History of Cranial Surgery in World War I: Experience on the Italian Front.

Since ancient history, men have been attempting to intervene when skull trauma occurs. The majority of traumas were always linked to war injuries, and in the modern era, the culprit was reached during World War I. Cranial traumas in wartime were very common, and consequently, physicians in wartime became particularly interested in the subject of cranial traumatology. In the following text, we want to bring to light the experience of some of the pioneers of cranial surgery in Italy during the First Great War. In fact before the war, very few medical officers had received training in central nervous system surgery. In addition, the surgical instruments for that clinical activity were inadequate and obsolete, but to deal with the medical emergency that had arisen on the front lines, the Italian government established Battlefield Medical Schools. And it is also from the reports and lectures of surgeons working on the front lines that the next generations of neurosurgeons were able to develop this surgical field into the complex and well-established surgical specialty that it is today.

Craniotomy Burr Hole Covers: A Comparative Study of Biomechanical, Radiological, and Aesthetic Outcomes Using 3 Different Plug Materials.

Burr holes in the cranial vault are usually made during trephination for craniotomy or drainage of chronic subdural hematomas. The resulting cranial defect might bring to unsatisfactory esthetic outcome. In the current study the authors report clinical data regarding a cohort of patients who were treated with 3 different types of burr hole covers; autologous bone dust from skull trephination, and 2 different types of cylindric plug made out of porous hydroxyapatite in order to evaluate medium and long-term esthetic and radiological outcomes. Twenty patients were consecutively enrolled in the study and in each patient all 3 types of materials were used to cover different holes. Clinical and radiological outcomes at 6 and 12 months, were analyzed for all 3 types of plugs in terms of thickness of the graft coaptation of margins, remodeling, fractures, mobilization, and contour irregularities. In all craniotomy holes filled with autologous bone dust the authors have observed partial or complete bone reabsorption at 1 year and in 60% of the cases a visible and palpable cranial vault contour irregularity was reported. Both types of bone substitutes gave satisfactory results, comparable to autologous bone dust at 6 months and superior at 12 months, especially in terms of thickness and esthetic appearance. Hydroxyapatite plugs have shown better esthetic and biomechanical results and higher patients' satisfaction compared to autologous bone dust while not giving any additional complications.

Reconstruction of the Axillary Region after Excision of Hidradenitis Suppurativa: A Systematic Review.

Introduction Hidradenitis suppurativa (HS) is a chronic, debilitating, recurrent, auto-inflammatory disease of the pilosebaceous units of the skin. The axillary region is the most affected anatomical site and its reconstructive options include skin grafts, local random plasties, regional axial flaps, and regional perforator flaps. The main aim of this systematic review is to identify the best surgical technique for axillary reconstruction in the context of HS, in terms of efficacy and safety. Methods We adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) throughout the whole review protocol build-up. The literature search was performed using MEDLINE, Embase, and Cochrane library databases, updated to March 2021. Quality was assessed for each study, through the National Institutes of Health Quality Assessment Tool. Results A total of 23 studies were included in the final analysis. We reviewed a total of 394 axillary reconstructions in 313 patients affected by HS Hurley Stage II or III. Skin grafts were associated with the highest overall complication rate (37%), and highest rate of reconstruction failure (22%). Between thoraco-dorsal artery perforator flap, posterior arm flap, and parascapular flap, the latter showed fewer total complications, recurrences, and failures. Conclusion Regional axial flaps should be considered as the best surgical approach in the management of advanced HS. The parascapular flap emerges as the most effective and safest option for axillary reconstruction. Local random flaps might be considered only for selected minor excisions, due to the higher risk of recurrence. The use of skin grafts for axillary reconstruction is discouraged.

Anxiety and depression mood disorder in patients with nasal septal deviation: A systematic review and meta-analysis.

