Prophylactic venous Supercharging in DIEP Flap Surgery: A Retrospective Dual-Center Study.

BACKGROUND: DIEP flap is nowadays considered the gold standard in breast reconstruction. However, venous congestion is still a leading cause of free flap failure. Despite the conspicuous articles regarding the use of a secondary venous anastomosis, there is a lack in the literature regarding the prophylactic use of a secondary venous route to reduce the incidence of complications during breast reconstruction. METHODS: A double-center retrospective study based on women undergoing DIEP breast reconstruction was conducted, dividing patients into case group(DIEP flaps with double venous anastomosis) and control group(DIEP flaps with single venous anastomosis). Demographic and surgical data and complications were compared and statistically analyzed and a reconstructive algorithm was proposed to improve the flap insetting. RESULTS: 154 patients were included in the study, divided into Case group(74 patients) and control group(80 patients). Median age at the time of surgery was 49,09 years (range 29 -68), slightly lower in Group 1 when compared to Group 2. Mean BMI was 25,52 kg/m2(range 21,09-29,37), in particular 25,47 kg/m2 (range 23,44 -28,63) in Group 1 and 25,58 kg/m2(range 21,09-29,37) in Group 2. No statistical differences were found between groups in terms of BMI and smoking and comorbidities history. Average operative times were 272,16 minutes in Group 1 (range 221 - 328) and 272,34 minutes in Group 2(range 221-327), with no significant difference between groups, as well as ischemia times(44,4 minutes in Group 1 (range 38 - 56) and 49,12 minutes in Group 2(range 41- 67). Statistical analysis showed a reduction in short term complications and a statistically significant reduction for take-backs in the comparison of two groups. CONCLUSIONS: Our study suggests that venous supercharging of DIEP flap by performing dual venous anastomosis can be routinely and safely done prophylactically, and thus not only after intraoperative assessment of venous congestion, in order to avoid flap venous congestion and rates of re-exploration.

Latissimus Dorsi Flap and Thoracodorsal Artery Perforator Flap with Immediate Fat Transfer (LIFT and TIFT): A Retrospective Study about Total Breast Reconstruction in High-Risk Patients.

INTRODUCTION: Microsurgical breast reconstruction has become popular over the past twenty years and allows a tailor-tuck approach to each patient. However, smoking or coagulation disorders may switch surgeon's choice towards alternative options. When facing these risk factors, we performed pedicled latissimus dorsi (LD) flap and thoracodorsal artery perforator (TDAP) flap reconstruction with immediate fat transfer (LIFT and TIFT), achieving satisfactory surgical outcomes. Hence, we aim to present our seven-years case-series and discuss our decisional algorithm. MATERIALS AND METHODS: Thirty smoker women and seven women affected by coagulation disorder (n = 37) respectively had LIFT and TIFT surgery and were retrospectively evaluated. Patients' demographics and outcomes were recorded and compared. RESULTS: LIFT patients received higher volumes of immediate fat grafting compared to TIFT patients (p < 0.05), which required additional lipofilling to provide adequate volume amount, since the TDAP flap was not immediately grafted. However, the additional lipofilling procedures and fat volume were similar (p > 0.05). Flap survival reached 100%, and flap necrosis or loss did not occur. Few minor complications were evidenced in the LIFT group only (p > 0.05). CONCLUSION: Based on our experience, we support the reliability of pedicled LD and TDAP flaps with immediate fat transfer in breast reconstruction as valuable alternative to microsurgery in smokers (LIFT) and patients with coagulation disorders (TIFT). However, the results of our study are not conclusive since still must be clarified the role of the smoking and coagulation disorders in microsurgery and the real benefit of a non-microsurgical procedure. LEVEL OF EVIDENCE IV: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. 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 .

An Original Approach to Massive Weight Loss Deformities in the Lower Thigh: A Retrospective Assessment of Results and Patients' Satisfaction.

