Comparisons of the morbidities of a double gastrocnemius flap and a medial gastrocnemius flap in the orthoplastic reconstruction around the knee.

BACKGROUND: The pedicled gastrocnemius flap is commonly used to treat lower limb defects. Either the medial, lateral, or both heads can be used. When extended soft tissue defects are present, a double gastrocnemius (DG) flap may be used. However, no data of the additional donor site morbidity compared to a medial gastrocnemius (MG) flap are available. The aim of this study was to compare the donor site morbidity of a DG with that of a MG. METHODS: Patients with a soft tissue defect around the knee, treated with a gastrocnemius flap between 2018 and 2021 at the University Hospital of Lausanne and Bari, with a minimum follow-up of 12 months, were included. According to the size and the position of the defect, it was decided whether one (10 patients) or two (9 patients) heads of the gastrocnemius were necessary for the coverage. The mean age was 61 years (range 42-82) in DG, and 63 years (range 45-78) in MG. The average defect size was 89.8 cm2 in the DG group and 53.4 cm2 in the MG group. The etiologies were trauma (n = 10), infection (n = 7) and sarcoma (n = 2). A medial approach or a posterior midline approach was used for the harvesting of the gastrocnemius muscle. Once the flap was harvested, it was rotated and transposed anteriorly over the defect, either through a subcutaneous tunnel or by dividing the intervening skin bridge, depending on the soft tissue defect. A split-thickness skin graft was used to close the skin over the remaining exposed muscle flap. The active range of motion of the ankle and knee joints was measured. Muscle strength was assessed with a hand-held dynamometer and by the ability to stand on tiptoe. Physical function was evaluated through the Lower Extremity Functional Scale (LEFS). RESULTS: The two groups were homogeneous, with no significant difference in age, sex, and BMI. All flaps survived in both groups. Both groups showed lower values in strength and range of motion of the operated leg, when compared to contralateral side. In plantar flexion, this accounted for a reduction in MG by 3.8 ± 1.0 kg of strength and 8 ± 3° of ROM, and in DG by 4.7 ± 1.7 kg and 16 ± 4°, respectively. For knee flexion, the reduction in MG was 4.4 ± 0.6 kg and 16 ± 7°, while in DG 5.6 ± 1.0 kg and 28 ± 6°. In the MG group, 60% were able to stand on the tiptoe of the operated leg, as opposed to 0% in DG. The average LEFS score in DG was lower by 10.9 points (p < .05). Questions concerning running and jumping had a lower score in DG (p < .01). CONCLUSIONS: The harvesting of both gastrocnemii led to significant additional donor site morbidity compared to the harvesting of the medial gastrocnemius alone. However, the additional morbidity did not have an impact on activities of daily living and walking, even though it limited the ability to perform more demanding tasks such as running and jumping. Therefore, based on our study, the choice of a DG flap should be critically assessed in younger, more demanding patients.

Evaluation of modulation of immunity by lymph node transfer: A preliminary histological evidence in lymphedema patients.

