The Quadrangular Cartilage in Rhinoplasty: A Surgically Focused CT Dimensional Analysis of Black African and Caucasian Populations.

The apparent lack of quadrangular cartilage in Black African noses is commonly observed both from a radiological and clinical point of view. To the best of our knowledge, only a few research papers have been conducted on the facial proportions and structural anatomy of black people of Southern and Eastern Africa. The aim of this retrospective comparative study is a radiological assessment of the total amount of septal quadrangular cartilage by measuring its area in sagittal CT views, in two selected Black South African and Caucasian (CA) samples and the comparison with the literature in our hands. Statistical analysis was conducted, categorical variables are shown as frequencies and percentages, while continuous variables as means and standard deviations. Normal distribution of variables was verified using the Shapiro-Wilk test or by means of skewness and kurtosis values. Differences among unpaired groups were evaluated using the independent Student's t-test for normally distributed data (complemented by the Cohen's d to show the effect size with the following cutoff: d = 0.2, "small" effect size; d = 0.5, "medium" effect size; d = 0.8, "large" effect size) and Mann-Whitney U test in case of non-normal distribution. Statistical significance was defined as p < 0.05 setting the α-error probability at 5%. This study shows that, on average, there is 30% more cartilage available in CA compared with Black African noses and confirms the apparent lack of quadrangular cartilage and in Black African noses which is commonly observed in surgery. The need for an adequate amount of autologous septal cartilage makes cartilage availability a major concern before surgery and being able to preoperative accurately measure the amount of septal cartilage that is available to be harvested for other grafts in the surgery is essential.

Endogenous Endophthalmitis Secondary to Infected Cutaneous Basal Cell Carcinoma: A Case Report.

INTRODUCTION: Endogenous endophthalmitis (EE) is a severe intraocular infection due to hematogenous spread of bacteria from an extraocular site. Recognition of the primary source of hematogenous spread of bacteria is essential to establish an adequate therapy and avoid other major complications. Infected cutaneous tumor has never been reported as a possible source of EE. PURPOSE: To describe the first case of EE due to hematogenous spread of methicillin-sensitive Staphylococcus aureus from an infected cutaneous basal cell carcinoma. Systemic antibiotic therapy and surgical excision of the cutaneous lesion were performed. CONCLUSION: Severe and long-standing skin infections should be considered as a rare cause of EE.

History of Cranial Surgery in World War I: Experience on the Italian Front.

Since ancient history, men have been attempting to intervene when skull trauma occurs. The majority of traumas were always linked to war injuries, and in the modern era, the culprit was reached during World War I. Cranial traumas in wartime were very common, and consequently, physicians in wartime became particularly interested in the subject of cranial traumatology. In the following text, we want to bring to light the experience of some of the pioneers of cranial surgery in Italy during the First Great War. In fact before the war, very few medical officers had received training in central nervous system surgery. In addition, the surgical instruments for that clinical activity were inadequate and obsolete, but to deal with the medical emergency that had arisen on the front lines, the Italian government established Battlefield Medical Schools. And it is also from the reports and lectures of surgeons working on the front lines that the next generations of neurosurgeons were able to develop this surgical field into the complex and well-established surgical specialty that it is today.

RIB Plaster: a versatile, moldable derivative from scraping the periphery of the rib.

A simple technique is described for obtaining "rib plaster" by scraping the whitish peripheral portion of residual segments of rib after the perichondrium is removed and appropriate multiple laminations are derived This putty-like substance tends to conglomerate appropriately due to its high density and has unique properties: readily compacted into diced cartilage inserters, smoothly injected, easily moldable. "Rib plaster" serves well for camouflage of irregularities of the dorsum and tip as well as for mild augmentation. It comes to no further cost and in an adequate supply once a full-thickness rib segment is harvested for secondary rhinoplasty.

Efficacy of Septoplasty in Patients with Nasal Obstruction: A Systematic Review and Meta-analysis.

