Double Lateral Osteotomy: Not Only the Correction of Crooked Noses but a Relevant Aesthetical Refinement in Structural Rhinoplasty.

BACKGROUND: Osteotomy represents a crucial step in structural rhinoplasty; however, there is not a unique approach accepted. Double lateral osteotomy has proven to be effective in the long-term correction of a deviated nose. In this series, we evaluated its aesthetic value also in non-deviated cases. MATERIALS AND METHODS: 864 patients who underwent primary structural rhinoplasty from 2012 to 2020 were divided into four groups. Group A and B included patients with a crooked nose treated with asymmetrical double osteotomy and bilateral double osteotomy, respectively. Patients who did not present nasal deviation were divided into group C, including cases treated with bilateral single osteotomy, and group D, including patients who underwent bilateral double osteotomy. Postoperative evaluations were performed by three independent plastic surgeons blinded to the surgical technique. Patient's satisfaction was assessed through the FACE-Q rhinoplasty module. RESULTS: FACE-Q scores reported a satisfaction rate higher than 30% for every item in all groups; however, group B and group D showed statistically higher satisfaction (p < 0.01). According to the evaluations performed by physicians, group B and group D showed the most satisfactory outcomes (p < 0.01). CONCLUSIONS: bilateral double osteotomies represent a significant aesthetic refinement in structural rhinoplasty, not only in crooked noses but also in non-deviated cases, since the reduction in the width of the nose is an aesthetical aspect very appreciated by patients.

Secondary post-oncologic vulvar reconstruction - a simplified algorithm.

Introduction: Surgical treatment is the gold standard of care for vulvar cancer and is burdened by a high risk of wound complications due to the poor healing typical of the female genital area. Moreover, this malignancy has a high risk of local relapse even after wide excision. For these reasons, secondary reconstruction of the vulvoperineal area is a relevant and challenging scenario for gynecologists and plastic surgeons. The presence of tissue already operated on and undermined, scars, incisions, the possibility of previous radiation therapy, contamination of urinary and fecal pathogens in the dehiscent wound or ulcerated tumor, and the unavailability of some flaps employed during the primary procedure are typical complexities of this surgery. Due to the rarity of this tumor, a rational approach to secondary reconstruction has never been proposed in the literature. Methods: In this observational retrospective study, we reviewed the clinical data of patients affected by vulvar cancer who underwent secondary reconstruction of the vulvoperineal area in our hospital between 2013 and 2023. Oncological, reconstructive, demographic, and complication data were recorded. The primary outcome measure was the incidence of wound complications. The secondary outcome measure was the indication of the different flaps, according to the defect, to establish an algorithm for decision-making. Results: Sixty-six patients were included; mean age was 71.3 ± 9.4 years, and the mean BMI was 25.1 ± 4.9. The mean size of the defect repaired by secondary vulvar reconstruction was 178 cm2 ± 163 cm2. Vertical rectus abdominis myocutaneous (VRAM), anterolateral thigh (ALT), fasciocutaneous V-Y (VY), and deep inferior epigastric perforator (DIEP) were the flaps more frequently employed. We observed five cases of wound breakdown, one case of marginal necrosis of an ALT flap, and three cases of wound infection. The algorithm we developed considered the geometry and size of the defect and the flaps still available after previous surgery. Discussion: A systematic approach to secondary vulvar reconstruction can provide good surgical results with a low rate of complications. The geometry of the defect and the use of both traditional and perforator flaps should guide the choice of the reconstructive technique.

Feasibility, indications and complications of SCIP flap for reconstruction after extirpative surgery for vulvar cancer.

