Body Self-Perception After Breast Reconstruction in Young Female Patients Affected by Poland Syndrome.

BACKGROUND: Cosmetic and social aspects of breast anomalies in Poland syndrome are not negligible. Early diagnosis and appropriate therapeutic timing may have a positive impact on quality of life. METHODS: Females affected by Poland syndrome, who had breast reconstruction between 2014 and 2018, were asked to complete the Body Uneasiness Test and the postoperative Breast-Q. Correlation between scores was evaluated. Correlation between scores was statistically evaluated. RESULTS: Thirty patients who had completed breast reconstruction at 20.9 ± 6.5 yo fulfilled the questionnaires at the average age of 26.5 ± 8.1 yo. BUT scores were similar to healthy population considering different age groups, with the exception of Compulsive Self-Monitoring subscale for 16-17-year age group. A correlation between Depersonalization and "Thighs" and "Legs" was present. On average, satisfaction with breast resulted 79.1%, satisfaction with surgical outcome was 94.9%, psychosocial well-being was 78.5%, sexual well-being was 75.3%, and relative physical well-being in chest and upper body was 36.9%. Global Uneasiness, Avoidance, Weight Phobia, Body Image Concern and Depersonalization were significantly correlated with lower psychosocial well-being. Avoidance was significantly correlated with lower sexual well-being. CONCLUSIONS: Breast reconstruction in Poland syndrome can help to improve quality of life. However, general body uneasiness can affect satisfaction with the final result. 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 http://www.springer.com/00266 .

"The use of Autologous Flaps in Breast Reshaping After Massive Weight Loss: A Systematic Review".

BACKGROUND: Massive weight loss (MWL) has a positive impact on the comorbidities associated with obesity but leaves patients with ongoing body issues due to skin excess. Almost all patients present some degree of breast ptosis and breast volume deficiency, which can be addressed with different techniques including autologous flaps. MATERIAL AND METHODS: A literature search was conducted by using PubMed, Google Scholar, and Cochrane databases. Patient's characteristics, type of bariatric surgery, amount of weight loss, flap size and design, simultaneous breast and extra-breast procedures were analyzed. Aesthetic and patient-reported outcomes, postoperative complications, revision rate, and donor site morbidity were also registered. RESULTS: Twelve articles fulfilled inclusion criteria, and 79 patients were included, for a total of 157 flaps. Different flap designs and flap combinations were described; those originating from lateral chest wall area were the most commonly used. Simultaneous breast procedures were reported in 72 patients. Simultaneous extra-breast body contouring (BC) procedure was performed in 40 cases. The overall complication rate was 9.55% and a total of ten revisionary procedures were performed. Satisfaction of the patients was globally quite high. CONCLUSIONS: Advantages of the use of autologous tissue in breast reshaping after MWL is the avoidance of implant-related complications and the simultaneous improvement of the silhouette. The complication rate resulted in acceptable, aesthetic, and patient-reported outcomes resulted to be encouraging, even if there was a lack of standardization in the evaluation. A comparative randomized study to confront the use of autologous flaps combined with mastopexy versus the use of implants combined with mastopexy can be useful to confirm the promising results. 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 .

Rehabilitation of the Dysmorphic Lower Eyelid From Hyaluronic Acid Filler: What to Do After a Good Periocular Treatment Goes Bad.

BACKGROUND: Chronic, long-lasting edema accompanied by the Tyndall effect as a delayed reaction to hyaluronic acid (HA) filler injection seems to occur exclusively in the eyelids. OBJECTIVES: The authors sought to present a treatment algorithm for management of patients with chronic lower eyelid edema as a delayed complication of HA filler injection. METHODS: Retrospective study including 61 patients with delayed-onset chronic periocular edema following uneventful HA filler injection in the lower eyelids or cheeks. All patients underwent hyaluronidase enzyme dissolution followed by secondary treatment. Three retreatment options were presented: (1) observation, (2) secondary treatment with HA filler, and (3) lower eyelid blepharoplasty. RESULTS: All patients underwent filler dissolution using hyaluronidase. The mean age was 48 years and 97% of the patients were female. Single treatment was effective in 92% of patients with 8% requiring another hyaluronidase injection to completely eradicate residual edema. Six patients (10%) were satisfied after hyaluronidase only and 6 patients (10%) underwent lower eyelid blepharoplasty. Secondary treatment with HA filler was performed in 48 patients (80%). All were satisfied with final results without further edema in the follow-up period. CONCLUSIONS: Delayed-onset chronic lower eyelid edema is a frequent HA-related complication and cause of concern when considering periocular HA treatment. Previous treatment has been limited to either hyaluronidase only or blepharoplasty as a secondary solution after hyaluronidase, with only a minority of patients satisfied. Hyaluronidase, shortly followed by HA filler retreatment, is a safe and effective solution.

