Breast and cervical cancer in transgender men: literature review and a case report.

Transgender individuals exhibit a higher prevalence of cancer-related risk factors, such as substance abuse and sexually transmitted infections. These factors, coupled with suboptimal adherence to cancer screening recommendations, may lead to a higher incidence of cancers, such as breast and cervical cancer, and contribute to delayed diagnoses in transgender patients. Herein, we report a unique case of a transgender man with a history of alcohol and drug abuse, undergoing gender-affirming exogenous testosterone therapy, who developed synchronous locally advanced breast cancer and human papilloma virus (HPV)-related cervical cancer. He underwent concurrent chemoradiation for cervical cancer and surgery followed by endocrine therapy for breast cancer. The treatments were suboptimals due to patient's comorbidities, among them liver cirrhosis leading to an early death. Additionally, we have conducted a review of existing literature, including case reports, clinical studies, and review articles investigating the role of potential risk factors specifically related to breast and cervical tumors in transgender men. Gender-affirming testosterone therapy is common among transgender men to induce gender affirmation, but its link to breast cancer risk remains ambiguous, with studies being limited and sometimes contradictory. Conversely, HPV is a well-established cause of up to 99% of cervical cancers. Despite persistent risk for cervical cancer in transgender men who retain their cervix, several studies indicate notable disparities in screening adherence, due to personal and structural barriers. Moreover, alcohol and drug use disorders, commonly encountered in transgender population, may negatively influence the adherence to screening programs. Current cancer screening guidelines for this population are somewhat unclear, and specific programs based on more robust data are urgently required along with further tailored studies.

Breast and cervical cancer in transgender men: literature review and a case report Transgender individuals are persons whose gender identity does not conform to that typically associated with the sex to which they were assigned at birth. Transgender people may have more cancer-related risk factors, such as substance abuse and sexually transmitted infections. These factors, along with suboptimal adherence to cancer screening, may lead to a higher incidence of cancers, among them breast and cervical cancer, and may also contribute to delayed diagnoses. Herein we report the case of a transgender man, recorded as female at birth but identifying as male, with a history of alcohol and drug abuse. He underwent testosterone therapy in order to affirm his gender. Moreover, he refused cancer screening, due to personal and social barriers. During the transition, he developed simultaneously a locally advanced breast cancer and a cervical cancer, the latter related to an infection from Human Papillomavirus. The patient was treated with chemoradiation for cervical cancer, and with surgery followed by endocrine therapy for breast cancer. The treatments were suboptimals due to patient's comorbidities, partly related to his previous lifestyle. Additionally, we have conducted a review of existing literature on the topic. Trangender men usually undergo testosterone to induce gender-affirmation. The role of testosterone therapy in breast cancer development remains unclear, with studies being contradictory. Conversely, Human Papillomavirus is a well-established cause of cervical cancers. Transgender men who retain their cervix are at risk for cervical cancer. Despite the persistent risk, notable disparities in screening adherence, due to personal and structural barriers, are reported. Moreover, alcohol and drug use disorders, commonly encountered in transgender population, may contrtibute to the low adherence to screening programs. Furthermore, screening guidelines are somewhat unclear, and specific programs are urgently required.

Soft tissue sarcomas of the proximal adductor area of the thigh: Indications, results and complications at medium follow-up in a series of 43 surgically treated patients.