BACKGROUND: The exact knowledge of the local biological and immunological effects of vascularized lymph node transfer (VLNT) continues to be an emerging science but a positive control positive control over infectious and immune-mediated processes is often advocated. Knowing the characterization of the inflammatory infiltrate associated with lymphedema, the aim of this paper is to verify the hypothesis that VLNT is able to modulate the inflammatory and immune microenvironment of lymphedematous tissue by evaluating any modification of the local inflammatory cell infiltrate. PATIENTS AND METHODS: A prospectively database of patients who received VLN transfer for lower extremity lymphedema between January 2018 and December 2020 was reviewed. Nine patients diagnosed with extremities' stage II secondary lymphedema were included, with a mean age of 55.3 (range 39-66 years) years. Gastroepiploic lymph node transfer was performed in all patients and transferred heterotopically. Full thickness 6-mm skin punch biopsies were obtained from all voluntary lymph node transfer patients at identical sites of the lymphedematous limb during the surgical procedure of VLNT (T0) and 1 year later (T1). Immunohistochemistry was performed using antibodies against the following markers: anti-CD3; anti-CD4; anti-CD8; anti-CD68. Data at T0 were compared to those at T1. RESULTS: Post-operative course was uneventful in all cases experiencing a significant reduction (almost a third) in terms of cellulitis episodes: The median duration of follow-up for patients was 28.3 months (range 12-40). The analysis of the density of the inflammatory cells as a whole revealed a significant reduction at T1 compared to T0. Specifically, CD3 expression levels turned from 16.36 ± 3.421 (cells/mm2 ) pre-operatively to 7.6 ± 1.511 (cells/mm2 ) post-operatively (p < .0001). CD4+ cells turned from 7.270 ± 3.421 (cells/mm2 ) at T0 to 4.815 ± 1.511 cells/mm2 at T1 (p = .0173). CD8 expression values decreased from 4.360 ± 3.421 (cells/mm2 ) to 2.753 ± 1.451 (cell/mm2 ) at T1 (p = .0003). Monocyte/macrophage marker CD68 varied from 8.208 ± 2.314 (cells/mm2 ) at T0 to 7.600 ± 1876 (cells/mm2 ) at T1 (p = .0003). CONCLUSION: VLNT decreases skin and subcutaneous tissues' infiltration of inflammatory cells, providing one explanation for the positive control of lymph node transfer procedure over infectious and immune-mediated processes.

Orthoplastic limb reconstruction using free fibula flap after trauma: Outcomes from a retrospective European multicenter study.

BACKGROUND: Free vascularized fibula flap represents the gold standard vascularized bone graft for the management of segmental long bone defects after traumatic injury. The current study represents the largest retrospective multicenter data collection on the use of free fibula flap (FFF) for extremities' orthoplastic reconstruction after trauma aiming to highlight current surgical practice and to set the basis for updating current surgical indications. METHODS: The study is designed as a retrospective analysis of prospectively collected data between 2009 and 2021 from six European University hospitals. Patients who underwent fibula flap reconstruction after acute traumatic injury (AF) or as a late reconstruction (LF) after post-traumatic non-union of upper or lower limb were included. Only extra-articular, diaphyseal fracture were included in the study. Surgical data were collected. Time to bone healing and complications were reported as clinical outcomes. RESULTS: Sixty-two patients were included in the study (27 in the AF group and 35 in the LF group). The average patients' age at the time of the traumatic event was 45.3 ± 2.9 years in the AF group and 41.1 ± 2.1 years in the LF group. Mean bone defect size was 7.7 ± 0.6 cm for upper limb and 11.2 ± 1.1 cm (p = .32) for lower limb. Bone healing was uneventful in 69% of treated patients, reaching 92% after complementary procedures. Bone healing time was 7.6 ± 1.2 months in the acute group and 9.6 ± 1.5 months in the late group. An overall complication rate of 30.6% was observed, with a higher percentage of late bone complications in the LF group (34%), mostly non-union cases. CONCLUSIONS: FFF reconstruction represents a reliable and definitive solution for long bone defects with bone healing reached in 92% cases with a 8.4 months of average bone healing time.

The medial sural artery perforator flap for retromolar trigone reconstruction: A multicenter case series.