BACKGROUND: Nasal septal deviation (NSD) is one of the most prevalent upper airway diseases causing airway obstruction, and it can negatively impact patients' quality of life (QoL). OBJECTIVE: The aim of this study was to determine the risk of anxiety and depression mood disorders in patients with NSD. METHODS: A systematic review and meta-analysis was performed according to the PRISMA statement. An electronic search was performed on PubMed/MEDLINE, Scopus and Google Scholar. Raw affect size data were pooled comparing standardized between group mean differences. RESULTS: A total of 625 patients (males: 53 %, n = 280/525) with a mean age of 32.4 years (n = 375, 95 % CI: 25.3-39.4) were included. The pooled standardized mean differences (SMD) for the prevalence of the anxiety disorder was 1.17 (n = 625, 95 % CI: 0.34-2.0). The pooled SMD for the prevalence of the depression disorder was 0.30 (n = 490, 95 % CI: 0.12-0.48). CONCLUSION: Prevalence of anxiety and depression mood disorders is higher in patients with NSD compared to controls. These diseases should be investigated and considered during the diagnostic and therapeutic process to improve the QoL of patients with NSD.

The Antibiotic Immersion of Custom-Made Porous Hydroxyapatite Cranioplasty: A Multicentric Cohort Study.

ABSTRACT: Cranioplasty is a common neurosurgical procedure performed to reconstruct cranial defects. The most common cranioplasty materials used today can be divided into 2 types: autologous bone and bone substitutes, such as polyetheretherketone, titanium mesh, poly-methyl methacrylate, and Hydroxyapatite (HA). Infection represents one of the most feared complications, ranging from 2.3% to 20%. Early implant infections occur within 30 days from the operation and are mostly due to pathogens from the skin and the paranasal cavity. The authors aim to demonstrate the efficacy of our preoperative antibiotic immersion protocol of custom-made HA prosthesis, to prevent early implant infections. The authors compare this population to cranioplasties without preoperative antibiotic elution and those with anonstandardized antibiotic elution. The authors retrospectively analyzed data from patients referred to 6 different hospitals in northern Italy, in the period 2000 to 2020. Inclusion criteria were patients requiring reconstruction of thecal bone with HA prosthesis after post-traumatic decompressive surgery; age more than 18 years; detailed patient history and clinical data; and follow-up of minimum 6 months. A total of 77 cranioplasties were included in the study, along with 120 retrospective cases in comparison. Infections occurred in 2.6% of cranioplasties with antibiotic immersion compared to 7.8% of cranioplasties without. Even if nonsignificant, these results support our hypothesis that pretreatment of HA implants with antibiotic appears to prevent cranioplasty infections and could be a viable option to improve cranioplasty outcomes in the future.

The Acute Achilles Tendon Rupture: An Evidence-Based Approach from the Diagnosis to the Treatment.

Background and Objective: Acute Achilles tendon rupture (AATR) is a common injury with a significant impact on daily living. Although various systematic reviews and meta-analyses have been written on the topic, no actual consensus exists on the best treatment. We aimed to collect the highest quality of evidence on the subject and to produce a document to which to refer, from the diagnosis to the final treatment. Material and Methods: Inclusion criteria were systematic reviews discussing Achilles tendon rupture, concerning either diagnostic criteria, classification, or treatment; English language; clearly stated inclusion and exclusion criteria for patients' selection. Results: Thirteen systematic reviews were included in the study. A strong consensus exists about the higher risk of re-rupture associated with non-operative treatment and a higher risk of complications associated with surgical repair. Conclusions: The combination of minimally invasive repair and accelerated functional rehabilitation seems to offer the best results in the treatment of Achilles tendon rupture.

Outcomes in Hybrid Breast Reconstruction: A Systematic Review.