Conscientious Objection to Animal Testing: A Preliminary Survey Among Italian Medical and Veterinary Students.

The use of animals for educational and research purposes is common in both veterinary and human medicine degree courses, and one that involves important ethical considerations. The aim of this study was to assess the extent of differences between the knowledge and attitudes of veterinary students and medical students on animal bioethics, on alternative strategies and on their right to conscientiously object to animal experimentation. To this end, a questionnaire was completed by 733 students (384 human medicine students (HMS) and 349 veterinary medicine students (VMS)). VMS were more aware than HMS (72.2% and 59.6%, respectively) of the existence of an Italian law on the right to conscientiously object to animal experimentation. However, very few of them had exercised this right. Many VMS (43.3%) felt that animal bioethics courses should be mandatory (only 17.4% of HMS felt the same way). More VMS than HMS (81.7% and 59.1%, respectively) expressed an interest in attending a course on alternatives to animal experimentation. The data suggest the need for appropriate educational interventions, in order to allow students to make choices based on ethical principles. Fostering close collaborations between departments of human medicine and veterinary medicine, for example, through shared study modules, could promote the development of ethical competence as a basic skill of students of both veterinary and human medicine courses.

Skin Rejuvenation and Volume Enhancement with the Micro Superficial Enhanced Fluid Fat Injection (M-SEFFI) for Skin Aging of the Periocular and Perioral Regions.

BACKGROUND: Adipose-derived stromal and stem cells (ADSC) in autologous fat promises regenerative advantages, and injected into the dermal and subdermal layers, enhances rejuvenation and volume. However, extremely superficial fat injection with current techniques is limited. OBJECTIVES: Efficacy and viability evaluation of fat harvested with extremely small side port (0.3 mm) cannulae without further tissue manipulation for the correction of aging/thin skin in the periocular and perioral regions. METHODS: Micro-superficial enhanced fluid fat injection (M-SEFFI) harvests adipose tissue with a multi-perforated cannula (0.3 mm), and autologous platelet rich plasma (PRP) is added. The tissue is injected into the dermal region of the periocular and perioral zones. Efficacy and viability were evaluated by histological and cell culture analysis. Clinical assessment included retrospective evaluation according to 1 = no effect, 2 = fair effect, 3 = good effect, 4 = excellent effect. RESULTS: Between June 2014 and July 2015, 65 patients (7 men; mean age 49.7 years) were treated with M-SEFFI. No intraoperative complications or visible lumpiness were recorded. Analysis demonstrated mature, viable adipocytes with a strong stromal component. Following PRP addition, there was a greater proliferation noted in the M-SEFFI compared to the SEFFI (0.5 mm). Mean follow-up was 4.1 months. Clinical assessment by surgeons and patients at 1 month was 3.52 and 3.74, and 6 months 3.06 and 2.6 respectively. CONCLUSIONS: M-SEFFI is effective and viable for lump free skin rejuvenation and volume enhancement, through the extraction of smoother ADSC rich, autologous fat tissue that does not require further tissue manipulation, to correct skin aging. LEVEL OF EVIDENCE: 4 Therapeutic.

Interaction Between Breast Cancer Cells and Adipose Tissue Cells Derived from Fat Grafting.

