Hyperbaric Oxygen Therapy in Upper Limb Crush Injury: Why and When?

Introduction In 2016, the European Committee for Hyperbaric Medicine strongly recommended hyperbaric oxygen therapy (HBOT) adjunctive to surgery in post-traumatic crush injuries, initiating as rapidly as possible. For the last 30 years, HBOT has been used in crush injury, but in most cases as a last resort, after skin flaps necrosis or wound bed infection, diminishing its potential benefits as a complementary treatment. It is, therefore, essential to understand how HBOT modulates the outcome of crush injury, and when to use it, since this can be a significant and underused therapeutic weapon that may alter the natural course of these patients. Methods Nineteen (n=19) adult patients with upper limb crush injuries underwent adjunctive HBOT, after the initial surgical approach. The measured outcomes included trauma-related acute complications (tissue necrosis and local infection), and late complications (pseudarthrosis and late deep infection). Results Only six (n=6) patients started HBOT in the first 24 hours. Four (n=4) patients presented acute complications; in half of those cases (n=2), HBOT was initiated more than 24 hours post-injury. Late complications were observed in three patients, none of which had initiated HBOT in the first 24 hours post-injury. Conclusions Either lack of awareness or logistic difficulties, preclude initiating timely HBOT, limiting its potential benefits. It is important to alert all practitioners to the right timing to initiate HBOT in order to improve these patients' outcomes.

Impact of polyurethane versus acellular dermal matrix coating on prepectoral reconstruction outcomes: Interface does matter.

BACKGROUND: Interfaces continue to be used in prepectoral breast reconstruction to refine breast appearance, but more clinical data are required to assess their effectiveness. This study compares the rates of capsular contracture, breast esthetics, and patient satisfaction between two commonly used interface materials, acellular dermal matrix (ADM) and polyurethane (PU) foam. METHODS: A cross-sectional assessment was conducted on all patients who underwent prepectoral direct-to-implant reconstruction with an interface material between June 2018 and June 2022. We compared capsular contracture rates (assessed in-person), esthetic outcomes (evaluated by a three-member panel using a specially designed scale), and patient satisfaction (measured using the Breast-Q questionnaire) among the members of the interface groups. RESULTS: Among the 79 reconstructed breasts (20 bilateral cases), 35 were reconstructed using ADM and 44 using PU implants. The ADM group had a significantly higher frequency of Baker III/IV capsular contracture compared with the PU group (14.3% vs. 0%, p = 0.014) and lower ratings from the panel in terms of capsular contracture (median 3.7 vs. 4.0, p < 0.001). PU reconstructions scored worse in implant visibility (median 2.3 vs. 3.3, p < 0.001) and rippling (median 3.0 vs. 3.7, p < 0.001). However, after appropriate adjustment for confounders, no significant differences in overall appearance and patient satisfaction were found. CONCLUSIONS: ADM reconstructions are prone to capsular contracture with all their related esthetic issues, but PU implants have certain cosmetic flaws, such as implant visibility and malposition. Since each technique has its own limitations, neither the experienced surgeons nor patients exhibited a clear preference for either approach.

A Two-Year Retrospective Analysis of the Clinical Outcomes of Immediate Submuscular Breast Reconstructions With Native® Acellular Dermal Matrix.