Background and Objectives: Lipofilling is a commonly performed procedure worldwide for breast augmentation and correction of breast contour deformities. In breast reconstruction, fat grafting has been used as a single reconstructive technique, as well as in combination with other procedures. The aim of the present study is to systematically review available studies in the literature describing the combination of implant-based breast reconstruction and fat grafting, focusing on safety, complications rate, surgical sessions needed to reach a satisfying reconstruction, and patient-reported outcomes. Materials and Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) throughout the whole review protocol. A systematic review of the literature up to April 2022 was performed using Medline, Embase, and Cochrane Library databases. Only studies dealing with implant-based breast reconstruction combined with fat grafting were included. Results: We screened 292 articles by title and abstract. Only 48 articles were assessed for full-text eligibility, and among those, 12 studies were eventually selected. We included a total of 753 breast reconstructions in 585 patients undergoing mastectomy or demolitive breast surgeries other than mastectomy (quadrantectomy, segmentectomy, or lumpectomy) due to breast cancer or genetic predisposition to breast cancer. Overall, the number of complications was 60 (7.9%). The mean volume of fat grafting per breast per session ranged from 59 to 313 mL. The mean number of lipofilling sessions per breast ranged from 1.3 to 3.2. Conclusions: Hybrid breast reconstruction shows similar short-term complications to standard implant-based reconstruction but with the potential to significantly decrease the risk of long-term complications. Moreover, patient satisfaction was achieved with a reasonably low number of lipofilling sessions (1.7 on average).

Wide Local Excisions and Pedicled Perforator Flaps in Hidradenitis Suppurativa: A Study of Quality of Life.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic skin pathology characterized by the occurrence of inflamed and swollen lesions, with a devastating impact of the disease on patient's quality of life. Wide local excision (WLE) of the affected tissue is the criterion-standard treatment, but there is no general consensus on the best reconstructive technique. The aim of this article is to evaluate the quality of life before and after WLE combined with pedicled perforator flap reconstruction, in patients suffering from HS. METHODS: We analyzed 26 consecutive patients suffering from Hurley stage III HS. Every patient underwent WLE, followed by reconstruction with pedicled perforator flap. Dermatology Quality of Life Index (DLQI) tests were administered to every patient preoperatively and 6 months after surgery, when the clinical condition was considered stable. Dermatology Quality of Life Index scores were compared in terms of means with Student t test. Linear regression studies were used to compare the changes in DLQI score with the surgical and clinical variables. RESULTS: Axillary area involvement was found in 21 of 27 patients; 6 patients had more than 1 body region involved. Thirty-two pedicled perforator flaps were performed, and 22 were thoracodorsal artery perforator flaps. Mean DLQI test score before the first operation was 21.31 ± 4.79; the average DLQI score after the last follow-up was 5 ± 2.95 (P < 0.0001). Dermatology Quality of Life Index scores were not influenced by complications including reoperation. There were also no correlations found between DLQI score delta and number of reoperation (-0.18) or days of hospital stay (-0.13). CONCLUSIONS: Wide local excision followed by pedicled perforator flap reconstruction allows a radical excision of HS areas with short postoperative healing periods. Dermatology Quality of Life Index scores confirmed high levels of patients' satisfaction. Disadvantages of this technique include difficult learning curve, long operating time, and a nonnegligible complications rate.

Comparison of Efficacy among Three Dermal Substitutes in the Management of Critical Lower-Limb Wounds: The Largest Biases-Reduced Single-Center Retrospective Cohort Study in Literature.

Background and objectives: The skin recently became the main focus of regenerative medicine and, in this context, skin substitutes are fully entering into the plastic surgeon's armamentarium. Among the various types of skin substitutes, dermal substitutes (DSs) are the most used. Our study aims to retrospectively compare three renowned and extremely similar DS in the management of critical lower limb wounds in the largest cohort analysis currently present in literature. Materials and Methods: We followed a strict protocol of application and evaluation of the DS for each patient and wound and, after a meticulous bias reduction process, we compared final outcomes in terms of efficacy and speed in achieving the defect coverage. Results: Among patients who did not receive a skin graft after the DS, we registered a wound healed surface of 50% for Pelnac, 52% for Integra, and 19% for Nevelia, after 30 days from the external silicon layer removal; among those who received a skin graft after the DS, we observed a significantly lower mean percentage of graft take after 7 days with Pelnac (53%) compared to Integra and Nevelia (92% and 80%, respectively). The overall percentage of wound healed surface obtained after 30 days from the external silicon sheet removal, either with or without skin graft, was 71% for Pelnac, 63% for Integra and 63% for Nevelia. We also ran a sub-group analysis only including grafted wounds with a negative microbiological test and the mean percentage of graft take was similar this time. Eventually, we assessed the influence of the wound's "chronicity" on its healing, comparing the mean graft take only in "acute" wounds who received a skin graft and it resulted 63% for Pelnac, 91% for Integra and 75% for Nevelia. Conclusions: Integra demonstrates the highest rate of skin graft viability and the highest rate of skin graft takes after 7 days. Pelnac shows the quickest induction of secondary healing in acute wounds. Nevelia is not different from Integra and shows a superior graft take compared to Pelnac, but features the lowest secondary healing induction rate. No differences exist between the three DSs in terms of wound healing after 30 days from the skin graft or from the removal of the external silicon layer.