INTRODUCTION: Massive weight loss (MWL) patients present skin and soft-tissue laxity and ptosis involving inner thighs. Previous efforts were focused on the upper two thirds of the thigh, while literature has never dealt specifically with lower thigh contouring. We present an original approach to the lower inner thigh, intended for patients who already had upper thigh lift, discussing outcomes, advantages, and limits of our technique. MATERIALS AND METHODS: Sixteen female MWL patients with persisting severe deformities in the lower inner thigh, following an upper thigh lift, received lower third medial thigh contouring, through concurrent liposuction and skin excision, between 2017 and 2019. The excision pattern consisted of an inferiorly-based vertical triangular component, centered on the inner midline, and a distal horizontal crescent, resulting in an inverted-T scar. Our series was retrospectively investigated, comparing preoperative and 12-month postoperative pictures and assessing the outcomes by means of a tailor-made 11-item survey. RESULTS: Three patients had minor complications (two cases of skin de-epithelization at the wound margin, one granuloma). Photographic assessment showed a 15.9% transverse diameter reduction (p<0.05). The questionnaire showed encouraging scores for all the investigated items. Mean overall satisfaction was 9.6/10. CONCLUSION: Despite the retrospective design and the limited sample size, in consideration of the applicability of this technique in selected cases, and the need for a two-step procedure, separate upper and lower thigh contouring, the results of our study showed a considerable improvement of the inner thighs by our personal combined liposuction and lower medial thigh lift approach. 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 .

Retrospective Analysis of Predictive Factors for Complications in Abdominoplasty in Massive Weight Loss Patients.

INTRODUCTION: Ex-obese patients present with redundancy of abdominal skin and soft tissue due to massive weight loss (MWL). The plastic surgeon can restore the body shape through body contouring procedures. Hence the need to adequately direct patients to body contouring by identifying suitable candidates exists. Our work aims to retrospectively analyze the abdominoplasty complications in our case series to identify associated risk factors and evaluate the effect of combined procedures on abdominoplasty outcomes. MATERIALS AND METHODS: We retrospectively investigated predictive factors of abdominoplasty procedure complications on 213 MWL patients who received abdominoplasty with and without rectus sheath plication, abdominal liposuction, and other body contouring procedures. We identified risk and protective factors with univariate and multivariate regression analysis. Furthermore, we assessed the impact of additional procedures on the complication rates. RESULTS: The overall complication rate was 49.8% (26.8% minor complications; 23% major complications). The delayed wound healing rate was 27.7%, and the revision surgery rate was 25.8% (14.7% early revision; 14.2% late revision). These results were compared with literature reports. Several negative predictors emerged as non-modifiable (advanced age, diabetes mellitus, surgical mode of weight loss) or modifiable (preoperative obesity and body mass index (BMI); active smoking; preoperative anemia; use of fibrin glue or quilting sutures). Performing rectus sheath plication improved most of the outcomes. Liposuction of hypochondriac regions and flanks led to increased safety and reduced the risk of surgical dehiscence and delayed wound healing, in contrast to epimesogastric liposuction. The other combined body contouring procedures did not worsen the outcomes, except for poor scarring. CONCLUSION: Our findings encourage us to continue associating rectus sheath plication, liposuction, and other body contouring surgeries with abdominoplasty. We emphasize the importance of proper patient selection, particularly with regard to anemia, before body contouring surgery in the interests of offering safe surgery and satisfactory results. Further studies are needed to investigate how the optimal BMI cut-off and abstinence from smoking (in terms of time) before surgery reduce postoperative complications. 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 https://www.springer.com/journal/00266 .

Reconstruction with bilateral posteromedial thigh (PMT) flaps after Fournier's gangrene.

Fournier gangrene (FG) is a deadliest condition affecting genitoperineal area in predisposed patients. A late diagnosis, thus a delayed surgical treatment, leads often to death. LRINEC score and CT scan can help in suspect, despite definitive diagnosis needs surgical exploration and histological findings. Furthermore, FG determines wide defects of genitoperineal area, thus reconstructive surgery is pivotal to restore form and function of the affected patient. Aim of this article is to discuss the use of posteromedial thigh (PMT) fasciocutaneous flap in FG reconstruction, based on authors' personal experience. A case report of a 63-year-old obese and diabetic man is presented. Two PMT flaps (10 x 17cm2) were harvested to cover a complete scrotal defect (20 x 40cm2), while penis integuments defect was treated with a two-staged surgery (dermal substitute application and skin graft). Follow-up at 4 months showed a successful outcome of PMT flaps reconstruction, with preservation of testes vitality, despite one of the flaps developed distal necrosis that was treated with further debridement and skin graft. The authors experience is followed by the decision-making process based on a literature review that led to the choice to use PMT flaps to achieve reconstruction. Furthermore, alternative flaps to treat FG, each of them with pros and cons, are discussed, despite there is not a gold standard treatment and every option must be tailored to the patient. KEY WORDS: Fournier gangrene, Genital reconstruction, Infection, Necrotizing fasciitis, Posteromedial thigh flap, Perineum reconstruction.