Introduction: When Soft Tissue Sarcomas are localized in the groin area, they pose specific challenges due to their proximity to important structures. These tumors exhibit elevated complication rates and a higher local recurrence rate compared to their locations in other limbs. The objective of this paper is to analyze a series of patients affected by soft tissue sarcomas in the adductor area of the proximal thigh. The analysis aims to elucidate the epidemiology, diagnostic and therapeutic approaches, complications, and outcomes. Additionally, the study seeks potential prognostic factors and to determine patients at a heightened risk of postoperative complications. Patients and methods: all patients who underwent surgeries for primary soft tissue sarcomas of the adductor area between October 2006 and March 2022 in a tertiary research hospital were valued. Epidemiology, tumor characteristics and therapeutic approaches were analyzed to identify risk factors for complications and local recurrences; survival was considered a secondary outcome. Results: The series comprised 43 patients, 26 males and 17 females, with an average age of 63.3 years. The most frequent histology was liposarcoma, followed by undifferentiated forms. All patients reported the presence of masses, with associated pain in 27.9% of cases. Limb-sparing surgery was performed in 86.0% of cases. Early and late complications were experienced by 34.9% and 20.0% of patients, respectively, with wound dehiscence being the most frequent problem. The recurrence rate was 9.3%, with no recurrences observed in low-grade patients. At an average follow-up of 51 months, 18 patients (41.9%) were alive, two of which with distant metastases. Conclusion: The present series provides evidence that when Soft Tissue Sarcomas localized in the groin area are managed in specialized centers, the rates of recurrence and complications are not significantly different from those observed in other anatomical sites.

A Pericardium Bovine Matrix Pocket in DTI Prepectoral Breast Reconstruction.

Breast reconstructive surgery has evolved significantly over the years. One of the recent advancements is the use of prepectoral implants in combination with synthetic and biological material as a natural and effective coverage. To date, there is little published data on breast reconstruction using acellular bovine pericardium matrix and most concern submuscular breast reconstruction. This study aimed to describe the multicentric-multisurgeon experience in performing direct to implant (DTI) prepectoral breast reconstructions using acellular bovine pericardium matrix (ABPM) pocket. A retrospective multicentric data collection of the all the immediate prepectoral breast reconstructions using acellular bovine pericardium was carried out by the authors. Surgical data including type of mastectomy, axillary surgery, type and size of implant, size of ABPM, duration of surgery were collected for each patient. Postoperative data including adjuvant treatments, complications, necessity to perform other interventions, patient's satisfaction were collected. Cosmetic results were also evaluated by 7 different observers at minimum 1 year follow-up. A total of 65 breast reconstruction were included in the study. Mean follow up was 21.3 months. Average surgical time was 1,42 hours. Minor complications occurred in 4 breasts; major complications occurred in 2 breasts. After 6 months follow-up, 7 patients underwent fat grafting to correct any rippling and /or wrinkling. Breast aesthetic and patients reported outcomes were satisfactory. Not significant capsular contracture was noted at the follow up control. To date, this is the largest study about prepectoral breast reconstruction with ABPM. On the basis of our results, prepectoral breast reconstruction ABPM assisted is a reliable, safe and suitable option providing good patient satisfaction outcomes.

Regina Elena Institute (R.E.I.) Protocol for Breast Implant Salvage: Preliminary Results.

INTRODUCTION: implants are the most popular means of restoring the breast mound after mastectomy; the most feared complication is implant infection accounting for 4.8% to 35.4% of cases. Various antibiotic regimens or other surgical revisions to treat implant infections have been reported, but their failure rates are unacceptable. Implant removal is subsequently the most common recourse for managing prosthesis infections. we report preliminary results of infected breast implant salvage using our Regina Elena Institute (REI) protocol. METHODS: Since June 2021, a prospective single-centre study has been ongoing for patients burdened by implant infection or exposure. All qualifying participants underwent our REI protocol. They receive a temporary smooth implant and 1 week of implant's pocket irrigation with antibiotic solution along with systemic antibiotic and then a new permanent prosthesis positioning. RESULTS: Ten of whom completed at least 6 months of follow-up and were eligible for this preliminary analysis. Overall, the REI protocol was applied to 13 breasts. No infections relapsed during the 6-month minimum follow-up intervals; and no early capsular contraction was evident, resulting in good cosmetic outcomes for every treated breast. DISCUSSION: The smooth-surfaced implant's sizer helps maintain tissue expansion, preventing skin retraction; and the slightly smaller diameters used (compared with originals) facilitate antibiotic wash distribution. Combining a targeted systemic antibiotic and a topical agent is the best way to optimise infection resolution. This preliminary analysis has clear limitations. A larger population is warranted to increase the level of evidence. Longer follow-up is also advisable to monitor for delayed infection recurrence.

