Clinical and Ultrasound Efficacy of Topical Hypertonic Cream (Jovita Osmocell®) in the Treatment of Cellulite: A Prospective, Monocentric, Double-Blind, Placebo-Controlled Study.

Background and Objectives: Cellulite, or edemato-fibro-sclerotic panniculopathy (EFP), is characterized by dermal and hypodermal changes leading to adipose tissue accumulation and compromised venous circulation. This study investigates the efficacy of a hypertonic cream containing concentrated sodium chloride (Jovita Osmocell®) in addressing water retention and structural alterations in adipose tissue, aiming to interrupt the cellulite formation process. Materials and Methods: A 12-week, prospective, monocentric, double-blind, placebo-controlled study enrolled 30 female subjects with grade II or III cellulite. Patients were randomized to receive hypertonic cream or a placebo. Thigh circumference, ultrasound evaluations, and standardized photographs were collected at baseline, intermediate, and endpoint visits. Adverse events were monitored. Results: After 84 days, the hypertonic cream group exhibited a significant reduction in thigh circumference compared to the placebo group (p = 0.0037). B-mode ultrasound examinations revealed significant changes in the parameters studied, such as the thickness of the subcutaneous tissue. No statistically significant changes were noticed in the placebo group. Volunteers reported the investigational product's pleasantness and good anti-cellulite activity, with no reported adverse events. Conclusions: The hypertonic cream demonstrated efficacy in reducing thigh circumference, addressing water retention and structural alterations in adipose tissue. The proposed mechanism involves osmosis, releasing accumulated fluids between fat cells, supporting drainage, and reducing inflammation. This study supports the efficacy and safety of hypertonic sodium chloride emulsions in cellulite treatment and confirms safety and user satisfaction.

Aesthetic Rehabilitation Medicine: Enhancing Wellbeing beyond Functional Recovery.

Although rehabilitation medicine emphasizes a holistic health approach, there is still a large gap of knowledge about potential interventions aimed at improving overall wellbeing through cosmetic interventions. Therefore, this narrative review investigates the role of different rehabilitative techniques in enhancing aesthetics, quality of life, and psychosocial wellbeing for patients with disabilities. The study follows the SANRA framework quality criteria for a narrative review. Literature searches across PubMed/Medline, Web of Science, and Scopus identified articles focusing on rehabilitation strategies within the aesthetic rehabilitation domain. The review identified evidence supporting injection procedures, such as Botulinum Toxin, Platelet-Rich Plasma, Hyaluronic Acid, Ozone, and Carboxytherapy, and assessing their applications in several disabling disorders. Additionally, physical therapies like Extracorporeal Shock Wave Therapy, Laser Therapy, Microcurrent Therapy, Tecar Therapy, and physical exercises were explored for their impact on cutaneous microcirculation, cellulite treatment, wound healing, and scar appearance improvement. Lastly, the manuscript underlines the role of manual therapy techniques in addressing both physical discomfort and aesthetic concerns, discussing their effectiveness in adipose tissue therapy, scar tissue mobilization, and regional fat thickness reduction. Taken together, this review emphasizes the role of a multidisciplinary approach, aiming to provide valuable insights into potential benefits for both functional and aesthetic outcomes.

Lower Extremity Trauma: A Multidimensional Reconstructive Approach with Hyperbaric Oxygen Therapy.

Background: Distal lower extremity reconstruction is challenging. This study aims to propose a protocol for the treatment of traumatic soft tissue defects. The key concept is to combine the surgical armamentarium of the reconstructive surgeon with the advantages provided by hyperbaric oxygen therapy. Methods: This retrospective study analyzed data of 57 patients affected with unilateral or bilateral lower extremity trauma distal to the knee and involving soft tissues with no indication of immediate reconstruction between 2010 and 2021. Before the reconstructive procedure, all the patients underwent a stick swab procedure for the collection of microbiological samples and debridement. Patients were divided into two treatment groups and only one group underwent a combined therapeutic procedure with hyperbaric oxygen therapy. Negative pressure wound therapy (NPWT) was employed only if deemed necessary according to the defect's depth and wound exudate. Surgical techniques, outcomes, and complications were discussed. Results: All patients achieved a complete recovery with no major complications and only minor complications observed. The study group treated with HBOT had a lower complication rate and lower percentages of minimal and partial graft loss compared with the same complications observed in the control group. No patients experienced HBOT-related complications. Significant reductions in the time to complete healing and the time from reconstruction to healing were found (p = 0.002 and p < 0.00001, respectively). Conclusions: A lower complication rate was observed in the group treated with HBOT. The administration of HBOT prior to soft tissue reconstruction significantly reduced the time to complete healing and the time interval from skin grafting to healing. However, prospective studies and randomized trials with larger cohorts should be designed to investigate the efficacy of HBOT for the treatment of lower extremity injuries with extensive soft tissue defects.