BACKGROUND: Retromolar trigone (RMT) cancer is a rare malignancy, which develops in a narrow area of the oral cavity. Surgical intervention requires wide excision and appropriate reconstruction usually with a free tissue transfer. Little has been published regarding the ideal microvascular reconstruction, mainly focusing on radial forearm and anterolateral thigh free flap. The medial sural artery perforator flap (MSAP) is not new for head and neck reconstruction but its use for RMT reconstruction has not been previously explored. The purpose of the study is to present a multicentric case series investigating the reliability of MSAP flap for RMT reconstruction. METHODS: The study is designed as a retrospective case series. All patients diagnosed with RMT cancer and undergone surgical resection and immediate reconstruction with a MSAP flap between February 2016 and March 2020 were identified. Patients' demographics and surgical details were collected. Functional results were evaluated using the Head and Neck Module of the European Organization for Research and Treatment of Cancer at 12 months of follow-up. A total of 34 patients with a mean age of 58 years were included in the study. An average defect size of 31.5 cm2 was observed after RMT tumor resection. RESULTS: The MSAP flaps' average dimensions were 11 ± 3.1 cm in length and 4.7 ± 1.6 cm in width with a mean thickness of 1.4 ± 0.8 cm. No flap complications were observed in 28 cases; four patients developed an orocutaneous fistula. One patient needed surgical revision for venous congestion while only one case of flap failure was observed. At 12 months of follow-up, 87% of the patient cohort had normal, understandable speech. No patient experienced complete loss of swallowing. Results of the H&N35 module showed a significative postoperative improvement in mouth soreness, mouth opening and social (p < .05*). No patient complained difficulty in motility at the donor site. CONCLUSIONS: The MSAP flap appears to be appropriate for RMT reconstruction and could be considered the workhorse for small to medium size defect of RTM region. It has a long pedicle of matching caliber and provides adequate tissue volume with minimal donor site morbidity.

Modulation of miR-146b Expression during Aging and the Impact of Physical Activity on Its Expression and Chondrogenic Progenitors.

The finding of molecules associated with aging is important for the prevention of chronic degenerative diseases and for longevity strategies. MicroRNAs (miRNAs) are post-transcriptional regulators involved in many biological processes and miR-146b-5p has been shown to be involved in different degenerative diseases. However, miR-146b-5p modulation has not been evaluated in mesenchymal stem cells (MSCs) commitment or during aging. Therefore, the modulation of miR-146b-5p in the commitment and differentiation of mesenchymal cells as well as during maturation and aging in zebrafish model were analyzed. In addition, circulating miR-146b-5p was evaluated in human subjects at different age ranges. Thus, the role of physical activity in the modulation of miR-146b-5p was also investigated. To achieve these aims, RT (real-time)-PCR, Western blot, cell transfections, and three-dimensional (3D) culture techniques were applied. Our findings show that miR-146b-5p expression drives MSCs to adipogenic differentiation and increases during zebrafish maturation and aging. In addition, miR-146b-5p expression is higher in females compared to males and it is associated with the aging in humans. Interestingly, we also observed that the physical activity of walking downregulates circulating miR-146b-5p levels in human females and increases the number of chondroprogenitors. In conclusion, miR-146b-5p can be considered an age-related marker and can represent a useful marker for identifying strategies, such as physical activity, aimed at counteracting the degenerative processes of aging.

Combined lymph node transfer and suction-assisted lipectomy in lymphedema treatment: A prospective study.

BACKGROUND: Recent studies have analyzed the combination of suction-assisted lipectomy (SAL) and vascularized lymph node transfer (VLNT) in lymphedema treatment, reporting positive outcomes. However, it is difficult to draw conclusions due to the heterogeneity of the studies. Aim of this prospective study is to evaluate the effectiveness of the combination of VLNT and SAL in lymphedema treatment. PATIENTS AND METHODS: Between January 2016 and May 2019, 94 patients with upper or lower limb stage IIb-III lymphedema were enrolled and treated with the gastroepiploic VLNT followed by SAL. Patients were prospectively evaluated through circumference measurement and clinical examination, including number of episodes of cellulitis. RESULTS: Among patients enrolled in the study 83 were affected by lower limb lymphedema (LLL) and 11 were affected by upper limb lymphedema (ULL). Average follow-up was 3 ± 0.8 years. In the LLL group, the mean circumference reduction rates (CRR) were 60.4, 56.9, 29.6, and 55.4% above and below the knee, above the ankle, and at the foot level, respectively. A statistically significant difference was noted at all the levels (p < .05), but above the ankle (p = .059). Regarding the ULL group, the mean CRR were 80.7, 60.7, 65.0 and 49.6% above and below the elbow, at wrist and at mid-hand, respectively. CRR were reported at all the levels but no statistical difference was noted. The number of episodes of cellulitis dropped significantly (p < .05). CONCLUSION: This study supports the use of VLNT+SAL in lymphedema grades IIb-III, with important implications for the clinical practice.