Proteomic and Ultrastructural Analysis of Cellulite-New Findings on an Old Topic.

: Background: Cellulite is a condition in which the skin has a dimpled lumpy appearance. The main causes of cellulite development, studied until now, comprehends modified sensitivity to estrogens, the damage of microvasculature present among dermis and hypodermis. The differences of adipose tissue architecture between male and female might make female more susceptible to cellulite. Adipose tissue is seen to be deeply modified during cellulite development. Our study tried to understand the overall features within and surrounding cellulite to apply the best therapeutic approach. METHODS: Samples of gluteal femoral area were collected from cadavers and women who had undergone surgical treatment to remove orange peel characteristics on the skin. Samples from cadavers were employed for an accurate study of cellulite using magnetic resonance imaging at 7 Tesla and for light microscopy. Specimens from patients were employed for the proteomic analysis, which was performed using high resolution mass spectroscopy (MS). Stromal vascular fraction (SVF) was obtained from the samples, which was studied using MS and flow cytometry. RESULTS: light and electron microscopy of the cellulite affected area showed a morphology completely different from the other usual adipose depots. In cellulite affected tissues, sweat glands associated with adipocytes were found. In particular, there were vesicles in the extracellular matrix, indicating a crosstalk between the two different components. Proteomic analysis showed that adipose tissue affected by cellulite is characterized by high degree of oxidative stress and by remodeling phenomena. CONCLUSIONS: The novel aspects of this study are the peculiar morphology of adipose tissue affected by cellulite, which could influence the surgical procedures finalized to the reduction of dimpling, based on the collagen fibers cutting. The second novel aspect is the role played by the mesenchymal stem cells isolated from stromal vascular fraction of adipose tissue affected by cellulite.

The Effect of Muscle Exercise on Perforators Flow: A Prospective Cohort Study.

Background and objectives: The metabolic response after exercise causes a significant increase in the muscle blood flow. While these effects are demonstrated for intra-muscular vessels, there is no evidence about the inter-muscular vessels, such as the septocutaneous perforators supplying the skin after they branch out from the deep source artery. The aim of our prospective study was to quantify the changes in the anterior tibial artery perforators arterial blood flow after mild isotonic exercise in a young and healthy population. Material and Methods: We performed a prospective analysis of 34 patients who were admitted to the Plastic Surgery Department from December 2019 to April 2020. Flow velocities of two previously identified anterior tibial artery perforators were recorded both before and after 10 complete flexion-extensions of the foot. The time to revert to basal flow was measured. We further classified the overmentioned patients based on their level of physical activity. Results: We registered a significant increase in systolic, diastolic and mean blood flow velocities both in proximal and distal anterior tibial artery perforators after exercise. Fitter patients exhibited a higher increase in proximal leg perforators than those who did less than three aerobic workouts a week. The time to return to basal flow ranged from 60 to 90 s. Conclusions: This was the first study to describe the effect of muscular activity on perforators blood flow. Even mild exercise significantly increases the perforator flow. Waiting at least two minutes at rest before performing the Doppler study, thus avoiding involved muscle activation, can notably improve the reliability of the pre-operative planning.