BACKGROUND: Implant-based submuscular breast reconstruction (SBR) can be performed with the aid of acellular dermal matrices (ADM) for implant coverage on their inferolateral pole, aiming at providing a biological interface for hiding the implant and therefore reducing the risk of complications. The purpose of this study is to assess the long-term post-operative outcomes obtained using the SBR-specific Native® ADM (DECO med s.r.l., Marcon, Venice, Italy). METHODS: All cases of Native®-assisted immediate SBR performed at our institution between October 2016 and March 2020 were retrospectively analysed. Demographic and surgical data were collected, and post-operative outcomes, including minor and major complications, were evaluated. Particular attention was paid to complications emerging before and after patient discharge. Dependence analyses were performed to uncover statistically significant relationships between risk factors and reconstructive outcomes. RESULTS: Data on 100 patients were collected, for a total of 128 breasts. The mean age of the cohort was 49.5 years, the mean BMI was 23.4 kg/m2, and the mean follow-up was 24 months. Out of this, 14.1% of patients received pre-operative radiotherapy, while 16.4% underwent post-mastectomy radiotherapy. Breasts appeared to develop short-term minor complications more likely during hospitalisation (11.7% vs. 7.8%), while short-term major complications occurred more often after discharge (7.8% vs. 15.6%). The most frequent long-term complications were capsular contracture and contour defects (both 9.4%). Risk factors that showed a statistically significant relationship with complications were pre- and post-mastectomy radiotherapy and post-operative chemotherapy. CONCLUSIONS: The retrospective analysis showed results in line with clinical outcomes reported in the literature for the same reconstructive technique. The use of Native® ADM in SBR is safe and effective in the long term.

Comparing Polyurethane and Acellular Dermal Matrix Implant Cover in Prepectoral Breast Reconstruction: Short-term Complications.

Implant covering with an interface material is the standard in prepectoral breast reconstruction. Acellular dermal matrix (ADM) is frequently used, but it is expensive and associated with complications. Alternatively, we have been using integrated devices consisting of a silicone implant coated with polyurethane (PU) foam. We aimed to compare both techniques in terms of acute complications. Methods: The authors retrospectively reviewed patients undergoing prepectoral direct-to-implant reconstruction from June 2018 to January 2022. Two cohorts were defined based on the interface material used: ADM versus PU. Total drainage volume, time to drain removal, and acute complications (hematoma, seroma, infection, and explantation) were analyzed. Results: Forty-four breast reconstructions were performed in 35 patients (10 bilateral); implants were covered with ADM in 23 cases and with PU foam in 21. Median total drainage volume (500 versus 515 cc for ADM and PU, respectively) and time to drain removal (9 versus 8 days) were not affected by the interface material used, but seromas and infections occurred exclusively in the ADM cohort (seromas in four of 23 of cases, P = 0.109; infections in three of 23 cases, P = 0.234). Overall complications occurred more often in cases reconstructed with ADM, but the difference was nonsignificant (P = 0.245). Conclusions: The use of interface materials is generally considered a prerequisite for state-of-the-art prepectoral breast reconstruction for a variety of reasons, including the prevention of capsular contracture. In this study, PU coating tended to be associated with fewer short-term complications than ADM, including seroma and infection.

Therapeutic Reduction Mammoplasty: Experience of a Single Institute.

INTRODUCTION: Breast cancer is the most common malignancy in women worldwide as reported by the World Health Organization. The concept of oncoplastic breast surgery appeared as an extension of breast-conserving surgery, applying breast reduction techniques with more acceptable aesthetic and functional outcomes. The purpose of the present study was to describe the breast cancer population of a single institute submitted to lumpectomy and bilateral immediate breast reduction or mastopexy and its complications. MATERIAL AND METHODS: This is a retrospective observational study including patients submitted to lumpectomy and immediate bilateral breast reduction or mastopexy. Patients and tumour characteristics, surgical technique, complications, follow-up period, and recurrence data were obtained and analyzed. RESULTS: A total of 49 patients were submitted to lumpectomy and bilateral breast therapeutic reduction/mastopexy, with a mean age of 56.47 ±8.58 years and a mean body mass index of 28.68kg/m2 ±3.94 kg/m² between January 2019 and December 2021. Invasive tumours of no specific type, associated or not, with carcinoma intraductal in situ were the most common histological type corresponding to almost 80% of the cases with T1 stage corresponding to more than half of the cases. Sixteen percent of the patients had early minor complications with wound dehiscence associated with wound delayed healing, corresponding to 75% of the cases. Body mass index had a statistical difference between groups (p=0,006, t-test). CONCLUSIONS: The low rates of minor and major complications show that immediate therapeutic breast reduction can be a suitable approach in selected cases.

