in male subjects which incidence varies widely in the world population. In adolescents, it is frequently temporary but, if it becomes persistent, it generates considerable embarrassment, inducing the patients to seek surgical consultation. Even in patients with good body contour, gynecomastia creates even greater distress considering the special attention given by these subjects to their physical appearance. The authors present their experience in the treatment of gynecomastia comparing different body types of patients with the aim to investigate dissimilar expectations, needs and surgical outcomes thus optimizing the management of the pathological condition, achieving high levels of agreement and reducing unsatisfied patients arising from cosmetic surgery. MATERIALS AND METHODS: Between January 2007 and January 2015, 312 selected patients have been treated surgically for gynecomastia. Patients were grouped according to their physical aspect: 97 were classified as high muscle mass body type (group A), 106 as normal (group B) and 109 as overweight patients (group C). All of them were adults ranging in age between 18 and 52 years. Follow-up ranged from 12 to 60 months. In all cases, an excision of the gland in the form of a subcutaneous mastectomy was performed; the most common surgical access was in the inferior part of the areola. RESULTS: No breast cancers were found at the histological examinations. Also, no skin or areola necrosis have been referred, and no recurrence of gynecomastia disorder has been reported. Six cases of seroma (limited to the fatty gynecomastia) and 3 cases of hematomas (requiring immediate surgical revision) were found. Although the patients in group B resulted more distressed by the disorder, higher levels of postoperative satisfaction were recorded in this group. CONCLUSIONS: The study demonstrates the importance of the different management of the same disorder according to the different patients' expectations, related to the different body type. Our experience demonstrated that most of the cases did not require extensive skin incisions, reducing the risk of unpleasant scars and that direct excision of glandular tissue ensures stable and satisfactory results.

Septum-Enhanced Mammaplasty in Inferocentral Pedicled Breast Reduction for Macromastia and Gigantomastia Patients.

BACKGROUND: Inferior pedicle and free nipple grafting are commonly used as breast reduction techniques for patients with breast hypertrophy and gigantomastia. Limitations of these techniques are, respectively, possible vascular compromise and total/partial necrosis of the nipple-areola complex (NAC). The authors describe the innovative inferocentral pedicled reduction mammaplasty (ICPBR) enhanced by preservation of Würinger's septum for severe hypertrophic breasts. MATERIALS AND METHODS: Among 287 breast reductions performed between January 2001 and 2015, 83 (28.9%) macromastia and gigantomastia patients met the inclusion criteria (breast volume resection ≥400 g-sternal notch-to-nipple distance ≥33 cm) and were included in the study. Patients were stratified according to pedicle type: Group A (51 patients) underwent ICPBR with Würinger's septum preservation; group B (32 patients) underwent IPBR. Groups were compared for NAC vascular complications, surgical revisions, wound-healing period and patient satisfaction at a minimum 6-month follow-up assessed by a five-category questionnaire (breast size, shape, symmetry, texture and scars appearance), with five Likert subscales (1 = poor to 5 = excellent). Descriptive statistics were reported, and comparisons of performance endpoints between groups were performed using Chi-squared, Fisher's exact and Mann-Whitney U tests, with p value <0.05 considered significant. RESULTS: Group A and group B had, respectively, a mean age of 48.3 ± 12.4 and 50.1 ± 11.7 years, mean BMI of 23.8 and 24.6, mean weight resected of 560 ± 232 g and 590 ± 195 g, mean sternal notch-to-nipple distance of 35.1 and 34.3 cm, average nipple elevation of 9.7 and 9.5 cm. Among group A and group B, NAC complication rates were, respectively, 6.2 and 24.2% (p = 0.03), surgical revision rates were 33.3 and 60% (p = 1.00), healing time was 15.90 ± 3.2 and 19.03 ± 5.9 days (p = 0.002), and mean patient satisfaction scores were 19.9 ± 2.6 and 18.7 ± 3.4 (p = 0.07). CONCLUSIONS: The ICPBR technique enhanced by Würinger's septum preservation was found to be a reproducible and effective procedure for hypertrophic breasted and gigantomastia patients, improving the reliability of the vascular supply to the inferior-central pedicle. The authors do believe this procedure should be regarded as an innovative and safe option giving optimal aesthetic outcomes in this demanding group of patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Impending Facial Skin Necrosis and Ocular Involvement After Dermal Filler Injection: A Case Report.

Demand for non-surgical rejuvenating procedure is constantly increasing due to the aging population, increasing expense of aesthetics and beauty procedures, introduction of new applications and rising demand for noninvasive aesthetic procedures over surgical procedures. Skin necrosis is a rare but severe potential complication. It is caused by impediment of the blood supply to the skin area by compression and/or obstruction of the vessel with filler material, and/or direct injury to the vessel. We report the case of a young patient who presented an acute and severe complication after a dermal filler injection by an unlicensed therapist. High-dose corticosteroids i.v. therapy among others helped in the process of healing. Skin necrosis left the patient with a full thickness scar on the forehead region. Dermal fillers are to be considered safe only when handled by trained doctors. 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 .

