The New Trend of Pre-pectoral Breast Reconstruction: An Objective Evaluation of the Quality of Online Information for Patients Undergoing Breast Reconstruction.

The Web has increasingly become the major source of information about health care, and patients who need to undergo breast reconstruction often use the internet to acquire an initial knowledge on the subject. We would like to present our study that investigates the quality of published information on pre-pectoral breast reconstruction. We searched the term "Pre-pectoral breast reconstruction" on Google® and Yahoo®. Forty-two web sites were selected and underwent qualitative and quantitative assessment using the expanded EQIP tool. The analysis of document contents showed a critical lack of information about qualitative risks and side-effects descriptions, treatment of potential complications, alert signs for the patient and precautions that the patient may take. Health professionals should inform patients about the potential difficulties of identifying reliable informational web sites about pre-pectoral breast reconstruction. The quality of available information should be improved, especially the important topics included in the content data section of the modified EQIP tool.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 .

Quality of the Information provided by ChatGPT for Patients in Breast Plastic Surgery: Are we already in the future?

Introduction: In recent years, artificial intelligence (AI) has gained popularity, even in the field of plastic surgery. It is increasingly common for patients to use the internet to gather information about plastic surgery, and AI-based chatbots, such as ChatGPT, could be employed to answer patients' questions.The aim of this study was to evaluate the quality of medical information provided by ChatGPT regarding three of the most common procedures in breast plastic surgery: breast reconstruction, breast reduction, and augmentation mammaplasty. Methods: The quality of information was evaluated through the expanded EQIP scale. Responses were collected from a pool made by ten resident doctors in plastic surgery and then processed by SPSS software ver. 28.0. Results: The analysis of the contents provided by ChatGPT revealed sufficient quality of information across all selected topics, with a high bias in terms of distribution of the score between the different items. There was a critical lack in the "Information data field" (0/6 score in all the 3 investigations) but a very high overall evaluation concerning the "Structure data" (>7/11 in all the 3 investigations). Conclusion: Currently, AI serves as a valuable tool for patients; however, engineers and developers must address certain critical issues. It is possible that models like ChatGPT will play an important role in improving patient's consciousness about medical procedures and surgical interventions in the future, but their role must be considered ancillary to that of surgeons.

Autologous breast augmentation combining the harvesting of the Anterior Intercostal Artery Perforator (AICAP) and Lateral Intercostal Artery Perforator (LICAP) flaps in massive weight loss patient: A case report.

Patients undergoing bariatric surgical procedures usually exhibit breast ptosis due to the quick weight loss. In this type of patients, the mastopexy represents a challenge for plastic surgeons considering the abundance of dystrophic cutaneous tissue, the loss of subcutaneous tissue and the impossibility to employ heterologous devices in the setting of Italian public healthcare. In addition, it is necessary to consider that patients undergoing post-bariatric surgery have increasingly high expectations. We describe a new reconstructive technique which combines and utilizes both the AICAP and LICAP flaps as "autoprosthesis". It could be considered a valid option for patients exhibiting a deficiency in the upper poles with hypotrophic and hypoelastic skin texture, associated with poor glandular representation. This procedure proves to be an excellent alternative to breast implants both in the reconstructive surgery and aesthetic surgery settings.

Exploring the Role of Caregivers in Day Surgery for Patients Undergoing Plastic and Reconstructive Surgery: A Comprehensive Patient and Caregiver Survey Approach.

This study investigates the interplay between plastic and reconstructive surgery patients and their respective caregivers in the Day Surgery Unit of Policlinico Umberto I, Rome, Italy. Utilizing a dual survey approach, we explored the role in patient safety and the challenges faced by caregivers during the perioperative period. This study, conducted at Policlinico Umberto I, covers all surgical procedures from October to December 2023, encompassing skin cancer removal, fat grafting, scar revisions, hand surgeries, and eyelid surgeries. Patient demographics reflect varying age distributions: 18-39 (4.9%), 40-59 (31.7%), 60-75 (34.1%), and over 76 years (29.3%).

Peripheral Blood Mononuclear Cells (PB-MNCs) for the treatment of chronic tissue dystrophy in a complex case of lower limb reconstruction.