OBJECTIVE: Septoplasty is the most frequently performed ENT surgery to correct nasal septal deviation (NSD). The present study aimed to quantify the effectiveness of septoplasty with or without turbinate surgery according to NOSE questionnaire scores, with the hypothesis that it is able to clinically improve patient-reported nasal obstructive symptoms in the post-operative follow-up. METHODS: An electronic search was performed on PubMed/MEDLINE, Embase, and Cochrane Library. The primary outcome was the change in NOSE score at 6 months after surgery. It was assessed with the mean difference (MD) between baseline and postoperative results. RESULTS: A total of 2577 patients (males: 65.1%, 95% CI: 59.9-70.2) with a mean age of 33.3 years (n = 1456, 95% CI: 30.4-36.2) were included in this meta-analysis. The pooled baseline NOSE mean score was 68.1 (n = 2577, 95% CI: 64.3-71.9). The pooled MD in NOSE score at 6-months follow-up compared to baseline was -48.8 (n = 1730, 95% CI: -54.6 to -42.9). CONCLUSIONS: Functional septoplasty with or without turbinate surgery shows a critical improvement of obstructive symptoms and quality of life according to the validated NOSE score. LEVEL OF EVIDENCE: NA Laryngoscope, 133:3237-3246, 2023.

Reconstruction of the Axillary Region after Excision of Hidradenitis Suppurativa: A Systematic Review.

Introduction Hidradenitis suppurativa (HS) is a chronic, debilitating, recurrent, auto-inflammatory disease of the pilosebaceous units of the skin. The axillary region is the most affected anatomical site and its reconstructive options include skin grafts, local random plasties, regional axial flaps, and regional perforator flaps. The main aim of this systematic review is to identify the best surgical technique for axillary reconstruction in the context of HS, in terms of efficacy and safety. Methods We adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) throughout the whole review protocol build-up. The literature search was performed using MEDLINE, Embase, and Cochrane library databases, updated to March 2021. Quality was assessed for each study, through the National Institutes of Health Quality Assessment Tool. Results A total of 23 studies were included in the final analysis. We reviewed a total of 394 axillary reconstructions in 313 patients affected by HS Hurley Stage II or III. Skin grafts were associated with the highest overall complication rate (37%), and highest rate of reconstruction failure (22%). Between thoraco-dorsal artery perforator flap, posterior arm flap, and parascapular flap, the latter showed fewer total complications, recurrences, and failures. Conclusion Regional axial flaps should be considered as the best surgical approach in the management of advanced HS. The parascapular flap emerges as the most effective and safest option for axillary reconstruction. Local random flaps might be considered only for selected minor excisions, due to the higher risk of recurrence. The use of skin grafts for axillary reconstruction is discouraged.

Modified Dorsal Split Preservation Hybrid Rhinoplasty for Cartilaginous Pushdown and Full Letdown Applications: A PROM-Based Review of 100 Consecutive Cases.

Splitting the middle vault on an anatomical plane along the "Septal T" allows a new hybrid perspective on the many modifications of "surface" preservation techniques. The "dorsal split preservation" concept can be applied both to cartilaginous pushdown as well as to full letdown techniques. The dorsal keystone area is maintained, while the middle vault is reshaped. The septum is addressed by conventional L strut septoplasty. Precise direct suture fixation of the high-middle strip is easily accomplished after flexing the osseous-chondral junction at the K area. Specific technical points are described to allow exact and stable configuration of the dorsum.A retrospective analysis on 100 consecutive patients demonstrated aesthetic and functional improvement.

Craniotomy Burr Hole Covers: A Comparative Study of Biomechanical, Radiological, and Aesthetic Outcomes Using 3 Different Plug Materials.

Burr holes in the cranial vault are usually made during trephination for craniotomy or drainage of chronic subdural hematomas. The resulting cranial defect might bring to unsatisfactory esthetic outcome. In the current study the authors report clinical data regarding a cohort of patients who were treated with 3 different types of burr hole covers; autologous bone dust from skull trephination, and 2 different types of cylindric plug made out of porous hydroxyapatite in order to evaluate medium and long-term esthetic and radiological outcomes. Twenty patients were consecutively enrolled in the study and in each patient all 3 types of materials were used to cover different holes. Clinical and radiological outcomes at 6 and 12 months, were analyzed for all 3 types of plugs in terms of thickness of the graft coaptation of margins, remodeling, fractures, mobilization, and contour irregularities. In all craniotomy holes filled with autologous bone dust the authors have observed partial or complete bone reabsorption at 1 year and in 60% of the cases a visible and palpable cranial vault contour irregularity was reported. Both types of bone substitutes gave satisfactory results, comparable to autologous bone dust at 6 months and superior at 12 months, especially in terms of thickness and esthetic appearance. Hydroxyapatite plugs have shown better esthetic and biomechanical results and higher patients' satisfaction compared to autologous bone dust while not giving any additional complications.