Novel three-dimensional acellular dermal matrix for prepectoral breast reconstruction: First year in review with BRAXON® Fast.

Implant-based breast reconstruction is part of breast cancer treatment, and increasingly optimized reconstructive procedures exploit highly biocompatible materials to ensure enhanced aesthetic-functional results. Acellular dermal matrices (ADMs) are collagen-based materials that made prepectoral implant placement possible, thanks to their bioactive antifibrosis action. Recently, the first three-dimensional ADM, BRAXON® Fast, has been produced. Its 3D design represents the technological evolution of BRAXON® ADM, a flat collagen matrix, and allows for a time-saving complete wrapping of the synthetic prosthesis, thus creating a total biological interface on the implant with patient's tissues. Here, we report our experience on the first 23 eligible patients who received BRAXON® Fast-assisted prepectoral reconstruction. On a total of 27 breasts, the overall complication rate was 11.1%, including one minor seroma (3.7%), one case of necrosis (3.7%), and one implant removal due to infection. As new-generation devices, 3D ADMs showed an effective performance, allowing to reduce the overall exposure time for implant preparation and providing an optimal safety profile.

Deep inferior epigastric perforator flap preoperative planning: A comparative analysis between dynamic infrared thermography, computerized tomography angiography, and hand-held Doppler.

INTRODUCTION: Hand-held Doppler (HHD) sonography and computerized tomography angiography (CTA) are the common assessment tools for deep inferior epigastric perforator (DIEP) flap preoperative planning. CTA is considered the gold standard method for preoperative perforator mapping but necessitates contrast medium and X-ray exposure. Dynamic infrared thermography (DIRT) does not have these drawbacks and allows the detection of hot and cold spots on a given body area. Our study aimed to compare DIRT, HHD, and CTA in perforator mapping for breast reconstruction using DIEP flap. PATIENTS AND METHODS: From March to September 2020, 12 consecutive patients scheduled for DIEP flap breast reconstruction were preoperatively investigated with HHD, CTA, and DIRT. The patients' mean age was 53 and the mean BMI was 29.23 kg/m2 . All the reconstructions were due to breast cancer. The results of preoperative perforator mapping on the lower abdomen were compared among the three techniques. All the evidence was compared to the intraoperative findings, during flap harvesting, to establish if the techniques were able to correctly locate the perforator. RESULTS: We detected 178 perforators intraoperatively, 178 with CTA, 178 with DIRT, and 125 with HHD. The latter revealed a lower number of perforator vessels for each patient (10.42 ± 3.58), compared with CTA (14.83 ± 3.04) and DIRT (14.83 ± 4.76). DIRT resulted superior to HHD (p < .05), while no statistically significant difference (p > .05) was found between DIRT and CTA. We calculated a mean sensitivity of 93.87% for CTA, 69.02% for HHD, and 92.06% for DIRT. CONCLUSION: DIRT is a useful tool in the preoperative planning of DIEP flaps, as it provides information about the location of perforators and the hemodynamic properties of angiosomes. It is easy to use, and it does not involve ionizing radiation. DIRT could represent an innovative and promising implementation of CTA and HHD techniques for preoperative perforator mapping in DIEP breast reconstruction.

Puboplasty as an integral step in massive weight loss abdominal contouring: a retrospective assessment of results, stability, and patients' satisfaction.

Ex-obese patients complain about abdomen and pubis deformities following massive weight loss, due to skin and soft tissue redundancy. Abdominoplasty is often the first corrective procedure performed, but residual mons pubis deformities may impair the final outcome, thus concomitant correction becomes necessary. Sixty patients were treated by the same surgeon between 2008 and 2018, 30 of them receiving only standard umbilical transposition abdominoplasty (A group), and 30 having concurrent monsplasty (AM group), namely skin excess removal, pubic suspension and skin redistribution following superolateral vectors, re-establishment of superficial fascia continuity, with or without liposuction. Retrospective comparison of the two groups included: a subjective evaluation through administration of questionnaires (BODY-QTM, a questionnaire assessing functional and aesthetic improvements after surgery, a questionnaire assessing the overall satisfaction), and an objective evaluation of pre- and post-operative pictures to estimate mons pubis suspension and result stability. Four minor complications were recorded: 1 wound dehiscence in A group, 3 seromas in AM group. All measured outcomes were higher in AM group, with statistically significant difference (p < 0.05) in almost all the questionnaire and BODY-QTM items, and the photographic assessment confirmed higher degree of mons pubis suspension and superior result stability in AM group. We presented a standardized approach to mons pubis reshaping during abdominoplasty, through a straightforward, safe and quick procedure. Our experience supports the significance of the concomitant correction of abdominal and mons pubis deformities, improving the results of the surgery from both a subjective and objective point of view.