BACKGROUND: Adipose tissue transplantation has the benefit of providing both regenerative and aesthetic outcomes in breast cancer treatment. However, the transplanted tissue can stimulate the growth of residual cancer cells. OBJECTIVES: The aim of this study is to identify the interactions between adipose tissue cell subpopulations and human cancer cell lines. METHODS: Intact adipose tissue from lipofilling procedures as well as fibroblasts derived from adipose tissue, were cocultured in the presence of MDA-MB-231, MCF-7 e ZR-75-1 breast cancer cell lines. The influence on cancer cell lines of fibroblasts, induced to differentiate into specific adipocytes, was also assayed. RESULTS: All cancer cell lines displayed a significant increase in proliferation rate when cocultured in the presence of either intact adipose tissue or induced adipocytes. To a lesser extent, uninduced fibroblasts stimulate breast cancer cell proliferation. CONCLUSIONS: Recent studies have shown that the microenvironment surrounding breast cancer cells may stimulate growth and promote progression of residual cancer cells when surgery is performed on the main tumor mass. Accordingly, the graft of adipose tissue could potentially promote or accelerate the development of a subclinical tumor or support its locoregional recurrence. Our data suggest that adipocytes have a remarkable influence on the proliferation of cancer cell lines. The oncological safety of the lipofilling procedure outcome is still debated; thus, further studies and consistent follow-up examination are needed.

Phenotypic and genotypic characterization of Staphylococci causing breast peri-implant infections in oncologic patients.

BACKGROUND: Staphylococcus epidermidis and S. aureus have been identified as the most common bacteria responsible for sub-clinical and overt breast implant infections and their ability to form biofilm on the implant as been reported as the essential factor in the development of this type of infections. Biofilm formation is a complex process with the participation of several distinct molecules, whose relative importance in different clinical settings has not yet been fully elucidated. To our knowledge this is the first study aimed at characterizing isolates causing breast peri-implant infections. RESULTS: Thirteen S. aureus and seven S. epidermidis causing breast peri-implant infections were studied. Using the broth microdilution method and the E-test, the majority of the strains were susceptible to all antibiotics tested. Methicillin resistance was detected in two S. epidermidis. All strains had different RAPD profiles and were able to produce biofilms in microtitre plate assays but, while all S. aureus carried and were able to express icaA and icaD genes, this was only true for one S. epidermidis. Biofilm development was glucose- and NaCl-induced (5 S. aureus and 1 S. epidermidis) or glucose-induced (the remaining strains). Proteinase K and sodium metaperiodate treatment had different effects on biofilms dispersion revealing that the strains studied were able to produce chemically different types of extracellular matrix mediating biofilm formation. All S. aureus strains harboured and expressed the atlA, clfA, FnA, eno and cna genes and the majority also carried and expressed the sasG (10/13), ebpS (10/13) genes. All S. epidermidis strains harboured and expressed the atlE, aae, embp genes, and the majority (six strains) also carried and expressed the fbe, aap genes. Genes for S. aureus capsular types 5 and 8 were almost equally distributed. The only leukotoxin genes detected were lukE/lukD (6/13). CONCLUSIONS: S. aureus and S. epidermidis breast peri-implant infections are caused by heterogeneous strains with different biofilm development mechanisms. Since the collagen adhesin (cna) gene is not ubiquitously distributed among S. aureus, this protein could have an important role in the cause of breast peri-implant infections.

Superficial Enhanced Fluid Fat Injection (SEFFI) to Correct Volume Defects and Skin Aging of the Face and Periocular Region.

BACKGROUND: Although recent research on micro fat has shown the potential advantages of superficial implantation and high stem cell content, clinical applications thus far have been limited. OBJECTIVES: The authors report their experience with superficial enhanced fluid fat injection (SEFFI) for the correction of volume loss and skin aging of the face in general and in the periocular region. METHODS: The finer SEFFI preparation (0.5 mL) was injected into the orbicularis in the periorbital and perioral areas, and the 0.8-mL preparation was injected subdermally elsewhere in the face. RESULTS: The records of 98 consecutive patients were reviewed. Average follow-up time was 6 months, and average volume of implanted fat was 20 mL and 51.4 mL for the 0.5-mL and 0.8-mL preparations, respectively. Good or excellent results were achieved for volume restoration and skin improvement in all patients. Complications were minor and included an oil cyst in 3 patients. The smaller SEFFI quantity (0.5 mL) was well suited to correct volume loss in the eyelids, especially the deep upper sulcus and tear trough, whereas the larger SEFFI content was effective for larger volume deficits in other areas of the face, including the brow, temporal fossa, zygomatic-malar region, nasolabial folds, marionette lines, chin, and lips. CONCLUSIONS: The fat administered by SEFFI is easily harvested via small side-port cannulae, yielding micro fat that is rich in viable adipocytes and stem cells. Both volumes of fat (0.5 mL and 0.8 mL) were effective for treating age-related lipoatrophy, reducing facial rhytids, and improving skin quality. LEVEL OF EVIDENCE: 4 Therapeutic.

