Anatomical Variations of the Axillary Arch and Implications in Breast Surgery.

INTRODUCTION: Langer's axillary arch (AA), the most common anatomical variant in the axillary area of definite clinical significance. This is an updated review of the reported variations in the structure, highlighting its morphological diversity and its potential in complicating axillary lymph node biopsy, lymphadenectomy, or breast reconstruction. METHODS: A review of the literature concerning the AA published between 1812 and 2020 was performed using the PubMed, Scopus, Embase, and Cochrane medical databases. The frequency, laterality, morphology, origin, lateral attachment points, vascularization, and neurosis of the AA were the parameters retrieved from the collected data. RESULTS: The prevalence of AA ranged from 0.8% to 37.5%. It is more often unilateral, muscular in nature, and extending from the latissimus dorsi to the pectoralis major. It is vascularized by the lateral thoracic vessels or the subscapular artery and innervated by the thoracodorsal nerve. CONCLUSIONS: Langer's AA, when present, may complicate surgical procedures in the area; therefore, every surgeon performing breast or axillary surgery should be aware of this entity and its variations to ensure maximal effectiveness and safety in the management of patients.

The Greek Surgeon-Gynecologist Savvas Georgiadis (1857-1942) and the First Vaginal Reconstruction in Smyrna.

The Greek surgeon-gynecologist Savvas Georgiadis from Phocaea in Asia Minor had performed in 1897 an innovative surgical operation in a young female patient, reconstructing her vagina. Having been educated both in Greece and France, specialized in gynecology, he became a famous surgeon in the Hellenic Hospital of Smyrna "Agios Charalampos," where the operation was masterfully executed. Although among the pioneers in neovagina techniques, Georgiadis still is searching his place among the important figures in the history of plastic surgery.

Sentinel lymph node metastasis in primary cutaneous basosquamous carcinoma. A cross-sectional study.

BACKGROUND AND OBJECTIVES: Basosquamous carcinoma (BSC) is a rare, biologically aggressive tumor. This cross-sectional study aims to define risk factors for subclinical nodal metastasis in primary BSC, and identify the patients who would benefit from routine sentinel node biopsy (SLNB) as part of the initial management. METHODS: A total of 142 patients, with histologically proven BSC without palpable lymph nodes, underwent SLNB after the initial excision. Clinicopathological features and demographics were analyzed between the patients with detected micrometastasis (SLNM) and those with negative SLN. RESULTS: In 7.7% patients, subcapsular and <0.1 mm SLNM were found. The frequency of SLNM was 0.9%, 11.8%, and 80.0% in patients with maximum lesion diameter ≤ 2 cm, 2.1-3.0 cm and >3.0 cm, respectively (P < 0.001) and was strongly associated with perineural (P < 0.001; OR = 26.46, 95% CI = 5.62-124.52) and lymphatic invasion (P < 0.001; OR = 17.35, 95% CI = 4.44-67.91). Within 18-84 months, no recurrence or metastasis were observed in SLNM positive patients. False negative SLNB rate of 15.4% was recorded. CONCLUSION: Cutaneous BSC is associated with early nodal metastatic potential. Tumor size >2 cm, lymphatic and perineural invasion are significant determinants for SLN micrometastasis. In the absence of palpable lymphadenopathy, wide resection and SLNB with long-term follow-up are highly recommended in these patients.

Mandibular Condyle Reconstruction With Fibula Free-Tissue Transfer: The Role of the Masseter Muscle.