Retrospective analysis of the predictive factors associated with good surgical outcome in brachioplasty in massive weight loss patients.

BACKGROUND: Upper arm lift is a widespread body contouring procedure, but no globally accepted guidelines exist in selecting patients and, due to comorbidity and heterogeneity of them, it is difficult to identify predictive factors of good surgical outcome. The authors review the team's experience of 56 brachioplasty performed in massive weighs loss patients. METHODS: Data of 56 consecutive arm lifts were reviewed for preoperative, perioperative and postoperative variables and outcomes (complications, scarring, wound healing, revision surgery, need for blood transfusion, satisfaction, etc.). Surgical technique and postoperative care are described. A statistical analysis was performed to identify relationship between possible predictive factors and outcomes. Furthermore, an evaluation of different employed wound management devices was conducted. RESULTS: Follow-up ranged from 6 to 36 months (mean 20.1 months). Outcomes summary is reported (overall complication rate 50%, poor scarring rate 25%, delayed wound healing rate 26.8%, revision surgery rate 37.5%, need for blood transfusion rate 8.9%, satisfaction rate 71.4%) and statistical investigation evidenced the role of prior plastic surgery BMI and the associated change in BMI before and after weight loss, just prior brachioplasty, and the modality of weight loss. CONCLUSION: The authors' technique resulted in positive outcomes overall, considering the difficulty in dealing with the problems of MWL patients. Based on our results, we aim to suggest to perform brachioplasty in patient with the lower achievable BMI (preferably <30kg/m2) to reduce the negative effect of unmodifiable factors as diabetes, modality of weight loss, a wide ΔBMI, and other well-known negative predictive factors.

Extended latissimus dorsi flap with propeller ascending design for reconstruction of a complex lateral lumbar defect: A case report and review of the literature.

Lateral lumbar defects are rarely encountered and difficult to manage because of the limited reach of loco-regional flaps and the unfavorable position of recipient vessels for microsurgical transfer. The purpose of this report is to describe the innovative application of an extended latissimus dorsi (LD) flap with propeller ascending design in the field of lumbar reconstruction, reviewing current reconstructive options accepted for lateral lumbar defect. A 68-year-old male patient underwent wide full thickness resection for a solitary hepatocellular carcinoma metastatic lesion arising in the left lumbar region, resulting in an extensive soft-tissue defect (20 x 13 cm) with deep structures exposure. An extended LD flap with propeller ascending orientation was obliquely designed, with the distal third of the skin island laying over the trapezius muscle. The skin paddle measured 34 x 9 cm. The flap, including a cuff of proximal LD muscle spared by the oncological resection and a fasciocutaneous superior extension, underwent 90°clockwise rotation on the main thoracodorsal artery perforator and further caudal advancement allowed by section of the LD cranial tendinous insertion. The rotation-advancement movement allowed tension-free flap insetting, while donor site was closed by primary intention. The post-operative course was uneventful without any complications registered. At 12-months follow-up, a satisfactory result and a stable coverage were achieved. Due to the surgical complexity traditionally associated with the repair of defects located in the lumbar region, the case reported may help to provide a new alternative solution to extend the indications of local flaps in similar cases and simplify such reconstructions.

Combining traditional and microsurgical reconstruction after a complex hand trauma with multiple tissue defects. A case report.

Complex injuries involving bones, tendons and soft tissues of the hand still represent a difficult challenge for reconstructive surgeons. Hereby, we present a case of a man suffering from a complex crush injury of the right hand that led to a wide three-dimensional defect with loss of two metacarpal bones, extensor tendons and skin. For composite hand defects, the most common surgical approach provides for a one-stage composite reconstruction or for an early restoration of bone and skin, with delayed tendon grafts. For the peculiarity of the defect, a one-stage reconstruction was not feasible. Hence, we opted for a two-stage reconstruction but the usual surgical steps have been inverted. First we secured tendon and skin restoration through a composite teno-cutaneous radial free flap. A month later, we reconstructed the two metacarpals with a modified Masquelet technique using fibular cortical graft. This strategy allowed the patient to start an early rehabilitation program and obtain a satisfactory recovery of his dominant hand. KEY WORDS: Composite flap, Hand trauma, Hand reconstruction, Microsurgery.