Modulation of miR-204 Expression during Chondrogenesis.

RUNX2 and SOX9 are two pivotal transcriptional regulators of chondrogenesis. It has been demonstrated that RUNX2 and SOX9 physically interact; RUNX2 transactivation may be inhibited by SOX9. In addition, RUNX2 exerts reciprocal inhibition on SOX9 transactivity. Epigenetic control of gene expression plays a major role in the alternative differentiation fates of stem cells; in particular, it has been reported that SOX9 can promote the expression of miRNA (miR)-204. Our aim was therefore to investigate the miR-204-5p role during chondrogenesis and to identify the relationship between this miR and the transcription factors plus downstream genes involved in chondrogenic commitment and differentiation. To evaluate the role of miR-204 in chondrogenesis, we performed in vitro transfection experiments by using Mesenchymal Stem Cells (MSCs). We also evaluated miR-204-5p expression in zebrafish models (adults and larvae). By silencing miR-204 during the early differentiation phase, we observed the upregulation of SOX9 and chondrogenic related genes compared to controls. In addition, we observed the upregulation of COL1A1 (a RUNX2 downstream gene), whereas RUNX2 expression of RUNX2 was slightly affected compared to controls. However, RUNX2 protein levels increased in miR-204-silenced cells. The positive effects of miR204 silencing on osteogenic differentiation were also observed in the intermediate phase of osteogenic differentiation. On the contrary, chondrocytes' maturation was considerably affected by miR-204 downregulation. In conclusion, our results suggest that miR-204 negatively regulates the osteochondrogenic commitment of MSCs, while it positively regulates chondrocytes' maturation.

Prevention of Secondary Lymphedema after Complete Lymph Node Dissection in Melanoma Patients: The Role of Preventive Multiple Lymphatic-Venous Anastomosis in Observational Era.

Background and Objectives: Current guidelines have limited the performance of complete lymph node dissection (CLND) for patients with clinically detectable lymphatic metastases. Despite the limitations of this surgical procedure, secondary lymphedema (SL) is an unsolved problem that affects approximately 20% of patients undergoing CLND. Preventive lymphatic-venous micro-anastomoses (PMLVA) has already demonstrated its efficacy in the prevention of SL in melanoma patients with a positive sentinel lymph node biopsy (SLNB), but the efficacy of this procedure is not demonstrated in patients with clinically detectable lymphatic metastases. Materials and Methods: This retrospective cohort study, was performed in two observation periods. Until March 2018, CLND was proposed to all subjects with positive-SLNB andPMLVA was performed in a subgroup of patients with risk factors for SL (Group 1). From April 2018, according to the modification of melanoma guidelines, all patients with detectable metastatic lymph nodes underwent PMLVA during CLND (Group 2). The frequency of lymphedema in subjects undergoing PMLVA was compared with the control group. Results: Database evaluation revealed 172 patients with melanoma of the trunk with follow-up information for at least 6 mounts. Twenty-three patients underwent PMLVA during CLND until March 2018, 29 from April 2018, and 120 subjects underwent CLND without any preventive surgery (control Group). The frequency of SL was significantly lower in both Group 1 (4.3% vs. 24.2%, p = 0.03) and Group 2 (3.5%, p = 0.01). Patients undergoing PMLVA showed a similar recurrence-free periods and overall survival when compared to the control group. Conclusions: PMLVA significantly reduces the frequency of SL both in immediate and delayed CLND. This procedure is safe and does not lead to an increase in length of hospitalization.

A prospective study on combined lymphedema surgery: Gastroepiploic vascularized lymph nodes transfer and lymphaticovenous anastomosis followed by suction lipectomy.