BACKGROUND: Free fibula flap is an option for primary restoration after disarticulation mandibular resection, though literature on technique refinements is scarce. The authors hypothesized that inset of the masseter, the key mandibular elevator muscle, at the reconstructed mandible may optimize functional recovery. METHODS: All patients undergoing reconstruction of mandibulectomy-condylectomy defect (January 2009 to January 2014) by means of a fibular flap were prospectively studied. The neocondyle was formed by the distal portion of the fibula and placed directly into the glenoid fossa with preservation of the temporomandibular disc. The deep portion of the masseter was inset at the angle of the reconstructed mandible.Condylar position was postoperatively evaluated by panoramic radiographs. Patients self-evaluated speech, chewing, swallowing, and facial appearance. RESULTS: Two patients had immediate and 3 delayed reconstruction involving condyle ramus body, in the study period. During a mean follow-up of 32 months, 4 patients had satisfactory occlusion, 1 patient had an open-bite deformity, but was able to masticate solid food and maintain an oral diet. Although no significant condyle dislocation was recorded, 2 patients had slight ipsilateral deviation on mouth opening. Nevertheless, cosmesis was satisfactory and all patients maintained intelligible speech. Functional score was 13.6 ± 1.14 and facial appearance score was 4 ± 0.7. CONCLUSION: The free fibula transfers with direct seating of the fibula into the condylar fossa followed by masseter muscle reinsertion provides acceptable functional reconstruction of the mandibulectomy-condylectomy defect.

Dermal Matrix for Intraoral Lining Following Composite Mandibular Defect Reconstruction With Chimeric Fibular Osseocutaneous Flap.

BACKGROUND: This report aims to first present Integra as an adjunct to complex mandibular reconstruction for intraoral lining resurfacing, and to review the literature on the use of dermal matrices for mucosal resurfacing of the floor of the mouth. CLINICAL REPORT: A 62-year-old female patient with previous ablation surgery for squamous cell carcinoma of the floor of the mouth, presented with extrusion of the mandibular plate through the chin skin and serious tongue tethering. The patient was managed with a chimeric osseocutaneous free fibula flap to restore the mandibular bone and chin skin defect, followed by a second-stage reconstruction of the intraoral defect with bilayer Integra. Complete release of tongue tethering was achieved enabling normal speech and deglutition and allowing for dental rehabilitation. CONCLUSIONS: Integra was safely used as an alternative for intraoral lining, in composite mandibular reconstruction, downgrading reconstructive demands and offering optimal functional results.

Tips and Outcomes of a New DIEP Flap Inset in Delayed Breast Reconstruction: The Dual-Plane Technique.

Purpose The dual-plane deep inferior epigastric perforator (DIEP) flap inset technique is herein presented with tips for optimizing the aesthetic outcome in delayed autologous breast reconstruction after radiation therapy. Patients and Methods A total of 42 women who underwent microsurgical reconstruction with a free DIEP flap participated in this prospective study. The flap was inset in a dual plane lying behind the pectoralis major at the upper pole and in front of the muscle at the lower pole of the reconstructed breast. Results The dual-plane flap inset resulted in natural transition from native and reconstructed tissues, excellent scar quality, optimal outline of the breast, and overall breast appearance. Moreover, dual-plane reconstruction was associated with constantly high patient satisfaction without wearing brassiere due to fullness of the upper pole and minimal ptosis with time. Conclusion The dual-plane DIEP flap inset results in optimal scar quality, breast shape, and fullness of the upper pole, resulting in high patient satisfaction.

Autologous fat grafting: in search of the optimal technique.

OBJECTIVE: Recent advances in adipose cellular biology have repopularized autologous fat grafting as a method widely used in both reconstructive and aesthetic surgery. This review aims to summarize our current knowledge on autologous fat grafting emphasizing harvesting techniques and processing methods as well as current trends and approaches. METHODS: A thorough search of earlier and recent literature until October 2013 was conducted using the terms autologous fat grafting, autologous fat transfer, lipoaspirate, lipoinjection, fat harvest, and lipotransfer in PubMed and ClinicalTrials.gov databases, and relevant English- and German-language articles were included. RESULTS: Findings were categorized in a step-by-step approach of the fat grafting procedure into indications, selection of donor site, techniques for harvesting, processing, and reimplantation of autologous fat. CONCLUSIONS: Further in-depth knowledge will provide definite answers on fat graft survival; demonstrate safe methods to increase cell viability, grafting outcome predictability; and reliability; enhance safety; and strengthen the scientific and clinical establishment of this increasingly promising method.

Patient-related delay in presentation for cutaneous squamous cell carcinoma. A cross-sectional clinical study.