Smooth Prosthesis: Our Experience and Current State of Art in the Use of Smooth Sub-muscular Silicone Gel Breast Implants.

BACKGROUND: The objective of this clinical review is to provide an overview of the use of silicone gel-filled breast implants placed in the sub-muscular position, with a focus on complication rates reported for both smooth and textured implants. Furthermore, our experience in this field is also reviewed. METHODS: MEDLINE, EMBASE, Web of Science, Scopus, the Cochrane Central and Google Scholar databases were reviewed to identify the literature related to smooth breast implants. Each article was reviewed by two independent reviewers to ensure all relevant publications were identified. The literature search identified 98 applicable articles. Of these, just a few articles were found to have a therapeutic level of evidence. The reference lists in each relevant paper were screened manually to include relevant papers not found through the initial search. RESULTS: Eight articles report the risk of capsular contracture when the breast implants were placed in the sub-muscular position. Six of these articles report a similar rate of capsular contracture in smooth and textured implants. Local complications such as wrinkling, late seroma and double capsules were found to be associated with the use of textured breast implants (4 articles). All articles concerning BIA-ALCL reported a total absence occurring in smooth breast implants. All cases have been associated with textured mammary prostheses. CONCLUSION: With our expertise in the field and the results of this up-to-date literature review, it can be concluded that there are no significant advantages of using one type of implant surface over the other when placed in the sub-pectoral position. 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.

Pedicled Thoracodorsal Artery Perforator and Muscle-Sparing Latissimus Dorsi Flaps in the Axillary Reconstruction After Hidradenitis Suppurativa Excision: Functional and Aesthetic Issues.

BACKGROUND: Wide axillary reconstruction after hidradenitis suppurativa (HS) excision still represents a great challenge. Thoracodorsal artery perforator flap is one of the most reliable local reconstructive techniques. Although its anatomy and harvesting technique have been well described, specific reconstructive criteria still lack. The aim of this study was to help surgeons in planning axillary reconstruction on flaps based on the thoracodorsal artery. METHODS: Twelve patients affected by HS at Hurley stage III underwent wide "en block" excision and immediate reconstruction with 15 local thoracodorsal artery perforator flaps and 2 muscle-sparing latissimus dorsi flaps. A thorough chart review has been performed with preoperative and postoperative photographic documentations. Early and late complications have been analyzed. RESULTS: A total of 15 perforator flaps on thoracodorsal artery and 2 muscle-sparing latissimus dorsi flaps have been raised. The early complication rate was 29%, whereas the late complication rate was 35%. Except for one, all patients declared they were satisfied or highly satisfied from both aesthetic and functional points of view. Analyzing specific aspects, we have described several important details to consider for the reconstruction of the axilla. Through a retrospective analysis, we have classified HS axillary patients into 4 categories to better plan surgical reconstruction. CONCLUSIONS: Axillary reconstruction is still a plastic surgery challenge. Peculiar surgical details should be considered when approaching this area. This new classification may help young surgeons during the reconstructive phase.

Necrotizing Fasciitis in Aesthetic Surgery: A Review of the Literature.

INTRODUCTION: Necrotizing fasciitis (NF) is a rare, potentially fatal, infective complication that can occur after surgery. Diagnosis is still difficult and mainly based on clinical data. Only a prompt pharmacological and surgical therapy can avoid dramatic consequences. There are few reports regarding NF as a complication after aesthetic surgical procedures, and a systematic review still lacks. MATERIALS AND METHODS: We have performed a systematic review of English literature on PubMed, covering a period of 30 years. Keywords used were "necrotising fasciitis" matched with "aesthetic surgery complications", "breast surgery", "mammoplasty", "blepharoplasty", "liposuction", "facelift", "rhinoplasty fasciitis", "arm lift", "thigh lift", "otoplasty" and "abdominoplasty fasciitis". No additional search and temporal limitation were set. RESULTS: Among 3782 papers concerning NF, only 18 were related to NF after an aesthetic surgical procedure. Liposuction was the most affected procedure, with buttocks and lower extremity the most involved anatomical regions. The majority of the infections were monomicrobial, promoted by Streptococcus pyogenes. In most cases, NF occurred within the third post-operative day with non-specific signs and symptoms. In 14 cases, a single or multiple surgical interventions were performed and survival was achieved in 11 patients. CONCLUSIONS: In case of infection after aesthetic surgery, we should always bear in mind NF. Clinical hallmarks still guide NF management. Because early signs and symptoms are usually non-specific, a strict clinical control is highly suggested. Once clinical suspicion is raised, prompt antibacterial therapy should be administered, followed by surgical debridement in case of ineffective response. 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 .

