Dermoscopy Education for Plastic Surgery Residents: How a Brief Theoretical Course and Practical Training Have an Impact.

Background: Currently, the evaluation of pigmented skin lesions relies on dermoscopy, which has become the standard of care. As melanoma is one of the principal areas of expertise in plastic surgery, it is essential that diagnostic skills be acquired during the course of specialization. This study aimed to assess the impact and effectiveness of a brief and intensive dermoscopy training program for plastic surgery residents. Methods: This study was carried out on a group of 41 doctors, who were divided into three categories based on their experience in dermoscopy (none, intermediate, and advanced). A preliminary assessment of each participant's baseline knowledge was conducted by using a 15-query test. Subsequently, the participants attended a 90-minute lecture on diagnostic techniques and the process of differentiating between various skin lesions. To determine the effectiveness of the lecture in improving diagnostic skills, the participants were tested immediately after the lecture and again after a 3-month period. Results: At the conclusion of the final examination, all three groups achieved an accuracy rate of at least 80% for dermatoscopic diagnosis. However, none of the groups was completely successful. The variations in diagnostic accuracy among the three groups are presented, and P values were calculated for each group. Conclusion: The short, intensive course of dermoscopy has proven to have a significant positive impact on plastic surgeons in their postdegree training program.

Aesthetic Surgery Tourism: An Opportunity or a Danger?

BACKGROUND: Medical and surgical tourism is a rapidly growing phenomenon in post-pandemic Europe. The exodus of patients abroad to perform surgery, especially cosmetic treatments, is spreading recently in industrialized countries. In the social media era, the ease of access to advertising about surgical procedures and their costs favors traveling. However, the information given is not always punctual, and there is often a lack of patient awareness about the risks related to the procedures. METHODS: The objective of the manuscript is to investigate, through clinical examples, the path that a patient operated on in a non-European country must face once he returns home. From the availability and translation of clinical documentation to the problems encountered in revision surgeries. RESULTS: Thirteen cases of surgical tourism, patients who presented to our department with surgical complications, are investigated. Adverse events occurring during medical treatment abroad raised medico-legal and appropriateness issues, as well as concerns regarding the follow-up of patients. CONCLUSIONS: The current literature confirmed the high complication rate: It affects individual patients and the native country's healthcare systems. Therefore, patients must learn more about the dangers of traveling abroad for surgery. Education initiatives in the patient's home country might help achieve this. 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 .

Lower-Limb Salvage Procedure using Anterolateral Thigh Free Flap and Multiple Tendon Grafts in a Road Injury Patient: A Case Report.

Introduction: The free anterolateral thigh (ALT) flap is commonly used to repair a large loss of soft tissue following a lower-limb injury. An issue to be managed is the choice of adequate recipient vessels when the tibial arteries result damaged. In this scenario, vein grafts can be interposed to connect a healthy recipient vessel to the ALT flap pedicle. Case Report: We present a report of a 19-year-old male who suffered a Gustilo fracture type IIIc after a road injury involving the right lower limb. After a failed first attempt of limb salvage with reconstruction of extensor tendons and a free ALT flap, a second procedure was performed using another ALT flap with interposed vein grafts to reach very proximal recipient vessels. Results: The patient demonstrated excellent recovery and restored ambulation. The effectiveness of the most complex reconstructive options for a high-demanding patient with no comorbidities is demonstrated in this case. Conclusion: The key to success in even the most complex injury cases is early intervention, meticulous surgical planning, and a multidisciplinary approach.

A Misdiagnosed Familiar Brooke-Spiegler Syndrome: Case Report and Review of the Literature.

