Modulating the skin mycobiome-bacteriome and treating seborrheic dermatitis with a probiotic-enriched oily suspension.

Seborrheic dermatitis (SD) affects 2-5% of the global population, with imbalances in the skin microbiome implicated in its development. This study assessed the impact of an oily suspension containing Lactobacillus crispatus P17631 and Lacticaseibacillus paracasei I1688 (termed EUTOPLAC) on SD symptoms and the skin mycobiome-bacteriome modulation. 25 SD patients were treated with EUTOPLAC for a week. Symptom severity and skin mycobiome-bacteriome changes were measured at the start of the treatment (T0), after seven days (T8), and three weeks post-treatment (T28). Results indicated symptom improvement post-EUTOPLAC, with notable reductions in the Malassezia genus. Concurrently, bacterial shifts were observed, including a decrease in Staphylococcus and an increase in Lactobacillus and Lacticaseibacillus. Network analysis highlighted post-EUTOPLAC instability in fungal and bacterial interactions, with increased negative correlations between Malassezia and Lactobacillus and Lacticaseibacillus genera. The study suggests EUTOPLAC's potential as a targeted SD treatment, reducing symptoms and modulating the mycobiome-bacteriome composition.

Comparisons of the morbidities of a double gastrocnemius flap and a medial gastrocnemius flap in the orthoplastic reconstruction around the knee.

BACKGROUND: The pedicled gastrocnemius flap is commonly used to treat lower limb defects. Either the medial, lateral, or both heads can be used. When extended soft tissue defects are present, a double gastrocnemius (DG) flap may be used. However, no data of the additional donor site morbidity compared to a medial gastrocnemius (MG) flap are available. The aim of this study was to compare the donor site morbidity of a DG with that of a MG. METHODS: Patients with a soft tissue defect around the knee, treated with a gastrocnemius flap between 2018 and 2021 at the University Hospital of Lausanne and Bari, with a minimum follow-up of 12 months, were included. According to the size and the position of the defect, it was decided whether one (10 patients) or two (9 patients) heads of the gastrocnemius were necessary for the coverage. The mean age was 61 years (range 42-82) in DG, and 63 years (range 45-78) in MG. The average defect size was 89.8 cm2 in the DG group and 53.4 cm2 in the MG group. The etiologies were trauma (n = 10), infection (n = 7) and sarcoma (n = 2). A medial approach or a posterior midline approach was used for the harvesting of the gastrocnemius muscle. Once the flap was harvested, it was rotated and transposed anteriorly over the defect, either through a subcutaneous tunnel or by dividing the intervening skin bridge, depending on the soft tissue defect. A split-thickness skin graft was used to close the skin over the remaining exposed muscle flap. The active range of motion of the ankle and knee joints was measured. Muscle strength was assessed with a hand-held dynamometer and by the ability to stand on tiptoe. Physical function was evaluated through the Lower Extremity Functional Scale (LEFS). RESULTS: The two groups were homogeneous, with no significant difference in age, sex, and BMI. All flaps survived in both groups. Both groups showed lower values in strength and range of motion of the operated leg, when compared to contralateral side. In plantar flexion, this accounted for a reduction in MG by 3.8 ± 1.0 kg of strength and 8 ± 3° of ROM, and in DG by 4.7 ± 1.7 kg and 16 ± 4°, respectively. For knee flexion, the reduction in MG was 4.4 ± 0.6 kg and 16 ± 7°, while in DG 5.6 ± 1.0 kg and 28 ± 6°. In the MG group, 60% were able to stand on the tiptoe of the operated leg, as opposed to 0% in DG. The average LEFS score in DG was lower by 10.9 points (p < .05). Questions concerning running and jumping had a lower score in DG (p < .01). CONCLUSIONS: The harvesting of both gastrocnemii led to significant additional donor site morbidity compared to the harvesting of the medial gastrocnemius alone. However, the additional morbidity did not have an impact on activities of daily living and walking, even though it limited the ability to perform more demanding tasks such as running and jumping. Therefore, based on our study, the choice of a DG flap should be critically assessed in younger, more demanding patients.