BACKGROUND: Delayed diagnosis of squamous cell carcinoma (SCC) increases recurrence, metastatic potential, and management costs. This study aims to identify risk factors of patient-related delayed presentation in cutaneous SCC. PATIENTS AND METHODS: A total of 513 patients, who first sought care for cutaneous lesions that were subsequently removed and histologically confirmed as SCCs, were included. Attitude to symptoms, psychosocial profile, and reasons for delayed presentation were obtained via a structured questionnaire-based interview. First presentation > 3 months from the onset of symptoms was considered as delayed. RESULTS: Mean presentation time was 3.90 ± 2.05 months, while 186 patients delayed presentation. Multivariate logistic regression analysis revealed that serious co-morbidity (p = 0.003), low education level (p < 0.001), non-recognition of the seriousness of symptoms (p < 0.001), a 'wait and see' attitude (p < 0.001), and fatalism (p = 0.005) were independent determinants of significantly higher risk for delayed presentation. In contrast, female sex (p = 0.006), new lesion (p = 0.012), accessible topography (p = 0.019), size increase (p = 0.002), color change (p = 0.017), non-healing wound (p = 0.048), and presence of social support/advice (p < 0.001) were independent determinants significantly associated with early presentation. CONCLUSION: Recognition of symptom seriousness and elimination of factors hindering self-referral may increase awareness and promote early patient presentation and diagnosis of cutaneous SCC.

Dermal Matrices: Game Changers in Leg and Foot Soft Tissue Reconstruction? A Case Series.

The present article aims to present the use of dermal matrices in severe degloving, avulsion, and necrotizing injuries of the leg and foot in 3 patients. Conventional reconstruction would require the use of free flaps, since exposure of vessels, nerves, joints, and tendons rendered the mere resurfacing with skin grafts insufficient, and extensive cutaneous detachment precluded the use of local fasciocutaneous flaps. All injuries underwent thorough and repeated surgical debridements and wash outs, followed by negative pressure wound therapy (NPWT). Once negative tissue cultures were obtained, the extremities were resurfaced with dermal matrix and immediately covered by split thickness skin grafts. NPWT on the grafted area for a week effectively secured the grafts on the recipient area. Complete healing was achieved in all grafted areas within 7 to 12 days. The function of joints and tendons as well as the quality of resurfacing at the weight bearing areas were tested and found satisfactory within a follow-up period of 5 to 15 months. The use of combined NPWT and dermal matrices in carefully selected patients provides a reliable and durable reconstructive option for leg and foot injuries with satisfactory functional outcomes.

Knowledge and Attitudes in First Aid Practices for Thermal Burns: a Cross-sectional Study Among Adults in Northern Greece.

Background: Burns are a major cause of morbidity, including prolonged hospitalization, disfigurement, disability, and emotional trauma. Long-term absence from work and high healthcare costs for burn treatment have a significant socio-economic impact. Objective: his study aims to evaluate the level of knowledge for burn management in the adult population of Thrace in Northern Greece and to determine factors associated with a better level of knowledge. Methods: A questionnaire-based cross-sectional study was conducted οn a random sample of the adult population of Thrace. Data were collected using a structured pre-coded questionnaire, which included subjects' socio-demographic characteristics and the first aid practices for burns. Multivariate logistic regression analysis was used to determine the effect of subjects' characteristics on their knowledge of burn first aid practices. Results: A total of 711 subjects (49.6% males; mean age, 41.89±16.48 years) were included in the study. The incidence of a previous burn was 55.4%. Only 10.5% of the subjects would apply the optimal practice, consisting of rinsing the burn wound with cool running water for at least 10 minutes, applying only non-adhesive dressing on it and leaving the blisters intact. The optimal practice was independently associated with female gender (aOR=1.86, p=0.016), high education level (aOR=2.00, p=0.023), the presence of >3 children (aOR=2.27, p=0.009) and previous training in first aid (aOR=2.36, p=0.001). A large number of participants reported the application of toothpaste (38%), moisturizer (35.4%), aloe (31.8%) or yogurt (27.7%) to the burn surface. Conclusion: Only a small proportion of the participants were aware of the optimal burn first aid practices, most of them female, of high socioeconomic status. We recommend a more targeted approach in the design of health campaigns in the future, in order to reach vulnerable parts of the population.

