The Role of Platelets and Aneurysm Thrombus in the EVAR Post Implantation Syndrome.

BACKGROUND: Post implantation syndrome (PIS) is a well-defined entity with unclear etiology, complicating a number of patients with abdominal aortic aneurysms treated with endovascular aortic repair (EVAR). The aim of this study was to assess the platelets' role and the influence of aneurysmal sac thrombus volumes in the development of PIS. A retrospective analysis of prospectively collected data was performed, and 76 patients who were treated by EVAR (2011-2013) were studied. Aneurysms with endoleak were not included in the study. Based on the criteria for systemic inflammatory response syndrome (SIRS), 17 patients (22%) developed PIS (which is considered a SIRS analogue), while 59 (78%) did not. METHODS: The 2 groups were compared in relation to the following parameters: baseline platelet count (PLT), decrease of platelet count (PLT drop), volume of the arterial flow before the procedure (V flow), volume of thrombus of the aneurysm (V thromb), ratio of thrombus volume to aneurysm sac volume (V ratio), and the volume of newly formed thrombus (V new). Volume flow measurements were calculated by Osirix software preoperatively and in the first month postoperatively. Parametric and nonparametric techniques (unpaired t-test, Mann-Whitney U test) were used accordingly. RESULTS: Baseline platelets absolute count was greater in the PIS group (239,000 ± 17,000) versus the non-PIS group (194,000 ± 6,900, P = 0.004), and the PLT drop was larger in the PIS group (74,000 ± 15,600 versus 45,000 ± 5,300, P = 0.019). No difference was found regarding the aneurysm volumes (V flow, V thromb, V ratio, and V new) between the 2 groups. CONCLUSIONS: Platelets, in terms of their absolute baseline count and their decrease after the procedure, seem to be an important factor in developing PIS after EVAR. Further, more tailored studies are needed to elucidate the role of platelets and flow or thrombus volumes in the development of PIS.

Extracellular Vesicles as Novel Diagnostic and Therapeutic Agents for Non-Melanoma Skin Cancer: A Systematic Review.

Standard non-melanoma skin cancer (NMSC) treatment involves surgery, recently combined with chemotherapy or immunotherapy in cases of advanced tumors. EVs, including exosomes, are integral to carcinogenesis, and are found in NMSC releasing mediators impacting tumor progression. Nevertheless, the precise intercellular signaling role of NMSC-derived EVs remains unclear. This review aims to elucidate their potential role in NMSC diagnosis and treatment. This systematic review encompassed literature searches in electronic databases from inception to September 2023, based on certain inclusion and exclusion criteria, addressing NMSC-derived EVs, their molecular cargo, and their implications in the diagnosis, prognosis, and treatment of NMSC. Key components were identified. Extracellular vesicle (EV) proteins and RNA have emerged as diagnostic biomarkers in EV-based liquid biopsy. Circular RNA CYP24A1, known for its molecular stability, holds promise as a diagnostic biomarker. Long noncoding RNAs (lincRNA-PICSAR) and Desmoglein 2 (DSg2) are linked to drug resistance, serving as prognostic biomarkers. EV mediators are being actively investigated for their potential role as drug delivery agents. In conclusion, this systematic review showed that NMSC-derived EVs display promise as therapeutic targets and diagnostic biomarkers. Further research is imperative to fully comprehend EV mechanisms and explore their potential in cancer diagnosis and treatment.

Towards non-invasive monitoring of non-melanoma skin cancer using spatially offset Raman spectroscopy.