Aim of the report: Brooke-Spiegler syndrome (BSS) is a rare autosomal dominant disease characterized by the growth of cylindromas, spiradenomas, trichoepitheliomas, or their combination. These neoplasms usually begin in the second decade and progressively increase in number and size over the years. Diagnosis necessitates consideration of family history, clinical examination, histological findings, and genetic analysis. The aim of this paper is to explore the clinical overlap between Brooke-Spiegler syndrome (BSS) and neurofibromatosis type 1 (NF1). We aim to highlight the challenges associated with their differential diagnosis and emphasize the lack of standardized diagnostic criteria and treatment approaches. Case presentation: Hereby, we introduce the case of a 28-year-old male referred for suspicion of neurofibromatosis type 1 (NF1) who initially declined the recommended surgical excision for a scalp mass. After four years, he returned with larger masses of the scalp, and underwent excision of multiple masses, revealing cylindromas, spiradenomas, and spiradenocylindromas. Family history reported similar tumors in his father, who was also diagnosed with NF1 for the presence of multiple subcutaneous lesions on the scalp. Clinical overlap led to a genetic consultation, but testing for CYLD mutations yielded no significant variations. Despite this, the strong family history and consistent findings led to a revised diagnosis of Brooke-Spiegler syndrome, correcting the initial misdiagnosis of NF1 syndrome. Conclusions: Thanks to the evolving landscape of BSS research over the past two decades, its molecular underpinnings, clinical presentation, and histopathological features are now clearer. However, a thorough family history assessment is mandatory when BSS is suspected. It is our belief that a multidisciplinary approach and cooperation between specialists are essential when dealing with BSS. By sharing this case, we hope to underscore the importance of considering BSS as a differential diagnosis, especially in cases with atypical presentations or overlapping features with other syndromes like NF1.

Retrospective Analysis of Predictive Factors for Complications in Abdominoplasty in Massive Weight Loss Patients.

INTRODUCTION: Ex-obese patients present with redundancy of abdominal skin and soft tissue due to massive weight loss (MWL). The plastic surgeon can restore the body shape through body contouring procedures. Hence the need to adequately direct patients to body contouring by identifying suitable candidates exists. Our work aims to retrospectively analyze the abdominoplasty complications in our case series to identify associated risk factors and evaluate the effect of combined procedures on abdominoplasty outcomes. MATERIALS AND METHODS: We retrospectively investigated predictive factors of abdominoplasty procedure complications on 213 MWL patients who received abdominoplasty with and without rectus sheath plication, abdominal liposuction, and other body contouring procedures. We identified risk and protective factors with univariate and multivariate regression analysis. Furthermore, we assessed the impact of additional procedures on the complication rates. RESULTS: The overall complication rate was 49.8% (26.8% minor complications; 23% major complications). The delayed wound healing rate was 27.7%, and the revision surgery rate was 25.8% (14.7% early revision; 14.2% late revision). These results were compared with literature reports. Several negative predictors emerged as non-modifiable (advanced age, diabetes mellitus, surgical mode of weight loss) or modifiable (preoperative obesity and body mass index (BMI); active smoking; preoperative anemia; use of fibrin glue or quilting sutures). Performing rectus sheath plication improved most of the outcomes. Liposuction of hypochondriac regions and flanks led to increased safety and reduced the risk of surgical dehiscence and delayed wound healing, in contrast to epimesogastric liposuction. The other combined body contouring procedures did not worsen the outcomes, except for poor scarring. CONCLUSION: Our findings encourage us to continue associating rectus sheath plication, liposuction, and other body contouring surgeries with abdominoplasty. We emphasize the importance of proper patient selection, particularly with regard to anemia, before body contouring surgery in the interests of offering safe surgery and satisfactory results. Further studies are needed to investigate how the optimal BMI cut-off and abstinence from smoking (in terms of time) before surgery reduce postoperative complications. 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 https://www.springer.com/journal/00266 .

Highly biocompatible material for enhanced abdominal wall repair: a retrospective study with EGIS® porcine dermal matrix.

In the early 2000s, medical devices based on acellular matrices multiplied in number. Nowadays, the use of porcine ADMs is to be considered a well-established technology, commonly applied in different surgical specialties. In this retrospective analysis of 110 cases, the use of non-crosslinked porcine ADM EGIS® results a safe and effective tool in many procedures and specialties.