Managing the animation deformity in breast reconstruction transposing the implant to a partial prepectoral pocket: Early experience and preliminary results with a new technique.

BACKGROUND: Two-stage implant-based breast reconstruction remains the most commonly used technique for rebuilding a breast. Subpectoral implant placement minimizes complications, such as capsular contracture, implant visibility, malposition, and extrusion. Nevertheless, it is associated with high animation deformity (AD). Prepectoral reconstruction eliminates AD but is subject to a higher risk of implant extrusion and visibility. In this prospective, single-center study we present a new technique aimed to create a new hybrid pocket in which the upper portion of the implant is placed subcutaneously, whereas its inferior pole is still covered by a pectoralis muscle sling reducing implant lower pole visibility and palpability. MATERIAL AND METHODS: In each case, the prosthesis was removed and a new hybrid pocket was created by splitting the muscle into two portions, separating its cranial part from the overlying subcutaneous tissue and anchoring it back to the chest wall. The caudal muscle sling was left adherent to the subcutaneous tissue of the central part of the breast. Patient outcomes were evaluated with a BREAST-Q questionnaire preoperatively and 1 year after surgery. RESULTS: Forty-eight patients with severe postoperative breast animation were enrolled (8 bilateral and 40 unilateral). No major complications occurred. After a 1-year follow-up, the aesthetic and functional satisfaction rate was high and a good implant coverage was achieved. No residual AD of the breast was observed. CONCLUSIONS: Changing the implant placement from the subpectoral to a partially subcutaneous plane, both severe AD and implant extrusion can be avoided, expanding the indications for safe prosthetic breast reconstruction. LEVEL OF EVIDENCE: Level of evidence IV.

Breast implant reverse surgery: A step-by-step approach.

The popularity of breast augmentation has seen a decrease in number in the recent years. Simultaneously, the request for breast implant removal has increased impressively. A total of 77 women undergoing breast implant removal with no exchange were divided into four groups depending on the type of "reverse surgery" following the explantation: simple implant removal, implant removal with lipofilling, implant removal with mastopexy, and implant removal with mastopexy and lipofilling. Following this, an algorithm was created to standardize the ideal "reverse" surgery. After surgery, all the patients were followed for at least 6 months to understand their level of satisfaction regarding the outcome of the surgery. The majority of patients were highly satisfied after explantation. Implant-related issues were found to be the main cause for explantation surgery. Capsulectomy was performed in the minority of cases, as the capsule was found to be an ideal layer for fat grafting. Grouping the patients into 4 categories allowed us to investigate a pattern behind the decision to undergo a certain type of secondary procedure and to create an algorithm with general rules that can be used as a guide for surgeons. The increased demand for this type of surgery underlines a new interesting trend in plastic surgery that, together with Breast Implant-Associated Anaplastic Large Cell Lymphoma advent, will probably have implications on the communication between surgeons and patients and most likely on the choice of choosing different ways of breast volume augmentation.

Pelvic ring reconstruction with tibial allograft, screws and rods following enneking type I and IV resection of primary bone tumors.

INTRODUCTION: Surgery of primary malignant tumors involving the sacroiliac joint requires wide resection, which often interrupts the pelvic ring. Nowadays, restoration of the pelvic ring to provide stability and which technique is most fitting remain subject to debate. The aim of this study is to evaluate the results of pelvic reconstruction with pedicle screw instrumentation and tibial allograft following Enneking Type I-IV resections. PATIENTS AND METHODS: All patients who underwent reconstruction with tibial allograft, screws and rods after resection of areas I and IV for primary bone tumors between 2017 and 2022 were reviewed. Clinical and radiological characteristics, fusion rate and functional results were analyzed. The MSTS score and the TESS were used to evaluate functional results. RESULTS: Seven patients were included in the study. Chondrosarcoma was the most common histology. Only four patients reported pain. No fractures were observed at tumor diagnosis. Computer-assisted navigation was used in six cases. Reconstruction was performed in four cases with a screw inserted in the homolateral L5 pedicle and in the ischium, in two cases with a screw in the homolateral L4 pedicle and another in the homolateral L5 pedicle, in the last case with two screws inserted in L4 and L5, one screw in the ischium and another one in the residual iliac wing. In this case a contralateral stabilization was also carried out. The spine screws and the iliac screws were connected with a rod. The mean follow-up for all 7 patients was 37 months. One patient (16.6%) died due to general complications not directly related to the surgery; while the others are alive and apparently free of disease. Complete fusion was obtained in four out of seven patients and the average time for fusion was 9 months. The average MSTS score and TESS were 58.7% and 57.8%, respectively. DISCUSSION: The need for reconstruction is thoroughly debated in literature. The advantages of restoring posterior pelvis stability are the prevention of long-term pain associated with limb shortening and secondary scoliosis. Re-establishment of the pelvic ring can be achieved through synthetic, biologic or hybrid reconstructions. CONCLUSIONS: More studies that assess the surgical consequences at long-term follow-up and help clarify the indications for reconstruction and the specific technique are necessary to confirm our preliminary results.