BCC (basal cell carcinoma) and SCC (squamous cell carcinoma) account for the vast majority of cases of non-melanoma skin cancer (NMSC). The gold standard for the diagnosis remains biopsy, which, however, is an invasive and time-consuming procedure. In this study, we employed spatially offset Raman spectroscopy (SORS), a non-invasive approach, allowing the assessment of deeper skin tissue levels and collection of Raman photons with a bias towards the different layers of epidermis, where the non-melanoma cancers are initially formed and expand. Ex vivo Raman measurements were acquired from 22 skin biopsies using conventional back-scattering and a defocused modality (with and without a spatial offset). The spectral data were assessed against corresponding histopathological data to determine potential prognostic factors for lesion detection. The results revealed a positive correlation of protein and lipid content with the SCC and BCC types, respectively. By further correlating with patient data, multiple factor analysis (MFA) demonstrated a strong clustering of variables based on sex and age in all modalities. Specifically for the defocused modality (zero and 2 mm offset), further clustering occurred based on pathology. This study demonstrates the utility of the SORS technology in NMSC diagnosis prior to histopathological examination on the same tissue.

Concomitant Reconstruction of Multiple Scalp Defects With One Rotational Flap.

The cornerstones of scalp reconstruction are provisions of adequate skin paired with a satisfactory cosmetic outcome without hairline distortion. Several techniques have been described over the years to reconstruct sizable defects. Currently, an individualized approach, based on the patient's medical status and needs, the defect characteristics, and the local tissue quality and availability, should be considered for an optimal outcome. The reconstruction of multiple scalp defects, by means of a well-planned rotational flap, is proposed as a viable option with many advantages. It enables concurrent reconstruction of the defects, obviates further surgical incisions, and elaborates surgical maneuvers, minimizing operative time and complications risk. A satisfactory esthetic outcome can be achieved.

The 'Facelift' Flap Revisited.

The reconstruction of facial defects focuses on the preservation of function without compromising facial symmetry and esthetics. The aim of the study is to describe and evaluate a revised 'facelift' flap technique to reconstruct large defects of the cheek, temple, frontotemporal area, and zygomatic arch. A prospective, observational study of facial defect reconstruction by means of a 'facelift' flap was conducted from January 2019 to January 2022. The revised 'facelift' flap technique, based on the defect location and characteristics, is described. The postoperative outcomes and patient satisfaction were evaluated. The flap was applied to 34 patients with defect diameters ranging from 3 cm to 9 cm. The mean operation time was 67±17 minutes and the mean hospital stay was 1 day. No major postoperative complications were encountered; reoperation was not needed. High patient satisfaction rates were reported (9.6±0.5). The revised facelift flap is a reliable and safe method for the reconstruction of large defects of the cheek, temple, frontotemporal area, and zygomatic arch, based on local tissue availability that ensures satisfactory esthetic outcomes with undetectable scars.

Antibiotic Prophylaxis in Reduction Mammaplasty: A Network Meta-Analysis.

BACKGROUND: Mounting evidence suggests that breast reduction surgery displays higher rates of surgical site infections (SSI) than initially presumed. Objective of this network meta-analysis is to evaluate the effectiveness of different antibiotic regimens in the prophylaxis from surgical site infections and delayed wound healing (DWH) following breast reduction. METHODS: A network meta-analysis was conducted using a predetermined protocol after searching the electronic databases MEDLINE, Scopus, the Cochrane Library and US National Institutes of Health Ongoing Trials Register from inception to July 2022. The included studies had to examine breast reduction in females with at least 1-month follow-up, receiving antibiotics in an intervention arm compared to a control arm. The quality of studies was assessed using the Cochrane risk of bias tool. A frequentist Mantel-Haenszel approach was adopted for the reported SSI rates while an inverse variance random effects model was used for the DWH rates. RESULTS: A total of 10 studies was included in the analysis involving 1331 patients. All but one study controlled for major risk factors, and no differences were observed in patients' baseline characteristics. Antibiotic administration significantly reduced the SSI rate after breast reduction, with the prolonged antibiotic regimen being the most efficacious (odds ratio [OR]: 0.36 [95%CI: 0.15-0.85]). No statistically significant reduction in delayed wound healing rate was revealed among the regimens. CONCLUSIONS: Antibiotics mitigate the SSI rate after breast reduction. This meta-analysis provides an evidence-based strategy to optimize antibiotic administration. Further research is needed though to examine antibiotic prophylaxis on delayed wound healing. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Efficacy of Different Nerve Blocks on Postoperative Pain and Sequelae in Patients Undergoing Abdominoplasty: A Network Meta-Analysis.