SCIP flap in head and neck reconstruction after oncologic ablative surgery: a systematic review.

BACKGROUND: In the surgical treatment of head and neck locally advanced malignancies, microvascular free flaps represent the most valuable solution to reconstruct the tissue defect after resection of the primary neoplasm. In particular, microvascular free flaps allow to restore the functional and aesthetical features of the head and neck compartments. The superficial circumflex iliac perforator (SCIP) flap represents, as an evolution of the groin flap, a valid alternative to the radial fasciocutaneous free (RFFF) flap or the anterolateral thigh (ALT) flap. METHODS: This systematic review adhered to the recommendations of the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) 2009 guidelines. A computerized MEDLINE search was performed using the PubMed service of the U.S. National Library of Medicine ( www.pubmed.org ) and Scopus database ( www.scopus.com ). Two authors screened the articles, then selected and extracted data on malignancies characteristics, reconstructive techniques, outcomes, and complications. RESULTS: A total of 25 articles were selected and reviewed among the 39 identified through the search string. Six out of the selected 25 articles were case reports, while the remaining 19 articles were retrospective case series. The whole study population was represented by 174 oncologic patients undergoing ablation of a head and neck tumor and reconstruction with a SCIP flap. The site of reconstruction was the oral cavity in 125 (71.0%) patients, being the tongue the most common subsite in 73 (41.5%) patients, the pharynx in 10 (5.7%) cases, the larynx in 3 (1.7%) and head and neck skin in 36 (20.4%) patients. Only two cases of total flap loss were reported. Partial flap loss or shrinkage requiring minor surgical revisions was observed in 11 patients (6.32%). Primary closure of the donor site was achieved in the whole study population, according to the available data. CONCLUSIONS: In head and neck postoncological reconstruction, despite the caliber and the length of the pedicle, SCIP flap offers a pliable and thin skin paddle, allowing single-stage resurfacing, medium to large skin paddle, possibility of composite-fashion harvest and a well-concealed donor site.

Multidisciplinary Management of Sternal Osteomyelitis Due to Klebsiella aerogenes after Open Heart Surgery in a Patient with Multiple Myeloma: A Case Report and Discussion of the Literature.

Sternal wound complications following cardiac surgery, including sternal dehiscence, mediastinitis, and osteomyelitis, pose significant challenges in terms of management and patient outcomes. We present a case report highlighting the complex management of a patient who underwent open heart surgery for severe aortic valve stenosis, followed by sternal wound dehiscence and sternum osteomyelitis due to extended spectrum beta lactamase (ESBL) producing Klebsiella aerogenes. A multiple myeloma diagnosis was also suspected at the positron emission tomography (PET) scan and confirmed with bone marrow biopsy. Multidisciplinary evaluation of the case led to a comprehensive treatment plan. To control the sternal osteomyelitis, total sternectomy was performed followed by immediate reconstruction with a bone (tibia) graft from the tissue bank and fixation with the minimal hardware possible. A microsurgical latissimus dorsi free flap was required to reconstruct the soft tissue defect. After 6 weeks of antibiotic treatment with ertapenem and fosfomycin based on a culture of intraoperative material, no clinical, imaging, or laboratory signs of infection were seen. Multiple myeloma treatment was then started. At 1 year of follow up, no recurrence of infection occurred, and the reconstruction was stable and closed. Multiple myeloma is under chronic treatment with novel agent combination, with an excellent haematological response.

Role of Autologous Fat Grafting in the Conservative Treatment of Fecal Incontinence in Children.