The McKissock's technique in reduction mammaplasty: A comparative study of outcomes and complications in 211 consecutive patients.

Reduction mammaplasty is one of the most popular plastic surgery procedures requested by patients. The areola holding flap can be sculpted using a variety of methods that have evolved over time dependent on vascularity. Our institution has always employed the vertical bipedicle technique proposed by Mckissock, and we still favor it over other methods for larger breasts. In this study, we examined the case-study data from the Padua University Hospital's Unit of Plastic and Reconstructive Surgery from January 2009 to December 2021. The rate of complications among patients who received breast reduction using the McKissock technique and all other procedures carried out at our facility was compared. We identified 90 postoperative problems in all (affecting 42.65% of the patients) and categorized them using the Clavien Dindo system. The groups were comparable in age, BMI, and follow-up time. Similar findings emerged from the study of the single groups' complication rate. The statistical analysis did not reveal any appreciable variation in total complications or scar quality across groups. Therefore, in order to guarantee NAC survival, a stable shape, and a full upper pole, we think it is preferable to bind more than one pedicle in cases of very large breasts. Based on the results of our experience, we also recommend the McKissock approach as the first option for patients with large and ptotic breasts, particularly those who have undergone bariatric surgery and need a full upper pole and a stable outcome.

Antibiotic Prophylaxis in Plastic Surgery: From Systematic Review to Operative Algorithm.

BACKGROUND: We aimed to provide a single, viable and user-friendly operative protocol for preoperative antibiotic prophylaxis that meets the needs of all plastic surgery practitioners. METHODS: The research was conducted through the abstract and citation databases of peer-reviewed literature Pubmed® (National Center for Biotechnology Information), Medscape® (General Surgery) and Scopus® (Elsevier), comparing existing data from 2010 to 2020. A separated and dedicated research was accomplished for each of 8 macroareas such as: skin and soft tissue, hand, breast, aesthetics, head and neck, trauma, burns and miscellaneous. RESULTS: The findings for each macroareas included the choice of the antibiotic, the route and timing of administration and the clinical applications. Finally, the review has been condensed in an operative algorithm for antibiotic use to apply in each field of plastic surgery. CONCLUSION: We could provide plastic surgeon an effective, easy-to-use operative protocol for antibiotic prophylaxis in daily activity.

Xeroderma Pigmentosum: A Genetic Condition Skin Cancer Correlated-A Systematic Review.

Background: Xeroderma pigmentosum (XP) is a rare autosomal recessive disorder of UV radiation-induced damage repair that is characterized by photosensitivity and a propensity for developing, among many others, skin cancers at an early age. This systematic review focused on the correlation between the clinical, pathological, and genetic aspects of XP and skin cancer. Methods: A systematic review was conducted through a literature search of online databases PubMed, Cochrane Library, SciELO, and Google Scholar. Search terms were "Xeroderma pigmentosum", "XP", "XPC", "Nucleotide excision repair", "NER", "POLH", "Dry pigmented skin", and "UV sensitive syndrome" meshed with the terms "Skin cancer", "Melanoma", and "NMSC". Results: After 504 abstracts screening, 13 full-text articles were assessed for eligibility, and 3 of them were excluded. Ten articles were selected for qualitative assessment. Conclusions: Patients with XP usually suffer shorter lives due to skin cancer and neurodegenerative disease. Deletion/alteration of a distinct gene allele can produce different types of cancer. The XPC and XP-E variants are more likely to have skin cancer than patients in other complement groups, and the most common cause of death for these patients is skin cancer (metastatic melanoma or invasive SCC). Still, aggressive preventative measures to minimize UV radiation exposure can retard the course of the disease and improve the quality of life.

Deep inferior epigastric perforator flap preoperative planning: A comparative analysis between dynamic infrared thermography, computerized tomography angiography, and hand-held Doppler.