BACKGROUND: Recently, the infiltration of a subpopulation of cells represented by mononucleated cells extracted from peripheral blood [Peripheral Blood-Mononuclear Cells (PB-MNCs)] is becoming a useful technique for medical and surgical regenerative procedures. Due to the angiogenetic and regenerative properties of PB-MNCs, the infiltration of these cells is, in our opinion, a new option indicated in the treatment of pathologies characterized by tissue dystrophy, loss of vascularization, and non-healing wounds. CASE PRESENTATION: A 25-year-old active smoker patient was diagnosed with Rhabdomyosarcoma of the anterior tibial muscle of his left leg and treated with neoadjuvant chemo- and radiotherapy (RT). After the tumor excision, the patient developed wound dehiscence with bone exposure and a perilesional radiation-induced chronic dermatitis characterized by skin dyschromia and hair thinning along the treated area. The patient underwent surgical debridement and reconstruction with autologous skin grafts and dermal substitutes, with poor outcomes due to graft failure. The patient was subsequently treated with surgical debridement and coverage with a reverse sural fascia-cutaneous flap. After 13 days, wound dehiscence was observed, and reconstruction of the dehiscent areas was performed with a split-thickness autologous skin graft with no success. After wound debridement, a new split-thickness skin graft was performed, and a concentrate of autologous PB-MNCs was injected in the flap and perilesional skin. After 14 days, graft take was reached, and improvements in perilesional tissue tropism were noted. At 2 months follow-up, the patient appeared completely healed. CONCLUSIONS: In our opinion, the use of PB-MNCs to treat conditions characterized by tissue dystrophy, which require neoangiogenesis and cell regeneration, can be a useful and unconsidered technique that could be utilized to improve tissue tropism. Furthermore, prospective trials are necessary to validate our observations.

The role of component separation in the treatment of severe diastasis recti abdominis: a new indication for a known technique.

OBJECTIVE: Diastasis of the rectus abdominis muscle (DRAM) is a widening of linea alba, it also could be accompanied by abdominal bulging. DRAM is often a cause of quality-of-life impairment, especially when it is of large dimensions. Repair with direct rectus plication is the most common treatment for Diastasis Recti Abdominis (DRA), but it can result in high recurrence rates. The authors aimed to show their results in applying the component separation technique in wide DRA cases. PATIENTS AND METHODS: From January 2015 to July 2018, 43 patients with DRA ≥ 10 cm at 3 cm over the umbilicus have been treated with component separation technique associated to panniculectomy. A biologic mesh was positioned onlay in cases of weakness along the semilunaris lines. RESULTS: DRA repair was achieved in all cases. All patients completed the 1-year follow-up and no recurrence nor major complication were registered. Minor complications were observed in 12 (27.9%) cases. CONCLUSIONS: This is the first study describing the component separation technique use in cases of DRA without hernia, associated to abdominoplasty surgery. Preliminary results were encouraging, but larger series are required.

Secondary lipofilling after breast reconstruction with implants.

BACKGROUND: Several Authors have reported on the use of lipoinjection as a low-risk and low-morbidity procedure that gives good results for the correction of soft-tissue defects. AIM: The purpose of this study was to review our caseload of fat grafting after breast reconstruction with prosthesis. PATIENTS AND METHODS: Between January 2008 and December 2011, 20 patients were treated for breast asymmetries with secondary autologous fat injection after nipple-sparing, skin-sparing and skin-reducing mastectomies breast reconstruction in our Departments. Exclusion criteria was postoperative radiotherapy. In order to assess aesthetic satisfaction, patients and an independent plastic surgeon filled an evaluation form (VAS = 1-10) preoperatively one and six months after surgery. RESULTS: In postoperative days no major complications occurred. Donor sites looks completely healthy and no scars were evident. The average values of aesthetic satisfaction in patients (VAS) were 5.2 (range 3-7) preoperatively, 7.9 (range 5-9) one month post-operatively and 7.2 six months postoperatively (range 5-9). Values reported by the surgeon team were an average of 4.9 (range 4-6) preoperatively, 7.6 after one month (range 6-9) and 7.1 after six months (range 5-9). CONCLUSIONS: Acquired contour deformities of the reconstructed breast are relatively common and independent from the technique used. Therefore, they present a frequent therapeutic challenge to reconstructive surgeons. Lipomodelling offers an "easy to perform" and predictable cosmetic solution to these patients. An objective examination of aesthetic results, in addition to our clinical analysis shows a significant improvement of cosmetic outcomes; moreover, all patients were satisfied for their final appearance.