The Acute Achilles Tendon Rupture: An Evidence-Based Approach from the Diagnosis to the Treatment.

Background and Objective: Acute Achilles tendon rupture (AATR) is a common injury with a significant impact on daily living. Although various systematic reviews and meta-analyses have been written on the topic, no actual consensus exists on the best treatment. We aimed to collect the highest quality of evidence on the subject and to produce a document to which to refer, from the diagnosis to the final treatment. Material and Methods: Inclusion criteria were systematic reviews discussing Achilles tendon rupture, concerning either diagnostic criteria, classification, or treatment; English language; clearly stated inclusion and exclusion criteria for patients' selection. Results: Thirteen systematic reviews were included in the study. A strong consensus exists about the higher risk of re-rupture associated with non-operative treatment and a higher risk of complications associated with surgical repair. Conclusions: The combination of minimally invasive repair and accelerated functional rehabilitation seems to offer the best results in the treatment of Achilles tendon rupture.

Outcomes in Hybrid Breast Reconstruction: A Systematic Review.

Background and Objectives: Lipofilling is a commonly performed procedure worldwide for breast augmentation and correction of breast contour deformities. In breast reconstruction, fat grafting has been used as a single reconstructive technique, as well as in combination with other procedures. The aim of the present study is to systematically review available studies in the literature describing the combination of implant-based breast reconstruction and fat grafting, focusing on safety, complications rate, surgical sessions needed to reach a satisfying reconstruction, and patient-reported outcomes. Materials and Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) throughout the whole review protocol. A systematic review of the literature up to April 2022 was performed using Medline, Embase, and Cochrane Library databases. Only studies dealing with implant-based breast reconstruction combined with fat grafting were included. Results: We screened 292 articles by title and abstract. Only 48 articles were assessed for full-text eligibility, and among those, 12 studies were eventually selected. We included a total of 753 breast reconstructions in 585 patients undergoing mastectomy or demolitive breast surgeries other than mastectomy (quadrantectomy, segmentectomy, or lumpectomy) due to breast cancer or genetic predisposition to breast cancer. Overall, the number of complications was 60 (7.9%). The mean volume of fat grafting per breast per session ranged from 59 to 313 mL. The mean number of lipofilling sessions per breast ranged from 1.3 to 3.2. Conclusions: Hybrid breast reconstruction shows similar short-term complications to standard implant-based reconstruction but with the potential to significantly decrease the risk of long-term complications. Moreover, patient satisfaction was achieved with a reasonably low number of lipofilling sessions (1.7 on average).

The "3 Points Compartmentalization" Technique in Subperichondrial-Subperiosteal Dissection in Primary Rhinoplasty to Reduce Edema and Define Contour.

Proper control of postoperative edema in rhinoplasty matters significantly, both regarding patient satisfaction and preventing loss of definition and aesthetic surface contour in the dorsum and tip. The "3 points compartmentalization" technique described in this paper aims to fulfill the above goals by (1) dissection in a subperichondrial-subperiosteal plane and (2) reducing the dead space by three strategically placed key sutures that compartmentalize the nose and redrape the single-plane dissection in an anatomically correct position.Level of Evidence IV 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 .

Anxiety and depression mood disorder in patients with nasal septal deviation: A systematic review and meta-analysis.