Use of free flaps in aesthetic breast surgery: a single centre experience and literature review.

BACKGROUND: Implant-based breast augmentation is one of the most performed procedures in aesthetic surgery, whereas autologous tissue application is confined to fat grafting as adjuvant procedure. The use of free flaps in cosmetic mammoplasties is not popular, but the number of reports in the literature is increasing. We believe that autologous tissue transfer for cosmetic purposes could be a valuable alternative for volume enhancement in selected conditions, especially following weight loss. In this paper, we provide a systematic literature review of the current literature of using autologous free flaps for breast augmentation in non-cancer patients, and we also report our experience on this topic to identify possible indications and criteria for the patients' selection. METHODS: PRISMA's guidelines have been followed for the literature review. In order to demonstrate the feasibility, safety and patient satisfaction with breast volume enhancement with autologous tissue, a retrospective single-centre study was conducted on women who underwent breast volume enhancement with autologous tissue. Patient's satisfaction was assessed with a visual analogue scale (VAS) creating an ad-hoc outcome scale, and the data were summarised with a descriptive statistic. RESULTS: Twelve patients were enrolled in the study. Weight loss was the main indication for surgery. The average length of procedure was 5.1 h, and the hospitalization was 2.3 days. After 12 month, the patient outcome was excellent in 2 cases, good in 9 cases and moderate in 1 case. CONCLUSIONS: Although further research is needed, the literature review and our case series show that the use of free flaps for breast volume enhancement is safe and gives a satisfactory outcome.

Nipple reconstruction with a modified arrow flap.

BACKGROUND: Nipple reconstruction, which allows a reconstructed breast to assume a more natural look, represents the completion of the breast reconstruction journey. Several techniques have already been described in literature but unfortunately, loss of the projection of the new nipple has been a common problem for all of them. We report our experience using a personal modification of the popular arrow flap, to which we have added maneuvers to compensate for the weaknesses of the conventional procedures. METHODS: A prospective study was performed on women who required nipple reconstruction after autologous or implant-based breast reconstruction; revisions of reconstructed nipples have been also included. Patients who underwent radiotherapy after reconstruction of the breast mound were excluded from the study. The new nipples were reconstructed using our modified arrow flap. Immediate postoperative nipple projection was recorded and compared after 6 weeks and 6 months. Descriptive statistics were used to summarize the characteristics of the study patients and the results. The F-test was performed to assess the statistical significance of our findings. RESULTS: Our modified arrow-flap procedure was used to reconstruct 27 nipples. The average projection reduction has been of 12.9% at 6 weeks and 19.7% at 6 months, and no statistical significance was recorded among the postoperative assessments (P=0.14). Complications have been recorded in 3 patients and consisted of 2 small wound dehiscence and 1 superficial infection. CONCLUSIONS: Our modified arrow-flap method for nipple reconstruction achieves a reproducible and reliable natural look and stable projection.

Hyponatremia after Autologous Breast Reconstruction: A Cohort Study Comparing Two Fluid Management Protocols.