Nasal reconstruction with the two stages vs three stages forehead flap. A three centres experience over ten years.

INTRODUCTION: In nasal reconstruction all anatomic layers as cover, lining, and support, have to be replaced to restore proper aesthetics. Forehead skin has been acknowledged as the best donor site to resurface the nose. Traditionally forehead flap reconstruction is performed in two stages, but Millard described an intermediate third stage between flap transfer and pedicle division. This study compared the two methods. MATERIALS AND METHODS: The study enrolled 31 patients undergoing total or subtotal nose reconstruction between January 2001 and January 2012. 20 patients underwent to the two-step technique (2S Group), and 11 the three-step technique (3S Group). Thickness of the flap was measured in three different areas. A plastic surgeon not involved in the study completed an evaluation questionnaire to assess aesthetic satisfaction (VAS = 1-10). RESULTS: The total number of procedures performed (including revisions) ranged from 3 to 6. The average number of procedures performed in group 2S patients was 4 (range: 3-6) in the group 3S was 3.46 (range: 3-5). VAS mean values were studied with t Student test and were found to be significant. DISCUSSION: The timing of thinning of the flap and detachment of the pedicle varies among Authors. There are generally two trends: defatting of the flap before the pedicle transection, performed usually 3 weeks from flap harvesting and defatting a few months after disconnection of the pedicle. We think this technique is suited for defects including underlying structures and particularly for all those defects located in the distal part of the nose (tip and nostrils).

Upper eyelid necrosis and reconstruction after spider byte: case report and review of the literature.

Spider bites are not very common, especially in the Mediterranean area, and those affecting the ocular-palpebral region involving reconstructive surgery are particularly rare. In May 2010, the case of a Caucasian 24-year-old female patient was brought to the attention of the Dermatology Department, University of Cagliari, Italy. The patient reported she woke up feeling an intense pain with itching and that also she had noticed a spider of an unknown species on her bed. The dermatosis had affected the right orbital region, where there was a considerable red and violet erythema and a hard edema, not foldable. When the necrosis appeared the patient was treated at the Plastic Surgery Unit where she underwent a reconstruction of the eyelid with a full thickness skin graft from the retroauricular area. The post-operative course was regular with a perfect in-take of the skin graft. When the patient was discharged she was sent to an Entomological University Centre to identify the spider species and the possible venom which caused the skin lesion. The spider which caused the injury has been a Loxosceles rufescens (Dufour, 1820). Loxoscelism is a necrotic arachnoidism caused by the poisonous bite of spiders belonging to the Loxosceles species. It is very important to identify what sort of lesion it is and to treat it in a combined way in order to choose the proper timing for surgery to avoid damages to the eyelid functioning.

An experience on primary thinning and secondary debulking of anterolateral thigh flap in head and neck reconstruction.

OBJECTIVES: The antero-lateral thigh flap (ALTF) has become one of the workhorses of reconstructive procedures of the head and neck. The cosmetic result of this flap is uncertain during the main reconstructive procedure, so free flap contouring in head and neck reconstruction following cancer ablation is usually performed at the end of therapy. To obtain an adequate symmetry of the flap a safe thinning during the primary inset or a secondary defatting may be performed. PATIENTS AND METHODS: The study includes 45 patients underwent reconstruction with ALTF for head and neck tumors. Patients were divided into two groups: Group 1 (20 patients underwent a primary thinning of the flap), Group 2 (25 patient underwent a secondary debulking of the flap). Patients were evaluated in terms of total number of cosmetic reconstruction procedures performed, hospital stay and aesthetic satisfaction. RESULTS: Epidemiological analysis showed an average age of 51 years old in patients. Patients were affected by squamous cell carcinoma in 33 cases. Within Group 1, 14 patients underwent surgery only once, 5 underwent surgery twice and one patient three times. In group 2, 8 patients underwent surgery once, 10 patients twice, 3 patients three times and 4 patients four times. Considering total of hospital stay, the average length of stay was 18.83 days in the group of patients subjected to primary debulking, versus 23.67 days in the group subjected to secondary defatting. CONCLUSIONS: The ALT flap is a safe and reliable free flap for head and neck reconstructive surgery. As showed in the study and in previous reports, the thinning of the flap is a safe procedure, without increasing the flap complications and allowing an immediate symmetry of the recipient site contour. Furthermore, ALTF thinning reduces major defatting revisions requiring general anesthesia and the total number of secondary procedures.