BACKGROUND: There is no consensus on the appropriate treatment of lymphedema. Proposed techniques include lymphaticovenous anastomosis (LVA), vascularized lymph nodes transfer (VLNT), and suction lipectomy (SL). The benefit of combined procedures has also been postulated. In this prospective study, a combined protocol is proposed as an alternative to single-procedure strategies. METHODS: Between January 2016 and October 2018, we enrolled patients with secondary lymphedema of lower limbs, stage II-III according to the International Society of Lymphology, progressive swelling and skin tonicity >60. Thirty-seven consecutive patients were dichotomized into group I, undergoing VLNT, and group II undergoing VLNT and LVA. Gastroepiploic lymphnode flap was harvested through laparoscopy, and in the same operation, LVAs were performed in group II on the basis of indocyanine green lymphography and patent blue findings. Two weeks later, SL was performed in all the patients. Patients were prospectively evaluated through clinical examination, circumference measurement, and skin tonicity. RESULTS: The average follow-up was 2 ± 0.8 years. The first consecutive 21 patients were treated with VLNT followed by SL. The next 16 patients underwent combined VLNT and LVA, followed by SL. A mean of 2.4 LVAs were performed. A significant difference in the postoperative circumference measurements was found overall (p < .05): 52.6 ± 18.9 above the knee, 42.9 ± 25 below the knee, 36.2 ± 37 at foot. The postoperative tonicity dropped by 12.7 ± 6.3% (p < .05). The episodes of cellulitis significantly decreased to 0.1 ± 0.3 (p < .05). CONCLUSIONS: LVA, VLNT, and SL can be integrated together in a combined approach, in synergy to enhance the outcomes.

Skin Reducing Mastectomy and Prepectoral Breast Reconstruction in Large Ptotic Breasts.

Large and/or ptotic breasts demonstrate significant difficulty in breast reconstruction and that the rates of perioperative complications are higher compared with the general population. The authors aim to clarify some details on their previously published technique on skin reducing mastectomy and prepectoral ADM breast reconstruction. 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 .

Free gastroepiploic lymph nodes and omentum flap for treatment of lower limb ulcers in severe lymphedema: Killing two birds with one stone.

BACKGROUND AND OBJECTIVES: In patients with lymphedema, the disruption of the lymphatic network increases skin turgor and fibrosis of subcutaneous tissue, delays wound healing, causing recurrent ulcerations and infections. In these cases, management of ulcers can be challenging. METHODS: Between January 2016 and June 2018, patients presenting with lymphedema were enrolled at our Institution. We selected patients with severe lymphedema and ulcers of lower limbs and we performed a surgical approach, involving free gastroepiploic lymph nodes and omentum flap, harvested through laparoscopy. RESULTS: We enrolled 135 patients presenting for lymphedema. Among them, 10 eligible cases underwent excision of the ulcer and reconstruction with omentum flap. Mean age was 57.8 years and average follow-up 24.1 months. Circumferences and skin tonicity significantly decreased from the preoperative period. Lymphoscintigraphy showed improvement of the lymphatic drainage and restoration of lymphatic network. No episodes of infection were recorded in the postoperative period. CONCLUSIONS: Our combined procedure merges free flap techniques and lymphedema surgery: omentum covers the defect while providing a new source of lymph nodes, improving the lymphatic networks of the affected limb. This technique can highly increase the quality of life of the patient in a single-stage operation with fast recovery and low donor site morbidity.

Microsurgical reconstruction of the isolated columellar defect with a prelaminated radial forearm free flap. A case report and a review of the literature.

The columella is one of the smallest subunits of the nose, but the loss of this structure has important aesthetic and structural implications. Few papers in literature present microsurgical techniques for the reconstruction of an isolated columellar defect. This report describes the use of a prelaminated radial forearm free flap (RFFF) for the reconstruction of an isolated columellar defect and reviews the current literature. A 45-year-old woman presented to our Unit with a history of palate squamous cell carcinoma and severe nasal deformity with an almost complete loss of the columella. A prelaminated RFFF with the fifth rib was used for a two-staged reconstruction of the isolated columellar defect. The radial pedicle was anastomosed to the facial vessels and the postoperative course was uneventful. Complete survival of the flap was achieved and, 10 months postoperatively, the patient had bilateral nasal patency, with an increased tip projection and a good aesthetic result. A prelaminated RFFF can be considered a valuable reconstructive option in cases of a large composite defect of the columella and limited availability of adjacent tissues.