The Ageing Foot.

Feet suffer significant stress throughout a lifetime and undergo ageing-associated problems due to gradual tissue degeneration affecting the skin, connective tissue, and nerves. Oxygen supply to the tissues may be diminished. The skin gets dry and calluses, ulcers and fungal infections of the skin and nails are not uncommon. Ligaments and tendons degenerate and, without proper prevention, deformities including claw toes, hammer toes, tendonitis, and bursitis may occur. Skeletal toe deformities such as bunions, bony spurs, and hallux valgus may increase discomfort, while stress fractures may have an adverse impact on the patients' quality of life. The ageing foot pathology may add up to common age-related problems, such as crystal deposition arthropathies, diabetes mellitus, peripheral circulatory disorders, and peripheral edema, increasing morbidity. This review summarizes ageing-related feet problems, focusing on prevention and treatment. Foot health has a paramount role in overall wellbeing, therefore prevention, proper foot care, and prompt diagnosis and management of ageing-related changes are vital for maintaining a healthy, active status.

A Linear Waxy Verrucous Plaque of the Scalp.

Nevus sebaceous of Jadassohn (NSJ) is an inborn, cutaneous hamartoma that is presented as a round-oval, or linear, yellowish-orange hairless plaque with an excess of sebaceous glands, typically localized to the head or neck. NSJ disease progresses slowly in three general stages. Due to its embryological origin, it yields an already documented potential for a variety of epidermal and adnexal tumors. The incidence of secondary neoplasms within NSJ is 10-30%, and the risk of neoplastic transformation increases with age. The majority of neoplasms are benign. Regarding malignant tumors, NSJ is usually associated with basal cell carcinoma. All neoplasms are typically encountered in long-standing lesions. Owing to NSJ's ample variety of associations with neoplasms, its management demands a case-driven tailored treatment. We present the case of a 34-year-old female with NSJ.

Pathologic findings in breast reduction specimens: detection of occult premalignant and cancerous lesions.

BACKGROUND: As reduction mammaplasty has become one of the most popular reconstructive procedures, there is an increasing number of reports regarding histopathologic findings in breast tissue yielded by the procedure. PATIENTS AND METHODS: This study evaluates histopathologic findings in breast tissue removed during reduction mammaplasty procedures performed during a 40-month period (2008-2011), and includes 300 patients of which 258 underwent bilateral breast reduction (group B) and 42 unilateral reduction for symmetry to the contralateral reconstructed breast (group U). RESULTS: Occult carcinomas were detected in 4 (1.55%) group B patients and 1 (2.38%) group U patient. Atypical hyperplasia and intraductal papillomas were identified in 22 (8.6%) and 5 (11.9%) patients, respectively. Benign pathologic changes including typical mild ductal hyperplasia, fibrocystic disease, adenosis, fibroadenoma, and lobular atrophy were identified in 174 (67.44%) group B and 26 (61.9%) group U patients. CONCLUSION: Breast carcinomas are rarely detected in breast tissue yielded by reduction mammaplasty procedures due to routinely performed preoperative assessment including clinical examination and mammograms. Pathologic examination of specimens provides the clinician with a conclusive diagnosis allowing for possible prompt further management.

Calcium sulfate cement in contained traumatic metaphyseal bone defects.