BACKGROUND: Nasal septal deviation (NSD) is one of the most prevalent upper airway diseases causing airway obstruction, and it can negatively impact patients' quality of life (QoL). OBJECTIVE: The aim of this study was to determine the risk of anxiety and depression mood disorders in patients with NSD. METHODS: A systematic review and meta-analysis was performed according to the PRISMA statement. An electronic search was performed on PubMed/MEDLINE, Scopus and Google Scholar. Raw affect size data were pooled comparing standardized between group mean differences. RESULTS: A total of 625 patients (males: 53 %, n = 280/525) with a mean age of 32.4 years (n = 375, 95 % CI: 25.3-39.4) were included. The pooled standardized mean differences (SMD) for the prevalence of the anxiety disorder was 1.17 (n = 625, 95 % CI: 0.34-2.0). The pooled SMD for the prevalence of the depression disorder was 0.30 (n = 490, 95 % CI: 0.12-0.48). CONCLUSION: Prevalence of anxiety and depression mood disorders is higher in patients with NSD compared to controls. These diseases should be investigated and considered during the diagnostic and therapeutic process to improve the QoL of patients with NSD.

Reducing complications in reconstruction of the cervical esophagus with anterolateral thigh flap: The five points protocol.

Patients suffering from hypopharyngeal cancer commonly present in the advanced stage and undergo a circumferential pharyngolaryngectomy. The possibility to reconstruct the esophagus and achieve an oral alimentation can significantly reduce the additional burden of a jejunostomy. The cervical esophagus is usually reconstructed with jejunal free flap (JFF) or fasciocutaneous free flap such as the anterolateral thigh (ALT) free flap. The latter has proved its donor-site safety and fast recovery. However, it is burdened by a high fistula rate. We present our five points protocol for reducing fistula rate and improving outcome. Twenty-eight patients underwent total pharyngolaryngectomy and required esophageal reconstruction with ALT flap from 2015 to 2020. In each patient, we performed five adjustments: a thicker dermal layer, a two-layer closure, a barrier from the tracheostomy, a nonabsorbable monofilament suture, and two NG tubes to enhance neoesophageal drainage. Twenty-five (89%) patients returned to solid or soft food diet after the reconstruction. Three patients had liquid diet. Contrast media leakage was observed in only 2 (7%) patients during esophagography at three weeks, with only one needing surgical revision. Our five points protocol for ALT reconstruction of cervical esophagus proved to be effective in achieving an incredibly low rate of complications, without the burden of significant donor-site complications.

One-Step Approach for Infections After Achilles Tendon Open Repair: The Distally Based Peroneus Brevis Muscle Flap.

The aim of this single-center, retrospective study is to demonstrate the effectiveness of distally based peroneus brevis muscle flap as first therapeutic option for infections after Achilles tendon open repair. We retrospectively analyzed 14 consecutive patients with complete Achilles tendon rupture and developing surgical site infection after an attempt of open surgical repair. Every patient was reconstructed with distally base peroneus brevis muscle flap. The primary outcome was the return to work and the initiation of full weight-bearing. Secondary outcomes were complication rate and time needed to return to work. A review of the literature was conducted to better define the actual standard treatment. Each patient returned to work. No flap necrosis occurred. Two minor healing delays and one hematoma were reported. Median time to wound healing was 17 days (interquartile range [IQR] = 13-20). Median time to full weight-bearing was 52 days (IQR = 47-55). Median follow-up (FU) was 21 months. Distally based peroneus brevis flap is a safe treatment for surgical site infections after Achilles tendon rupture repair. Patients regained full weight-bearing after a median time of 52 days from the surgical reconstruction. No major complications were observed. This flap clearly emerges as first reconstructive option for complications after surgery of Achilles tendon region.

Comparison of Efficacy among Three Dermal Substitutes in the Management of Critical Lower-Limb Wounds: The Largest Biases-Reduced Single-Center Retrospective Cohort Study in Literature.