BACKGROUND: Although abdominoplasty is growing in popularity, it still results in considerable postoperative pain, which prolongs recovery. OBJECTIVES: The aim of this network meta-analysis was to combine evidence about different regional nerve blocks to examine their effectiveness in the management of postoperative pain sequelae and recovery following abdominoplasty. METHODS: An electronic literature search in the MEDLINE (PubMed; National Institutes of Health, Bethesda, MD), Scopus (Elsevier, Amsterdam, the Netherlands), Cochrane Library (London, UK) and US National Institutes of Health Ongoing Trials Register electronic databases (Bethesda, MD) was conducted from inception to July 2022. Inclusion criteria were the presence of intervention and control groups; data derived from controlled studies evaluating nerve blocks after abdominoplasty, in terms of analgesia needs, complications, and patient satisfaction; and publication in peer-reviewed journals. The quality of studies was assessed via Cochrane's risk-of-bias tool. A frequentist random-effects network meta-analysis was conducted for all outcomes of interest. RESULTS: A total of 12 studies, containing 543 patients with no differences in age, sex, BMI, and comorbidities, met the inclusion criteria. Transversus abdominis plane blocks have been found to reduce 24-hour and 48-hour opioid consumption (-3.70 and -5.01 weighted mean difference, respectively). In addition, the nerve blocks reviewed effectively prolonged the time to first rescue analgesia request, were safe in terms of complications, and were associated with high satisfaction rates. CONCLUSIONS: Nerve blocks emerge as an effective and safe adjunct for adequate pain management following abdominoplasty. This meta-analysis provides an evidence-based strategy to optimize the current analgesia regimens following abdominoplasty.

The Association of Vitamin D with Non-Melanoma Skin Cancer Risk: An Umbrella Review of Systematic Reviews and Meta-Analyses.

Background and Objectives: Previous studies revealed the anti-angiogenic, antiproliferative, and anti-inflammatory effects of Vitamin D (VitD) on cancer cells. Although this body of evidence supported the correlation of high VitD levels with reduced incidence rates for various malignancies, contradictory results were reported regarding non-melanoma skin cancer (NMSC). The aim of this overview was to summarize the available evidence from the existing pool of systematic reviews and meta-analyses, focusing on VitD serum status, dietary intake, and VitD receptor (VDR) polymorphisms in correlation to NMSC incidence. Materials and Methods: A literature search in electronic databases was conducted from inception to January 2023. The inclusion criteria were systematic reviews and meta-analyses published in peer-reviewed journals, evaluating VitD serum levels, dietary and/or supplementary intake, or VDR gene polymorphisms, and reporting data on NMSC. Results: A total of 10 studies were included in the data analysis models. A positive association between VitD serum levels and NMSC is highlighted. However, dietary/supplementation of VitD does not exhibit a likewise strong linkage to NMSC. Despite the contradictory findings, VDR polymorphisms may play a crucial role in the intricate NMSC pathogenesis. Conclusions: This umbrella review shows that high VitD levels are associated with increased NMSC incidence, potentially due to its direct correlation with increased sun exposure. Further research on VDR polymorphisms is suggested to explore their true effect size on NMSC risk.

Takotsubo Syndrome in the Perioperative Period: A Case Report and a Comprehensive Review of Pertinent Literature.