Basal cell carcinoma of the scalp: surgical approach and reconstructive options.

INTRODUCTION: Surgical therapy of basal cell carcinomas (BCC) is based on complete excision of the neoplasm and its immediate suitable reconstruction. The aim of this work was to evaluate the possibility of creating a reconstructive algorithm in cases of scalp BCC, depending on the amplitude of the tumor. EVIDENCE ACQUISITION: A literature search was carried out using the databases of PubMed, Scopus and Cochrane. EVIDENCE SYNTHESIS: Based on the experiences reported in the literature, it was possible to structure a decision-making algorithm that summarizes the various steps involved in the choice of the most suitable reconstructive surgical therapy. CONCLUSIONS: The algorithm described we hope will be of reference or help to less experienced reconstructive plastic surgeons.

Active Occipital Motion with Digipressure as Preoperative Screening in Migraine Surgery.

Background: Modern surgical therapy of chronic headaches/migraines is essentially based on the release/neurolysis of extracranial nerves, which, when compressed or inflamed, act as trigger points and, as such, trigger headache attacks. The aim of this article was to describe a novel maneuver we use as an aid in the preoperative planning of occipital trigger sites. Methods: In the period of January 2021-September 2023, we operated on 32 patients (11 men, 21 women, age range: 26-68 years), who underwent migraine surgery for occipital trigger point release. All patients were evaluated using the described preoperative maneuver. In a dedicated card, the levels of tenderness at each point were marked accordingly, differentiating them by intensity as nothing (-), mild (+), medium (++), or high (+++). Patients were then operated on at the points corresponding only to the ++ and +++ signs. Results: At 6-month follow-up, we observed significant improvement (>50%) in 29 patients (91%), with complete recovery in 25 patients (78%). Conclusions: In our experience, the maneuver described, in addition to being very simple, has been shown to have good sensitivity and reproducibility. We therefore recommend its use, especially for those surgeons beginning their practice in this particular area of plastic surgery.

Relationship between Breast Cancer Surgical Treatment and Psychiatric Symptomatology: Which Sociodemographic and Clinical Factors Could Influence It? A Preliminary Study.

This study aimed to investigate psychiatric symptomatology in a sample of patients affected by breast cancer undergoing surgery, evaluating the potential mediators on perceived stress levels, depression and hopelessness. The study was conducted on eighty-five patients with breast cancer, admitted consecutively to the Breast Unit of the IRCCS Ospedale Policlinico San Martino, between May 2018 and December 2019. Sociodemographic (age of diagnosis, gender, marital and occupational status, educational level, having children) and clinical (type and side of surgery, previous breast surgery, neoadjuvant chemotherapy and axillary dissection) characteristics were investigated through a semi-structured interview. The following rating scales were administered: Beck Depression Inventory, Beck Hopelessness Scale, and Perceived Stress Scale. Our findings indicate that the presence of children and of a partner was associated with a lower total score on the clinical dimensions evaluated. Furthermore, we found demolitive surgery to be a mediator between perceived stress and hopelessness, while history of previous breast surgery was found to be a mediator between demolitive surgery and perceived stress. In conclusion, patients affected by breast cancer undergoing more complex and demolitive surgery or with history of previous breast surgery should be mostly monitored from a psychological and psychiatric point of view from the beginning of treatments to evaluate the first manifestations of psychiatric symptomatology.

Breast Reconstruction Using the Lateral Thoracic, Thoracodorsal, and Intercostal Arteries Perforator Flaps.

