Guidelines How to Integrate Surgery and Targeted Therapy with Biologics for the Treatment of Hidradenitis Suppurativa: Delphi Consensus Statements from an Italian Expert Panel.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by recurrent and painful nodules and abscesses in intertriginous skin areas, which can progress to sinus tract formation, tissue destruction, and scarring. HS is highly debilitating and severely impairs the psychological well-being and quality of life of patients. The therapeutic approach to HS is based on medical therapy and surgery. First-line medical therapy includes topical antibiotics, systemic antibiotics, and biologics. Main surgical procedures include deroofing, local excision, and wide local excision. Despite the availability of multiple therapeutic options, the rates of disease recurrence and progression continue to be high. In recent years, the possibility of combining biologic therapy and surgery has raised considerable interest. In a clinical trial, the perioperative use of adalimumab has been associated with greater response rates and improved inflammatory load and pain, with no increased risk of postoperative infectious complications. However, several practical aspects of combined biologic therapy and surgery are poorly defined. In June 2022, nine Italian HS experts convened to address issues related to the integration of biologic therapy and surgery in clinical practice. To this purpose, the experts identified 10 areas of interest based on published evidence and personal experience: (1) patient profiling (diagnostic criteria, disease severity classification, assessment of response to treatment, patient-reported outcomes, comorbidities); (2) tailoring surgery to HS characteristics; (3) wide local excision; (4) presurgery biologic treatment; (5) concomitant biologic and surgical treatments; (6) pre- and postsurgery management; (7) antibiotic systemic therapy; (8) biologic therapy after radical surgery; (9) management of adverse events to biologics; and (10) management of postoperative infectious complications. Consensus between experts was reached using the Estimate-Talk-Estimate method (Delphi Method). The statements were subsequently presented to a panel of 27 HS experts from across Italy, and their agreement was assessed using the UCLA Appropriateness Method. This article presents and discusses the consensus statements.

The Impact of Reduction Mammaplasty on Breast Sensation: A Systematic Review.

Loss of sensation is one of the most feared complications of breast reduction surgery. Although several techniques have been proposed to maximize sensitivity preservation, the scientific literature still reports contradictory findings. This systematic review aimed to assess whether breast reduction mammaplasty is associated with measurable changes in breast sensation. This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed (National Institutes of Health, Bethesda, MD), Scopus (Elsevier, Amsterdam, the Netherlands), and Web of Science (Clarivate, Philadelphia, PA) databases were searched for clinical studies investigating breast sensation after breast reduction mammaplasty. The initial search identified 1523 studies of which 22 articles met our specific inclusion criteria. Most of the included studies are consistent in describing only transient sensation decrease or even sensation improvement after surgery compared to the presurgery condition with any approach, except those investigating outcomes after superior or superolateral pedicle reduction mammaplasty. Nevertheless, the overall quality of evidence is low or very low due to the limited availability of randomized controlled trials or controlled studies and the high risk of bias.

A Shakespearean Dilemma in Breast Augmentation: to Use Drains or not? a Systematic Review : Drains in Breast Augmentation.

BACKGROUND: Breast augmentation is one of the most commonly requested and performed plastic surgery procedures. In order to prevent early postoperative complications such as seroma or hematoma, surgical drains could be useful. The aim is to perform a systematic review of the literature on the use of surgical drains in primary breast augmentation. METHODS: This review was performed following the PRISMA guidelines. PubMed, SCOPUS, Web of Science and Cochrane Library databases were queried in search of clinical studies describing the use of surgical drains in women undergoing primary breast augmentation with implants and documenting seroma and/or hematoma formation rate and/or infection rate. RESULTS: Initial search identified 2596 studies, and 162 were found relevant. Full-text review and application of our inclusion criteria to all retrieved papers produced 38 articles that met inclusion criteria. Among the included studies, 16 papers reported the use of surgical drains in breast augmentation, while in the remaining 22 articles drains were not used. Only 5 studies specifically investigated the role and effectiveness of surgical drains in augmentation mammaplasty and its possible relationship with complication rate such as seroma, hematoma or infection. CONCLUSIONS: Despite similar complication rates emerged from the analyzed articles, because of the heterogeneity of the studies, we were not able to demonstrate specifically whether drain use affects the rate of early postoperative complications such as seroma, hematoma and infection. Additional randomized controlled trials are strongly advocated in order to provide the necessary scientific evidence. LEVEL OF EVIDENCE III: 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 .