Editorial for the Special Issue "Vasorum Lymphaticorum: From the Discovery of the Lymphatic System to the New Perspectives in Microsurgical Reconstruction and Patient Rehabilitation".

Lymphedema is a complex clinical condition that appears as a result of the failure of the lymphatic system function, and it is characterized by edema, fibrosis, and adipose deposition [...].

Lower Lip Reconstruction after Skin Cancer Excision: A Tailored Algorithm for Elderly Patients.

BACKGROUND: Lower lip reconstruction is crucial to restore oral integrity post-cancer excision. A perfect balance between form and function should be achieved. With an aging demographic, adapting surgical methods to meet the unique needs of the elderly becomes imperative. Our study aims to introduce a specialized algorithm for lower lip reconstruction; it was tailored to geriatric patients and emphasized the use of "simpler flaps". Additionally, "Pearls and Pitfalls" were provided for surgeons approaching lower lip reconstruction. METHODS: Between January 2018 and June 2021, a retrospective study was carried out. Data collection included patient demographics, defect attributes, reconstructive approaches, flap viability assessment, wound healing, and complications. The follow-up was carried out for a period of a minimum of 6 months. RESULTS: Among 78 patients, squamous cell carcinoma predominated with a mean defect area of 3308 cm2. Postoperative complications were recorded in two patients. All patients reported sensory restoration and overall satisfaction at the 6-month follow-up; secondary procedures were not necessary. CONCLUSION: Our reconstructive algorithm, focused on elderly patients, prioritizes less invasive reconstructive techniques and introduces innovative modifications to the established methods to achieve both aesthetic and functional outcomes with a low complication rate. In patients undergoing lower lip reconstruction, the subjective microstomia was found to be less relevant than the objective microstomia.

Mind the Gap: A Questionnaire on the Distance between Diagnostic Advances and Clinical Practice in Skin Cancer Treatment.

Background and Objectives: Significant progress has been made in skin cancer diagnosis, with a surge in available technologies in recent years. Despite this, the practical application and integration of these technologies in dermatology and plastic surgery remain uneven. Materials and Methods: A comprehensive 20-question survey was designed and distributed using online survey administration software (Google Forms, 2018, Google, Mountain View, CA, USA) from June 2023 to September 2023. The survey aimed to assess the knowledge and utilization of dermatologic diagnostic advancements among plastic surgeons in various European countries. Results: Data were obtained from 29 plastic surgeons across nine European countries, revealing a notable gap between diagnostic technologies and their routine use in surgical practice. The gap for some technologies was both cognitive and applicative; for electrical impedance spectroscopy (EIS) and multispectral imaging, only 6.9% of the sample knew of the technologies and no surgeons in the sample used them. In the case of other technologies, such as high-frequency ultrasound (HFUS), 72.4% of the sample knew about them but only 34.5% used them, highlighting a more significant application problem. Conclusions: Spotlighting this discrepancy provides a valuable foundation for initiating collaborative efforts between units and facilitating knowledge exchange among diverse specialists. This, in turn, contributes to advancing clinical practice by integrating the innovative opportunities presented by ongoing research.

Injection Treatments for Vulvovaginal Atrophy of Menopause: A Systematic Review.

BACKGROUND: Injection treatments have been proposed as novel treatment options for Vulvovaginal Atrophy of Menopause (VVA) also known as Genitourinary Syndrome of Menopause (GSM). However, to date data about these treatments are poor. OBJECTIVE: To assess all available injection treatments for VVA. METHODS: A systematic review was performed by searching five electronic databases for peer-reviewed studies that assessed injection treatments for VVA. RESULTS: Eight studies (7 observational and 1 randomized) with 236 women were included. Assessed injection materials were: autologous platelet-rich plasma (PRP) + hyaluronic acid (HA), not cross-linked HA plus calcium hydroxyapatite (NCLHA + CaHA), micro-fragmented adipose tissue (MFAT), hyaluronan hybrid cooperative complexes (HCC), crosslinked HA, microfat and nanofat grafting + PRP, and PRP alone. Improvement in GSM symptoms after treatment was assessed through Visual Analogic Scale (VAS) for GSM symptoms or patient satisfaction, several validated questionnaires (FSFI, VHI, FSD, SF12, ICIQ UI SF, PGI-I, FSDS-R, VSQ), symptoms severity, changes in vaginal mucosa thickness, flora, pH, and expression on vaginal mucosal biopsies of Procollagen I and III and ki67 immunofluorescence or COL1A1 and COL3A1 mRNA. Injection treatments showing significant improvement in GSM-related symptoms were: (i) HCC in terms of VAS for GSM symptoms and FSFI score; (ii) Crosslinked HA in terms of VAS for GSM symptoms, FSFI and VHI score, COL1A1 and COL3A1 mRNA expression on vaginal mucosal biopsies; (iii) NCLHA + CaHA in terms of FSFI score; (iv) PRP + HA in terms of VHI, FSD and SF12 score; (v) microfat and nanofat grafting + PRP in terms of VHI score and FSDS-R score; (vi) PRP alone in terms of VHI and VSQ scores. CONCLUSIONS: All assessed injection treatments except for MFAT seem to lead to significant improvement in VVA symptoms on validated questionnaires. Further studies are necessary in the field. LEVEL OF EVIDENCE II: 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 .