INTRODUCTION: Surgical therapy for vulvar cancer involves wide defects that often require flap-based reconstruction. The goal of the reconstruction is fast wound healing with low donor site morbidity. MATERIALS AND METHODS: This is a retrospective observational cohort study in which we reviewed all patients who underwent surgery for vulvar cancer followed by reconstruction using the Superficial Circumflex Iliac Artery Perforator (SCIP) flap between 2015 and 2020. The primary outcome measure of this investigation was the incidence of wound complications. The secondary outcomes were the surgical indications in terms of establishing the anatomical subunits involved in the resection that made us choose this flap for reconstruction. This study adheres to the STROBE guidelines. RESULTS: Thirty-two patients were included; in two cases, the flap was performed bilaterally for a total of 34 SCIP flaps. The mean age of patients was 70.6 ± 8.6 years, and the mean BMI was 26.8 ± 4.7. The SCIP flap was always feasible. The mean flap size was 128.8 ± 74.3cm2. Three patients showed wound complications. In every patient, the defect involved the vulva, perineum and inguinal area; in 18 patients, the mons pubis was also involved. The mean follow-up was 30 months. During the follow-up, six patients died, and four showed local or nodal cancer relapse. CONCLUSION: Our results suggest that the advantages of SCIP flap for the reconstruction of vulvoperineal defects secondary to vulvar cancer surgery include low complication rate, minimal donor site morbidity, quick dissection, proximity of donor and recipient sites, possibility to harvest large skin islands of variable thickness and chimeric flaps.

The Triple Plane, the Bra-Flap, and the Inverted Bra-Flap Modified Dual Plane Techniques for Breast Augmentation.

BACKGROUND: Breast augmentation (BA) is a very common procedure performed for a wide range of indications. The short-term and long-term outcomes are strongly correlated with the choice of the correct implant pocket, which should be tailored to the anatomic features of the breast. OBJECTIVES: The aim of this study was to report the safety and efficacy of the triple-plane technique and Bra-flap modified dual-plane techniques for BA. METHODS: From January 1995 to January 2016, 605 patients underwent BA procedures that utilized the triple-plane technique or Bra-flap modified dual-plane techniques. Patient evaluation was performed preoperatively and postoperatively at 6 and 12 months and every 5 years thereafter. The occurrence of ptosis and implant malposition, as well as breast animation deformity, were assessed. Patient satisfaction was evaluated with the BREAST-Q Augmentation Module. RESULTS: The average patient age was 39.3 years. The follow-up period ranged from 24 months to 20 years. The triple-plane technique was performed in 450 patients, the Bra-flap modified dual-plane technique in 97, and the inverted Bra-flap modified dual-plane technique in 58. No cases of double-bubble deformity or implant bottoming-out were observed. Regarding animation deformity, 209 patients presented with mild to moderate distortion, whereas no patients presented with severe distortion. The BREAST-Q questionnaire reported significant postoperative improvements in all scales. CONCLUSIONS: In over 20 years of experience, the triple-plane technique has proven to be a reliable procedure that offers natural and long-lasting results. The Bra-flap and inverted Bra-flap modified dual-plane techniques are efficient options to expand the range of breast conditions treated.

Rainbow graft for tip reconstruction in revision rhinoplasty.

Patients undergoing revision rhinoplasty can show complex tip deformities such as asymmetry, dome angulation with cartilage interruption, alar pinch and retraction, and underprojection. When these defects are present at the same time, often multiple cartilage grafts are needed to restore a pleasing tip and functional external nasal valve. This study reports our experience with the rainbow graft, a previously described technique that can repair with a single cartilage graft the above-mentioned defects. We performed a retrospective review of 21 patients who had undergone revision rhinoplasty between 2006 and 2017 employing the rainbow graft technique to correct complex tip deformities. The presence of tip deformities such as asymmetry, dome angulation with cartilage interruption, alar pinch, alar retraction, and under/overprojection was recorded preoperatively and postoperatively. Complete photographic documentation was done, and Rhinoplasty Outcome Evaluation (ROE) questionnaire was administered to the patients. Five patients were male and 16 were females. Mean age of patients was 40 ± 7.6 years. Follow-up ranged from 1 to 12 years, mean 5 ±â€¯3 years. Eight patients had undergone one rhinoplasty, 10 patients had undergone two, and three patients had undergone three. Before surgery, all patients showed asymmetry, 20 dome angulation, 19 alar pinch, and 18 retraction. Eight showed tip overprojection, six underprojection, and seven no alteration of tip projection. The mean ROE score was 20.23 ± 7.37. After surgery, two patients showed persistent asymmetry, none had dome angulation, one alar pinch, and two alar retraction. Projection was corrected in every patient. We observed no case of graft infection, malposition, or resorption, and corrections achieved remained stable during follow-up. Mean postoperative ROE score was 80.75 ± 6.24. Its improvement was statistically significant (p < 0.001). The rainbow graft is a safe and effective technique in revision rhinoplasty indicated for the total restoration of nasal tip appearance in the presence of complex secondary deformities.