The "Arrow Flap" Technique in Reduction Mammaplasty: Combining Short Scars, Narrow Base, and High and Persistent Breast Projection.

INTRODUCTION: Breast reduction is one of the most common procedures performed by plastic surgeons worldwide. Despite that several techniques have been proposed for management of ptotic or hypertrophic breasts, most of them often deal with too large breast bases, poor breast projection, persistent "dog ears," and a certain percentage of bottoming out. Lower-pole shaping of the breast remains one of the challenge of vertical mammoplasty. MATERIALS AND METHODS: The authors report their 5-year-long experience with a modification of the vertical scar technique, the "arrow flap," in which they harvest a double lateral glandular and cutaneous flap, to tighten and better shape the base of the breast and to improve the breast projection with a "double-bra" effect. From April 2015 to February 2019, 75 patients with moderate to severe macromastia/breast ptosis underwent bilateral reduction mammoplasty. RESULTS: Postoperative outcomes showed an overall satisfactory results and low incidence of complications. Two patients presented with an asymmetry between the 2 breasts, and no nipple-areola complex necrosis occurred. One patient reported a wider vertical scar, whereas no bottoming out was observed. CONCLUSIONS: All patients reported a stable and durable projection of the breast, with pleasant cosmetic results. By combining short scars and narrow base, we can obtain a pleasant lower pole reshaping of the breast, even in that challenging cases of large and squared breast. The authors believe that this technique provides a useful surgical option, increasing the versatility of the superior pedicle vertical mammaplasty both for mastopexy and breast reduction, even in cases of severe macromastia.

Dual-Plane Retro-pectoral Versus Pre-pectoral DTI Breast Reconstruction: An Italian Multicenter Experience.

BACKGROUND: The use of conservative mastectomies has risen significantly during the last few years. The reconstructive choice of direct-to-implant reconstruction has become more practicable with modern mastectomy techniques. The initial trend in Italian centers was to use dual-plane hybrid reconstruction. However, a high level of complications has been registered. From 2015 onward, in our centers, a pre-pectoral approach has been adopted. The authors sought to describe the Italian trend to gradually discard the sub-pectoral technique with lower lateral pole coverage of the prosthesis using ADMs comparing it with the pre-pectoral approach with ADMs, without any muscle dissection, in terms of complication rates. MATERIALS AND METHODS: A multicenter retrospective clinical study was performed from January 2010 to June 2018. The enrolled patients were divided into two groups: Cases with an ADM-only coverage pre-pectoral reconstruction made up the first group (Group 1). Those with the retro-pectoral muscular position + ADM implant coverage comprised the second one (Group 2). Complications such as seroma, hematoma, wound dehiscence, surgical site infection, reconstruction failure, animation deformity and capsular contracture were recorded. RESULTS: We performed 716 direct-to-implant reconstructions: 509 were partially sub-pectoral and 207 were pre-pectoral. Minimum follow-up was 1 year. Incidence of complications was higher in dual-plane reconstructions. There were statistical significant differences in the rates of seroma and hematoma. CONCLUSION: Using the pre-pectoral approach, the authors have experienced favorable aesthetics and superior clinical and functional outcomes. Retro-pectoral muscular ADM implant coverage has to be considered only in specific complicated second-stage surgeries. 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 .

Efficacy and Safety of Topical Pidobenzone 4% as Adjuvant Treatment for Solar Lentigines: Result of a Randomized, Controlled, Clinical Trial.