Treatment of organic fecal incontinence in children, typical of anorectal malformations, is most often conservative; however, when necessary, it can be surgical. Autologous fat grafting, or lipofilling, can be used to improve fecal incontinence. We present our experience with the echo-assisted anal-lipofilling and its effects on fecal incontinence in children and on the quality of life of the entire family. Under general anesthesia, fat tissue was harvested according to the traditional technique, and processed in a closed system Lipogems® set. Injection of the processed adipose tissue was guided by trans-anal ultrasound assistance. Ultrasound and manometry were also used for follow-up. From November 2018, we performed 12 anal-lipofilling procedures in six male patients (mean age 10.7 years). Five children had a stable improvement in bowel function with Krickenbeck's scale scores going from soiling grade 3 pre-treatment in 100% of children to grade 1 post-treatment in 75% of them. No major post-operative complications developed. An increase in thickness of the sphincteric apparatus was shown at ultrasound during follow-up. The quality of life of the entire family, evaluated with a questionnaire, improved after the surgical treatment of the children. Anal-lipofilling is a safe and effective procedure to reduce organic fecal incontinence thereby benefiting both the patients and their families.

A Planned Multidisciplinary Surgical Approach to Treat Primary Pelvic Malignancies.

The pelvic anatomy poses great challenges to orthopedic surgeons. Sarcomas are often large in size and typically enclosed in the narrow confines of the pelvis with the close proximity of vital structures. The aim of this study is to report a systematic planned multidisciplinary surgical approach to treat pelvic sarcomas. Seventeen patients affected by bone and soft tissue sarcomas of the pelvis, treated using a planned multidisciplinary surgical approach, combining the expertise of orthopedic oncology and other surgeons (colleagues from urology, vascular surgery, abdominal surgery, gynecology and plastic surgery), were included. Seven patients were treated with hindquarter amputation; 10 patients underwent excision of the tumor. Reconstruction of bone defects was conducted in six patients with a custom-made 3D-printed pelvic prosthesis. Thirteen patients experienced at least one complication. Well-organized multidisciplinary collaborations between each subspecialty are the cornerstone for the management of patients affected by pelvic sarcomas, which should be conducted in specialized centers. A multidisciplinary surgical approach is of paramount importance in order to obtain the best successful surgical results and adequate margins for achieving acceptable outcomes.

Human Adipose Mesenchymal Stromal/Stem Cells Improve Fat Transplantation Performance.

The resorption rate of autologous fat transfer (AFT) is 40-60% of the implanted tissue, requiring new surgical strategies for tissue reconstruction. We previously demonstrated in a rabbit model that AFT may be empowered by adipose-derived mesenchymal stromal/stem cells (AD-MSCs), which improve graft persistence by exerting proangiogenic/anti-inflammatory effects. However, their fate after implantation requires more investigation. We report a xenograft model of adipose tissue engineering in which NOD/SCID mice underwent AFT with/without human autologous AD-MSCs and were monitored for 180 days (d). The effect of AD-MSCs on AFT grafting was also monitored by evaluating the expression of CD31 and F4/80 markers. Green fluorescent protein-positive AD-MSCs (AD-MSC-GFP) were detected in fibroblastoid cells 7 days after transplantation and in mature adipocytes at 60 days, indicating both persistence and differentiation of the implanted cells. This evidence also correlated with the persistence of a higher graft weight in AFT-AD-MSC compared to AFT alone treated mice. An observation up to 180 d revealed a lower resorption rate and reduced lipidic cyst formation in the AFT-AD-MSC group, suggesting a long-term action of AD-MSCs in support of AFT performance and an anti-inflammatory/proangiogenic activity. Together, these data indicate the protective role of adipose progenitors in autologous AFT tissue resorption.

Combined Orthoplastic Approach in Fracture-Related Infections of the Distal Tibia.

This series reports on the treatment of distal tibia (DT) fracture-related infections (FRI) with a combined orthoplastic approach. Thirteen patients were included. In eight patients with extensive bone involvement and in those with a non-healed fracture, the DT was resected ("staged approach"). In five cases, the DT was preserved ("single-stage approach"). A wide debridement was performed, and the cavity was filled with antibiotic-loaded PerOssal beads. All patients had a soft-tissue defect covered by a free vascularized flap (anterolateral thigh perforator flap in eight cases, latissimus dorsi flap in five). At the final follow-up (mean 25 months, range, 13-37), no infection recurrence was observed. In one patient, the persistence of infection was observed, and the patient underwent a repeated debridement. In two cases, a voluminous hematoma was observed. However, none of these complications impacted the final outcome. The successful treatment of FRI depends on proper debridement and obliteration of dead spaces with a flap. Therefore, when dealing with DT FRI, debridement of infected bone and soft tissues must be as radical as required, with no fear of the need for massive reconstructions.