ABSTRACT: Stress-induced cardiomyopathy or takotsubo syndrome is a rare, nonischemic, heart condition resembling that of an acute coronary syndrome. Its distinctive feature is a transient wall motion abnormality occurring usually at the apical segment of the heart, with the degree of symptom manifestation and severity varying among patients. Although early data were supportive of a benign sequela and outcome, high degree of adverse events, such as acute heart failure and pulmonary edema, are anticipated, and the mortality rate approaches 5%. Hyperactivation of the sympathetic nervous system and adrenergic drugs have been pointed out as possible precipitators of the condition. Surgical procedures are a known cause of emotional and physical stress on patients, acting as an ideal substrate for the presentation of this syndrome. On occasion of a perioperative takotsubo syndrome case in a female patient during second-stage implant-based breast reconstruction, a review of the pertinent literature is presented. The acute onset and severity of the manifestations in this surgically uneventful procedure necessitated a multidisciplinary approach. Consequently, this report should raise awareness of the syndrome among plastic surgeons and anesthesiologists to promptly recognize and manage it effectively.

An Algorithmic Approach for the Reconstruction of Extended Upper-Third Auricular Soft Tissue Defects.

ABSTRACT: Auricular defects are demanding to reconstruct due to the complex anatomy and the three-dimensional shape of the ear. The functional perspective needs to be addressed without neglecting aesthetic outcomes though, given that it is a prominent facial landmark. In this report the reconstruction of a sizable soft tissue defect of the helical crus and upper third of the right auricle, following surgical excision of a skin tumor, is presented. A variety of treatment options is explored, and a relevant algorithm is proposed. This defect was reconstructed using a transposition flap from the postauricular area, accomplishing single-stage full defect coverage combined with optimal postoperative aesthetic results. High patient satisfaction levels were achieved, avoiding more complicated and prolonged procedures. This case exemplifies the proposed algorithmic approach of upper-third auricular defects, addressing these defects in a systematic and logical manner.

The impact of treatment delay on skin cancer in COVID-19 era: a case-control study.

BACKGROUND: The outbreak of COVID-19 pandemic led to a 2-month lockdown in Europe. Elective surgeries, including skin cancer excisions, were postponed. The purpose of this prospective case-control study was to assess the impact of the treatment delay on patients with non-melanoma skin cancer (NMSC) or melanoma operated in the first post-lockdown period. METHODS: A comparative study of skin cancer operations performed in a 4-month period either in 2020 or in 2019 was conducted. All data were collected from a prospectively maintained clinic database and the pathological reports. Continuous variables were compared with t test or Mann-Whitney U test according to their distribution. Categorical variables were compared with Fisher exact test. Odds ratio (OR) with 95% confidence interval (95% CI) was used to assess the risk of excising high-risk NMSC in 2020 compared with 2019. RESULTS: Skin cancer excision was performed in 158 cases in 2020 compared to 125 cases in 2019 (26.4% increase). Significantly, more SCC were excised in 2020 (p = 0.024). No significant difference for several clinical parameters regarding BCC, SCC, and melanoma was identified. However, the reconstructive method applied, following NMSC excision, was significantly different, requiring frequently either skin grafting or a flap. CONCLUSION: These results indicate that skin cancer treatment delay, due to COVID-19 pandemic, is related to an increased incidence of SCC and more complicated methods of reconstruction. Considering the relapsing COVID-19 waves, significant skin cancer treatment delays should be avoided. TRIAL REGISTRATION: The study adhered to the STROBE statement for case-control studies.

Single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata: A case report.

Reconstruction of complex soft tissue defects in the distal lower leg remains challenging, since anatomical constraints limit the local options available in this area. In this report, we present a case of single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata. A 55-year-old patient underwent wide excision of a synovial sarcoma in the distal lower leg, which resulted in a complex defect including the peroneus longus and brevis tendons (10 cm), and the overlying skin (14 × 8 cm). Functional reconstruction was achieved in a single stage with a composite anterolateral thigh flap with vascularized fascia lata of similar dimensions to those of the defect. The fascia lata component of the flap was longitudinally split in two segments. Each of them was rolled up, and that way, two separate vascularized neotendons were created. The neotendons bridged the gap of peroneal tendons, whereas the skin paddle of the flap provided stable soft tissue coverage to the reconstructed tendons. Flap pedicle was anastomosed to the anterior tibial vessels. Early and late postoperative periods were uneventful. Follow up at 1 year postoperatively showed excellent neotendon incorporation, as well as a very good functional and aesthetic outcome. The use of the method described may be a useful alternative in single stage functional reconstruction of composite defects comprising two or even more tendons and the overlying skin.