Prognostic significance of tyrosinase expression in sentinel lymph node biopsy for ultra-thin, thin, and thick melanomas.

BACKGROUND: Investigate if the tyrosinase mRNA expression may be predictive of the outcome on ultra-thin, thin, and thick melanoma patients. AIM: In our study, we sought to correlate tyrosinase mRNA expression to the outcome in a group of 71 patients with thick, thin and ultra-thin melanomas. MATERIALS AND METHODS: 71 patients with melanomas underwent a SLNB (sentinel lymph node biopsy) at the "Sapienza" University of Rome. Among these, 38 patients had thin melanomas, while the other 33 patients had thick melanomas. In every patient's sample histology, immunohistochemistry and reverse transcriptase-polymerase chain reaction (RT-PCR) was completed. We then correlated tyrosinase mRNA expression to the statistical analysis of the outcome of patients. RESULTS: Positivity of histology was found in one patient (1.4%), immunohistochemistry in five patients (7%), and tyrosinase in 52/71 (73.2%). Thickness and tyrosinase positivity were predictive for disease progression (p < 0.05). The median follow-up was 58.24 months. There were recurrences and/or deaths in both groups of patients. CONCLUSIONS: Nodal metastasis in melanoma is uncommon, especially in patients with thin melanomas. In this study, histology and immunohistochemistry were found to be non predictive for the risk of nodal metastases, while instead, tyrosinase m-RNA expression appeared to play a role in highlighting those patients with a risk of disease progression. Moreover, no differences among the thin melanoma groups of patients (0.30-0.75 mm and 0.76-1.00 mm) were observed.

Pyoderma Gangrenosum and inflammatory bowel disease: a combined medical and surgical approach - case report and literature review.

OBJECTIVE: Pyoderma Gangrenosum (PG) is an immune-mediated neutrophilic dermatosis, characterized by large painful ulcers occurring in various body segments. It can be associated to Inflammatory Bowel Disease (IBD) including both Ulcerative Colitis and Crohn Disease. Prompt and effective management is fundamental, due to its high morbidity and mortality rates. By presenting our clinical experience, we aimed at showing the efficacy of a combined therapeutic approach, in which the best of every specialty cooperates managing this hazardous disease. PATIENTS AND METHODS: We report on two patients attending our outpatient clinic with ulcerative skin lesions at the level of the back. Patient 1 suffered from Crohn disease and Patient 2 presented a positive history of abdominal pain, diarrhea with mucus and blood in the stool. Histological exam was performed with final diagnosis of PG associated with IBD. A Literature review was carried out in order to highlight the role of combined clinical-surgical management of PG in adult patients with IBD. RESULTS: Complete resolution of the lesions was achieved in 4 months and 3 months for each patient respectively without relapse. PubMed was searched from 2000 to 2020 with the following keywords: (Pyoderma) AND/OR (Pyoderma Gangrenosum) AND (Inflammatory Bowel Disease) AND/OR (Ulcerative Colitis) AND/OR (Crohn Disease) AND (Management). Seven papers were included (4 case reports, 2 case series, 1 comprehensive review) and reviewed using a descriptive checklist. CONCLUSIONS: PG should be treated by dedicated multidisciplinary teams, in which every specialist plays a crucial role from the diagnosis to the treatment and up to the long-term follow-up.