Defining the Inframammary Fold by Liposuction: An Essential Tool in Aesthetic Shaping of the Reconstructed Breast. Technique and Long-term Results in a Series of Patients.

BACKGROUND: A good inframammary fold (IMF) definition and position is essential to achieve a satisfactory and natural result in breast surgery. This structure can be damaged, especially during mastectomies. Multiple methods are reported in the literature to restore IMF or improve its definition. In this study, we present the results achieved in a series of patients treated with subdermal liposuction. METHODS: We report on all our patients who underwent IMF liposuction between January 2016 and June 2020. Subdermal liposuction was performed with a blunt 3 mm cannula along the new IMF to promote skin retraction and adherence between skin and fascia. Results were evaluated subjectively by the patients and objectively by 8 individuals not involved with the treatment. RESULTS: We performed IMF liposuction in 88 breasts (69 patients), aged 21-74 (mean 52) years for 82 implant-based reconstructions, 2 tuberous breasts, and 4 contralateral breast augmentations. Mean follow-up was 28 months (6-64). Subjective results: the overall result evaluated with the VAS scale reached 86.6/100. All the 22 patients interviewed judged as well defined the new inframammary fold. Objective results: in 83% of cases the definition of the inframammary fold was judged as good or excellent, while symmetry with contralateral IMF, natural appearance, and overall aesthetic outcome were judged as good. CONCLUSION: Based on our long-term satisfactory results, we recommend the technique of subdermal liposuction to improve the definition of IMF in breast reconstruction after mastectomy and other breast procedures. It is effective, easy to perform, minimally invasive, and durable. LEVEL OF EVIDENCE IV: 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 .

Use of the Spare-Part Strategy to Reconstruct the External Auditory Canal After Subtotal Auriculectomy for Basal Cell Carcinoma.

After removal of an infiltrative BCC of the auditory meatus, a soft tissue defect of the temporal-mastoid area with bone exposure, needed reconstruction. Several options have been taken into account and a simple yet effective solution has been found following the spare-parts principle. The ear lobe, preserved during cancer removal, was split and used as a thin skin flap. Adequate coverage of the bone exposure and resurfacing of the external auditory canal was obtained with minimal donor site morbidity and a short surgery in a fragile patient with several comorbidities. The spare-parts strategy can provide successful solution to difficult reconstructive cases regardless of the anatomical area.

Surgical treatment of pressure injuries in children: A multicentre experience.

Pressure injuries (PI) are infrequent in paediatric patients, prevalence estimates ranging from 1.4% to 8.2%, and reaching values as high as 43.1% in critical care areas. They can be associated with congenital neurological or metabolic disorders that cause reduced mobility or require the need for medical devices. In children, most pressure injuries heal spontaneously. However, a small percentage of ulcers that is refractory to conservative management or is too severe at presentation (Stage 3 or 4) will be candidates for surgery. We retrospectively reviewed the clinical history of paediatric patients affected by pressure injuries from four European Plastic Surgery Centres. Information was collected from clinical and radiology records, and laboratory reports. An accurate search of the literature revealed only two articles reporting on the surgical treatment of pressure injuries in children. After debridement, we performed surgical coverage of the pressure injuries. We report here our experience with 18 children aged 1-17 years, affected by pressure injury Stages 3 and 4. They were successfully treated with pedicled (17 patients) or free flaps (1 patient). The injuries involved the sacrum (6/18 patients), lower limb (3/18 patients), thoracic spine (2/18 patients), ischium (3/18 patients, bilateral in one patient), temporal area (3/18 patients), hypogastrium (1/18 patients) and were associated to medical devices in three cases. Flaps were followed for a minimum of 19 months and up to 13 years. Only two patients developed true recurrences that were treated again surgically. Pressure injuries are infrequent in children and rarely need surgical treatment. Pedicled flaps have a high success rate. Recurrences, contrary to what is reported in the literature, were rare.