Reduction Mammaplasty for Breast Symmetrisation in Implant-Based Reconstructions.

BACKGROUND: Healthy breast surgery constitutes an important step to achieve symmetry in unilateral implant-based reconstructions. We analysed long-term results of breast symmetry obtained with reduction mammaplasties, and we evaluated whether different glandular pedicles may better preserve long-term stability. METHOD: Between 2006 and 2012, 90 patients underwent mastectomy and immediate reconstruction with tissue expanders and simultaneous contralateral reduction mammaplasty. In 30 patients, a superior nipple-areola pedicle was harvested (GROUP A), in another 30 patients a medial pedicle was performed (GROUP B), and an inferior pedicle was used in the remaining 30 women (GROUP C). An objective evaluation of the reconstructed breast and the reduced one was performed at 1 and 24 months after surgery. One-way ANOVA and Tukey's HSD tests were used for analysis. Furthermore, three independent plastic surgeons filled out a questionnaire to assess aesthetic results. RESULTS: Measurements of the reconstructed breasts showed similar variations between 1- and 24-month evaluations within the three groups with no significant difference (P value >0.05). Measurements of the reduced breast at the 1- and 24-month follow-up (Tukey's test) revealed significant differences among the three groups. Patients from GROUP C showed a significantly higher decrease in Δ nipple-lower clavicle margin distance and Δ nipple-inframammary fold compared to GROUP A and B (P value = 0.01). Surgeons' assessments revealed no statistically significant difference between the three groups. CONCLUSION: Superior or medial pedicle reduction mammaplasties seem to better preserve breast shape and position, and they maintain a more similar appearance to the contralateral prosthetic breast over time. 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 .

A Simple and Effective Technique of Breast Remodelling After Conserving Surgery for Lower Quadrants Breast Cancer.

BACKGROUND: Quadrantectomy is an oncologically safe procedure for the treatment of early-stage breast cancer, but it often results in poor aesthetic outcomes such as breast shape deformity, which is more visible if the tumour is located in the lower pole. We recommend the use of the transverse incision, which retains the oncological advantages of the quadrantectomy while leading to better aesthetical results. METHOD: We evaluated the clinical results of 24 patients with breast cancer who underwent quadrantectomy of the lower breast pole and volume replacement with remodelling through three posterior scorings from January 2012 to January 2014, with cosmetic evaluations performed according to the criteria set by the Japanese Breast Cancer Society. RESULTS: Minimum follow-up after surgery was 2 years, with an average of 28.4 months. Among treated patients, the percentage of complications was extremely low and the degree of satisfaction fairly good. Moreover, the assessment of the medical team matched patient self-assessments. CONCLUSION: Immediate breast reconstruction of a defect performed after a quadrantectomy of the lower breast pole using the "posterior scoring technique" provided better cosmetic results compared to the transposition of residual breast tissue. This technique provides reliable and reproducible results, and it also appears to be rather successful on patients with small-moderate breasts in the absence of a certain degree of ptosis, therefore increasing its already considerable appeal. LEVEL OF EVIDENCE V: This journal requires that the 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 amnion muscle combined graft (AMCG) conduits: a new alternative in the repair of wide substance loss of peripheral nerves.