Development of a Scoring System for the Prediction of Early Graft Failure after Peripheral Arterial Bypass Surgery.

BACKGROUND: An occluded lower limb arterial bypass is associated with poor prognosis for the limb. Currently, no risk assessment method to estimate the risk of early graft failure exists. Aim of this study was to investigate the effect of various potential factors on early graft failure of infrainguinal bypass surgery and to develop a risk-scoring model to predict it. METHODS: A prospective observational clinical study was performed. One hundred infrainguinal bypass procedures (60 autologous and 40 synthetic grafts), throughout a 3-year period were included. Nearly, 84 patients suffered by chronic limb ischemia, whereas 16 by acute limb ischemia or popliteal aneurysm disease. Various possible factors including demographic data, atherosclerosis predisposing factors, and technical details of the procedure were examined as possible causes of early graft failure. Using a combination of univariable and multivariable analysis techniques, the most significant factors were extracted, and a simple predicting risk-scoring system of early graft failure was calculated. RESULTS: The overall early graft failure rate was 14%. The factors related to it at a statistically significant level, 0.05, were the female gender, a bypass performed after a previous ipsilateral lower limb angioplasty, a redo procedure on the same limb, and a distal anastomosis at an inframalleolar level (pedal bypass). After internal validation, the FARP2-predicting scoring system was formed as following: Female gender 1 point (F), bypass after a previous Angioplasty 1 point (A), Redo bypass 1 point (R), and Pedal bypass 2 points (P2). An overall score equal or greater than 2, provided an early graft failure prediction with sensitivity of 100%, specificity 86%, positive predictive value 54%, and negative predictive value of 100% (area under the receiver operator characteristic curve: 0.959). CONCLUSIONS: FARP2 is a simple scoring system for predicting early graft failure after an infrainguinal bypass procedure. Further external validation in larger populations is needed.

Prevention of Seroma Formation Following Abdominoplasty: A Systematic Review and Meta-Analysis.

Background: With seroma formation being the most common complication of abdominoplasty, multiple surgical strategies have been proposed to lower the seroma rate, yet their effectiveness is unclear. Objectives: The objective of this systematic review and meta-analysis was to comprehensively summarize and quantify the effects of preventive surgical measures for seroma in patients undergoing abdominoplasty. Methods: A predetermined protocol was used. An electronic search in MEDLINE, Scopus, the Cochrane Library, and CENTRAL electronic databases was conducted from inception to June 2016. This search was supplemented by a review of reference lists of potentially eligible studies and a manual search of key journals in the field of plastic surgery. Eligible studies were prospective controlled studies, which investigated prevention of seroma formation and reported on seroma rate. Secondary outcomes were rate of hematoma, wound dehiscence, infection, reoperation and hospital readmission, time to drain removal, total drain output, and length of hospital stay. Results: The meta-analysis included nine studies with 664 abdominoplasty patients. Seroma rate was 7.5% in the prevention group and 19.5% in the control group with the odds ratio (95% confidence interval) being 0.26 (0.10-0.67), P = .006, favoring the prevention group. Similar results were also revealed for infection rate, time to drain removal, and length of hospital stay. Subgroup analysis showed that preservation of Scarpa's fascia, tissue adhesives and, possibly, progressive tension sutures reduce, independently, seroma formation. Conclusions: This meta-analysis provides strong evidence that the use of certain preventive measures during abdominoplasty, compared to conventional procedure, reduces seroma formation.