Selective lymphadenectomy for penile cancer.

INTRODUCTION: Lymph node treatment in patients with penile cancer has been longly debated in the last 15 years, with surgeons advocating therapeutic lymphadenectomy and others advocating selective lymphadenectomy (SLND). MATERIALS AND METHODS: We evaluated the outcome of clinically node negative penile cancer patients treated with SLND. Since March 2000, 35 node negative penile cancer patients were operated on mainly at the Division of Plastic Surgery, San Gallicano Institute, Rome (Italy), with SLND. RESULTS: A sentinel node was detected in 34 out of 35 patients (42 groins). With a minimum of five years follow up, metastases were noted in 5 out of 35 patients. Out of the remaining 30 patients, 2 developed node metastases in the operated inguinal region (6.6%). DISCUSSION: SLND for penile cancer compared to surveillance only greatly improves survival rate and disease-free rate (91% vs 79% after 3 years follow-up). Identification of more specific markers for SCC lymph node metastases will make the false negative-rate drop further.

Cagliari University Hospital (CUH) protocol for immediate alloplastic breast reconstruction and unplanned radiotherapy. A preliminary report.

INTRODUCTION: Alloplastic breast reconstruction necessitating postmastectomy radiotherapy (PMRT) is at increased risk for complications such as capsular contracture, infection, extrusion, and poor cosmetic results. However, often the indication for PMRT is not decided until a permanent histological examination with review of the permanent sections is carried out, and the expander has already been inserted. Techniques described to face this issue (delayed-immediate reconstruction and Memorial Sloan Kettering Cancer Center protocol) both have disadvantages. MATERIALS AND METHODS: The protocol we suggest is based on (1) reconstruction with tissue expander placement at the time of mastectomy; (2) complete tissue expansion during postoperative chemotherapy; (3) radiotherapy, as suggested by oncologists; (4) two or three fat grafting session, according to Coleman's technique, 4-6 months after RT; (5) exchange of the tissue expander for a permanent implant approximately 3 months after the completion of fat grafting. Ten patients were treated according to these guidelines. RESULTS: Results at 15 months have been encouraging, with no grade 3-4 Baker's capsular contracture. DISCUSSION: Although the group of patients treated according to our CUH Protocol for immediate implant-based breast reconstruction and radiotherapy is small, and follow-up is short; nevertheless, results are encouraging.

Acute nephrotoxicity of NSAID from the foetus to the adult.

NSAIDs are generally considered to be safe and well tolerated, but, even with the advent of selective COX-2 inhibitors, nephrotoxicity remains a concern. An impaired renal perfusion caused by the inhibition of prostaglandin synthesis is claimed like the more frequent cause of an acute renal failure due to NSAIDs, while a chronic interstitial nephritis or an analgesic nephropathy are believed the causes of a chronic renal failure. The real incidence of renal side effects of NSAIDs is still unclear and it differs between the age of the patients and the reports present in the literature. The occurrence of renal side effects following prenatal exposure to NSAIDs seems to be rare considering the large number of pregnant woman treated with indomethacin or other prostaglandin inhibitors. NSAID-related nephrotoxicity remains an important clinical problem in the newborns, in whom the functionally immature kidney may exert a significant effect on the disposition of the drugs. Instead, nephrotoxicity is a rare event in children and the risk is lower than adults. In healthy adult patients the incidence of renal adverse effects is very low, less than 1%. The risk increased with age. The elderly are at higher risk, and it is correlated at the presence of pretreatment renal disease, hypovolemia due to use of diuretics, diabetes, congestive heart failure or alteration of NSAID pharmacokinetics.

Venous thromboembolism prophylaxis in plastic surgery: state of the art and our approach.