The use of autologous sural nerve grafts is still the current gold standard for the repair of peripheral nerve injuries with wide substance losses, but with a poor rate of functional recovery after repair of mixed and motor nerves, a limited donor nerve supply, and morbidity of donor site. At present, tubulization through the muscle vein combined graft, is a viable alternative to the nerve autografts and certainly is a matter of tissue engineering still open to continuous development, although this technique is currently limited to a critical gap of 3 cm with less favorable results for motor function recovery. In this report, we present a completely new tubulization method, the amnion muscle combined graft (AMCG) technique, that consists in the combination of the human amniotic membrane hollow conduit with autologous skeletal muscle fragments for repairing the substance loss of peripheral nerves and recover both sensory and motor functions. In a series of five patients with loss of substance of the median nerve ranging 3-5 cm at the wrist, excellent results graded as S4 in two cases, S3+ in two cases, and S3 in one case; M4 in four cases and M3 in one case were achieved. No iatrogenic damage due to withdrawal of a healthy nerve from donor site was observed. This technique allows to repair extensive loss of substance up to 5 cm with a good sensory and motor recovery. The AMCG thus may be considered a reasonable alternative to traditional nerve autograft in selected clinical conditions.

Tattoo ink-related cutaneous pseudolymphoma: a rare but significant complication. Case report and review of the literature.

BACKGROUND: The demand for decorative tattoos is steadily growing worldwide, and in the US it is estimated that up to 24% of adults has one or more tattoos. Subsequently, the number of tattoo-related complications is increasing. Among these, lymphoproliferative disorders play a minor but important role. The aim of this article is to arouse the awareness of plastic surgeons and dermatologists about this rare but serious complication and to stimulate stricter clinical control of their tattooed patients. METHODS: We report a new case of tattoo-related cutaneous pseudolymphoma (CPL) and perform a review of the last 30 years of literature on the topic in PubMed. RESULTS: Apart from this new case, only 18 cases of CPL have been reported in PubMed so far. In contrast to the classic knowledge, the T cell was the predominant phenotype in 68% of cases. Red is confirmed to be the most involved ink. Topical and intralesional steroids, laser therapy, and surgery were used for treatment of CPL. CONCLUSIONS: Even if CPL is a very rare and benign complication, we should not forget that in rare cases pseudolymphoma may evolve into a true lymphoma. Diagnosis is still difficult and is based on anamnestic, clinical, and histopathological data. From the review of the literature, the T cell predominance suggests a reclassification of tattoo-induced CPL and there is not a gold standard treatment yet. Finally, once a pseudolymphoma is diagnosed, there must be a long follow-up because of the possibility to transform into a malignancy. 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 .

A treatment algorithm for hyaluronic acid filler related complications of the face.

BACKGROUND: Throughout the last decade, a notable increase in HA-filler-related complications have been observed, owing to the increase in demand for filler injections and availability of multiple products. OBJECTIVES: The aim is to provide practical advice on the best way to prevent and treat HA-filler-related complications. METHODS: Thirty patients who experienced visible and/or symptomatic complications localized within the facial area were treated according to our algorithm. Patients with inflammatory lesions underwent antibiotic and anti-inflammatory therapy, followed by hyaluronidase injections. Patients with abscesses were treated with antibiotics, incision, and drainage. Each patient completed the dermatology-specific quality of life questionnaire (DLQI) at the first and last examinations. RESULTS: Among the 29 patients who received antibiotic therapy, 3 healed without further treatment. However, 18 received hyaluronidase injections, 9 underwent incision and drainage, and 5 presented with fistulas and developed retracted scars. Moreover, 80% of the patients were completely healed, 13% significantly improved, and 3% did not show any improvement. The DLQI scores analysis showed a notable impact of patients' diseases on their quality of life, mainly in the terms of personal relationships and symptoms, with minor impacts on intimate relationships, ability to work, and study. We demonstrated that our algorithm resulted in a significant improvement in the overall quality of life at the last follow-up (p < 0.001). CONCLUSIONS: The use of filler injections requires caution and specific training because they can lead to serious complications. If these complications are recognized promptly, healing can be optimized. Our treatment algorithm demonstrated high rate of healing and significant improvement in the patients' quality of life.