BACKGROUND/OBJECTIVE: This study aims at the evaluation of the efficacy and safety of a combination therapy based on pidobenzone 4% and fractional CO2 laser or cryotherapy in the treatment of solar lentigines and the prevention of eventual posttreatment hyperchromia. METHODS: Efficacy was clinically evaluated by grading the pigmentation level with the Skin Tone Color Scale (STCS), and by grading patients' impression through a Visual Analog Scale (VAS). RESULTS: Our study shows that the associated treatment was safe and that it improves the therapeutic results on solar lentigines and prevents postiatrogenic hyperpigmentation compared with physical therapy alone. CONCLUSION: The combination of cryotherapy and pidobenzone 4% has been found to be the most useful treatment.

Alteration of Skin Mechanical Properties in Patients Undergoing Botulinum Toxin Type A Injections of Forehead Rhytides.

BACKGROUND: Although application of botulinum toxin type A (BTX-A) for the treatment of forehead rhytides has become very popular, the effects of its intramuscular injections on the skin mechanical properties remain unclear. OBJECTIVES: We prospectively investigated the alterations in the mechanical properties of the skin of patients who received intramuscular injections of botulinum toxin A (BTX-A) for forehead rhytides and compared two injection doses. METHODS: Of the 42 enrolled patients, one randomly assigned half received intramuscular injections of two units (group I), and the other half received four units (group II) of BTX-A in each injection point. The baseline and post-treatment skin mechanical parameters, including gross elasticity (R2), net elasticity (R5), viscoelastic ratio (R6) and biological elasticity (R7), were measured using the Cutometer(®) and compared. RESULTS: Treatment with BTX-A resulted in significant overall alterations in the mechanical properties of skin at the injection sites of both treatment groups during the 16-week period, and no significant differences were observed between groups. Significant decreases in biological elasticity, net elasticity and viscoelasticity properties were observed at 2 weeks follow-up and began to recover at that time. All of the skin mechanical properties recovered to baseline levels by 16 weeks of follow-up in both dosage groups, which indicates that the higher dosage (4 units) did not delay relapse compared to the two-unit dosage. CONCLUSIONS: We concluded that intramuscular injections of BTX-A significantly regulated the gross elasticity, net elasticity, functional elasticity and viscoelastic elasticity at the injection point over a radius of 1.5 cm at 2, 4 and 8 weeks follow-up. The alteration in the skin measurements had completely diminished by the 16-week follow-up. 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 .

Easy and cheap way to prepare skin extenders.

Skin extender is a very useful method to repair wounds when oedema and skin retraction make a direct suture impossible. We have developed a new, simple and cheap way to prepare skin extenders based only on elastic vessel loops and metal clips stapler commonly used for skin suture and available in any operating room. This simple method can be performed both in the operating room and at the patient bedside, even under local anaesthesia, causes no bleeding and appears to be inexpensive and rapidly usable and should be made readily available in any hospital.

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature.

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical-related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high-risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re-operation and re-hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero-haematoma formation and on the re-operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

Sebum Production Alteration after Botulinum Toxin Type A Injections for the Treatment of Forehead Rhytides: A Prospective Randomized Double-Blind Dose-Comparative Clinical Investigation.

BACKGROUND: Research has investigated the decrease in human skin sebum after the application of botulinum toxin. Few studies of the mechanism and objective assessments of this phenomenon have been conducted and the correlation between the sebum production and injection dosages or techniques remains unclear. OBJECTIVES: We prospectively investigated the sebum regulation and its gradient around the injection site in patients who received intramuscular injections of botulinum toxin A (BTX-A) for forehead rhytides, comparing two injection doses. METHODS: Forty-two female volunteers with rhytides on the forehead region were randomly assigned to receive 10 or 20 units of BTX-A, which was administered in five standard injection sites. The baseline and post-treatment sebum production was measured using a Sebumeter. RESULTS: Treatment with BTX-A exhibited significant sebum alteration at the injection site of both groups, with a sebum gradient surrounding the injection point. The efficacy did not improve at higher injection doses, with the four-unit regimen generally not being more potent than the two-unit regimen. The sebum production recovered to normal levels at the 16 week follow-up for both treatment groups, indicating that a higher dosage (four units) did not result in a longer duration until relapse compared with the two-unit dose. CONCLUSIONS: We determined that the sebum production has a positive correlation with the distance away from the injection point. Intramuscular injection of BTX-A significantly reduces sebum production at the injection site but increases the sebum production of the surrounding skin at a radius of 2.5 cm at the 2, 4, and 8 week follow-ups. LEVEL OF EVIDENCE: 2 Therapeutic.