BACKGROUND: Perioperative fluid management is an important component of enhanced recovery pathways for microsurgical breast reconstruction. Historically, fluid management has been liberal. Little attention has been paid to the biochemical effects of different protocols. This study aims to reduce the risk of postoperative hyponatremia by introducing a new fluid management protocol. METHODS: A single-institution cohort study comparing a prospective series of patients was managed using a new "modestly restrictive" fluid postoperative fluid management protocol to a control group managed with a "liberal" fluid management protocol. RESULTS: One-hundred thirty patients undergoing microsurgical breast reconstruction, at a single institution during 2021, are reported. Hyponatremia is demonstrated to be a significant risk with the original liberal fluid management protocol. At the end of the first postoperative day, mean fluid balance was +2,838 mL (± 1,630 mL). Twenty-four patients of sixty-five (36%) patients had low blood sodium level, 14% classified as moderate-to-severe hyponatremia. Introducing a new, "modestly-restrictive" protocol reduced mean fluid balance on day 1 to +844 mL (±700) (p ≤ 0.0001). Incidence of hyponatremia reduced from 36 to 14% (p = 0.0005). No episodes of moderate or severe hyponatremia were detected. Fluid intake, predominantly oral water, between 8am and 8pm on the first postoperative day is identified as the main risk factor for developing hyponatremia (odds ratio [OR]: 7; p = 0.019). Modest fluid restriction, as guided by the new protocol, protects patients from low sodium level (OR: 0.25; confidence interval: 95%; 0.11-1.61; p = 0.0014). CONCLUSION: The original "liberal" fluid management protocol encouraged unrestricted postoperative oral intake of water. Patients were often advised to consume in excess of 5 L in the first 24 hours. This unintentionally, but frequently, was associated with moderate-to-severe hyponatremia. We present a new protocol characterized by early cessation of intravenous fluid and an oral fluid limit of 2,100 mL/day associated with a significant reduction in the incidence of hyponatremia and fluid overload.

The iliac stemmed cup in reconstruction of the acetabular defects secondary to tumor resection: a systematic review of literature.

INTRODUCTION: Stemmed acetabular cups are suitable for reconstruction in case of important bone loss. Nevertheless, their use is not so common, because generally judged very invasive and technically difficult to implant. The aim of the present review is to verify the results of their use and to evaluate indications and complications. MATERIALS AND METHODS: Literature research was performed in the main healthcare databases; indications, surgical technique, related complications, functional results and implant survival were valued and analyzed for every selected paper. RESULTS: 13 studies were selected, for a population of 424 patients and 428 hips. The main indication was reconstruction after tumor removal; the primary non-oncologic indication was revision for aseptic loosening. The most frequent complications were aseptic loosening and implant failure (16.2%), followed by deep infection (11.3%) and dislocation (9.8%). The average MSTS score was 65.9%; while data regarding functional results for degenerative cases are quite fragmented. The 5-years implant survival was 73.6%. CONCLUSIONS: Data regarding SAC prostheses are quite rare in the literature; no prospective studies with comparisons with other reconstruction techniques are available so their use is mainly based on the experience of single centers. While data for tumors are more consistent and supported by studies, information on revisions of hip prosthesis implanted for degenerative problems is quite scarce. Preliminary results on the SAC prosthesis as a valid alternative both for tumoral and degenerative revision cases are encouraging. Prospective randomized studies are advocated to value results compared to alternative techniques.

Safe mobilisation of transverse upper gracilis flap in patients with hip replacements.

BACKGROUND: The transverse upper gracilis (TUG) flap is easily harvested to recruit a fair volume of tissue from the inner upper thigh region, making it the second choice of certain authors. Hip replacement is deemed prohibitive due to positional requirements that predispose to anterior dislocation of prosthetic femoral heads. In this report, we describe a simple and safe way to raise TUG flap in patients with existing hip prostheses, detailing patient assessments, and technical variations in a limited case series. MATERIAL AND METHODS: A retrospective single cohort study was conducted on patient who underwent TUG flap-based reconstruction after hip replacement. Hip joint instability was assessed clinically and with CT. Flap harvesting was performed to prevent the extra-rotation of the femoral head by the thigh flex or dissecting the pedicle keeping the thigh straight. RESULT: Eleven patients were qualified for the study, and the flap raising time was superimposable to the conventional technique. Six flaps were elevated, while the thigh was kept in the flexed position without any extra-rotation, and the pedicle dissection was completed in 5 cases by keeping the thigh in the straight position. No intra- or postoperative hip dislocations resulted. All patients ambulated on mornings after surgery, returning to daily activities within 4 weeks. CONCLUSION: TUG flap is a viable alternative that is not necessarily prohibited by existing prosthetic hips. Careful patient assessment and positioning during surgery are key considerations for safe and successful procedures.