Radioanatomical Study of the Pedicle of the Superficial Circumflex Iliac Perforator Flap.

BACKGROUND: The superficial circumflex iliac perforator (SCIP) flap has many ideal features, such as fast dissection, possibility to harvest thin, pliable, wide skin island, and concealed donor site scar. In spite of these features, its use was limited because of the wide anatomical variation of the pedicle, which is relatively shorter and has a smaller caliber than other more popular perforator flaps. Several names were given to the branches and perforators in the literature, thus adding confusion to the understanding of its anatomy. METHODS: We performed a surgical and a radioanatomical study of the SCIP pedicles analyzing high-resolution contrast-enhanced computed tomography (CT) scan of 95 groins, with particular attention to the deep branch (DB) of the superficial circumflex iliac artery (SCIA). Twenty-three of these patients were also studied by detecting the surgical anatomy during SCIP flap harvest. We employed a system of coordinates based on the line between pubic tubercle (PT) and anterior superior iliac spine (ASIS) to describe the position of the perforator of the DB. RESULTS: We found a 100% correlation between surgical and radiological findings. The length of the DB from the origin to the point in which its perforator pierced the sartorius fascia ranged from 1.6 to 6.5 cm, mean = 3.62 ± 0.92 cm. The distance between the origin of the DB and the inguinal ligament ranged from 1.1 to 7.5 cm, mean = 2.8 ± 1 cm. The perforator of the DB could be found in 91% of the cases within a box of 4 cm × 3 cm drawn caudally to the line joining the PT with the ASIS. This vessel can show a vertical or horizontal course in the subcutaneous layer. CONCLUSION: Our findings confirm other previous studies and add new information about the position and the course of the perforator of the DB of the SCIA. Important features of the SCIP pedicles can be investigated by the color Doppler ultrasound and CT scan.

Pedicled neurocutaneous anterolateral thigh flap for groin reconstruction - A case report.

Several different flaps based on the feeding vessels of sensitive nerves have been described in the limbs. This article reports the case of a neurocutaneous flap based on the lateral femoral cutaneous nerve (LFCN), employed for reconstruction of an inguinal defect. A 61-years-old female patient had undergone vulvectomy and bilateral inguinal lymphadenectomy for vulvar cancer with postoperative left groin wound breakdown. After a 3 weeks negative pressure therapy course, she presented a 10 × 4 cm skin and subcutaneous defect with undermined edges in the left inguinal area. Reconstruction with 14 × 6 cm pedicled left anterolateral thigh flap was planned. After the dissection of the vascular pedicle and of the sensitive nerve, complete thrombosis of both the veins and arterial spasm of perforating pedicle was detected. As the flap color was good, and slow marginal bleeding was present, we inspected the small vessels surrounding the nerve that were pulsating. To confirm the vascularization coming from the neural pedicle, we clamped the perforator and performed intraoperative indocyanine green (ICG) fluorescence angiography that showed a good fluorescence of the flap with a proximal to distal pattern of progression. The flap was transferred on the neural pedicle, survived completely, and wounds healed normally. Three months after surgery, the patient underwent radiotherapy, with uneventful course. In her last follow-up, 2 years after surgery, patient was free of disease and the flap showed normal scarring. This is the first case reported of a pedicled neurocutaneous flap based on the LFCN, indicating that in case of unsuitable perforators it could be an alternative pedicle.

The angiogenic properties of human adipose-derived stem cells (HASCs) are modulated by the High mobility group box protein 1 (HMGB1).