Microvascular coupler device versus hand-sewn venous anastomosis: A systematic review of the literature and data meta-analysis.

BACKGROUND: Successful vascular anastomosis is essential for the survival of free tissue transfer. The aim of the study is to review the current literature and perform a meta-analysis to assess the potential advantages of a mechanical anastomosis coupler device (MACD) over the hand-sewn (HS) technique for venous anastomoses. METHODS: A systematic Medline search was performed to gather all reports of articles related to MACD from 1984 until now. The following data were extracted: first author and publication date, study design, number of patients and anastomosis, coupler size, site and type of reconstruction, venous anastomotic time, flap failure. A meta-analysis was performed on articles that met the following inclusion criteria: studies comparing MACD and HS technique in venous anastomosis, reporting anastomotic time, and postoperative complications. RESULTS: Thirty-three studies were included for the analysis. Twenty-four were retrospective case series and nine were retrospective comparative studies. A total of 12,304 patients were enrolled with a mean age of 49.23 years (range 31-72). A total of 13,669 flaps were accomplished. The thrombosis rate recorded with MACD was 1.47%. The meta-analysis revealed that MACD significantly decreased anastomotic time (standard difference in means = -0.395 ± 0.105; Z = -3.776; p < .001) and postoperative flap failure risk (odds ratio [OR] = 0.362, 95% confidence interval [CI] = 0.218-0.603, Z = -3.908, p < .001), but it did not decrease postoperative venous thrombosis risk (OR = 0.504, 95% CI = 0.255-1.129, Z = -1.666, p = .096). CONCLUSIONS: MACDs are a safe and effective alternative to traditional anastomosis. The anastomotic coupler is easier, much faster, and requires less technical skills than a HS microvascular anastomosis.

Skin-Reducing Mastectomy and Pre-pectoral Breast Reconstruction in Large Ptotic Breasts.

OBJECTIVES: Pre-pectoral breast reconstruction is increasingly offered to breast cancer patients, as the one-stage technique has proved surgical and oncological safety and aesthetic effectiveness. Nevertheless, there are limited data on outcomes after pre-pectoral breast reconstruction in large and ptotic breasts. The aim of the paper is to present the authors' experience in performing Wise pattern mastectomy with pre-pectoral implant and complete acellular dermal matrix (ADM) coverage as a single-stage procedure in patients with large ptotic breasts. MATERIALS AND METHODS: A retrospective review of protective collected data from January 2017 to June 2019 of patients who presented with large and ptotic breasts undergoing skin-reducing mastectomy and immediate pre-pectoral breast reconstruction with complete ADM coverage and inferior dermal sling was performed. Oncological and surgical outcomes were collected. Satisfaction with reconstruction and related quality of life were evaluated through BREAST-Q questionnaire. RESULTS: Nineteen patients met the inclusion criteria. The average patient age was 55.6 years, and the mean body mass index was 31.2. Mean follow-up was 23.2 months from the initial reconstruction. One patient experienced seroma, and two cases of wound dehiscence at the T junction were observed and treated conservatively with no implant loss. All patients were satisfied with the final reconstruction. CONCLUSION: The Wise pattern skin-reducing mastectomy and pre-pectoral breast reconstruction could be offered to patients presenting with large and ptotic breasts. Future studies should better define long-term outcomes. 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.

The versatility of the thoracodorsal artery based composite flaps with vascularized rib and a systematic review of the literature.

Pedicled and free composite flaps derived from the thoracodorsal artery system, including the latissimus dorsi-rib (LD-R) and the serratus anterior-rib (SA-R) osteo-muscular or osteo-myocutaneous flaps, are potential options to address head and neck, thorax, upper and lower extremity bone, and soft tissue defects' reconstruction. We aimed to report our series of LD/SA-R composite pedicled and free flaps, evaluating outcomes and complications, and to systematically identify all literature reporting results following LD/SA-rib reconstructions.

The medial-central septum based mammaplasty: A reliable technique to preserve nipple-areola complex sensitivity in post bariatric patients.