Abdominal perforator exchange flap (APEX): A classification of pedicle rearrangements.

INTRODUCTION: Abdominal-based reconstruction is the most commonly performed method for breast reconstruction after mastectomy using the patient's own tissues. DIEP flap has allowed to reduce the donor site morbidity but the incidence of bulging or hernia remains still high, especially when flap is based on multiple perforators. Abdominal Perforator Exchange flap (APEX) represents a further step forward in preserving the abdominal wall structures by disassembling the pedicle components and their reconstitution at the end of the dissection. In this study, we explore the possible anatomical configurations of perforators exchange for APEX, providing a simple classification of perforators reconstitution patterns and the possible clinical implications. MATERIALS AND METHODS: A retrospective study was conducted on patients who received APEX flap for abdominal based breast reconstruction. Preoperative CT scans and procedure descriptions were analyzed to identify the vascular patterns during flap harvesting and the pedicle reconstitution sites. The onset of abdominal wall and flap related complications were investigated. RESULTS: APEX flap was performed on 51 women and four vascular patterns were identified. We identified the Type A pattern in 36 cases (70.6%), the Type B pattern in 8 (15.7%), and the Type C pattern in 5 (9.8%). We performed an extra-anatomical reanastomosis (Type D) in only two case (3.9%) (p = .09). We recorded anastomotic problems in five pedicles' reconstitution and the odds ratio showed a possible correlation between the localization of pedicle division and the anastomosis problems (p > .05). No total or partial flap loss was recorded during this study. Marginal fat necrosis was clinically observed in three cases, which had very large flaps. No bulging or hernia was recorded. CONCLUSION: Our perforators exchange classification for abdominal-based flap helps clinician in planning the surgery and also in describing the procedure easily allowing a more efficient communication. This classification could be used to approach perforator flaps with multiple vessels at other anatomical locations as well.

Preoperative volume estimation in transverse upper gracilis flap surgery: A pilot study.

BACKGROUND: The transverse upper gracilis (TUG) flap provides a good alternative to the gold standard DIEP in breast reconstruction. However, flap volume estimates are subjective, making preoperative planning potentially challenging. STUDY AIM: To derive a reliable, accurate, and reproducible mathematical algorithm for the preoperative calculation of TUG flap volumes. MATERIALS AND METHODS: Nineteen consecutive patients with 30 TUG flaps were prospectively included. On the assumption that the TUG flap resembles two isosceles prisms, the formula of the volume of a prism was used to calculate their preoperative flap weights. These were then intraoperatively compared to the actual flap weights. A regression equation was calculated from the correlation analysis of 10 random flaps. This was then applied to the remaining 20 flaps to assess for improved reliability and weight prediction accuracy. RESULTS: The prism volume equation used to clinically calculate flap volumes was: Geometric flap weight = (h1bT)/2+ (h2bT)/2, (h = height, b = base, T = flap thickness); all in centimetres. Geometric and actual flap weights were found to be significantly correlated (r2 = 0.977) generating the following regression formula: predicted TUG weight = 0.924 × geometric weight + 26.601. When this was applied to the remaining 20 flaps, no significant difference was found (p = 0.625) between predicted and actual flap weights, demonstrating an increased accuracy of predicting flap volume. CONCLUSION: The proposed formula provides the clinician with a more accurate and reliable estimation of available TUG flap volume and may potentially aid with preoperative planning and patient consultations.

A three-dimensional scar assessment tool for keloid scars: Volume, erythema and melanin quantified.