Reply to De Luca et al. Comment on "Marra et al. Metastatic Renal Cell Carcinoma to the Soft Tissue 27 Years after Radical Nephrectomy: A Case Report. Medicina 2023, 59, 150".

We appreciated the comments of De Luca and colleagues [...].

Metastatic Renal Cell Carcinoma to the Soft Tissue 27 Years after Radical Nephrectomy: A Case Report.

Background and Objectives: Approximately 20-40% of patients affected with renal cell carcinoma (RCC) develop either distant metastatic or locally recurring disease following radical nephrectomy. Soft tissue, skin, and the central nervous system are less common metastatic sites. We present the case of a patient who has received a diagnosis of RCC; it was found that she had no metastases at the time of nephrectomy but had metastases in the soft tissue and subcutaneous tissue of the scalp 27 years later. As far as we can tell, this is the longest period elapsed between primary renal tumor and subcutaneous/soft tissue metastasis; moreover, this case is the first report of a combined soft tissue/subcutaneous metastasis from RCC. Case presentation: A 73-year-old woman underwent right radical nephrectomy 27 years earlier for clear cell renal cell carcinoma (CCRCC). She presented at our unit because she noticed swelling in the left temporal region; after radiological exams, a benign lesion was suspected. The patient underwent surgical eradication, but the massive bleeding did not allow the removal of the lesion. A biopsy of the mass was performed and the histological examination was consistent with RCC metastases. Conclusions: Metastases from renal cell carcinoma to the subcutaneous and soft tissues are rare. It is essential to take into account RCC metastases in the differential diagnostic of the new starting mass of the head and neck, and the necessity for close and continuous surveillance of patients diagnosed with renal cancer even after a long disease-free period should be emphasized.

The breast cancer-related lymphedema multidisciplinary approach: Algorithm for conservative and multimodal surgical treatment.

BACKGROUND: Multiple surgical alternatives are available to treat breast cancer-related lymphedema (BCRL) providing a variable spectrum of outcomes. This study aimed to present the breast cancer-related lymphedema multidisciplinary approach (B-LYMA) to systematically treat BCRL. METHODS: Seventy-eight patients presenting with BCRL between 2017 and 2021 were included. The average age and BMI were 49.4 ± 7.8 years and 28.1 ± 3.5 kg/m2 , respectively. Forty patients had lymphedema ISL stage II (51.3%) and 38 had stage III (48.7%). The mean follow-up was 26.4 months. Treatment was selected according to the B-LYMA algorithm, which aims to combine physiologic and excisional procedures according to the preoperative evaluation of patients. All patients had pre- and postoperative complex decongestive therapy (CDT). RESULTS: Stage II patients were treated with lymphaticovenous anastomosis (LVA) (n = 18), vascularized lymph node transfer (VLNT) (n = 12), and combined DIEP flap and VLNT (n = 10). Stage III patients underwent combined suction-assisted lipectomy (SAL) and LVA (n = 36) or combined SAL and VLNT (n = 2). Circumferential reduction rates (CRR) were comparable between patients treated with LVA (56.5 ± 8.4%), VLNT (54.4 ± 10.2%), and combined VLNT-DIEP flap (56.5 ± 3.9%) (p > .05). In comparison to LVA, VLNT, and combined VLNT-DIEP flap, combined SAL-LVA exhibited higher CRRs (85 ± 10.5%, p < .001). The CRR for combined SAL-VLNT was 75 ± 8.5%. One VLNT failed and minor complications occurred in the combined DIEP-VLNT group. CONCLUSION: The B-LYMA protocol directs the treatment of BCRL according to the lymphatic system's condition. In advanced stages where a single physiologic procedure is not sufficient, additional excisional surgery is implemented. Preoperative and postoperative CDT is mandatory to improve the outcomes.