INTRODUCTION: Massive weight loss is associated with the ptosis of the breast, loss of the upper pole fullness, medialization of the nipples and volume depletion. Post bariatric patients often need breast reshaping with mastopexy or breast reduction. We report the author's experience with the medial central septum based mammoplasty for breast reshaping after massive weight loss. METHODS: We retrospectively reviewed the records of 85 women who underwent a medial-central septum based mammaplasty, analyzing patients (age, BMI, comorbidities) and operation specific characteristics' (surgical technique, complications) to identify the advantages and the drawbacks of the adopted technique. All the procedures were performed at a single institution by the senior author of this article. RESULTS: 85 patients were included in the review, in total 170 medial-central septum based mammaplasty were performed over a five years period. Early complications, as hematoma and seroma occurred in 2 patients. No total or partial nipple-areola losses were recorded and the viability of the nipple-areola complex (NAC) was excellent in all the treated patients. Sensation was retained in all breasts. Nine patients showed delayed wound healing at the joint of the T scar; in 5 patients we observed spreading scars. CONCLUSION: The medial-central septum based mammaplasty seems to be an effective and safe choice for breast reshaping after massive weight loss, as none of our patients experienced nipple loss and all of them reported good nipple sensation. Moreover, the technique is versatile and can be applied to patients with hypertrophic breasts or gigantomastia.

Efficacy and early results after combining laparoscopic harvest of double gastroepiploic lymph node flap and active physiotherapy for lower extremity lymphedema.

BACKGROUND: Lymph node flap transfer has gradually gained popularity for the treatment of upper and lower limb lymphedema. The aim of this study is to present the outcomes of an integrated treatment protocol based on double gastroepiploic lymph node flap (DG-VLN) and active physiotherapy in patients affected by Stage II and III lower extremity lymphedema. METHODS: All Stage II and III lower limb lymphedema patients operated between September 2015 and December 2017 were retrospectively identified and only those treated with an integrated approach of DG-VLN flap and active physiotherapy were included. Outcomes were assessed clinically with limb circumference measurement and radiologically with lymphoscintigraphy. Flap viability was evaluated through indocyanine green lymphography. Lymphedema related quality of life was evaluated preop and at 1 year follow up through LYMQOL questionnaire. RESULTS: Sixteen patients met inclusion criteria. Mean follow up was 26.2 months. Significant reduction in lower limb volume was observed for all patients from pre to post intervention. At 3 months of follow up, the mean CRR was 42.4% at below knee (BK) level and 25.4% at above knee (AK) level. At 12 months of follow up, the mean CRR was 58.3% at BK level (p = .001*) and 43.4% at AK level (p < .04*). LYMQOL metrics showed significantly better scores in all domains. CONCLUSIONS: Patients with lower limb lymphedema can benefit from combined DG-VLN flap and active physiotherapy, as this approach seem to fasten the onset of improvement and to have a positive impact on patients' quality of life.

Lymphatic-venous anastomosis in a rat model: A novel exercise for microsurgical training.

BACKGROUND AND OBJECTIVES: Lymphedema is a condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system. Lymphaticovenular anastomoses (LVA) and multiple lymphatic-venous anastomoses (MLVAs) have been recognized as efficient methods to treat chronic lymphedema. Because few models for lymphatics microsurgical training have been described, the aim of this study is to present a new training model for MLVA in a rat. METHODS: Ten norvegicus rats were used for this study. After a longitudinal xifo-pubic incision, lumbar nodes were injected with blue patent violet (BPV) to identify from two to four lymphatic vessels (LVs). MLVAs were carried out inserting lymphatics into the right lumbar vein. RESULTS: The mean weight of the rats was 511.4 g. The average diameter of the abdominal LVs used for MLVA was 0.26 mm, and the mean size of the right lumbar vein was 0.84 mm. The average time to perform MLVA was 49.8 minutes. Anastomosis patency rate was 70% based on the passage of BPV from the lymphatics into the vein. CONCLUSIONS: The rat is still a feasible resource to train microsurgeons, and the MLVA model proposed is simple and reliable and could be very useful for microsurgeon training.