The enhanced healing of a high-risk, clean, sutured surgical incision by prophylactic negative pressure wound therapy as delivered by Prevena™ Customizable™: cosmetic and therapeutic results.

According to the literature, incisional closure complications may range from postoperative surgical site infections, representing 17-22% of health care-associated infections, surgical wound dehiscence and formation of haematomas or seromas, and can lead to delayed or impaired incision healing. These kinds of situations are more common when wounds are closed under tension or in specific patient morbidities. Obesity, in particular, is associated with an impaired blood flow to tissues, predisposing the patient to increased risk of wound complications by various mechanisms. Incisional complications can become relevant economic burdens for health care systems because of an increase in the average length of hospital stay and readmissions, and additional medical and surgical procedures. Thus, a preventive therapy may have a critical role in the management of healing. Negative pressure wound therapy (NPWT) technology as delivered by Prevena™ Customizable™ (Kinetic Concepts Inc., San Antonio, TX) has recently been the focus of a new investigation, as a prophylactic measure to prevent complications via immediate postoperative application in high-risk, clean, closed surgical incisions. The authors present a 62-year-old class II obese female, who underwent bilateral inguinal dermolipectomy. Prophylactic NPWT as delivered by Prevena™ was performed successfully over surgical incisions. Cosmetic and therapeutic results are shown.

A conservative approach to perineal Fournier's gangrene.

Fournier's gangrene (FG) is a disease involving necrosis of perineum and external genitalia; in 95% of cases it is possible to diagnose the Fournier's gangrene just by physical examination. The clinical presentation of FG varies from an initial localized infection to large areas with necrotizing infection. The disease typically affect elderly men (6°-7° decade) with important systemic comorbidities; women are less frequently affected. Despite improvements in diagnosis and management, the mortality rate nowadays is between 20% and 43%. The severity and mortality of the disease is dependent upon the general condition of the patient at presentation and upon the rate of spread of the infection. Treatment involves a multidisciplinary approach: intensive systematic management, broad-spectrum antibiotic therapy, early surgical debridement (wide abscission of necrotic tissues and surgical drainage of peritoneum, scrotum, penis, and inguinal areas), hyperbaric oxygen therapy; surgery can eventually be repeated if necessary; reconstructive surgery has an important role in the final treatment of the disease. The technical difficulties frequently encountered and the inability to make a complete removal of the necrotizing tissues at the time of surgery in some cases has led to the application of combined techniques, in view of the enhancement effect of specific advanced medications, targeted antibiotic therapy and hyperbaric medicine. We have considered 6 patients affected by Fournier's gangrene treated at our institution; all the patients received treatment with the help of plastic surgeons of the same institution. After debridement, all the patients were treated with advanced specific dressings consisting of plates and strips made of calcium alginate, hydrogels and polyurethane and twodimensional cavity foams. Reconstructive surgery was necessary in one case. Hyperbaric oxygen therapy (HBO) has been performed in all cases. The multidisciplinary approach, the combined use of HBO therapy and the adoption of advanced specific dressings, have made possible the complete healing of the lesions in a shorter period, avoiding further surgery in 5 out of 6 patients.

[An example of a hub and spoke network system in Plastic Surgery: the Regional reference center for non-healing wounds in Ancona (Italy)]. / Esempio di sistema in rete Hub & Spoke in Chirurgia Plastica: il Centro di Riferimento Regionale "Ferite Difficili" di Ancona.