The aim of this study was to evaluate prospective patients with periarticular fractures where a meta physeal bone defect was grafted with high compressive calcium sulfate cement. The calcium sulfate cement MIIG X3, (Wright Medical Technology, Inc, Arlington, TN) was used in 45 patients with periarticular fractures--distal radial, tibial plateau, humeral head, and calcaneal fractures--to fill the metaphyseal defect. All fractures were treated either with open or closed reduction, fracture fixation, and the cement was applied openly or closed. Radiographs were evaluated for fracture reduction, joint line gap, and step, as well as for rate of graft replacement by bone. All fractures united without an additional procedure. There were no wound infections or other complications attributed to the graft. At three-month follow-up, a complete graft replacement by bone was observed in all fractures. Joint line step was not developed in any patient, but a joint line gap of 3 mm was observed postoperatively in one patient with a tibial plateau fracture. Loss of reduction occurred in one patient with an extra-articular distal radial fracture treated with closed reduction and k-wire fixation. Cement that escaped into the joint or the surrounding soft tissues was not visible at the six-week follow-up. In conclusion, the results of this study confirm the safety and the efficacy of this cement when it is used as graft with the appropriate fixation method in traumatic metaphyseal bone defects.

Stem cell therapy for idiopathic pulmonary fibrosis: a protocol proposal.

BACKGROUND: Idiopathic pulmonary fibrosis represents a lethal form of progressive fibrotic lung disorder with gradually increasing incidence worldwide. Despite intense research efforts its pathogenesis is still elusive and controversial reflecting in the current disappointing status regarding its treatment. PATIENTS AND METHODS: We report the first protocol proposal of a prospective, unicentric, non-randomized, phase Ib clinical trial to study the safety and tolerability of the adipose-derived stem cells (ADSCs) stromal vascular fraction (SVF) as a therapeutic agent in IPF. After careful patient selection based on functional criteria (forced vital capacity-FVC > 50%, diffuse lung capacity for carbon monoxide-DLCO > 35% of the predicted values) all eligible subjects will be subjected to lipoaspiration resulting in the isolation of approximately 100- 500 gr of adipose tissue. After preparation, isolation and labelling ADSCs-SVF will be endobronchially infused to both lower lobes of the fibrotic lungs. Procedure will be repeated thrice at monthly intervals. Primary end-point represent safety and tolerability data, while exploratory secondary end-points include assessment of clinical functional and radiological status. RESULTS: Preliminary results recently presented in the form of an abstract seem promising and tantalizing since there were no cases of clinically significant allergic reactions, infections, disease acute exacerbations or ectopic tissue formation. In addition 6 months follow-up data revealed a marginal improvement at 6-minute walking distance and forced vital capacity. CONCLUSIONS: Adipose tissue represents an abundant, safe, ethically uncontested and potentially beneficial source of stem cells for patients with IPF. Larger multicenter phase II and III placebo-controlled clinical trials are sorely needed in order to prove efficacy. However, pilot safety studies are of major importance and represent the first hamper that should be overcome to establish a rigid basis for larger clinical trials.

Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature.

PURPOSE: The purpose of this study was to evaluate the relation between pelvic fracture patterns and the angiographic findings, and to assess the effectiveness of the embolisation. METHODS: This retrospective study, included patients with pelvic fractures and angiographic evaluation. Demographics, Injury Severity Score (ISS), associated injuries, embolisation time, blood units needed, method of treatment and complications were recorded and analysed. Fractures were classified according to the Burgess system. RESULTS: Between 1998 and 2008, 34 patients with pelvic fractures underwent angiographic investigation. Twenty six were males. The mean age was 41 years. Twenty-seven were motor vehicle accidents and seven were falls. There were 11 anterior posterior (APC) fractures, 12 lateral compression (LC), eight vertical shear (VS) patterns and three with combined mechanical injuries. The median ISS was 33.1 (range 5-66). From the 34 who underwent angiography, 29 had positive vascular extravasations. From them, 21 had embolisation alone, two had vascular repair and embolisation, five required vascular repair alone and one patient died while being prepared for embolisation. Five cases were re-embolised. The findings suggested that AP fractures have a higher tendency to bleeding compared with LC fractures. Both had a higher chance of blood loss compared to VS and complex fracture patterns. We reported 57 additional injuries and 65 fractures. The complications were: one non lethal pulmonary embolism, one renal failure, one liver failure, one systemic infection, two deep infections and two psychological disorientations. Seven patients died in hospital. CONCLUSION: Control of pelvic fracture bleeding is based on the multidisciplinary approach mainly related to hospital facilities and medical personnel's awareness. The morphology of the fracture did not have a predictive value of the vascular lesion and the respective bleeding.