Peripheral arterial disease (PAD), is a major health problem. Many studies have been focused on the possibilities of treatment offered by vascular regeneration. Human adipose-derived stem cells (HASCs), multipotent CD34+ stem cells found in the stromal-vascular fraction of adipose tissues, which are capable to differentiate into multiple mesenchymal cell types. The High mobility group box 1 protein (HMGB1) is a nuclear protein involved in angiogenesis. The aim of the study was to define the role of HMGB1 in cell therapy with HASCs, in an animal model of PAD. We induced unilateral ischemia in mice and we treated them with HASCs, with the specific HMGB1-inihibitor BoxA, with HMGB1 protein, and with the specific VEGF inhibitor sFlt1, alternately or concurrently. We measured the blood flow recovery in all mice. Immunohistochemical and ELISA analyses was performed to evaluate the number of vessels and the VEGF tissue content. None auto-amputation occurred and there have been no rejection reactions to the administration of HASCs. Animals co-treated with HASCs and HMGB1 protein had an improved blood flow recovery, compared to HASCs-treated mice. The post-ischemic angiogenesis was reduced when the HMGB1 pathway was blocked or when the VEGF activity was inhibited, in mice co-treated with HASCs and HMGB1. In conclusion, the HASCs treatment can be used in a mouse model of PAD to induce post-ischemic angiogenesis, modulating angiogenesis by HMGB1. This effect is mediated by VEGF activity. Although further data are needed, these findings shed light on possible new cell treatments for patients with PAD.

Lymphatic and Sensory Function of the Upper Limb After Brachioplasty in Post-Bariatric Massive Weight Loss Patients.

BACKGROUND: Varied deformities of the upper arm are common after massive weight loss. Brachioplasty techniques have been successively modified to improve aesthetic outcomes and avoid complications, especially lymphedema and sensory damage. OBJECTIVES: The authors evaluated lymphatic drainage and sensory function of the upper limbs after brachioplasty performed with a double-ellipse marking technique, a medial incision, superficial undermining, and posterior arm liposuction. METHODS: This prospective study included 12 women who underwent brachioplasty after bariatric surgery and massive weight loss. Lymphatic drainage was evaluated by forearm volumetry and indocyanine green lymphography of the entire limb. Cutaneous sensitivity thresholds were determined with Semmes-Weinstein monofilaments. RESULTS: Patients received postoperative follow up for 12 months. Complications included a small dehiscence for 1 patient and hypertrophic scarring for 2 patients. Cutaneous sensitivity and forearm volumetry were unchanged after brachioplasty for all patients. Results of indocyanine green lymphography indicated that all patients had normal linear lymphatic patterns pre- and postoperatively. CONCLUSIONS: Results of the study support the belief that this type of brachioplasty does not disrupt sensory or lymphatic function of the limb. LEVEL OF EVIDENCE: 4.

Lymphatic mapping of the upper limb with lymphedema before lymphatic supermicrosurgery by mirroring of the healthy limb.

INTRODUCTION: Supermicrosurgical lymphatic-venous anastomosis (LVA) can improve limbs lymphedema. We describe a technique that we employ for preoperative lymphatic mapping of the upper limb (UL), when indocyanine green (ICG) lymphography shows only dermal backflow (DB) and no lymphatic vessel is detectable. PATIENTS AND METHODS: Sixteen patients undergoing LVA for unilateral UL lymphedema, showing "stardust" or "diffuse" DB pattern, were included. Demographic, clinical data, and limbs measurements were recorded. LymQoL arm questionnaire was administered. Mean age of patients was 58.8 ± 13.1 years. Fifteen were females and 1 male. Lymphatic anatomy of the healthy limb was investigated by ICG lymphography and reported on the affected limb by a four steps technique: marking the main lymphatic pathway on the healthy limb, measuring of the distances at seven levels between the pathway and a line joining fixed landmarks, reporting these measurements on the affected limb with a correction proportional to the degree of swelling, marking skin incisions at the intersection of this pathway with venules, individuated by near infrared light system. Results were analyzed by postoperative questionnaire and changes of limb measurements. RESULTS: For every limb, we could find 3 ± 0.73 incision sites each containing at least one lymphatic vessel suitable for anastomosis. In every patient, we could perform 3.38 ± 0.62 anastomoses. Mean follow-up was 12.13 ± 2.73 months. After surgery, mean preoperative QoL score increased from 5.5 to 7.9 (P < .001), and mean difference between the mean circumferences of the affected and healthy limbs decreased from 4.3 ± 1.3 to 2.5 ± 1.3 cm, showing improvement of swelling after surgery (P < .01). CONCLUSION: This technique allowed to preoperatively map UL lymphatics even if diffuse DB was present.