BACKGROUND: There is no non-invasive objective assessment tool to measure keloid scar characteristics over time. This study aimed to ascertain the ability of the Antera 3D® camera to detect differences in keloid features pre- and post-steroid injection. In order to identify whether those variation could be considered as treatment response predicting factors. METHODS: Enrolled patients received three intra-lesional steroid injections at four-weekly intervals. Images were taken with the Antera 3D camera 12 and 24 weeks after treatment. Keloids' colour, volume, and area as well as haemoglobin and melanin average levels and variation have been analysed pre- and post-steroid injection. t Tests and relative risk have been used to analyse the significance and association strength of our finding. RESULTS: Forty patients have been enrolled in the study. Significant changes as been recorded in keloids' volume and colour after steroid injection (P < 0.05). 53% have recorded a Hb reduction showing no recurrence of pathology, patient who had increase in Hb showed an early recurrence. Melanin variation was significant after steroid injection (P < 0.05) but no correlation has been found with treatment response. CONCLUSIONS: The Antera 3D camera is able to detect differences in the investigated keloid's features helping in two ways: by providing an objective, longitudinal method to monitor and document changes in scar morphology, and through monitoring haemoglobin change, which strongly correlates to both response to treatment and likelihood of recurrence. Allowing clinicians to identify which patients will respond early, in order to change treatment if necessary, limiting morbidity and costs.

Functional Outcomes of the Medial Sural Artery Perforator Flap in Oral Cavity Reconstruction.

BACKGROUND: The medial sural artery perforator (MSAP) flap is an ideal option for reconstruction of oral cavity defects owing to its thin and pliable nature and favorable donor site. Our study presents an assessment of functional outcomes including speech and swallowing in patients with oral cavity tumors reconstructed with MSAP flaps. METHODS: Patients undergoing MSAP reconstruction for oral cavity tumors between January 2014 and January 2018 were identified from our prospective head and neck cancer database. Functional outcomes were assessed in conjunction with the Speech and Language Team with a minimum follow-up of 6 months. Function (speech and swallowing) was recorded as a performance status scale set up by the assessing health care professional. RESULTS: A total of 38 patients underwent reconstruction with the MSAP flap over the study period. The patient cohort included 10 female patients and 28 male patients. The age range was from 30 to 78 years, with a mean age of 56.8 years. Complications included 1 flap loss and 1 donor site wound dehiscence.Most patients (84.2%) had intelligible speech at 6-month follow-up and further improvement at 1 year (92.1%). All patients resumed feeding on postoperative day 4, and only 7.8% (n = 3) of the patients required assistance with feeding at 1-year follow-up. CONCLUSIONS: The MSAP flap provides adequate small-volume replacement for oral cavity reconstructions. Our results indicate that most patients achieve a full diet with no restrictions by 1 year after reconstruction. Most of our patients demonstrated excellent speech with little or no need for repetition in conversation. Over the past few years, this has become the flap of choice for oral cavity reconstruction in our unit.

Preoperative Perforator Mapping in SGAP Flap: Does Magnetic Resonance Imaging Make the Difference?

BACKGROUND: Preoperative vascular mapping has emerged as an excellent adjunct to perforator flap surgery, improving operative time while aiding the surgeon in the selection of the ideal perforator. This study evaluated the effect of preoperative vascular mapping by magnetic resonance imaging to identify tissue for a superior gluteal artery perforator (SGAP) flap on total operative time and compared radiologic mapping by magnetic resonance imaging with Doppler ultrasonography for perforator localization. The authors also investigated whether drawing the flap according to magnetic resonance imaging perforator localization or tissue availability affected the outcome of the donor site. METHODS: A prospective study was performed on patients undergoing SGAP flap breast reconstruction. Patients were randomized into two groups. One group received preoperative magnetic resonance imaging for flap tissue planning based on localization of the perforator. The other group received flap planning based on tissue availability and then underwent external Doppler ultrasonography to identify the dominant perforator. An ad hoc outcome scale was created to evaluate outcomes of the donor sites. RESULTS: Preoperative vascular mapping by magnetic resonance imaging or external Doppler ultrasonography was performed the day of surgery on 35 and 27 patients, respectively. The mean flap elevation times of the imaging patients versus the ultrasonography patients were 252 and 228 minutes, respectively. The differences between flap elevation times and cosmetic outcomes for the two patient groups were not significant. CONCLUSION: The authors' findings indicate that the use of magnetic resonance imaging for SGAP flap planning did not reduce operative time, and that donor-site outcomes were not affected by the modality used for preoperative perforator mapping. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Breast reconstruction with Superior Gluteal Artery Perforator free flap: 8 years of experience.