Breast-conserving surgery followed by radiotherapy represents the standard of care for early-stage breast cancer. The aim of this article was to provide a review of the literature about the use of the lateral thoracic artery perforator (LTAP) flap, the lateral thoracodorsal (LTD) flap, and the lateral intercostal artery perforator (LICAP) flap in lateral partial breast defect. METHODS: A literature search was performed via PubMed, Medline, and Cochrane. Patient's characteristics, topography and size of breast defect, flap size and design, number of perforators, and operative time were analyzed. Aesthetic and patient-reported outcomes, postoperative complications, and donor site morbidity were also registered. RESULTS: Thirteen articles fulfilled inclusion criteria, and 432 patients were included. Different flap designs and flap combinations were described. Satisfactory outcomes were reported for between 78% and 100% of cases. Patient satisfaction ranged from 75.8% to 92.5% of cases. The overall complication rate was 9.25%, and donor site morbidity was very low (3.7%). CONCLUSIONS: A distinct advantage of LTAP, LTD, and LICAP flap reconstruction is that the thoracodorsal pedicle is not sacrificed, not compromising eventual delayed breast reconstruction with TDAP or latissimus dorsi flaps. This staged approach to partial breast reconstruction is especially useful in cases where the oncological margins are uncertain and wider resections (or mastectomies) are secondly required.

Site V Surgery for Temporal Migraine Headaches.

BACKGROUND: Auriculotemporal nerve is demonstrated to contribute to migraine pain in temporal area. In particular, its relationship with the superficial temporal artery in the soft tissues superficial to the temporal parietal fascia has attracted researchers' attention for many decades. The objective of this review was to explore whether site V nerve surgical decompression is effective for pain relief in temporal area. METHODS: A literature search, according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, was conducted to evaluate the surgical treatment of auriculotemporal migraine. Inclusion was based on studies written in English, published between 2000 and February 2020, containing a diagnosis of migraine in compliance with the classification of the International Headache Society. The treatment must consist of surgical procedures involving the auriculotemporal nerve and/or arteries in site V, with outcome data available for at least 3 months. RESULTS: Three hundred twenty-four records were identified after duplicates were removed, 31 full-text articles were assessed for eligibility, and 2 records were selected for inclusion. A total of 77 patients were included in the review. A direct approach at the anatomical site identified with careful physical examination and confirmed with a handheld Doppler probe is generally performed under local anesthesia. Blunt dissection to the superficial temporal fascia to expose the auriculotemporal nerve and the superficial temporal artery is followed by artery cauterization/ligament and eventual nerve transection/avulsion. Site V surgery results in a success rate from 79% to 97%. CONCLUSIONS: Despite the recent advances in extracranial trigger site surgery and a success rate (>50% improvement) from 79% to 97%, site V decompression is still poorly described. Elaborate randomized trials are needed with accurate reporting of patient selection, surgical procedure, adverse events, recurrencies or appearance of new trigger points, quality of life outcome, and longer follow-up times.

Surgical Correction of Inverted Nipples.

Nipple inversion is a common pathologic condition affecting 2%-10% of women. Congenital inversions are the most common forms, while acquired inversions are less frequent. This condition can induce psychological discomfort, functional problems that could prevent adequate breast feeding, and cosmetic dissatisfaction, and create local irritation and infection. The aim of this article was to provide a comprehensive review of the literature about surgical treatment of inverted nipple. METHODS: A literature search was conducted by using PubMed, Google Scholar, and Cochrane database using the following MeSH terms: "inverted nipple," "inverted nipple surgery," "inverted nipple treatment," and "inverted nipple management." Studies that described surgical treatment and included outcomes and recurrence rate were included. RESULTS: Thirty-three articles were considered suitable, including 3369 inverted nipple cases. Eight studies described techniques with lactiferous ducts damaging, while 25 studies described techniques with lactiferous duct preservation using dermal flaps, sutures, or distractor systems. The average follow-up was 23.9 months. Overall, a satisfactory correction was reached in 88.6% of cases, and the recurrence rate was 3.89%. CONCLUSIONS: To our knowledge, our review includes the largest sample size in the literature. The heterogeneity and subjectivity of outcomes make it more complicated to state which is the best surgical strategy to adopt to obtain satisfactory and stable results with minimal morbidity. This study highlights the need of a standardized method to evaluate outcomes, including aesthetic, functional and psychological results, while using objective and subjective measurement instruments.