Different Hydraulic Constructs to Optimize the Venous Drainage of DIEP Flaps in Breast Reconstruction: Decisional Algorithm and Review of the Literature.

BACKGROUND: Venous congestion is the most common perfusion-related complication of deep inferior epigastric artery perforator (DIEP) flap. Several hydraulic constructs can be created for venous superdrainage in case of flap venous engorgement or as a preventive measure. These can be classified based on the choice of the draining vein of the flap, either a second deep inferior epigastric vein (DIEV) or a superficial inferior epigastric vein (SIEV), and of the recipient vein, either a vein of the chest or the DIEV. METHODS: We conducted a comprehensive systematic literature review in Medline, Scopus, EMBASE, Cochrane Library, and Google Scholar to find publications that reported on venous congestion in DIEP flap. The keywords used were DIEP Flap, breast reconstruction, venous congestion, supercharging, superdrainage, SIEV, and DIEV. RESULTS: Based on the studies found in the literature, we developed an algorithm to guide the surgeon's decision when choosing the veins for the superdrainage anastomosis. CONCLUSION: Several alternatives for venous anastomosis in superdrainage are available. We propose an algorithm to simplify the choice. The use of the ipsilateral SIEV to be connected to a vein of the chest appears to be advantageous. The anatomical position that allows the easiest anastomosis dictates which chest vein to favor.

Meta-analysis of the effects of venous super-drainage in deep inferior epigastric artery perforator flaps for breast reconstruction.

INTRODUCTION: Venous congestion is the most common vascular complication of the deep inferior epigastric artery perforator (DIEP) flaps. Adding a second venous drainage by anastomosing a flap vein and a recipient vein (super-drainage) is considered the solution of choice. Evidence to support this procedure, had not yet been confirmed by an analysis of the literature. We aimed to provide this evidence. MATERIALS AND METHODS: We searched the literature (MedLine, Scopus, EMBASE, Cochrane Library, and Google Scholar), for studies discussing venous congestion and venous super-drainage in DIEP flap for breast reconstruction. Thirteen of the 35 articles compared results between one or two venous anastomoses. Meta-analysis was performed following PRISMA guidelines. Pooled risk ratio (RRs) for congestion, fat necrosis, partial necrosis, and total necrosis with corresponding 95% confidence intervals (CI) were calculated using a fixed-effect model with the Mantel-Haenszel method. The need to return to surgery (95% CI) was estimated with a random effect model using the DerSimonian and Liard method. RESULTS: We showed a statistically significant advantage of super-drainage to reduce the venous congestion of the flap (RR: 0.12, 95% CI: 0.04-0.34, p-value <.001), partial flap necrosis (RR: 0.50, 95% CI: 0.30-0.84, p-value .008), total flap necrosis (RR: 0.31, 95% CI: 0.11-0.85, p-value .023), and the need to take the patient back to surgery for perfusion-related complications (RR: 0.45, 95% CI: 0.21-0.99, p value .048). CONCLUSIONS: Performing a second venous anastomosis between the SIEV and a recipient vein (venous superdrainage) reduces venous congestion and related complications in DIEP flaps for breast reconstruction.

Microsurgical Reconstruction of the Nose: The Aesthetic Approach to Total Defects.

