Botulinum Toxin-A Infiltration to Control Post-Operative Pain after Mastectomy and Expander Reconstruction as Potentially Useful Tool: A Narrative Review.

Botulinum toxin-A (BTX-A), a neurotoxin produced by Clostridium botulinum, was assessed for relieving implant-related pectoralis major muscle's painful spasms. In detail, 100 units of BTX-A can reduce muscle activity and, as a consequence, muscle spasms. The latter is considered the leading cause of post-operative pain after the sub-pectoral tissue expansion, sometimes leading to early expanders' removal. In addition, women choosing post-mastectomy reconstruction surgery seem to suffer worse post-operative pain than those who stop at the mastectomy stage. However, there is no unanimous consensus concerning the potential benefits of BTX-A in reducing pain related to the sub-pectoral placement of tissue expanders in breast reconstruction due to the exiguity of evidence. Therefore, this review aims to describe BTX-A-related evidence in this reconstruction setting. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Is Quality of Life After Breast Reduction Influenced by Different Surgery's Technique? A Prospective Study.

BACKGROUND: Breast hyperplasia is a condition with a significant impact on the quality of life and psychological well-being of patients. Over time, various surgical techniques have been developed to reduce breast mass, which have proven effective in improving the quality of life of women undergoing the procedure. It is not yet well described how various techniques may influence the improvement in QoL (Quality of Life). The aim of this study is to assess the impact of different techniques on the improvement of quality of life. MATERIAL AND METHODS: We analyzed the responses to the Breast-Q questionnaire from 95 patients undergoing breast reduction surgery between 2021 and 2023. The questionnaires were completed both before the procedure and during the 6-month follow-up. We assessed the questionnaire responses and overall satisfaction with the results, categorizing the data based on the specific surgical technique used. RESULTS: A statistically significant improvement in the quality of life was observed in the postoperative period, as well as a remarkable satisfaction with the outcome (mean score of 81 out of 100). We did not detect statistically significant differences in the levels of quality of life and satisfaction with the outcome among the various techniques. CONCLUSION: The breast reduction surgery procedure continues to prove its ability to significantly improve the quality of life for patients with breast hypertrophy, regardless of the specific surgical technique employed. LEVEL OF EVIDENCE III: 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 .

Large Skull Metastasis in Follicular Thyroid Carcinoma: A Comprehensive Case Presentation and Systematic Review.

BACKGROUND: Skull metastases from follicular thyroid carcinoma (FTC) are infrequent but clinically significant, often presenting with localized pain, neurologic deficits, and cranial nerve dysfunction. Early detection and accurate diagnosis pose challenges due to their asymptomatic nature in some cases. METHODS: A systematic literature review, conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identified and analyzed 15 relevant studies focusing on large skull metastases in FTC. Data extraction and synthesis included clinical presentation, diagnostic methods, treatment strategies, and patient outcomes. RESULTS: The systematic review encompassed 20 patients with secondary skull metastases from FTC, offering insights into the clinical diversity of this rare condition. Clinical presentations varied, with localized pain (70% of cases) and headaches being predominant symptoms. Imaging techniques, including computed tomography (CT) and magnetic resonance imaging (MRI), played a pivotal role in diagnosis. Surgical resection was considered in select cases, achieving complete or near-complete tumor removal in 30 to 50% of patients. Radiotherapy, including external beam radiation therapy (EBRT) and stereotactic radiosurgery (SRS), provided local control and symptom relief in 70 to 80% of cases. Systemic therapies, such as tyrosine kinase inhibitors (TKIs), showed promise in disease stabilization or regression (45% of patients). Prognosis remained poor, with a median overall survival of 6 to 12 months, reflecting an advanced and aggressive disease state. CONCLUSION: Managing secondary skull metastases from FTC requires a comprehensive approach, including surgical intervention, radiotherapy, and potential systemic therapies. The rarity of these metastases underscores the need for further research to establish standardized treatment guidelines, explore molecular profiling, and investigate immunotherapy and combination therapies, offering hope for improved outcomes in this challenging clinical scenario.

Intraventricular Cerebral Metastases: A Comprehensive Systematic Review.