INTRODUCTION: Hand-held Doppler (HHD) sonography and computerized tomography angiography (CTA) are the common assessment tools for deep inferior epigastric perforator (DIEP) flap preoperative planning. CTA is considered the gold standard method for preoperative perforator mapping but necessitates contrast medium and X-ray exposure. Dynamic infrared thermography (DIRT) does not have these drawbacks and allows the detection of hot and cold spots on a given body area. Our study aimed to compare DIRT, HHD, and CTA in perforator mapping for breast reconstruction using DIEP flap. PATIENTS AND METHODS: From March to September 2020, 12 consecutive patients scheduled for DIEP flap breast reconstruction were preoperatively investigated with HHD, CTA, and DIRT. The patients' mean age was 53 and the mean BMI was 29.23 kg/m2 . All the reconstructions were due to breast cancer. The results of preoperative perforator mapping on the lower abdomen were compared among the three techniques. All the evidence was compared to the intraoperative findings, during flap harvesting, to establish if the techniques were able to correctly locate the perforator. RESULTS: We detected 178 perforators intraoperatively, 178 with CTA, 178 with DIRT, and 125 with HHD. The latter revealed a lower number of perforator vessels for each patient (10.42 ± 3.58), compared with CTA (14.83 ± 3.04) and DIRT (14.83 ± 4.76). DIRT resulted superior to HHD (p < .05), while no statistically significant difference (p > .05) was found between DIRT and CTA. We calculated a mean sensitivity of 93.87% for CTA, 69.02% for HHD, and 92.06% for DIRT. CONCLUSION: DIRT is a useful tool in the preoperative planning of DIEP flaps, as it provides information about the location of perforators and the hemodynamic properties of angiosomes. It is easy to use, and it does not involve ionizing radiation. DIRT could represent an innovative and promising implementation of CTA and HHD techniques for preoperative perforator mapping in DIEP breast reconstruction.

A New CT Analysis of Abdominal Wall after DIEP Flap Harvesting.

The abdominal microsurgical flap based on the deep inferior epigastric artery perforator (DIEP) flap has become the most popular option worldwide for autologous breast reconstruction. Several authors have investigated the results of reconstructed breasts, but the literature lacks systematic reviews exploring the donor site of the abdominal wall. To fulfil our aims, a new diagnostic muscle imaging analysis was designed and implemented. This study focused on rectus abdominal muscle morphology and function in a single series of 12 consecutive patients analysed before and after breast reconstruction with a microsurgical DIEP flap. Patients were divided into two groups, namely, "ipsilateral reconstruction" and "contralateral reconstruction", depending on the side of the flap harvest and breast reconstruction, then evaluated by computed tomography (CT) scans scheduled for tumor staging, and clinically examined by a physiatrist. Numerous alterations in muscle physiology were observed due to surgical dissection of perforator vessels, and rectus muscle distress without functional impairment was a common result. Postoperatively, patients undergoing "contralateral reconstruction" appeared to exhibit fewer rectus muscle alterations. Overall, only three patients were impacted by a long-term deterioration in their quality of life. On the basis of the newly developed and implemented diagnostic approach, we concluded that DIEP microsurgical breast reconstruction is a safe procedure without major complications at the donor site, even if long-term alterations of the rectus muscle are a common finding.

Complete Implant Wrapping with Porcine-Derived Acellular Dermal Matrix for the Treatment of Capsular Contracture in Breast Reconstruction: A Case-Control Study.