BACKGROUND: Reconstruction of complex defects involving nose and close facial units represents an aesthetic and functional challenge. Restoring satisfactory nasal shape, combining aesthetic, nasal function and patent airways is mandatory. In this paper, we describe our approach to total nose defects and we report our 20-year experience in microvascular nose reconstruction.Clinical cases are shown to illustrate different surgical techniques and the evolution of our approach. METHODS: Nasal reconstruction procedures were performed on 21 patients between 2000 and 2020 using the radial forearm flap (RFF) or anterolateral thigh (ALT) flap. Reported reconstructions included total/subtotal nasal defects, caused by cancer resections. The key point of our approach is the expanded forehead flap for skin coverage. Reconstruction is completed by cartilage grafts to restore nasal framework and to shape nasal tip. Ancillary procedures were needed in some cases to optimize aesthetic outcomes. RESULTS: Twenty-one patients completed the multistage nasal reconstruction. The RFF flap was used in 56% of the cases (n = 11), while the ALT flap was used in 44% (n = 10) of our case series. No difference has been detected in the number of reconstructive stages required to achieve the final result comparing RFF and ALT reconstruction (3.3 vs. 3.1 reconstructive steps). Ancillary procedures were performed in 7 patients. CONCLUSION: Microvascular tissue transfer plays a key role in full-thickness nasal defects restoration. Comparing the two groups, both the RFF and ALT are effective and reliable options in lining reconstruction, although with different indications. Expanded forehead flap, combined to free cartilage graft, is our gold standard to provide external skin coverage to rebuild the nasal framework. According to our current approach, accurate preoperative planning, supported by modern technologic tools, multistage reconstruction, and ancillary procedures are useful to accomplish satisfactory functional and aesthetic outcomes.

Ceftolozane-Tazobactam Treatment of Hypervirulent Multidrug Resistant Pseudomonas aeruginosa Infections in Neutropenic Patients.

The effectiveness of ceftolozane/tazobactam for the treatment of infections in neutropenic patients caused by hypervirulent multidrug-resistant (MDR) Pseudomonas aeruginosa has not been previously reported. We identified seven cases of MDR P. aeruginosa infection in neutropenic patients over a four-month period within the same hematology ward. Four cases were associated with rapid progression despite piperacillin-tazobactam or meropenem therapy, and three patients developed sepsis or extensive skin/soft tissue necrosis. In three of the four cases, patients were empirically switched from meropenem to ceftolozane/avibactam before carbapenem susceptibility test results were available, and all four patients underwent extensive surgical debridement or amputation of affected tissues and survived. Further investigation revealed a common bathroom source of MDR P. aeruginosa clonal subtypes ST175 and ST235 that harbored genes for type III secretion system expression and elaboration of ExoU or ExoS exotoxin. We conclude that ceftolozane/tazobactam plus early source control was critical for control of rapidly progressing skin and soft infection in these neutropenic patients caused by highly virulent ST175 and ST235 clones of MDR P. aeruginosa.

3D Exoscope-Assisted Microvascular Anastomosis: An Evaluation on Latex Vessel Models.

BACKGROUND: Over the last few years, advances in technologies and digital imaging have led to the introduction of systems that enable a new approach to microsurgery and supermicrosurgery. The exoscope is a new magnification system that provides a 3D image of the surgical field: microsurgical procedures can be performed with the aid of this instrument. Here, we describe our preliminary experience with a high-definition 3D exoscope (VITOM®, Karl Storz, Tuttlingen, Germany), evaluating the characteristics of the instrument, and also its use as a magnification device for microanastomosis training. METHODS: Six microsurgeons with various levels of experience were asked to perform three end-to-end anastomoses and two end-to-side anastomoses on latex vessel models, using, as a magnification system, the VITOM® 3D 4K exoscope. None of the surgeons involved had previous experience with the exoscope, with robotic surgery, with endoscopic surgery, nor with training simulators. RESULTS: The results of the reported evaluation of the tool's qualities, (VITOM Quality Assessment Tool) included: a good focusing of the surgical field; high image quality; strong luminance; good magnification; clear stereoscopy; and excellent freedom of movement. The exoscope proved to be user-friendly. A constant reduction in the time needed to perform the microsurgical anastomosis at each exercise was recorded. Among other advantages were the easy switching from the magnified image to the macroscopic view, superior ergonomics allowing a relaxed posture while performing the anastomosis, adequate space, and a convenient setting for the assistants to view the operating field. CONCLUSIONS: Our study showed that the exoscope VITOM 3D can be successfully used as a magnification tool for microsurgical anastomosis on synthetic vessels, and that it can also be helpful during training courses in microsurgery.