Comparison of total anastomosis time between four different combinations of suturing and knot tying techniques in microsurgical anastomosis.

BACKGROUND: Various techniques have been described for performing microsurgical anastomosis with providing high patency rates. Although the total anastomotic time may not be an issue when dealing with a single set of anastomoses, using a faster technique may save significant amount of time in cases of transferring flaps with shorter critical ischemia time or where multiple anastomoses are required. This study compares the total anastomosis time between four different combinations of commonly used suturing and knot tying techniques. METHODS: Twenty-four rats were divided into 4 groups. Simple interrupted suture with conventional knot tying technique (SIS-CT) was used in group I, continuous suture technique with conventional knot tying (CST) was used in group II, simple interrupted suture with airborne knot tying technique(SIS-AT) was used in group III, and continuous-interrupted suture with airborne knot tying technique(CIS-AT) was used in group IV for microsurgical anastomosis. Total anastomosis time and patency rates with each technique and samples from anastomotic sites were analyzed. RESULTS: The mean time required for microvascular anastomosis of the femoral artery was 1075 s in group I, 799 s in group II, 844 s in group III, and 973 s in group IV. The difference between four groups was statistically significant. The anastomoses in group II and group III were completed in the shortest period of time. Intergroup comparison revealed that the difference between group II and group III was not statistically significant, however, total anastomosis time for completion of the anastomosis was significantly longer for group I, followed by group IV. Thrombosis rates and histological analysis revealed no significant differences among four groups. CONCLUSION: CST and SIS-AT techniques can significantly reduce microsurgical anastomosis time and provide high patency rates. Also, the time needed to complete an anastomosis was significantly shorter for CIS-AT when compared to SIS-CT.

Surgical Treatment and Rehabilitation Strategies for Upper and Lower Extremity Lymphedema: A Comprehensive Review.

Lymphedema is a chronic disabling condition affecting a growing number of patients worldwide. Although lymphedema is not life-threatening, several reports underlined detrimental consequences in terms of distress, pain, functional impairment, and infections with a relevant decrease in quality of life. Currently, there is no cure, and the therapeutic management of this condition aims at slowing down the disease progression and preventing secondary complications. Early diagnosis is paramount to enhance the effects of rehabilitation or surgical treatments. On the other hand, a multidisciplinary treatment should be truly integrated, the combination of microsurgical and reductive procedures should be considered a valid strategy to manage extremity lymphedema, and rehabilitation should be considered the cornerstone of the multidisciplinary treatment not only for patients not suitable for surgical interventions but also before and after surgical procedures. Therefore, a specialized management of Plastic Reconstructive Surgeons and Physical and Rehabilitative Medicine physicians should be mandatory to address patients' needs and optimize the treatment of this disabling and detrimental condition. Therefore, the aim of this review was to characterize the comprehensive management of lymphedema, providing a broad overview of the potential therapy available in the current literature to optimize the comprehensive management of lymphedema and minimize complications.

Axillary Web Syndrome in Breast Cancer Women: What Is the Optimal Rehabilitation Strategy after Surgery? A Systematic Review.

BACKGROUND: Axillary web syndrome (AWS) is one of the most prevalent and underrecognized disorders affecting breast cancer (BC) women. However, the optimal therapeutic strategy to manage AWS is far from being fully characterized. Therefore, this systematic review aims to provide a broad overview of the available rehabilitation treatments in this burdensome condition. METHODS: On 13 January 2022, PubMed, Scopus, Web of Science, Cochrane, and PEDro were systematically searched for clinical studies assessing rehabilitation interventions in post-surgical BC women with AWS. The outcomes analyzed were pain, AWS clinical resolution, upper limb function, and health-related quality of life (HR-QoL). RESULTS: The search identified 1115 records, of which 11 studies were included. A total of 174 patients were assessed (ages ranging from 37 and 66 years old). The interventions included manual lymphatic drainage, manual therapy, stretching, resistance training, mobilization techniques, and Kinesio tape. Positive improvements were reported in terms of pain relief (in 7 studies), AWS clinical resolution (in 9 studies), upper limb function (in 10 studies), and HR-QoL (in 2 studies). CONCLUSIONS: Our findings suggest that rehabilitation might be considered an effective therapeutic strategy in AWS patients. Further RCTs are needed to characterize the optimal rehabilitative interventions.