Background and objectives: The skin recently became the main focus of regenerative medicine and, in this context, skin substitutes are fully entering into the plastic surgeon's armamentarium. Among the various types of skin substitutes, dermal substitutes (DSs) are the most used. Our study aims to retrospectively compare three renowned and extremely similar DS in the management of critical lower limb wounds in the largest cohort analysis currently present in literature. Materials and Methods: We followed a strict protocol of application and evaluation of the DS for each patient and wound and, after a meticulous bias reduction process, we compared final outcomes in terms of efficacy and speed in achieving the defect coverage. Results: Among patients who did not receive a skin graft after the DS, we registered a wound healed surface of 50% for Pelnac, 52% for Integra, and 19% for Nevelia, after 30 days from the external silicon layer removal; among those who received a skin graft after the DS, we observed a significantly lower mean percentage of graft take after 7 days with Pelnac (53%) compared to Integra and Nevelia (92% and 80%, respectively). The overall percentage of wound healed surface obtained after 30 days from the external silicon sheet removal, either with or without skin graft, was 71% for Pelnac, 63% for Integra and 63% for Nevelia. We also ran a sub-group analysis only including grafted wounds with a negative microbiological test and the mean percentage of graft take was similar this time. Eventually, we assessed the influence of the wound's "chronicity" on its healing, comparing the mean graft take only in "acute" wounds who received a skin graft and it resulted 63% for Pelnac, 91% for Integra and 75% for Nevelia. Conclusions: Integra demonstrates the highest rate of skin graft viability and the highest rate of skin graft takes after 7 days. Pelnac shows the quickest induction of secondary healing in acute wounds. Nevelia is not different from Integra and shows a superior graft take compared to Pelnac, but features the lowest secondary healing induction rate. No differences exist between the three DSs in terms of wound healing after 30 days from the skin graft or from the removal of the external silicon layer.

Artificial dermal substitutes for tissue regeneration: comparison of the clinical outcomes and histological findings of two templates.

OBJECTIVE: Artificial dermal substitutes (DSs) are fundamental in physiological wound healing to ensure consistent and enduring wound closure and provide a suitable scaffold to repair tissue. We compared the clinical and histological features of two DSs, Pelnac and Integra, in the treatment of traumatic and iatrogenic skin defects. METHODS: This prospective observational study involved 71 randomly selected patients from our hospital. Wound healing was analyzed using the Wound Surface Area Assessment, the Vancouver Scar Scale, and a visual analog scale. Histological and immunohistochemical evaluations were also performed. RESULTS: At 2 weeks, greater regeneration with respect to proliferation of the epidermis and renewal of the dermis was observed with Pelnac than with Integra. At 4 weeks, the dermis had regenerated with both DSs. Both templates induced renewed collagen and revascularization. Differences in the Vancouver Scar Scale score were statistically significant at 4 weeks and 1 year. Pelnac produced a significant increase in contraction at 2 weeks with increasing effectiveness at 4 weeks. Integra produced a higher percentage reduction in the wound surface area and a shorter healing time than Pelnac for wounds >1.5 cm deep. CONCLUSION: Our observational data indicate that both DSs are effective and applicable in different clinical contexts.

The Effect of Muscle Exercise on Perforators Flow: A Prospective Cohort Study.

Background and objectives: The metabolic response after exercise causes a significant increase in the muscle blood flow. While these effects are demonstrated for intra-muscular vessels, there is no evidence about the inter-muscular vessels, such as the septocutaneous perforators supplying the skin after they branch out from the deep source artery. The aim of our prospective study was to quantify the changes in the anterior tibial artery perforators arterial blood flow after mild isotonic exercise in a young and healthy population. Material and Methods: We performed a prospective analysis of 34 patients who were admitted to the Plastic Surgery Department from December 2019 to April 2020. Flow velocities of two previously identified anterior tibial artery perforators were recorded both before and after 10 complete flexion-extensions of the foot. The time to revert to basal flow was measured. We further classified the overmentioned patients based on their level of physical activity. Results: We registered a significant increase in systolic, diastolic and mean blood flow velocities both in proximal and distal anterior tibial artery perforators after exercise. Fitter patients exhibited a higher increase in proximal leg perforators than those who did less than three aerobic workouts a week. The time to return to basal flow ranged from 60 to 90 s. Conclusions: This was the first study to describe the effect of muscular activity on perforators blood flow. Even mild exercise significantly increases the perforator flow. Waiting at least two minutes at rest before performing the Doppler study, thus avoiding involved muscle activation, can notably improve the reliability of the pre-operative planning.