Periareolar Access for Pectus Excavatum Correction with Silicone Implants: A New Method to Minimize Postoperative Scars-Review of the Literature, Considerations and Statistical Analysis of Clinical Outcomes.

BACKGROUND: Pectus excavatum (PE) is one of the most frequent thoracic malformations. Generally, the malformation is not associated with functional disorders and often constitutes an aesthetic alteration with significant psychological distress. OBJECTIVES: To reduce the visibility of the residual scarring produced by corrective surgery and to improve the aesthetic outcome, the authors propose a new prosthetic implant technique through a periareolar access. METHODS: From January 2005 to January 2015, 11 patients affected with PE underwent the surgical procedure with a sternal prosthesis implanted through a periareolar access with the help of a fiberscope. The preoperative evaluation of the perception of the malformation and postoperation results were made using different questionnaires. The data collected in our series were compared with that reported in 4 different papers where other forms of access were used: sternal, inframammary and transumbilical. RESULTS: No major complications or dislocation of the implants were reported. Among the complications, 6 postoperative seromas were reported. The patients' perception of improvement through the use of 2 questionnaires and an evaluation scale showed substantial improvement in all the aesthetic outcomes. CONCLUSIONS: The periareolar technique provides excellent cosmetic results compared to the sternal one. This access causes fewer complications and necessitates a shorter average hospital stay than the sternum access. To conclude, according to what is shown in the literature, periareolar access seems to be a quicker procedure, requiring a shorter stay in hospital, and results in scars that can more easily be hidden and are more accepted by patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Skin substitutes based on allogenic fibroblasts or keratinocytes for chronic wounds not responding to conventional therapy: a retrospective observational study.

Chronic wounds are an expression of underlying complex pathologies and have a high incidence. Skin substitutes may represent an alternative approach to treat chronic ulcers. The aim of this retrospective observational study was to evaluate the wound reduction using skin substitutes based on allogenic fibroblasts or keratinocytes in 30 patients not responding to conventional therapy. Wound bed was prepared, then keratinocytes on Laserskin(®) to treat superficial wounds or fibroblasts on Hyalograft 3D(R) to treat deep leg ulcers were applied, and finally wounds were treated with a secondary dressing composed of nanocrystalline silver. Once a week constructs were removed and new bioengineered products were applied, as well as nanocrystalline silver medication. In none of the cases under examination did any complications arise relating to the treatment. We also achieved a reduction in wound dimension and exudates, and an increase in wound bed score. Postoperative assessment shows a degree of healing that is statistically higher in the group treated with keratinocytes as compared with the fibroblast group. This retrospective study improves our understanding and defines the clinical indications for the various uses of the two types of skin substitutes.

Penile length is a very important factor for cosmesis, function and psychosexual development in patients affected by hypospadias: Results from a long-term longitudinal cohort study.

Few studies of long-term outcome of hypospadias treatment in terms of voiding, surgical complications, sexual functioning, intimate relationships and cosmetic results have been investigated and contrasting results have been obtained so far. The aim of our study is to investigate the long-term outcome of urinary and sexual function, cosmesis and the quality of intimate relationships in a series of hypospadias. In this study, 42 patients who underwent surgery for hypospadias were prospectively followed for 15 years. Medical records provided the hypospadias data, the number of reconstructive operations and the reconstruction technique that was used. Patients underwent physical examination, including penile length measurement and completed International Prostatic Symptoms Score (I-PSS), International Index Of Erectile Function (IIEF 15) and the Penile Perception Score questionnaire (PPPS). Twenty patients agreed to participate in the study. At the enrolment, the median value of HOSE was 13, as regards PPPS, 18/20 (90%) were satisfied, while in 1998 only 80% were satisfied. No significant statistical difference has been reported from the results obtained at enrolment and those obtained at follow-up, in terms of PPPS (P = 0.81), IPSS and IIEF-15. Penile length was 6.5 cm flaccid and 10.5 cm stretched. Our data show how cosmesis, function and psychosexual development for these patients are highly connected to surgical outcome, which is understood to be a decrease in penile size.

Wide-undermining neck liposuction: tips and tricks for good results.

BACKGROUND: Neck rejuvenation is one of the most sought after procedures in the restoration of the facial contour. Numerous techniques to improve the aesthetic outcome and reduce downtime have been described. In our experience, wide undermining and local anesthesia are key to obtaining good results in selected patients who want a quick recovery. This article presents our experience with liposuction of the neck and proposes some tips and tricks to master wide-undermining neck liposuction. METHODS: From January 2005 to September 2012, a total of 118 patients (34 males, 84 females) underwent neck liposuction. Patient selection was based mainly on age and neck-aging features. The procedure was performed with the patients under local anesthesia. A wide rhomboid-shaped skin undermining of the submandibular and neck area was performed and a very thin fat layer was preserved. Dressing was applied for 3 days. RESULTS: Improvement of the neck's contour was observed in all patients. Redefinition of the cervicomandibular angle and skin redraping of the cervical area occurred in all cases. No further touch-ups were needed. Edema and ecchymosis resolved in a few days. No major complications were observed. CONCLUSIONS: Our results show that wide-undermining neck liposuction performed under local anesthesia is an effective and safe procedure. Patient selection based on age and anatomical features was fundamental to obtain impressive improvement of neck contour. 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 .