BACKGROUND: Capsular contracture (CC) represents one of the most common complications in breast reconstruction surgery, impairing final result and patients' well-being. The role of acellular dermal matrixes (ADM) has been widely described for the treatment and prevention of contracture. The aim of the study was to evaluate the efficacy and safety of complete implant coverage with porcine-derived ADM in preventing CC limiting complications. In addition, patients' reported outcomes were evaluated in order to define the role of ADM in improving sexual, physical and psychosocial well-being and satisfaction. METHODS: 42 patients who underwent surgical treatment of 46 contracted reconstructed breasts from May 2018th to May 2019th were collected in the two groups (ADM group vs. Control group). RESULTS: The ADM group showed lower rate of CC recurrence and a higher rate of implant losses and minor complications. A significant difference was observed in red breast syndrome (27.3% in the ADM group vs. absent in control the group) and skin ulceration rates (18.2% in the ADM group vs. 4.18% in the control group). As for patients' perceived outcomes, the ADM group showed a statistically significant higher postoperative Satisfaction of Breast Scale score compared to the control group. In addition, a significant difference was observed in the improvement of Physical Well-Being of the Chest Scale and the Satisfaction of Breast Scale after surgery, in favor to the ADM group. CONCLUSION: Complete implant coverage with ADM may reduce the risk of CC recurrence in breast reconstruction. An accurate patient selection allows minimizing complications improving patient well-being and satisfaction. 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 .

Retrospective analysis of the predictive factors associated with good surgical outcome in brachioplasty in massive weight loss patients.

BACKGROUND: Upper arm lift is a widespread body contouring procedure, but no globally accepted guidelines exist in selecting patients and, due to comorbidity and heterogeneity of them, it is difficult to identify predictive factors of good surgical outcome. The authors review the team's experience of 56 brachioplasty performed in massive weighs loss patients. METHODS: Data of 56 consecutive arm lifts were reviewed for preoperative, perioperative and postoperative variables and outcomes (complications, scarring, wound healing, revision surgery, need for blood transfusion, satisfaction, etc.). Surgical technique and postoperative care are described. A statistical analysis was performed to identify relationship between possible predictive factors and outcomes. Furthermore, an evaluation of different employed wound management devices was conducted. RESULTS: Follow-up ranged from 6 to 36 months (mean 20.1 months). Outcomes summary is reported (overall complication rate 50%, poor scarring rate 25%, delayed wound healing rate 26.8%, revision surgery rate 37.5%, need for blood transfusion rate 8.9%, satisfaction rate 71.4%) and statistical investigation evidenced the role of prior plastic surgery BMI and the associated change in BMI before and after weight loss, just prior brachioplasty, and the modality of weight loss. CONCLUSION: The authors' technique resulted in positive outcomes overall, considering the difficulty in dealing with the problems of MWL patients. Based on our results, we aim to suggest to perform brachioplasty in patient with the lower achievable BMI (preferably <30kg/m2) to reduce the negative effect of unmodifiable factors as diabetes, modality of weight loss, a wide ΔBMI, and other well-known negative predictive factors.

Current Surgical Therapy of Locally Advanced cSCC: From Patient Selection to Microsurgical Tissue Transplant. Review.

Among the non-melanoma skin cancers (NMSC) the squamous cell carcinoma (SCC) is one of the most challenging for the surgeon. Local aggressiveness and a tendency to metastasize to regional lymph nodes characterize the biologic behavior. The variants locally advanced and metastatic require wide excision and node dissection. Such procedures can be extremely detrimental for patients. The limit of the surgery can be safely pushed forward with a multidisciplinary approach. The concept of skin oncoplastic surgery, the ablative procedures and the reconstructive options (skin graft, pedicled flap, microsurgical free flap) are discussed together with a literature review.

Brief history in the time of SARS-CoV-2 pandemic in Italy. A close look on a Plastic Surgery Unit and Plastic Surgeons efforts during the COVID-19 outbreak.

BACKGROUND: SARS-CoV-2 and its related COVID-19 are now affecting people worldwide. The pandemic, started at the end of 2019 and spread in Europe and all over the world at the beginning of the 2020, is the biggest threat to the health and to the economy of all countries, since the time of Spanish Flu. A global effort is being made to counter the virus with social distancing and restrictions, but our habits and behavior have dramatically been modified. Hospital activity has changed, and Plastic Surgery is affected as well as other disciplines. MATERIALS, METHODS AND RESULTS: Our work describes the impact of the pandemic on a Plastic Surgery Unit in a tertiary care hospital and estimates the possible consequences in the near future. Elective procedures and consultations have been postposed and rescheduled, but we ensured treatment for life-threatening conditions and offered the best therapy, complying with the new safety standard to protect the patients and the healthcare providers. Media helped in keeping in touch the people, ensuring continuity in education and circulation of the data about SARS-CoV-2 research. CONCLUSION: We don't know yet what the overall cost of the crisis will be on the global economy and on the National Health Systems. Definitely, it will be a big challenge to face, both for the Governments, for the people, as for healthcare providers. However, to date, we should remind our responsibilities as doctors, as we can contribute with our efforts and our knowledge to ensure continuity of care and research. KEY WORDS: COVID, COVID-19, Italy, Outbreak, Pandemic, Plastic Surgery, SARS-Cov-2.