Chronic wounds cause morbidity due to local infections, sepsis, osteomyelitis, but also increase mortality in the most severe cases and in patients with multiple comorbidities. Their increasing prevalence, associated disabilities and relevant health costs make chronic wounds a real social disease. At a time in which we hear more and more about spending reviews and reduction of health care costs, the natural evolution of Medicine and Health Care is increasingly directed towards the achievement of high quality standards while at the same time, reducing costs. It is in this framework that a hub and spoke model was used for organizing Plastic Surgery services in Ancona (Italy). In order to ensure appropriate clinical and organizational management of services, the activities of reference centres need to be widely integrated, by functional interconnections with activities of peripheral hospitals and local centres. Through a careful analysis of the Regional Reference Center for non - healing wounds in Ancona, the authors make some considerations regarding appropriate diagnostic-therapeutic-healthcare pathways and the correct use of human, material and technological resources in the area of wound healing.

Perforator flaps in late-stage pressure sore treatment: outcome analysis of 11-year-long experience with 143 patients.

BACKGROUND: In the last decade, perforator flaps have been introduced for the treatment of pressure ulcers as alternative to the more popular myocutaneous local flaps. We reviewed our single-team 11-year experience in order to define whether real advantages could be achieved. METHODS: We analyzed 143 patients undergoing perforator flap surgery for a single late-stage pressure sore. All patients underwent the same protocol treatment. Data regarding associated pathologies, demographics, complications, healing, and hospitalization times were collected. RESULTS: Ninety-three percent of 143 patients were white Caucasian, and 61% were men, with median age of 51 years. Of 143 stage 4 ulcers, 46.2% were ischial, 42.7% sacral, and 11.2% trochanteric. The most common diagnosis was traumatic paraplegia/tetraplegia (74.9%); no significant difference was found in diagnosis distribution and in ulcer location between recurrent and nonrecurrent patients. We performed 44 S-GAP, 78 I-GAP, 3 PFAP-am, and 18 PFAP-1 flaps. At 2 years' follow-up, the overall recurrence was 22.4% and new ulcer occurrence was 4.2%. Mean hospital stay was 16 days. The overall complication percentage was 22.4%, mostly due to suture-line dehiscence (14%) and distal flap necrosis (6.3%). PFAP flaps had a significant higher risk of developing recurrence than I-GAP flaps. The recurrence risk was significantly higher for subjects suffering from coronary artery disease. CONCLUSIONS: Late-stage pressure sore treatment with local perforator flaps can achieve reliable long-term outcomes in terms of recurrences and complications. When compared to previously published data, perforator flaps surgery decreased postoperative hospital stay (by an average of nearly 1 week), reoperations (5.6%), and occurrences.

Augmentation mammoplasty/mastopexy: lessons learned from 107 aesthetic cases.

BACKGROUND: One-stage augmentation/mastopexy entails the challenge of augmenting breast volume with an implant while resecting excess skin. Although both augmenting and lifting the breast in a one-stage operation is gaining in popularity, its safety and its efficacy are still under debate and merit deeper evaluation. METHODS: We retrospectively reviewed our experience over a 5-years period with patients who underwent augmentation mammoplasty/mastopexy with the specific objectives of documenting their outcomes and formulating algorithms for safe, simple, and effective operative strategies to manage such patients. Our surgical approach to augmentation/mastopexy breast ptosis was described step by step. Patient satisfaction with the results was also evaluated. RESULTS: One hundred seven patients underwent successful simultaneous augmentation/mastopexy surgery. Sixty-nine underwent primary breast surgery and 38 underwent secondary breast surgery. In 12 cases a periareolar mastopexy scar was used, while in 51 patients a vertical approach was preferred; in 11 and 33 patients a short "T" and an inverted "T" scar mastopexy was necessary, respectively. Few complications were observed, with a very low overall complication rate (14 %) and a reoperation rate of 12.1 % at 14.7 months. Patient satisfaction with the results of this procedure was extremely high. CONCLUSIONS: Simultaneous augmentation/mastopexy is an effective and versatile way to lift the NAC, tighten the breast skin, increase breast projection, and fill in the upper pole. Our technique of simultaneous breast mastopexy after augmentation through a lower periareolar approach showed excellent correction of pre-existing ptosis, making this method highly reliable because the intraoperative tailor-tacking was customized to the patient, implant size, and projection.