Temporal Fascia Free Flap for Thumb Coverage in Electrical Burn Injuries: A Case Series Analysis With DASH Score Outcomes Evaluation.

Electrical burns pose unique challenges in reconstructive surgery due to the extensive tissue damage they cause. The thumb is particularly susceptible to electrical burns, leading to severe functional impairment. This case series introduces the use of the temporal fascia free flap for thumb coverage in patients with electrical burn injuries. The study aims to assess the functional outcomes of this approach using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Six male patients underwent thumb reconstruction using temporal fascia free flaps following electrical burn injuries. The extent of the injury was assessed, and necrotic tissue was debrided. Functional outcomes were evaluated using the DASH questionnaire 6 months postoperation. All procedures were conducted in accordance with ethical guidelines, and informed consent was obtained from all patients. All patients achieved successful transplants using temporal fascia free flaps. The average DASH score at the 6-month follow-up indicated satisfactory functional recovery. Patients reported improvements in thumb mobility and functionality, and the cosmetic appearance of the thumb was acceptable. The appearance of the scar in the donor area was well-received. The temporal fascia free flap proved to be an effective method for thumb reconstruction following electrical burn injuries. Its thin and flexible nature allows for optimal contouring and improved range of motion. Although one case of partial flap loss was observed, overall functional and aesthetic outcomes were satisfactory. Further research with larger sample sizes is warranted to optimize surgical techniques and postoperative care for better outcomes.

Implementing Nexobrid for Burn Debridement in a Major Italian Burn Center: A Retrospective Review of Patient Outcomes.

This retrospective study examines the implementation of Nexobrid, an enzymatic debriding agent developed from bromelain, for burn debridement in a major Italian burn center. With previous research showing encouraging results for Nexobrid in terms of reducing the need for surgical intervention and faster eschar removal, the current study aims to add to the growing body of evidence regarding its potential benefits and limitations. The patient database was utilized to identify patients who received Nexobrid treatment between October 2019 and June 2023. A retrospective analysis was conducted to gather demographic information, burn causes, procedural details, and patient outcomes. Of the 30 patients treated with Nexobrid, 10% did not require further surgical intervention, showcasing Nexobrid's potential to improve patient outcomes. However, over 80% of patients still required additional surgical intervention, demonstrating that Nexobrid's effectiveness varies across patients and should be considered a tool rather than a definitive solution in burn wound management. A few patients developed complications, and about 10% of patients succumbed to systemic complications. The study results reveal both the potential benefits and limitations of using Nexobrid in burn debridement. While it successfully eliminated the need for further surgical intervention in a small percentage of patients, the majority still required additional surgical procedures. These findings not only highlight Nexobrid's role as a tool in burn wound management but also point toward the discrepancies with previous studies. The authors suggest future research should include randomized controlled trials, direct comparisons between Nexobrid and traditional debridement methods, and studies incorporating larger and more diverse patient groups.

Experience in Post-Bariatric Abdominoplasty for Patients with Significant Weight Loss: A Prospective Study.

BACKGROUND: Abdominoplasty is a critical aesthetic and functional procedure for individuals who have undergone massive weight loss. Numerous techniques have been proposed to optimize aesthetic results while minimizing complications. METHODS: This prospective study examined 500 patients who underwent abdominoplasty during body-contouring procedures between 1 January 2018 and 31 December 2021 at a tertiary center. The Skin-Adipose Tissue-Muscle (SAM) protocol was employed to analyze the operative strategies and complication rates and compare them with the existing literature. Furthermore, patient satisfaction and aesthetic outcomes were measured one year post-operation using a comprehensive four-point questionnaire evaluated by the patients themselves and two independent surgeons. RESULTS: Participants had an average age of 34.8 years and a mean BMI of 31.1 kg/m2. The surgeries included 328 full abdominoplasties and 172 T-inverted abdominoplasties. Notable complications included wound infection (4%), wound dehiscence (8.6%), tissue necrosis (0.6%), seroma (8.4%), and hematoma (2.6%). A higher BMI was correlated with an increased risk of complications and lower patient satisfaction. Data analysis was performed using Stata version 18 software. CONCLUSIONS: The increasing prevalence of obesity highlights an urgent need for more bariatric surgeries and subsequent abdominoplasties to mitigate the effects of massive weight loss. A crucial link between elevated BMI and a heightened risk of postoperative complications, emphasizing the necessity for standardized surgical protocols tailored to individuals with higher BMI, was noted. Innovatively, future studies must further investigate the intricate dynamics between BMI and surgical risks. Exploring and establishing uniform, adaptive surgical guidelines promise to revolutionize patient care by significantly reducing complications and enhancing recovery and satisfaction following abdominoplasty.