The Role of Portable Incisional Negative Pressure Wound Therapy (piNPWT) in Reducing Local Complications of Post-bariatric Brachioplasty: A Case-Control Study.

BACKGROUND: Due to the great impact of bariatric surgery on the overweight epidemic, the number of post-bariatric body-contouring procedures is constantly increasing worldwide. The portable incisional negative pressure wound therapy (piNPWT) is a promising medical device for accelerating wounds closure and controlling post-operative complication, which have been shown promising results in post-bariatric population. We aimed to evaluate the role of piNPWT in optimizing wound healing and controlling post-operative complications after a post-bariatric brachioplasty. PATIENTS AND METHODS: 26 post-bariatric female patients who underwent a brachioplasty followed by either a piNPWT (14 cases) or a standard wound treatment (12 controls) were analyzed. The number of post-operative dressing changes, the rate of local post-operative complications (re-operation, hematoma and serosa development, dehiscence and necrosis), the time to dry as well as the scar quality and hospitalization length were evaluated. RESULTS: None of the patients prematurely stopped treatment with piNPWT due to intolerance. The piNPWT patient group showed a significant lower healing time as well as a significant reduction of the number of post-operative dressing changes and hospital stay. Despite the scarring process was excellent from the functional point of view in the long term, we noticed a higher rate of hyperchromic scarring at 90 days after surgery. CONCLUSION: The piNPWT is a cost-effective and user-friendly medical tool that increase and promote wound healing. We suggest the use of this device in post-bariatric patients who undergo a brachioplasty, especially if there is the need to minimize the number of post-operative dressing changes. 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 Table of Contents or the online Instructions to Authors www.springer.com/00266.

Merkel Cell Carcinoma: Evaluation of the Clinico-Pathological Characteristics, Treatment Strategies and Prognostic Factors in a Monocentric Retrospective Series (n=143).

BACKGROUND: Merkel cell carcinoma (MCC) is a rare neuroendocrine tumor of the skin. The incidence of the disease has undergone a significant increase in recent years, which is caused by an increase in the average age of the population and in the use of immunosuppressive therapies. MCC is an aggressive pathology, which metastasizes early to the lymph nodes. These characteristics impose an accurate diagnostic analysis of the regional lymph node district with radiography, clinical examination and sentinel node biopsy. In recent years, there has been a breakthrough in the treatment of the advanced pathology thanks to the introduction of monoclonal antibodies acting on the PD-1/PD-L1 axis. This study aimed to describe the clinico-pathological characteristics, treatment strategies and prognostic factors of MCC. METHODS: A retrospective cohort study was conducted involving 143 consecutive patients who were diagnosed and/or treated for MCC. These patients were referred to the Veneto Institute of Oncology IOV-IRCCS and to the University Hospital of Padua (a third-level center) in the period between December 1991 and January 2020. In the majority of cases, diagnosis took place at the IOV. However, some patients were diagnosed elsewhere and subsequently referred to the IOV for a review of the diagnosis or to begin specific therapeutic regimens. RESULTS: 143 patients, with an average age of 71 years, were affected mainly with autoimmune and neoplastic comorbidities. Our analysis has shown that age, autoimmune comorbidities and the use of therapy with immunomodulating drugs (which include corticosteroids, statins and beta-blockers) are associated with a negative prognosis. In this sense, male sex is also a negative prognostic factor. CONCLUSIONS: Autoimmune and neoplastic comorbidities were frequent in the studied population. The use of drugs with immunomodulatory effects was also found to be a common feature of the population under examination. The use of this type of medication is considered a negative prognostic factor. The relevance of a multidisciplinary approach to the patient with MCC is confirmed, with the aim of assessing the risks and benefits related to the use of immunomodulating therapy in the individual patient.