Integrated Treatment of Breast Cancer-related Lymphedema: A Descriptive Review of the State of the Art.

BACKGROUND/AIM: Upper limb breast cancer-related lymphedema (BCRL) is a chronic and severe condition affecting a significant percentage of breast cancer survivors. Even though its physiopathology is well-known, there is no worldwide consensus on BCRL evaluation and a gold-standard treatment. This narrative review aims at providing a brief descriptive overview with regard to BCRL treatment modalities. MATERIALS AND METHODS: We conducted a literature search within the PubMed database, and 33 articles out of 56 were selected, including reviews, systematic reviews, and meta-analyses aiming find the most updated evidence regarding BCRL treatment modalities. RESULTS: Physical exercise (aerobic exercise, resistance exercise, aquatic therapy), bandages, and intermittent pneumatic compression were shown to be most effective in BCRL patients, in terms of swelling reduction in the acute-intensive phase. Furthermore, physical exercise was beneficial also as a maintenance tool. Manual lymphatic drainage demonstrated efficacy in preventing secondary lymphedema if applied immediately after breast cancer surgery or in early phases of BCRL or as a maintenance tool. Complementary procedures such as acupuncture, reflexology, yoga and photo-biomodulation therapy did not show conclusive results in BCRL treatment. Surgery was shown effective in managing symptoms (liposuction), preventing (lymphaticovenular anastomosis) and treating BCRL (vascularized lymph node transfer). CONCLUSION: BCRL is still a challenging condition either for breast cancer survivors and clinicians, deeply impacting patient functioning and quality of life. Due to the lack of globally accepted criteria in evaluating BCRL, to date a gold standard treatment for this widespread issue is still needed.

Brief history in the time of SARS-CoV-2 pandemic in Italy. A close look on a Plastic Surgery Unit and Plastic Surgeons efforts during the COVID-19 outbreak.

BACKGROUND: SARS-CoV-2 and its related COVID-19 are now affecting people worldwide. The pandemic, started at the end of 2019 and spread in Europe and all over the world at the beginning of the 2020, is the biggest threat to the health and to the economy of all countries, since the time of Spanish Flu. A global effort is being made to counter the virus with social distancing and restrictions, but our habits and behavior have dramatically been modified. Hospital activity has changed, and Plastic Surgery is affected as well as other disciplines. MATERIALS, METHODS AND RESULTS: Our work describes the impact of the pandemic on a Plastic Surgery Unit in a tertiary care hospital and estimates the possible consequences in the near future. Elective procedures and consultations have been postposed and rescheduled, but we ensured treatment for life-threatening conditions and offered the best therapy, complying with the new safety standard to protect the patients and the healthcare providers. Media helped in keeping in touch the people, ensuring continuity in education and circulation of the data about SARS-CoV-2 research. CONCLUSION: We don't know yet what the overall cost of the crisis will be on the global economy and on the National Health Systems. Definitely, it will be a big challenge to face, both for the Governments, for the people, as for healthcare providers. However, to date, we should remind our responsibilities as doctors, as we can contribute with our efforts and our knowledge to ensure continuity of care and research. KEY WORDS: COVID, COVID-19, Italy, Outbreak, Pandemic, Plastic Surgery, SARS-Cov-2.

The Role of Portable Incisional Negative Pressure Wound Therapy (piNPWT) in Reducing Local Complications of Post-bariatric Brachioplasty: A Case-Control Study.

