Combined Double-breasted Full-thickness Abdominal Flap Plication and Acellular Dermal Matrix in Prune-belly Syndrome Reconstruction.

Background: Reconstruction of the abdominal wall in patients with prune-belly syndrome (PBS) following previous intra-abdominal procedures is a challenging problem with a high incidence of revision due to persistent bulging or herniation. The abdominal wall flaccidity not only produces a severe psychological and aesthetic discomfort for the patient but often determines functional disabilities, including inability to cough properly, impaired bowel and bladder function, and delay in posture and balance. Methods: The authors describe three cases of reconstruction of abdominal wall using a modified double-breasted abdominoplasty fascial plication with additional acellular dermal matrix interposition and review the literature for innovations in the use of abdominal repair for reconstruction of these difficult cases. Results: Three children with PBS at a mean age of 7.3 years achieved successful reconstruction of the abdominal wall, using the modified double-breasted abdominoplasty fascial plication with acellular dermal matrix interposition. Patients underwent previous procedures, including orchiopexy in two patients and bilateral nephrectomy in one patient. No postoperative complications have been found, apart from superficial skin dehiscence along the abdominal incision treated conservatively in one child. At mean follow-up of 42 months (range 28-56 months), no patient presented incisional hernia, persistent or recurrent fascial laxity with abdominal bulging. All patients achieved significant aesthetic and functional improvements, including children's ability to cough, spontaneous gain of abdominal tonus, balance, and ambulation. Conclusion: Modification of the original vertical, two-layer plications of the deficient abdominal interposing biological mesh has the purpose of improving strength, aesthetics, and function of the abdominal wall in pediatric patients with PBS.

Reconstruction of Complex Anterior Chest Wall Defects: The Lasagna Technique.

Background: Sternal tumors are rare, comprising only 0.94% of all bone tumors, with the majority being sarcomas. An extensive composite defect is often the result of surgical resection. Reconstruction of this anatomical area is a challenge for plastic surgeons. Reconstruction must fulfil two different tasks: restoration of soft tissues and stabilization of the chest wall. Both are well defined, and many techniques have been historically proposed. Methods: We present the case of a 66-year-old man affected by sternal metastasis of lung non-small cell carcinoma with sarcomatoid features. After wide tumor resection, a large defect was created. Results: The patient underwent a complex multilayer reconstruction that combined multiple techniques: Gore DualMesh to reconstruct the pericardial plane and protect the heart muscle, omental flap to facilitate integration of the mesh, titanium bars to recreate chest wall stability, and bilateral pectoralis muscle flaps to cover hardware. This multilayer reconstruction was named the "lasagna technique." Conclusions: Due to the rarity of primary malignancies of the sternum, it is difficult to standardize a therapeutic approach. For this reason, it is necessary to customize the surgical treatment by combining several techniques and materials. Our lasagna technique may be considered a valuable option in treating these complex reconstructive cases.

Secondary Autologous Fat Grafting for the Treatment of Chin Necrosis as a Consequence of Prone Position in COVID-19 Patients.

Due to the spread of the coronavirus disease 2019 pandemic, an increasing number of ill patients have been admitted to intensive care unit requiring mechanical ventilation. Although prone positioning is considered beneficial, long periods in this position may induce important complications, including pressure ulcers in high-risk and uncommon body areas. We report five cases of pressure ulcer necrosis of the chin in coronavirus disease 2019 patients as a consequence of mechanical ventilation in prone positioning using autologous fat grafting (AFG) as a secondary technique. A series of five patients with secondarily-healed chin necrosis treated by AFG between February and June 2020 were reviewed. All patients had been treated initially with surgical debridement followed by conservative treatment. Secondary AFG was performed to reduce patient's pain, improve chin contour-projection, and minimize cosmetic sequelae and scarring. Patient satisfaction was assessed using a five-point Likert scale (0-4). Vancouver scale was used to evaluate the chin scars clinically. The average amount of fat injected into the chin area was 8.1 ± 2.0 ml. At 6-month follow-up, all patients were mostly satisfied (average Likert-scale 3.2 ± 0.4). Based on the Vancouver scale, improvement of the chin scar from 9.5 ± 0.8 to 4.7 ± 0.8 was found. We report a positive experience with secondary AFG for correction of painful and unaesthetic scarring and contour abnormality following surgical debridement and secondary-intention healing of chin pressure ulcers.

Early venous congestion after diep flap breast reconstruction: case report of a successful management.