OBJECTIVE: The issue of prevention of thromboembolism in plastic surgery is a rather controversial subject. The actual frequency of VTE among plastic surgery patients is probably higher than we know. Although several studies have shown that chemoprophylaxis likely increases rates of re-operative hematoma by less than one percent, surgeons are strongly resistant to adopting chemoprophylaxis due to the fear of increased bleeding and its complications. MATERIALS AND METHODS: A literature review was conducted. The 2012 ACCP guidelines suggest the use of the 2005 Caprini score as the most widely used and well-validated individualized risk-stratification tool. We propose a modified 2005 Caprini score, with specific changes pertaining to plastic surgery, in which we combine a patient risk stratification model and a procedure-driven approach explicitly indicating what procedures have to be considered at high or low risk. RESULTS: The risk of venous thromboembolism in plastic surgery cannot be disregarded. However, the plastic surgery literature still lacks high-level evidence for appropriate means of VTE prophylaxis, although an increasing amount of attention has been paid to the topic. We suggest the development of an international guideline, based on plastic surgical data, using a validated risk assessment model, which combines the surgical risk with the patient-related risk. CONCLUSIONS: Determining the proper venous thromboembolism prophylaxis is a clinical decision that should be made on a patient-to-patient basis. The algorithm presented in this article is meant to simplify this complex problem and to help expedite and clarify the decision-making process.

Back to basics with distal thumb reconstruction. Easy management of the incomplete amputation.

Thumb reconstruction has always been challenging for hand surgeons. The disability can severely influence the working and social life of the patient, even if just the distal phalanx is affected. Revascularization is the best surgical option for incomplete distal amputation, although microsurgical reconstruction, sometimes, could be not feasible. A simple basic-skills-based reconstructive method, that takes into account the length preservation and a short recovery should be advocated. We treated 14 incomplete distal thumb amputations with bone exposure, classified as Hirase zone IIA-IIB. The distal thumb was held by a short tissue islet, nor neurovascular bundle, nor dorsal vein was included. Patients were assessed for skin and bone healing, length of thumb shortening, and time of return to full occupational activity. QDASH score was evaluated along with a two-point discrimination test. The outcome was fair in all 14 patients. Partial distal thumb necrosis was observed in six cases (40%); they healed by secondary intention. Finger shortening had a mean of 6.9 mm (range, 6-8 mm), mean interphalangeal joint motion was 48 degrees (range,45-55 degrees). The median static two-point discrimination was 7.1 mm (range, 6-9 mm), the mean quick DASH score was 1.8 (range, 0-4.5). All patients returned to work within a mean of 4.3 weeks (range, 4-5 weeks). The follow-up period was 12 months. Length preservation, fast recovery and easy return to manual work, above all, are the keystones of our successful procedure. Whether the revascularization is not executable, we provide a reliable and simple method to grant a functional thumb.

Superior mesenteric artery spontaneous and isolated dissection diagnosed by using MDCTA.

We report the case of a 49-year-old man admitted to our Institute because he suffered acute abdominal pain induced by eating. Sonography don't revealed pathological findings. Then underwent a multi-detector row computed tomography angiography (MDCTA) that revealed an intimal flap separating true and false lumens that was located 2 cm from the origin of the superior mesenteric artery (SMA) and with an extension of 8 cm. Since the dissection was limited without occlusion of the SMA and the mesenteric marginal artery served as a collateral vessel on the distal side of the SMA, the treatment has been conservative. Improved CT technology facilitates the diagnosis of superior mesenteric artery dissection. Prompt diagnosis and treatment result in the lowest mortality rate and minimize the prevalence of intestinal infarction. Only 107 cases (including the present case) of isolated spontaneous SMA dissection without associated aortic dissection were identified from the literature.

Melkersson-Rosenthal syndrome associated with Down syndrome.

We present a clinical case of Melkersson-Rosenthal (M-R) syndrome associated with Down syndrome. No evidence of this association is described in the literature. We also present a technique for the macrocheilia treatment of lower lip caused by M-R syndrome in a patient with Down syndrome. This patient during pediatric age had many events of facial nerve paralysis and edematous episodes of lower lip with unknown etiology. This technique is based on a wedge full thickness central excision of the lower lip and on a transversal lozenge excision in the vermilion portion with orbicular muscle to reverse the chin-labial corner. The results are an agreeable aspect of the lip and physiological digestive and phonetic processes. The technique is safe and simple and the aesthetic functional result is very good. In our case, the postoperative complication is caused by an insufficient collaboration of the patient and it is solved in three weeks.