Clinical Evaluation of the Efficacy and Tolerability of Rigenase® and Polyhexanide (Fitostimoline® Plus) vs. Hyaluronic Acid and Silver Sulfadiazine (Connettivina® Bio Plus) for the Treatment of Acute Skin Wounds: A Randomized Trial.

OBJECTIVES: Compare the efficacy and tolerability of Connettivina® Bio Plus (Group A) gauze and cream, and Fitostimoline® Plus (Group B) gauze and cream for the treatment of acute superficial skin lesions. DESIGN: Single-center, parallel, randomized trial. A block randomization method was used. SETTING: University of Salerno-AOU San Giovanni di Dio e Ruggi d'Aragona. PARTICIPANTS: Sixty patients were enrolled. All patients fulfilled the study requirements. INTERVENTION: One application of the study drugs every 24 h, and a six-week observation period. MAIN OUTCOME MEASURES: Efficacy and tolerability of the study drugs. RESULTS: In total, 60 patients (Group A, n = 30; Group B, n = 30) were randomized; mean age was 58.5 ± 15.8 years. All patients were included in the outcome analysis. Total wound healing was achieved in 17 patients undergoing treatment with Connettivina® Bio Plus and 28 patients undergoing treatment with Fitostimoline® Plus. The greater effectiveness of the latter was significant (p = 0.00104). In Group B, a significantly greater degree of effectiveness was observed in reducing the fibrin in the wound bed (p = 0.04746). Complications or unexpected events were not observed. CONCLUSIONS: Both Connettivina® Bio Plus and Fitostimoline® Plus are secure and effective for treating acute superficial skin lesions. Fitostimoline® Plus was more effective than Connettivina® Bio Plus in wound healing of acute superficial skin lesions, especially if fibrin had been observed in the wound bed.

Soft palate reconstruction with free jejunum flap: Impact on the velopharyngeal insufficiency.

If inadequately reconstructed, large resections of the soft palate inevitably cause velopharyngeal insufficiency, nasal regurgitation and reduce speech intelligibility. A series of 12 free Jejunal flaps are presented, with 28.5 months median follow up (IQR 10.5), with evidence that the flaps provided appropriate secretions and good functionality for speech and resumption of oral intake. A retrospective case series was performed, from 2004 to 2020, including patients diagnosed with palate locally advanced squamous cell carcinoma and reconstructed with free jejunum flap. Twelve patients were included, with mean age of 66 years. No flap loss, thrombosis or infection were recorded. Oral feeding was achieved in all patients, on an average after 36 days from the operation. Speech intelligibility improved by 4 points in a scale 0-10. The thin, pliable, and elastic properties of the free jejunal flap are optimally suited for a functional reconstruction of the three-dimensional palatal defects. With its serous and mucous secretion, the free jejunal flap can lead to early return to solid diet and minimize functional impairment of phonation and speech.

The Combination of Lymph Node Transfer and Excisional Procedures in Bilateral Lower Extremity Lymphedema: Clinical Outcomes and Quality of Life Assessment with Long-Term Follow-Up.

BACKGROUND: Bilateral lower extremity lymphedema is a rare and invalidating condition that poses a great challenge to the scientific community, and deeply affects the quality of life (QoL) of affected patients. A combined protocol consisting of lymph node transfer and a reductive method have never been reported for the treatment of this condition, except for small case series with brief follow-up periods. METHODS: This retrospective study analyzed data of 29 patients, mean age 51 ± 17.1 years, who had been diagnosed with bilateral lower extremity lymphedema. Gastroepiploic vascularized lymph node transfer was performed in all the patients, and an excisional procedure was associated according to the clinical stage. Clinical history, circumferential limb measurements, complications, episodes of cellulitis, and responses to the Lymphedema Quality of Life Questionnaire were analyzed. RESULTS: The mean follow-up was 38.4 ± 11.8 months. A significant reduction in the episodes of cellulitis per year was observed (p < 0.001). In our series, BMI and duration of symptoms were significantly related to the development of cellulitis during the postoperative period, p = 0.006 and p = 0.020, respectively. The LYMQoL questionnaire showed a significant quality of life improvement from 3.4 ± 0.9 to 6.2 ± 0.8 (p < 0.05). CONCLUSIONS: An integrated approach is essential for the treatment of bilateral lower extremity lymphedema: reductive and reconstructive methods are complementary to achieve a successful outcome. Timely treatment and BMI reduction are relevant in order to decrease the number of episodes of cellulitis. An attentive follow-up is necessary to identify recurrence and treat affected patients in time.