BACKGROUND AND AIM: More than 250 000 women estimated to be diagnosed with breast cancer in the USA every year. Mastectomy is primary treatment for more than a third of those with early-stage disease. Most of the patients undergoing mastectomy receive breast reconstruction. A number of. Surgical techniques have been described to reconstruct the breast. With autologous tissue breast reconstruction, the plastic surgeon uses patient's own tissues, taken from a different part of the body where there is an excess of fat and skin. Deep inferior epigastric perforator (DIEP) flap is the autologous breast reconstruction technique of choice in our department due to long lasting results, low donor site morbidity and positive patient reported outcomes have been described.   Case Report: We present the case of a 42-year-old woman who underwent neoadjuvant chemotherapy followed by left breast simple mastectomy, axillary lymph-nodes dissection and later adjuvant radiation therapy (RT). After conclusion of RT a DIEP flap breast reconstruction was performed. Nine-hours after the operation, signs of acute venous congestion were noted. The venous congestion was treated by a combined surgical and medical approach based on pedicle discharge and ICU resuscitation protocol. After take back surgery, the patient was tightly monitored in the intensive care unit where intravenous heparin infusion and leech therapy were performed for 2 days. Flap congestion resolved completely, and the patient was discharged.   Conclusions: Venous congestion is very difficult to treat due to its potential multifactorial nature. The most important step is to recognize this kind of emergency because irreversible microvascular damages will develop in 6-8 hours. Because of multiple causes of venous congestion a timely multidisciplinary approach is mandatory, to maximize flap salvage and success rates.

Filler-induced complications of the lips: 10 years experience with intralesional laser treatment and refinements.

BACKGROUND: The number of minimally invasive cosmetic procedures has steadily increased every year. In the last decade, the rates of filler injection reactions have also increased. This study presents our experience in the management and treatment of permanent filler complications to the lips. Undoubtedly, in these adverse reactions, the lips are the hallmark that most stigmatizes an unnatural look of the face. METHODS: One hundred and eighty-one patients (168 female and 13 male) with permanent filler complications to the lips were treated from September of 2009 to September of 2019 at the University Hospital of Modena. One hundred and thirty-five patients underwent intralesional laser treatment (ILT). Forty-six patients underwent a stab incision and drainage and 10 of these patients had solid and calcified nodules and therefore underwent a combined technique. Thirty-three patients underwent further cosmetic procedures. RESULTS: In 95% of patients there was a clinical improvement of which complete resolution in 38.7% and partial improvement in 34.2% of cases. Nine patients stopped the treatment because they were not satisfied. No patient was considered to have worsened after the treatment. Thirty-three patients underwent further treatments. CONCLUSIONS: A systematic combined approach between antibiotic therapy and treatments (ILT and a stab incision) represents the best therapeutic approach in dealing with permanent fillers complications to the lips. This treatment modality allows both the removal of the foreign material and the inflammatory reaction with low morbidity and little cosmetic disfigurement. Further cosmetic procedures may be applied to improve aesthetic appearance once most of the non-resorbable substance has been removed.

Breast Cancer-Related Lymphedema: Recent Updates on Diagnosis, Severity and Available Treatments.

Breast cancer-related lymphedema (BCRL) represents a global healthcare issue affecting the emotional and life quality of breast cancer survivors significantly. The clinical presentation is characterized by swelling of the affected upper limb, that may be accompanied by atrophic skin findings, pain and recurrent cellulitis. Cardinal principles of lymphedema management are the use of complex decongestive therapy and patient education. Recently, new microsurgery procedures have been reported with interesting results, bringing in a new opportunity to care postmastectomy lymphedema. However, many aspects of the disease are still debated in the medical community, including clinical examination, imaging techniques, patient selection and proper treatment. Here we will review these aspects and the current literature.

Standardization and Selection of High-risk Patients for Surgical Wound Infections in Plastic Surgery.