A Misdiagnosed Desmoplastic Neurotropic Melanoma of the Scalp: A Challenging Case for the Pathologist and Surgeon.

Desmoplastic neurotropic melanoma (DNM) is a rare melanoma subtype that shows tropism for the nerves, perineural invasion correlates to higher rate of local recurrence, poorer prognosis and worse morbidity. Given the paucity of typical melanoma features, both clinical and pathological, this confusing skin cancer may act as a pretender, thus leading clinician to misdiagnosis and subsequent inappropriate conservative treatment. Sarcomatoid-like cells rearrangement and absence of pigmentation can lead towards sarcoma diagnosis, so specific skills are required to pathologist to properly recognize this melanoma subtype. In this case report, we present an example of how challenging can be the diagnosis, and how it can affect clinical outcome.

Multidisciplinary oncoplastic approach to chest wall reconstruction following wide resections. Report of three cases.

An advanced cancer or an infection process localized on chest wall often require large full thickness resection to obtain free margins and site sterilization. Superior skills and expertise can be provided by a multidisciplinary surgical team, overcoming technical difficulties otherwise insurmountable for a single specialist. Only a multidisciplinary approach, providing both skeletal reconstruction and soft tissue coverage, allows to restore chest wall functions and stable coverage of lung and viscera. Furthermore, in case of lung exposition, immediate reconstructive procedure is demanded for stable coverage. We present 3 complex clinical cases, in which an immediate plastic reconstruction followed a wide resection of thoracic wall, performed by combining synthetic or biologic mesh with large myocutaneous flaps. Meticulous pre-op planning of every step, integration of reconstructive modalities proper of different specialties, and full cooperation among surgical teams are the backbone of such complex surgery. The goals consist in reaching margins free of disease and fast healing, so reducing recovery time and promoting an immediate respiratory rehabilitation. The clinical results of this report supports the importance of multidisciplinary approach in wide chest wall resections. KEY WORDS: Basal cell carcinoma, Biologic mesh, Chest wall reconstruction, Oncoplastic, Osteomyelitis, Squamous cell carcinoma.

Persistent Sciatic Artery and its role in limb salvage in oncological surgery.

AIM: The Persistent Sciatic Artery (PSA) is a rare congenital anomaly due to missed involution of embryo-fetal sciatic artery, which is the main blood supply to lower limb during embryonic development until superficial femoral artery (SFA) is formed. The PSA is frequently related to complications in adults like aneurysm and embolism. Here we present a case in which the discovery of a complete PSA resulted limb saving. In case of oncologic or trauma surgery, when no other options are available, the PSA can help in management of reconstructive surgery. CASE REPORT: A case of PSA was discovered during management of a patient affected by a soft tissue sarcoma of the lower limb. Tumor resection needed the femoral neurovascular bundle demolition to ensure radical surgery and subsequent vascular reconstruction, which failed due to complications. RESULTS: Despite failure reconstruction, a misdiagnosed type IIa PSA, replacing the role of the SFA, saved the lower limb from ischemia and subsequent amputation. Functional reconstruction was thus achieved with almost total recovery of lower limb function. DISCUSSION AND CONCLUSIONS: In oncological and trauma surgery we recommend investigate the whole lower limb vascularization, from the pelvis to the foot, suspecting the PSA existence. Indeed, although it is always preferable to reconstruct the SFA system despite a complete PSA is present, due to its frequent complications, the PSA can represent a limb saving option. KEY WORDS: Computerized tomography angiography, Persistent sciatic artery, PSA, Superficial femoral artery, SFA fibromyxoid sarcoma.