BACKGROUND/AIM: Intraventricular cerebral metastases (IVCM) are a rare but clinically significant subset of brain metastases. This systematic review aimed to provide a comprehensive analysis of IVCM by synthesizing current literature on epidemiology, clinical presentation, imaging features, pathophysiology, and treatment options. MATERIALS AND METHODS: A systematic literature search was conducted, identifying 11 relevant studies encompassing 11 studies encompassing 842 IVCM cases. Data regarding primary tumor origins, patient demographics, presenting symptoms, treatment modalities, and survival outcomes were analyzed. RESULTS: IVCM cases displayed a diverse range of primary tumor origins, with the kidney (27.4%), thyroid (21.6%), lung (19.8%), colon (11.7%), melanoma (8.4%), and breast ductal carcinoma (7.9%) being common sources. Patients presented with a wide spectrum of symptoms, including headaches (42.3%), nausea (31.5%), altered mental status (25.7%), neurological deficits (18.2%), and others. Treatment approaches varied, encompassing surgical resection (41.2%), radiation therapy (32.5%), chemotherapy (15.3%), and immunotherapy (7.9%). Overall survival was generally limited, with a mean duration of approximately 10.3 months (±8.7 months). The time to recurrence after treatment exhibited considerable variability. CONCLUSION: IVCM represents a challenging and underexplored metastatic disease. This systematic review underscores the need for further research to enhance our understanding of IVCM's pathophysiology and develop tailored diagnostic and treatment approaches. Such efforts are crucial to improving outcomes and the overall quality of life for patients facing this complex condition. The multidisciplinary nature of IVCM management, involving neurologists, neurosurgeons, oncologists, radiologists, and other healthcare professionals, is emphasized as essential for individualized patient care.

Highly Concentrated Stabilized Hybrid Complexes of Hyaluronic Acid: Rheological and Biological Assessment of Compatibility with Adipose Tissue and Derived Stromal Cells towards Regenerative Medicine.

Cells and extracts derived from adipose tissue are gaining increasing attention not only in plastic surgery and for aesthetic purposes but also in regenerative medicine. The ability of hyaluronan (HA) to support human adipose stromal cell (hASC) viability and differentiation has been investigated. However, the compatibility of adipose tissue with HA-based formulation in terms of biophysical and rheological properties has not been fully addressed, although it is a key feature for tissue integration and in vivo performance. In this study, the biophysical and biochemical properties of highly concentrated (45 mg/mL) high/low-molecular-weight HA hybrid cooperative complex were assessed with a further focus on the potential application in adipose tissue augmentation/regeneration. Specifically, HA hybrid complex rheological behavior was observed in combination with different adipose tissue ratios, and hyaluronidase-catalyzed degradation was compared to that of a high-molecular-weight HA (HHA). Moreover, the HA hybrid complex's ability to induce in vitro hASCs differentiation towards adipose phenotype was evaluated in comparison to HHA, performing Oil Red O staining and analyzing gene/protein expression of PPAR-γ, adiponectin, and leptin. Both treatments supported hASCs differentiation, with the HA hybrid complex showing better results. These outcomes may open new frontiers in regenerative medicine, supporting the injection of highly concentrated hybrid formulations in fat compartments, eventually enhancing residing staminal cell differentiation and improving cell/growth factor persistence towards tissue regeneration districts.

Extremely rare case of unilateral gigantomastia after hormonal stimulation treated with a modified wise pattern technique: A case report.

INTRODUCTION: Gigantomastia, characterized by excessive breast size (usually heavier than 2.5 kg), can result from various causes and significantly affect patients' lives. Surgical intervention is often required, and over time, several techniques have been developed for its treatment. These techniques aim to address the functional and aesthetic concerns associated with gigantomastia, providing relief to patients and improving their quality of life. PRESENTATION OF THE CASE: A 40-year-old primiparous housewife developed unilateral gigantomastia as a consequence of hormone therapy. To address this, a modified reduction mammoplasty procedure was undertaken, incorporating NAC (Nipple-Areola Complex) grafting. The reduction involved removing 3450 g of tissue, resulting in restored breast symmetry and enabling the patient to reintegrate into normal daily life. DISCUSSION: Compared to the traditional technique, the introduction of some modifications in the design allowed for the absence of complications such as dehiscence of the scar at the intersection of the T, the failure of the nipple graft attachment, and the maintenance of a conical shape over time, enabling complete symmetrization of the two breasts. CONCLUSION: The use of a modified version of the Thorek technique allowed for optimal functional and aesthetic restoration even in the case of a significantly disproportionate breast compared to the contralateral one, with no complications.

Comparative Analysis of Nipple Reconstruction Techniques: Five Flap vs. C-V Flap.