BACKGROUND: The aim of the present study was to show that the Infection Risk Index (IRI), based on only 3 factors (wound classification, American Society of Anesthesiologists score, and duration of surgery), can be used to standardize selection of infection high-risk patients undergoing different surgical procedures in Plastic Surgery. METHODS: In our Division of Plastic Surgery at Modena University Hospital, we studied 3 groups of patients: Group A (122 post-bariatric abdominoplasties), Group B (223 bilateral reduction mammoplasties), and Group C (201 tissue losses with first intention healing). For each group, we compared surgical site infection (SSI) rate and ratio between patients with 0 or 1 risk factors (IRI score 0 or 1) and patients with 2 or 3 risk factors (IRI score 2 or 3). RESULTS: In group A, patients with IRI score 0-1 showed an SSI Ratio of 2.97%, whereas patients with IRI score 2-3 developed an SSI ratio of 27.27%. In group B, patients with IRI score 0-1 showed an SSI ratio of 2.99%, whereas patients with IRI score 2-3 developed an SSI ratio of 18.18%. In group C, patients with IRI score 0-1 showed an SSI ratio of 7.62%, whereas patients with IRI score 2-3 developed an SSI ratio of 30.77%. CONCLUSIONS: Existing infection risk calculators are procedure-specific and time-consuming. IRI score is simple, fast, and unspecific but is able to identify patients at high or low risk of postoperative infections. Our results suggest the utility of IRI score in refining the infection risk stratification profile in Plastic Surgery.

Lipofilling after Laser-Assisted Treatment for Facial Filler Complication: Volumetric and Regenerative Effect.

BACKGROUND: Nonresorbable substances are still injected to enhance soft-tissue volumes and fill subcutaneous defects. The minimally invasive intralesional laser treatment can remove foreign substances and the inflammatory reaction, eventually leaving depression and scar tissue in the treated area. Fat grafting can restore volume loss and improve scar tissue. METHODS: From March of 2010 to February of 2017, 33 patients were studied. All of them had suffered from inflammatory reactions to permanent facial fillers and had been treated with the 808-nm diode laser at the authors' institution. The evacuation of material had left facial asymmetry and visible depression. To restore facial aesthetic units, fat grafting was performed. The minimum follow-up was 6 months. RESULTS: Volume restoration was recognized (according to the Global Aesthetic Improvement Scale) as significantly improved in 22 patients, moderately improved in eight patients, and slightly improved in three patients. Improvement in atrophic and scarred tissues (with an apparent thickening of the skin or even elimination of scars) was also assessed with the following results: 25 patients were very much improved and eight were moderately improved. CONCLUSIONS: This is the first study on filler-induced complications of the face treated by intralesional laser treatment followed by lipofilling. A systematic approach to volume restoration is proposed to patients who had filler removal of the face. There was a high degree of patient satisfaction with this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Soft tissue coverage of the upper limb: A flap reconstruction overview.

Different opinions about the reconstructive choice for upper limb are described in literature: advancement or rotation flaps, regional flaps and free flaps are the most common reconstructive options. Local and regional flaps can be used to cover small defects while large wounds require the use of free flaps or distant pedicled flaps. The coverage of large wounds opens a discussion about when to use free flaps and when distant pedicled flaps. This review will describe the different methods used for the coverage of soft tissues injuries affecting hand and/or forearm (excluding fingers). The aim is to show all flap reconstructive options in order to support the inexperienced surgeon during the management of traumatic injuries of the upper limb.

Laparoscopically Assisted Transperineal Approach in the Management of a Giant Pelvic Lipoma.

Giant lipomas affecting the retroperitoneum and pelvis are quite rare. The surgical management of these lesions may be technically demanding and controversies exist with respect to diagnosis, competences being involved, type of surgical approach, radicality, and timing. A unique case presentation of a giant lipoma occupying the whole pelvis and the gluteal region is presented. Due to its size, many anatomical areas are involved, requiring the expertise of multiple specialists to treat. After multidisciplinary counseling, the lesion is radically resected in one stage by using a new videolaparoscopically assisted transperineal access to the pelvis. This type of surgical approach may be of interest for resecting pelvic tumors in women and men.

Consensus based recommendations for diagnosis and medical management of Poland syndrome (sequence).

BACKGROUND: Poland syndrome (OMIM: 173800) is a disorder in which affected individuals are born with missing or underdeveloped muscles on one side of the body, resulting in abnormalities that can affect the chest, breast, shoulder, arm, and hand. The extent and severity of the abnormalities vary among affected individuals. MAIN BODY: The aim of this work is to provide recommendations for the diagnosis and management of people affected by Poland syndrome based on evidence from literature and experience of health professionals from different medical backgrounds who have followed for several years affected subjects. The literature search was performed in the second half of 2019. Original papers, meta-analyses, reviews, books and guidelines were reviewed and final recommendations were reached by consensus. CONCLUSION: Being Poland syndrome a rare syndrome most recommendations here presented are good clinical practice based on the consensus of the participant experts.

Necrobiosis Lipoidica Affecting the Leg: What Is the Best Treatment in a Patient with Very High Aesthetic Demand?