Nummular Headache and Its Surgical Treatment.

Nummular headache (NH) is an uncommon primary headache characterized by pain limited to a precise small area of the scalp. There is no global consensus on its pathogenesis, but its extracranial origin is the most accepted theory. Moreover, peripheral mechanism is supported by the overlapping symptomatology of secondary forms of NH and is well described in the literature. However, a standard effective treatment is still lacking. METHODS: A literature search according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was conducted to evaluate surgical strategies for NH. Inclusion criteria were English language, diagnosis of primary NH according to International Classification of Headache Disorders, 3rd Edition, or of secondary NH, and follow-up at a minimum of 3 months. The treatment had to consist of peripheral surgery. RESULTS: One hundred eighty-seven records were identified after duplicates were removed, 15 full-text articles were assessed for eligibility, and 4 records were selected for inclusion. A total of 53 patients were included in this review, 50 of whom were diagnosed with primary NH. The general positive response after surgery (>50% reduction in occipital migraine headaches) was about 70.0% for primary NH, while secondary NH always showed complete pain relief. However, many variations in patient selection and type of surgery were described. CONCLUSIONS: Neurovascular relationship in the extracranial tissues seems to be involved in the onset of NH. However, only limited data from meager literature and from few patients are currently available. Shared multicentric research protocols are badly required.

Prepectoral implant pocket conversion in breast reconstruction.

INTRODUCTION: While many authors have reported their experience in immediate prepectoral breast reconstruction (BR), implant pocket conversion from a submuscular to a prepectoral plane is less well described. The aim of this study is to provide a comprehensive review on plane conversion in implant-based BR, including the indications, surgical techniques, functional, and esthetic results. MATERIALS AND METHODS: A literature search via PubMed, Medline, Google Scholar, and Cochrane databases was performed using the following MeSH terms: "prepectoral pocket conversion", "subcutaneous pocket conversion", "prepectoral plane conversion", "subcutaneous plane conversion", and "prepectoral breast reconstruction". RESULTS: Ten articles in which 504 breasts were studied were deemed eligible for inclusion. The indications to perform plane conversion were animation deformity (AD), chronic pain, and implant malposition. Seven studies described complete or partial capsulectomy. The use of acellular dermal matrices (ADM) was reported in all cases except for three studies. The mean follow-up was 10.64 months. There was resolution of AD in 100% of cases. Three studies reported complete resolution of chronic pain. The overall complication rate was 12.102% and capsular contracture (CC) was the most frequent complication. Cosmetic revisions were reported in six studies (9.52%). The use of ADMs and fat grafting appeared to decrease the rate of subsequent CC formation and cosmetic revisions. CONCLUSIONS: The current article represents the first review about implant pocket conversion from a submuscular to a prepectoral plane, delineating its indications, surgical technique, postoperative complications, and functional and esthetic outcomes.

Peripheral Occipital Nerve Decompression Surgery in Migraine Headache.

BACKGROUND: Migraine headache in the occipital region is characterized by a recurrent pain of moderate to severe intensity. However, the diagnosis can be difficult because of the multitude of symptoms overlapping with similar disorders and a pathophysiology that is not well-understood. For this reason, the medical management is often complex and ineffective. METHODS: A literature search according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted to evaluate the surgical treatment of occipital migraines. Inclusion criteria were: English language, diagnosis of migraine, occipital neuralgia, or tension headache in compliance with the classification of the International Headache Society, follow-up at minimum 3 months, and adult age. The treatment had to consist of peripheral occipital nerve surgery. RESULTS: 323 records were identified after duplicates were removed, 30 full text articles were assessed for eligibility, and 9 records were selected for inclusion. A total of 1046 patients were included in the review. General positive response after surgery (>50% reduction in occipital migraine headaches) ranged from 80.0% to 94.9%. However, many differences in the selection of patients, target of decompression surgery, and measurement outcome were described. CONCLUSION: Despite the decennial proven effectiveness and safeness of surgical therapy for chronic occipital migraine headaches, more significant proof is needed to definitively confirm its use as a standard therapy.