Versatility of pedicled anterolateral thigh flap in gynecologic reconstruction after vulvar cancer extirpative surgery.

OBJECTIVE: Ablative surgery for vulvar cancer can involve the resection of perineum, vagina, urethra, groins, mons pubis, and abdominal wall creating complex defects. In our opinion, ALT flap is an ideal flap for reconstruction, because of low incidence of complications, long pedicle outside the radiotherapy field, capability of carrying fascia and muscle, possibility of sensate reconstruction, and low donor site morbidity. The purpose of this report is to describe our experience with ALT flap for reconstruction after vulvar cancer extirpative surgery, discussing our indications for complex defects and focusing on its versatility. PATIENTS AND METHODS: We performed a retrospective review of 15 cases of complex postoncologic gynecological wounds, reconstructed with 16 pedicled ALT flap, after vulvar cancer ablative surgery between 2014 and 2016. Age of the patients ranged from 44 to 77, with mean age of 62.6. Postoperative outcomes were evaluated. RESULTS: The flap size ranged from 12 × 8 cm to 22 × 15 cm., in two cases we harvested vastus lateralis to fill the dead space after pelvic exenteration. In nine flaps, we could include only 1 perforator, in 7 we could use two, 5 were septocutaneous and 18 myocutaneous with a pedicle length ranging from9cm.to15cm.We had no flap necrosis.3 flaps showed dehiscence of a part of the wound that healed by dressings. In one case of obese patient the donor site showed partial wound edge necrosis, and required secondary grafting. During follow-up that ranged from 1 month to 2 years, cancer relapsed locally in 5 patients. Global performance and specific pain improved after surgery. CONCLUSION: ALT flap should be included in the first line options for reconstructions of complex defects resulting from vulvar cancer surgery because of its reliability and versatility. © 2016 Wiley Periodicals, Inc. Microsurgery 37:516-524, 2017.

The lymphatic superficial circumflex iliac vessels deep branch perforator flap: A new preventive approach to lower limb lymphedema after groin dissection-preliminary evidence.

OBJECTIVE: Groin dissection is the procedure with the highest risk of lower limb lymphedema.As lymph stasis causes irreversible alterations to the limb over time,therapies should be administered in early stages,or better yet, lymphatic drainage impairment should be prevented.We developed a new preventive approach to lymphedema after groin dissection, and we report our preliminary experience. PATIENTS AND METHODS: We enrolled 5 patients undergoing bilateral groin dissection for vulvar cancer. Preoperative study of lower limbs lymphatic function was obtained by lymphoscintigraphy, with lymphatic transport index, indocyanine green (ICG) lymphography, and volume measurement with lower extremity lymphedema (LEL) index calculation. At the end of lymphadenectomy, one groin was closed in the standard way. On the other side, a lymphatic flap pedicled on the distal perforator of the deep branch of the superficial circumflex iliac vessels, was transposed into the groin region. Lymphatic function examination of the limbs was repeated 6 months after surgery. RESULTS: Before surgery no patient showed lymphatic drainage impairment at lymphoscintigraphy or lymphography, LEL index was in every limb lower than 250 (mean: 217.3 ± 13.83). After surgery the limbs treated with the flap showed no pathological swelling, LEL-index < 250 (mean: 235.4 ± 13.069), linear pattern at lymphography, and normal lymphoscintigraphy. The untreated limbs showed from moderate to severe edema with 265 < LEL-index < 310 (mean: 283 ± 16.3), diffuse dermal backflow at lymphography and interruption of lymph flow, with dermal backflow, at lymphoscintigraphy. Mean difference between preoperative and postoperative volumes was 64.8 ± 25.1 in the untreated side and 19 ± 11.7 in the side with the flap. The difference between preoperative and postoperative volumes compared between the treated and untreated side was statistically significant (P < .01). CONCLUSION: Our preliminary evidence suggests that this flap can prevent lymphedema after groin dissection. Further studies are necessary to confirm these results.