The Oxygen Therapy Tube as a Tool for Breast Squeezing during Pedicle De-epithelialization in Reduction Mammaplasty.

During breast reduction, pedicle de-epithelialization, as meticulous as possible, is necessary to ensure satisfying breast sculpting and to avoid any epidermoid cyst. To perform an effective and rapid de-epithelialization, a good tension of the skin is mandatory. Several techniques to improve skin tension of the breast are described in the literature. We report a cheap, effective, and easily reproducible method, based on the use of an oxygen tube with nasal cannula.

An unusual case of dermatofibrosarcoma protuberans misdiagnosed as vascular malformation for over 30 years: A case report.

INTRODUCTION: Dermatofibrosarcoma protuberans (DFSP) is a rare and slowly growing soft tissue tumor and it is frequently misdiagnosed and mismanaged like more common masses. Therefore diagnostic delays are common and may result in challenging reconstructions. CASE PRESENTATION: We report the peculiar case of a 36-year-old patient with dermatofibrosarcoma protuberans of the right iliac fossa misdiagnosed as vascular malformation for over 30 years. Due to the delayed diagnosis resulting in a large tumor to be resected, surgical reconstruction was performed with a miniabdominoplasty approach with an excellent cosmetic and functional result. DISCUSSION: The review of the literature showed that mismanagements and delayed diagnosis of this sarcoma are frequent. Large skin and soft-tissue defects are frequently encountered in the surgical treatment of this tumor, and adequate knowledge of the reconstructive options is mandatory to provide the best possible outcome. CONCLUSIONS: Superficial skin masses could be easily misdiagnosed. These diagnostic delays may lead to increased patient morbidity and more challenging reconstructive procedures. In this scenario, preoperative biopsies of suspicious lesions may be useful to avoid mismanagement of rare malignant neoplasms such as DFSP. In some challenging cases, the use of a surgical approach typical of cosmetic procedures may be useful to obtain satisfactory aesthetic and functional results.

Aeromonas hydrophila Infection following Leech Therapy for the Treatment of Nipple-Areola Complex Congestion after Breast Reduction: A Case Report.

Several strategies for the management of venous congestion of the nipple-areola complex (NAC) after reduction mammaplasty have been proposed. Among these, hirudotherapy represents an ancient but still effective method, even though the risk of infections related to leeches should be considered. We report a peculiar case of breast infection and sepsis after leech therapy in a patient who underwent a reduction mammaplasty. A prompt surgical debridement of the wounds and necrotic tissues associated with targeted antibiotic therapy led to a fast improvement of clinical conditions, and partial preservation of the NAC was obtained. Accurate knowledge of the clinical presentation of soft tissue infections related to leeching allows for an early diagnosis and would serve as a warning for surgeons who approach such breast cosmetic procedures.

The Use of Hard Palate Mucosal Graft Combined with Lateral Canthus Suspension for Ocular Prosthesis Stability.

Different surgical approaches exist for lower eyelid reconstruction. The hard palate mucosa graft stands out due to its abundance, accessibility, good tolerance, and ability to yield long-term stable results in eyelid elevation. This case report details the successful full-thickness reconstruction of the lower eyelid in an anophthalmic patient using a palatal mucosal graft, complemented by orbicularis muscle suspension. The patient presented with severe lower eyelid retraction state and instability of the ocular prosthesis. After a thorough assessment, the decision was made to address the mucosal defect using a split-thickness palatal mucosal graft, supplemented by lateral canthus suspension. Postoperatively, there were no complications, and the cosmetic result was excellent. With our method, we were able to obtain a functional and cosmetically good result of lower eyelid reconstruction in an anophthalmic socket.