Necrobiosis Lipoidica (NL) is a rare necrotising disorder of the skin characterized by collagen degeneration, thickening of blood vessels, and granulomatous inflammatory process. Its main clinical features are brownish-red papules and yellowish plaques with atrophic central areas. NL affects 0.3% -1.2% of the diabetic population, mostly women (female/male ratio is 3:1). Management of NL is challenging, especially for large lesions refractory to medical therapy, thus requiring surgical excision as an alternative option. Due to the rare occurrence of this condition no treatment guidelines exist and individualized treatment mostly depends on the severity of the lesion, location and patient's expectations. A case of a 30-year-old diabetic woman with very high aesthetic expectations was succesfully treated with staged resections of a giant NL to the leg and reconstruction with dermal template and full thickness skin grafts. Grafts were taken from the groin region bilaterally and from the lower abdomen after a cosmetic mini-abdominoplasty procedure. This approach allowed for a stable and very satisfactory aesthetic result with no donor site exposed scars.

Tattooing of the nipple-areola complex: What not to do. A case series.

INTRODUCTION: Reconstruction of the nipple areola complex (NAC) is the final and easier step of breast reconstruction. However, surgeons, especially if trainees, typically have not developed tattoo skills during their training. The aim of this report is to share advice developed in our clinical practice that would minimize patient complaints and complications while performing NAC tattoos. METHODS: From January 2016 to May 2018, reconstruction of NAC was performed in 48 consecutive patients. Nipple reconstruction was performed initially using skin flaps and this was followed three to eight months later by NAC tattooing. We analyzed medical reports at 12 months follow-up where we usually record patient satisfaction (very satisfied, satisfied, dissatisfied) and every patient's complaint or complication. RESULTS: Thirty-two patients (67%) were very satisfied of NAC tattooing, twelve patients (25%) satisfied, while four patients (8%) dissatisfied. Patients complained for not having involved in choosing color, areas without sufficient pigment, extreme darkness of the tattooed NAC and artificial look. CONCLUSION: Tattooing is a simple and safe procedure, with a high satisfaction rate. Based on our experience, despite some technical aspects have to be considered, it is a procedure that can be safely performed by plastic surgical trainees.

Pectus excavatum correction enhanced by pectoralis muscle transposition: A new approach.

BACKGROUND: Indications for the surgical correction of pectus excavatum include functional/physiological, cosmetic, and psychosocial reasons. The most popular open technique for pectus excavatum repair was proposed by Ravitch in 1949 as an open approach that requires partial resection of the costal cartilage, xiphoid excision, and osteotomy of the sternum. The goal is to remove abnormal rib cartilage while preserving the perichondrium, allowing regrowth of the rib cartilage to the sternum in a more anatomic manner. OPERATIVE TECHNIQUE: We present a case of bilateral pectoralis muscle flap transposition during a modified Ravitch procedure is presented herein. CONCLUSION: This approach allows for a significant reduction in late complications and improves both functional and aesthetic outcomes.

Wound complication after modified Ravitch for pectus excavatum: A case of conservative treatment enhanced by pectoralis muscle transposition.

INTRODUCTION: Multiple surgical debridement sessions are mandatory before wound closure in cases of infection after a modified Ravitch procedure for pectus excavatum. Vacuum-assisted closure (VAC) is a well-established technical resource for treating complicated wounds; however, in cases of suspicion of bone infection, this approach is not enough to prevent bar removal. PRESENTATION OF THE CASE: We present a case of surgical wound dehiscence with hardware exposure in a patient who had undergone chondrosternoplasty for pectus excavatum. Several sessions of debridement (three) and VAC were applied every time. The final result was achieved without the necessity to remove the hardware; however, to avoid the risk of infection, a bilateral pectoralis muscle flap mobilization was performed as the final step after the surgical wound revisions, although this approach is suggested to be used during the modified Ravitch procedure. This approach allows for a significant reduction in late complications and improves morphological outcomes. DISCUSSION: In summary, the pectoralis muscle flap transposition is very useful not only for aesthetical results but also in combination with multiple surgical revisions for conservative management in case of wound infection during a modified Ravitch procedure. In our case, this technique was adopted after accurate care of the wound and before the final closure, which helps to maintain good vascularization and a very satisfying result. CONCLUSION: It is important to consider this approach during the modified Ravitch procedure, not only for better aesthetical results but also to prevent infections or wound dehiscence at the level of the bar.