BACKGROUND: Due to the great impact of bariatric surgery on the overweight epidemic, the number of post-bariatric body-contouring procedures is constantly increasing worldwide. The portable incisional negative pressure wound therapy (piNPWT) is a promising medical device for accelerating wounds closure and controlling post-operative complication, which have been shown promising results in post-bariatric population. We aimed to evaluate the role of piNPWT in optimizing wound healing and controlling post-operative complications after a post-bariatric brachioplasty. PATIENTS AND METHODS: 26 post-bariatric female patients who underwent a brachioplasty followed by either a piNPWT (14 cases) or a standard wound treatment (12 controls) were analyzed. The number of post-operative dressing changes, the rate of local post-operative complications (re-operation, hematoma and serosa development, dehiscence and necrosis), the time to dry as well as the scar quality and hospitalization length were evaluated. RESULTS: None of the patients prematurely stopped treatment with piNPWT due to intolerance. The piNPWT patient group showed a significant lower healing time as well as a significant reduction of the number of post-operative dressing changes and hospital stay. Despite the scarring process was excellent from the functional point of view in the long term, we noticed a higher rate of hyperchromic scarring at 90 days after surgery. CONCLUSION: The piNPWT is a cost-effective and user-friendly medical tool that increase and promote wound healing. We suggest the use of this device in post-bariatric patients who undergo a brachioplasty, especially if there is the need to minimize the number of post-operative dressing changes. 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 Table of Contents or the online Instructions to Authors www.springer.com/00266.

Persistent Sciatic Artery and its role in limb salvage in oncological surgery.

AIM: The Persistent Sciatic Artery (PSA) is a rare congenital anomaly due to missed involution of embryo-fetal sciatic artery, which is the main blood supply to lower limb during embryonic development until superficial femoral artery (SFA) is formed. The PSA is frequently related to complications in adults like aneurysm and embolism. Here we present a case in which the discovery of a complete PSA resulted limb saving. In case of oncologic or trauma surgery, when no other options are available, the PSA can help in management of reconstructive surgery. CASE REPORT: A case of PSA was discovered during management of a patient affected by a soft tissue sarcoma of the lower limb. Tumor resection needed the femoral neurovascular bundle demolition to ensure radical surgery and subsequent vascular reconstruction, which failed due to complications. RESULTS: Despite failure reconstruction, a misdiagnosed type IIa PSA, replacing the role of the SFA, saved the lower limb from ischemia and subsequent amputation. Functional reconstruction was thus achieved with almost total recovery of lower limb function. DISCUSSION AND CONCLUSIONS: In oncological and trauma surgery we recommend investigate the whole lower limb vascularization, from the pelvis to the foot, suspecting the PSA existence. Indeed, although it is always preferable to reconstruct the SFA system despite a complete PSA is present, due to its frequent complications, the PSA can represent a limb saving option. KEY WORDS: Computerized tomography angiography, Persistent sciatic artery, PSA, Superficial femoral artery, SFA fibromyxoid sarcoma.

Symmetrical peripheral gangrene reconstruction after lower limb amputation.

Symmetrical peripheral gangrene (SPG) is a complication of septicemia, characterized by progressive skin lesions, which can result in wide necrosis of all the extremities. Severe necrosis is often responsible of disfiguring consequences. It is important to limit the amputation and to provide a stable and functional soft tissue coverage of the stumps. Limited amputation and free flap reconstruction may help to prevent tissue loss and to provide an effective prosthetization and a prompt rehabilitation. We present a clinical case of a 60-year-old male admitted in our department for lower limbs necrosis due to SPG after a pneumococcal infection. The patient underwent bilateral forefeet amputation and microsurgical reconstruction with antero-lateral thigh flap was performed on the left stump. Vascular complications determined a progressive necrosis of the flap and the failure of the reconstruction. A careful analysis of the local and systemic inflammatory vascular and coagulative issues following the SPG has been performed to explain the failure of the microsurgery. Although the opinion of several authors is divided about the use of free tissue transfer, we believe that microsurgical reconstruction remains the first choice of treatment due to the reduced morbidity and early rehabilitation it provides. KEY WORDS: Amputation, Free flaps, Free tissue transfer, Limb salvage, Microsurgery salvage, Prosthesis, Sepsis, Septicaemia, Symmetrical peripheral gangrene.

Inguinocrural dermolipectomy A retrospective study.