Surgical therapy of vulvar cancer: how to choose the correct reconstruction?

OBJECTIVE: To create a comprehensive algorithmic approach to reconstruction after vulvar cancer ablative surgery, which includes both traditional and perforator flaps, evaluating anatomical subunits and shape of the defect. METHODS: We retrospectively reviewed 80 cases of reconstruction after vulvar cancer ablative surgery, performed between June 2006 and January 2016, transferring 101 flaps. We registered the possibility to achieve the complete wound closure, even in presence of very complex defects, and the postoperative complications. On the basis of these experience, analyzing the choices made and considering the complications, we developed an algorithm to help with the selection of the flap in vulvoperineal reconstruction after oncologic ablative surgery for vulvar cancer. RESULTS: We employed eight types of different flaps, including 54 traditional fasciocutaneous V-Y flaps, 23 rectus abdominis myocutaneous flaps, 11 anterolateral thigh flaps, three V-Y gracilis myocutaneous flaps, three free style perforators V-Y flaps from the inner thigh, two Limberg flaps, two lotus flaps, two deep inferior epigastric artery perforator flap, and one superficial circumflex iliac artery perforator flap. The structures most frequently involved in resection were vulva, perineum, mons pubis, groins, vagina, urethra and, more rarely, rectum, bladder, and lower abdominal wall. CONCLUSION: The algorithm we implemented can be a useful tool to help flap selection. The key points in the decision-making process are: anatomical subunits to be covered, overall shape and symmetry of the defect and some patient features such as skin laxity or previous radiotherapy. Perforator flaps, when feasible, must be considered standard in vulvoperineal reconstruction, although in some cases traditional flaps remain the best choice.

Abdominal Subcutaneous Mass After Laser-Assisted Lipolysis and Immediate Multiple Treatments with a Dual-Wavelength Laser, Vacuum and Massage Device.

UNLABELLED: Body contouring by means of minimally invasive procedures is a growing trend. Current approaches to body contouring often involve a combination of surgical techniques (eg, laser-assisted liposuction) and a series of noninvasive device-based treatments aimed at accelerating recovery and improving aesthetic outcomes. In this case study, we describe a 38-year-old woman who presented with an abdominal-wall mass that resembled a tumor when assessed with magnetic resonance imaging. Twenty-six months before presenting to our office, the patient had undergone laser lipolysis and a series of treatments with a device that delivered dual-wavelength laser energy and vacuum-assisted massage. To address the patient's concerns, we removed the mass and performed abdominal dermolipectomy. No postoperative complications occurred, and the patient was highly satisfied with the aesthetic outcome. The results of histologic studies indicated that the mass was pseudocystic and fluid-filled, surrounded by a fibrous capsule, and characterized as a foreign-body granuloma. Further analysis is warranted regarding the safety of laser lipolysis without aspiration combined with a device delivering dual-wavelength laser energy and vacuum-assisted massage. LEVEL OF EVIDENCE: 5 Risk.

Supramicrosurgical lymphatic-venous anastomosis for postsurgical subcutaneous lymphocele treatment.

Postsurgical subcutaneous lymphocele is caused by accidental lesion of a lymphatic vessel that keeps on flowing lymph under the scar. Traditional treatments include aspiration and compression, with probable recurrence, and sclerotherapy which destroys both lymphatic cyst and vessel, creating risk of lymphedema. We describe the case of a postsurgical subcutaneous lymphocele of the left leg that was treated by supramicrosurgical lympatic-venous anastomosis. A single anastomosis was performed end-to-end, between one lymphatic vessel, individuated through indocyanine green lymphography, and one subcutaneous vein, distally to the lymphocele, under sedation and local anesthesia. Postoperative course was uneventful; the lymphocele completely resolved and never recurred during the nine months followup. This technique may heal the lymphocele with no impairing of lymph drainage function.