ESPRAS Survey on Breast Reconstruction in Europe.

BACKGROUND: The European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) previously identified the need for harmonisation of breast reconstruction standards in Europe, in order to strengthen the role of plastic surgeons. This study aims to survey the status, current trends and potential regional differences in the practice of breast reconstruction in Europe, with emphasis on equity and access. MATERIALS AND METHODS: A largescale web-based questionnaire was sent to consultant plastic and reconstructive surgeons, who are experienced in breast reconstruction and with understanding of the national situation in their country. Suitable participants were identified via the Executive Committee (ExCo) of ESPRAS and national delegates of ESPRAS. The results were evaluated and related to evidence-based literature. RESULTS: A total of 33 participants from 29 European countries participated in this study. Overall, the incidence of breast reconstruction was reported to be relatively low across Europe, comparable to other large geographic regions, such as North America. Equity of provision and access to breast reconstruction was distributed evenly within Europe, with geographic regions potentially affecting the type of reconstruction offered. Standard practices with regard to radiotherapy differed between countries and a clear demand for European guidelines on breast reconstruction was reported. CONCLUSION: This study identified distinct lack of consistency in international practice patterns across European countries and a strong demand for consistent European guidance. Large-scale and multi-centre European clinical trials are required to further elucidate the presented areas of interest and to define European standard operating procedures.

Negative pressure wound therapy for skin graft closure in complex pilonidal disease.

Pilonidal disease occurs in 26 in 100 000 people, affecting mainly men aged 20-30 years. It is treated by a variety of surgical techniques; however, there is a lack of consensus on the optimal choice of treatment for complex pilonidal disease. In addition, there is no consensus regarding care of the wound after surgery. Negative pressure wound therapy applied to open wounds following pilonidal disease surgery has been suggested as a way to decrease healing times and costs and is an emerging option for complex and or recurrent pilonidal disease. This study describes a case of complex pilonidal disease managed with local excision and negative pressure wound therapy followed by a split-thickness skin graft.

Microsurgical reconstruction of the maxilla: Algorithm and concepts.

INTRODUCTION: The main purpose of this article is to highlight free tissue transfers as the first-choice method for three-dimensional (3D) maxillary reconstruction, particularly in providing enough bone for palate and maxillary arch reconstruction and consequently an implant-retained prosthesis. To achieve this, the myosseous free iliac crest was selected whenever possible as the first choice inside the reconstructive algorithm and free flap armamentarium. A new maxillectomy classification and algorithm reconstruction are proposed. Technical modifications and improvements accomplished over time are discussed, considering palate, dental implants and prosthesis, nasal sidewall, cranial base and dura, as well as recipient vessels. We present functional and aesthetic outcomes of the senior author's past 24-year experience (H. C.) with complex midface reconstructions. MATERIAL AND METHODS: The authors report and analyse a 24-year experience with 57 midface defects in 54 patients (30 males and 24 females). A total of 57 maxillary defects - classified as Class I (limited maxillectomy) = 12, Class II (subtotal maxillectomy) = 15, Class III (total maxillectomy) = 19 and Class IV (orbitomaxillectomy) = 11 - were analysed regarding sex, age, tumour recurrence, free flap, reconstruction and necrosis. In addition, functional outcomes were evaluated regarding diet, speech, globe position and vision, while aesthetic outcomes were evaluated by patient and surgeon scores. RESULTS: A total of 52 free flaps were performed in 47 patients; three patients were operated upon twice; and two other patients needed two sequentially linked flow-through flaps. The free flap survival was 96% with two total flap losses (4%). The other seven patients were fitted with a soft tissue-retained obturator prosthesis. CONCLUSIONS: Microsurgical vascularised osteomyocutaneous free flaps are actually the gold standard for reconstruction of complex defects following maxillectomy. This algorithm is based on the anatomofunctional defect of the maxilla and it facilitates flap selection, which is a must.