INTRODUCTION AND AIM: Inguinocrural dermolipectomy is a constantly increasing surgical procedure, especially for postbariatric patients with significant weight loss. The "crescent medial" and "vertical medial" thigh lifting techniques (CMTL/VMTL) are the most effective type of surgery to treat laxity and excess of skin and soft tissues in the medial region of the thighs Aim of this article is to suggest which patients may be eligible for a surgical thighplasty with an acceptable risk of postoperative complications. MATERIALS AND METHODS: We performed a retrospective study with 30 female patients who underwent a surgical thighplasty between 2018 and 2008. Several parameters were evaluated such as age, patient weight and BMI before weight loss and before plastic surgery, the mode of weight loss (surgical vs. non-surgical), the type of technique performed ("crescent medial" vs. "vertical medial"), the association with other surgical procedures of size reduction plastic operation (ICD10 Procedure Code 8683), smoking at the time of the intervention. The correlations between these preoperative parameters and the development of postoperative complications were taken into consideration and different outcomes were evaluated, of which the modification of the size of the trousers after the thigh lifting operation, the days of hospitalization, the maintenance time drainage, the time needed to return to normal daily activities and improvement in the same, in walking and in physical activity after the execution of the procedure and the satisfaction in general of the patients. RESULTS: The association with other excisional surgeries such as brachioplasty, abdominoplasty or mastopexy, the BMI before thighplasty and weight loss modality condition significantly influence patient's post-operative outcomes. However, there is no clear correlation with age, smoking, the type of plastic surgery performed and its possible association with liposuction, and a drastic "drop" of BMI. DISCUSSION: In our opinion, even more than a single parameter predicts patients' post-operative complications. Acting on the significant findings of our investigation, surgeons could minimize post-operative risks as well as surgical minor complications. CONCLUSIONS: Therefore we advise to evaluate these factors before the intervention in order to select the patients more accurately and define the ideal candidate patient for inguinocrural dermolipectomy, so as obtain a reduction in postoperative complications. KEY WORDS: Body contouring, Massive weight loss, Thigh lift.

The Posterior Arm Flap for Reshaping the Postbariatric Breast.

Postbariatric surgery, either by itself or in association with other procedures, tries to correct physical defects and body deformities. Because of the intrinsic complexity of massive weight loss (MWL) patients, more than a single procedure is, most of the time, required. We report a combined surgical method able to improve arms' and breasts' contour that aims to obtain a satisfying functional and aesthetic result by reducing surgical times and costs. METHODS: A female MWL patient with proper body mass index was clinically evaluated and considered suitable for surgery. While authors performed a modified Pascal-Le Louarn brachioplasty for the upper arm, a standard McKissock mastopexy followed by a Wise pattern skin closure was selected to obtain the breast lift. By sparing the proximal pedicle, the fasciocutaneous flaps were harvested on both posteromedial sides of the arms. The posterior arm flaps (PAF) were tunneled and transposed below the subcutaneous skin bridge across the axilla and finally used to increase the breast mound. RESULTS: In the immediate postoperative follow-up, no complications were reported. After the 6-month and 1-year follow-up, both arms' silhouette was documented as healthy and symmetric. Breasts were soft, without any signs of ptosis and/or contracture. No skin disorders or scar hypertrophy or lymphedema were reported. CONCLUSIONS: PAF in breast contouring procedures is an interesting surgical option, but more patients need to be treated to validate the effectiveness of the procedure. This technique should be considered when there is a need for simultaneously improving arm's contour and breast's volume and shape.

Endoscopic Sinus Surgery Associated with Rhinoseptoplasty: A Case-control Study.

OBJECTIVE: To examine the difference between outcomes in the administration of concurrent endoscopic sinus surgery (ESS), septoplasty (SP), and rhinoplasty (RP) and concurrent ESS and SP in 1 single surgical session. METHODS: Patients who underwent concurrent ESS and SP from September 2004 to July 2015 were identified. Furthermore, patients among them who underwent functional primary RP were selected. Subjects who had been administered concurrent ESS, SP, and RP (primary RP) were matched for sex, age, sinonasal surgical procedures for treatment of chronic rhinosinusitis with patients underwent concurrent ESS and SP, used as control subjects. A literature review was performed to find previous articles describing results of concurrent procedures among ESS, SP, and RP. RESULTS: Twenty subjects, who underwent concurrent ESS, SP, and RP, were compared with a matched control group made of 20 patients who underwent concurrent ESS and SP, evaluating different postoperative outcomes (postoperative complications, postoperative improvement of respiratory symptoms, persistence of chronic rhinosinusitis symptoms 6 months to 1 year postoperative, need of revision surgery, satisfaction of the patient). Obtained P values showed that there was no statistically significant difference (P > 0.05) as regards the different outcomes, except for postoperative complications, increased because of the invasiveness proper of RP (P < 0.05). CONCLUSIONS: Therefore, execution of concurrent ESS, SP, and RP seems to be safe and effective, and additional RP does not modify postoperative outcomes of concurrent ESS and SP except for a little increase of postoperative complications, even if most of them had low impact on result of procedures.