INTRODUCTION: The SGAP flap represents an alternative for autologous breast reconstruction when DIEP is not available. In this article, we report eight years of experience in breast reconstruction using SGAP free flap and discuss our results, how our procedures have evolved, the outcomes and complications rates and how to perform this procedure efficiently while managing the challenges inherent to this type of flap. MATERIALS AND METHODS: A retrospective study was conducted from June 2009 and June 2017. Patients requiring SGAP flap breast reconstruction were enrolled. Donor site availability was categorised into 4 classes according to the availability of tissue. An ad hoc outcome scale was created to standardise the results and ensure data comparability. RESULTS: A total of 119 patients were enrolled in the study. We recorded 18 cases of excellent results, 57 good, 30 moderate and 14 poor. Our results show that donor site class impacts complications and patient outcome. The odds ratio analysis demonstrated that the third class donor site has a protective impact on complications and has a direct correlation with good patient outcomes. CONCLUSIONS: SGAP flap can provide very good outcomes, and it should be considered as another option when DIEP is not available. Patient selection and efficiency are the keys to achieve optimal results and minimise complications. Although this flap is available for patients with a low BMI, the donor site has to provide enough tissue to achieve symmetry with the contralateral breast and allow a tension-free closure without contour deformity.

Reducing complications in post-bariatric plastic surgery: our experience and literature review.

BACKGROUND: With the rise in obesity, there has been a similar increase in bariatric surgery. This resulted in numerous patients losing significant weight with accompanying circumferential body contouring issues. This has led to an amazing increase in the number of body contouring procedures performed. METHODS: The aim of this work is to revise the cases of body contouring in 78 ex-obese patients who underwent body contouring surgery in the Department of Health Life and Environmental Sciences - Plastic Reconstructive and Aesthetic Plastic Surgery Section, from 2007 to 2016. RESULTS: The authors have noticed a deep relationship between adverse events and cigarette smoking and with pre-operative BMI. Regardless of these variables, the authors focused on the protocol for the management of patients, which required a collaboration between medical and nursing staff. CONCLUSIONS: Ex-obese patients have an important risk for complications, but the comparison of our personal data with those of the international literature confirms the efficacy of our management protocol with regard to the prevention of complications. (www.actabiomedica.it).

Fibrous dysplasia: an unusual case of a very aggressive form with costo-vertebral joint destruction and invasion of the contralateral D7 vertebral body.

Fibrous dysplasia (FD) is a benign fibro-osseous disease of the bone that may be solitary or multicentric. It is important to distinguish this type of lesion from low-grade osteosarcomas (LGOS) and from secondary sarcomas, because malignant transformation has rarely been reported. It is classically described as having a ground-glass appearance, endosteal scalloping, and thinning of the cortex. Cortical disruption is considered evidence of malignancy, but it can also be present in benign FD with aggressive behavior. We present an unusual case of aggressive FD of the 7th left rib, already diagnosed more than 22 years ago, where cortical and costo-vertebral joint disruption and 7th thoracic vertebral body involvement were not evidence of malignant behavior. From a histological perspective, FD and LGOS are similar; even if histology is of fundamental importance, the diagnosis has to be made based on the clinical and radiological aspects as well, although at imaging, differentiation between FD and LGOS can be difficult. In the present case, even though the histological examination suggested a benign lesion, the radiological examination instead consistently suggests malignancy. It is for this reason that there should be a high index of suspicion during follow-up and a new biopsy should be scheduled in case any changes occur during follow-up.