Tracking the risk factors associated with high-risk cSCC: A 10-year, Two-Institution, Greek study.

PURPOSE: We sought to identify independent risk factors for positive sentinel lymph node biopsy (SLNB), local recurrence (LR), metastasis (M) and death caused by cutaneous squamous cell carcinoma (cSCC) (DCS) in high-risk cSCC patients. Moreover, we compared the Brigham and Women's Hospital (BWH) system with the previous used in Greece (based on tumor size) and proposed a new classification system. METHODS: 1,524 cSCC patients were enrolled between January 2004 and December 2014, from two medical institutions. Potential risk factors for SLNB (local recurrence/LR, metastasis/M, death caused by SCC/DCS) were analyzed by univariate and multivariate Cox logistic regression models. RESULTS: Of the included patients with a median follow-up of 60 months 107 developed local recurrence (7%) while 84 developed metastases (5.5%). Among 36 patients undergoing sentinel lymph node biopsy (SLNB), 25% showed a positive SLNB with a false-negative result (11%). On multivariate analysis, key prognostic factors for LR were tumor diameter ≥2 cm, poor differentiation, incomplete excision and perineural invasion and for M were high-risk tumor site, tumor diameter ≥2 cm, poor differentiation, invasion beyond subcutaneous tissue, incomplete excision, perineural invasion and recurrence. DCS seems to be affected by tumor diameter ≥ 2 cm, poor differentiation, invasion beyond subcutaneous tissue, incomplete excision, perineural invasion and recurrence independently. CONCLUSIONS: These suggest the determined role of tumor diameter of cSCCs. Harnessing knowledge and collecting the up-to-date data along the clinical journey of high-risk cSCC, the future looks bright (development of new clinical trials, adjuvant therapies and tumor staging with SLNB).

Lower Limb Pain Attributed to Bone Marrow Edema Syndrome: A Commonly Ignored Pathology.

Bone marrow edema syndrome (BMES) is a highly uncommon, self-limited syndrome of unclear etiology. The syndrome most commonly affects middle-aged men. Magnetic resonance imaging is essential for the diagnosis because of the characteristic pattern of bone marrow edema. The diagnosis of BMES is a challenge for clinicians. Other causes of lower extremity pain, with poor prognosis, must be excluded. We present three cases of BMES. All three patients initially complained of mild lower extremity pain, which progressively deteriorated and led to a severe limitation of their daily activities. They were all treated conservatively by weight-bearing restriction and symptoms resulted within a few months. The aim of the present study is to outline this rare, benign pathology.

Adipose-Derived Mesenchymal Stem Cells in the Treatment of Diabetic Foot Ulcers: A Review of Preclinical and Clinical Studies.

This review provides an outline of the use of adipose-derived mesenchymal stem cells (AMSCs) in the treatment of diabetic foot ulcers (DFUs). A systematic search of PubMed and the Cochrane database was performed on October 2, 2019. Eighteen studies were identified (14 preclinical and 4 clinical). Studies in animal models have demonstrated that AMSCs enhance diabetic wound healing, accelerate granulation tissue formation, and increase reepithelialization and neovascularization. Only 1 randomized control trial has been published so far. Patients (n = 25) with DFUs were treated using an allogeneic AMSC directly on the wound bed as a primary dressing, and improvements were found in complete wound closure in the treatment group (n = 16). Three clinical studies showed that autologous AMSC might be a safe alternative to achieve therapeutic angiogenesis in patients with diabetes and peripheral arterial disease. Based on the available evidence, AMSCs hold promise in the treatment of DFUs. However, this evidence requires confirmation by well-designed trials. Additional studies are also required to understand some issues regarding this treatment for DFUs. For example, the potential application of autologous or allogeneic AMSCs in different types of DFUs, optimal dose/infusion schedules, safety evaluations, and cost-effectiveness.