Background: Nipple-areola complex reconstruction represents the final phase in the comprehensive post-mastectomy treatment regimen. Despite the diversity of approaches available, there is currently no universally accepted benchmark technique for this critical aspect of breast reconstruction. In this study, we conducted a comparative assessment of two prominent techniques, the five Flap and C-V Flap. Materials and Methods: Between November 2016 and April 2023, we recruited 100 female patients who had undergone unilateral post-oncological mastectomy and divided them into two groups: Group A comprising 50 patients who underwent the 5-Flap technique, whereas Group B comprising the remaining 50 underwent the C-V Flap technique. Over a 6-month observation period, we assessed nipple projection loss and evaluated overall satisfaction through self-reporting by patients and independent assessments by a medical observer. Results: In our study, none of the reconstructed nipples in Group A (5 Flap) experienced either total or partial necrosis, contrasting with Group B (C-V Flap) which encountered a 10% incidence of partial necrosis and 4% incidence of total necrosis. Furthermore, the average nipple projection loss in Group B was substantial, measuring a 30% reduction from the initial projection at the 1-year mark, whereas Group A demonstrated a significantly lower 13% reduction. Notably, despite these variations in outcomes, both groups reported an equal and high level of satisfaction, with patients and external observers providing an average satisfaction score of 8.0 and 9.0, respectively. Conclusion: The five-flap technique represents a safe and effective approach for patients undergoing nipple reconstruction.

Use of pragmatic randomized trials in multiple sclerosis: A systematic overview.

BACKGROUND: Pragmatic trials are increasingly recognized for providing real-world evidence on treatment choices. OBJECTIVE: The objective of this study is to investigate the use and characteristics of pragmatic trials in multiple sclerosis (MS). METHODS: Systematic literature search and analysis of pragmatic trials on any intervention published up to 2022. The assessment of pragmatism with PRECIS-2 (PRagmatic Explanatory Continuum Indicator Summary-2) is performed. RESULTS: We identified 48 pragmatic trials published 1967-2022 that included a median of 82 participants (interquartile range (IQR) = 42-160) to assess typically supportive care interventions (n = 41; 85%). Only seven trials assessed drugs (15%). Only three trials (6%) included >500 participants. Trials were mostly from the United Kingdom (n = 18; 38%), Italy (n = 6; 13%), the United States and Denmark (each n = 5; 10%). Primary outcomes were diverse, for example, quality-of-life, physical functioning, or disease activity. Only 1 trial (2%) used routinely collected data for outcome ascertainment. No trial was very pragmatic in all design aspects, but 14 trials (29%) were widely pragmatic (i.e. PRECIS-2 score ⩾ 4/5 in all domains). CONCLUSION: Only few and mostly small pragmatic trials exist in MS which rarely assess drugs. Despite the widely available routine data infrastructures, very few trials utilize them. There is an urgent need to leverage the potential of this pioneering study design to provide useful randomized real-world evidence.

Lumbar Spinous Process-Splitting Technique for Ligamentum Flavum Cyst Removal.

BACKGROUND: Laminotomy for lumbar stenosis is a well-defined procedure and represents a routine in every neurosurgical department. It is a common experience that the uni- or bilateral paraspinal muscle detachment, together with injury of the supra- and interspinous ligaments, can lead to postoperative pain. In the literature, the application of a minimally invasive technique, the lumbar spinous process-splitting (LSPS) technique, has been reported. METHODS: In this study, we present a case series of 12 patients who underwent LSPS from September 2019 to April 2020. Two patients had a cyst of the ligamentum flavum, eight a single-level lumbar canal stenosis (LCS), and two a two-level LCS. Moreover, we propose a novel morphological classification of postoperative muscle atrophy and present volumetric analysis of the decompression achieved. RESULTS: There were no complications related to this technique. In all patients, the vertebral canal area was more than doubled by the procedure. The muscle sparing showed grade A, according to our classification. CONCLUSION: To our knowledge, this is the first description of this surgical technique and the first LSPSL case series in Europe. Furthermore, cases of ligamentum flavum cyst removal using this safe and effective technique have not yet been reported.

Comparison of Different Techniques for the Assessment of Sentinel Lymph Node Biopsy in Melanoma: A Systematic Review.

Background: The gold standard for sentinel lymph node staging in melanoma is the use of the combined technique of radioisotope plus blue dye. New techniques and alternative methods have been proposed, with the promise of achieving comparable efficacy. We then carried out a literature search. Methods: We conducted a literature search using the "sentinel lymph node biopsy" and "melanoma" keywords, then selected the case-control studies (the quality of which was assessed using the STROBE criteria). Results: Twelve studies of 13,017 were selected, concerning the identification rate of indocyanine green fluorescence and indocyanine green-99mtc-nanocolloid techniques. We have found a comparable identification rate between the various techniques, even if given the small population present for some techniques, the results did not reach statistical significance. Conclusions: The use of new techniques in sentinel lymph node detection promises results comparable to the gold standard techniques, but further studies are needed to validate these methods in the context of melanoma surgery.