Polyurethane Implants in Revisional Breast Augmentation: A Prospective 5-Year Study.

BACKGROUND: Revisional surgery for aesthetic breast augmentation remains a challenging procedure. Polyurethane (PU) implants have been found to avoid capsular contracture recurrence as well as to prevent implant displacement by bio-integrating with the pocket. OBJECTIVES: Our study aimed to assess the use of PU implants in breast revisional surgery and to provide an algorithm. METHODS: Over a 5-year period, a prospective study was conducted involving consecutive patients undergoing implant revision. Patient demographics, previous breast procedures, and specific surgical details were documented. Postoperative outcomes were followed up. RESULTS: Out of 92 patients (184 breasts), 78 (156 breasts) were included in the analysis. The average age was 47.5, with a BMI of 22.3 and a mean follow-up of 5 years. A majority (63%) represented secondary revisional cases, while 37% were tertiary cases. Implant size averaged 296 cc, with 53% placed in retropectoral position and 47% prepectoral. Significantly more implants in secondary cases were changed from prepectoral to retropectoral (P = .005), and in tertiary changed from retropectoral to prepectoral (P = .002). Complete capsulectomy was performed in 61.5% and partial in 25.6%. Additional lipofilling was performed in 32%, and concurrent mastopexy in 40%. Revisional surgery in our series had a 1.9% acute complication rate, 4.5% longer-term reoperation rate for corrections, 0.6% implant exchange rate, and no recurrent capsular contracture. CONCLUSIONS: This is the first study to provide data on outcomes of revisional breast augmentation surgery with PU implants. It shows that polyurethane implants offer consistent stability and have low rates of recurrent capsular contracture in revisional surgery.

Using an Elastomeric Skin Protectant to Manage Donor Site Wounds of Split-thickness Skin Grafts: A Case Series.

ABSTRACT: Split-thickness skin grafting (STSG) is a common surgical procedure to manage acute and chronic wounds. A plethora of dressings exists to treat STSG donor site wounds (DSWs). Recently, a new elastomeric skin protectant was adopted (Cavilon Advanced Skin Protectant; 3M) in the treatment of incontinence-associated dermatitis. In this report, the authors assess the effects of this elastomeric skin protectant as an alternative wound dressing for STSG donor sites.The authors report a single-center prospective case series that was performed to establish a treatment protocol. Nine consecutive patients with different indications for treatment with an STSG from May to September 2018 were included. Collected data included general patient information, comorbidities, complications, blood loss, pain during dressing change, and the duration of DSW healing.This case series showed promising results in terms of duration of DSW healing when applying the elastomeric skin protectant. The authors also observed less blood loss and less pain during dressing changes. No infections were seen during the trial.

Redefining the vascular anatomy of the medial gastrocnemius muscle: A computed tomography angiography study.

BACKGROUND: The medial gastrocnemius (GN) muscle flap is a historical reconstructive option in lower limb reconstruction. The flap is proximally based on the medial sural artery, and it is assumed not possible to harvest a distally based flap because of the absence of other minor pedicles. The aim of this study is to investigate the presence and the anatomy of a distal secondary pedicle given off by the posterior tibial artery (PTA). METHODS: A retrospective CTA study was performed of 120 limbs between April 2018 and June 2020. 3D reconstruction was performed to delineate the anatomy of the distal secondary pedicle, if present. The distance of the pedicle, if found, from the intermalleolar line to the patella was noted. The number of pedicles, if multiple, was documented, as well as branches to the soleus muscle and the skin. RESULTS: A distal pedicle to the gastrocnemius muscle was found in 64% of limbs. The average location from the intermalleolar line is 168 mm. The branching pattern from the PTA showed an isolated vessel going to the distal medial gastrocnemius (32.8%), two branches to the medial gastrocnemius and skin (39.3%), two branches to the medial gastrocnemius and soleus (24.6%), and three branches to the medial gastrocnemius, soleus, and the skin (3.3%). CONCLUSIONS: This study confirms the presence of the secondary axial distal pedicle of the GN muscle. Furthermore, this study confirms that there is a likely association between the distal medial gastrocnemius pedicle and the PTA skin perforators.

The monsplasty: Surgical and functional outcomes using an effective and reproducible surgical technique.

BACKGROUND: The available literature on monsplasty remains sparse and most of the reports are limited to the description of one surgical technique, with limited to no post-operative data. This study aims to describe a reproducible monsplasty surgical technique and to analyze the post-operative functional and esthetic outcomes. METHODS: Patients with at least grade 2 mons pubis ptosis were included in the study and observed for 3 months. Pre- versus post-operative analysis included body image, psychological function, sexual function, urinary function, hygiene maintenance of the pubic area, and post-operative complications. An additional retrospective analysis of a larger group of patients was also performed. RESULTS: Between April 2021 and January 2022, a total of 25 patients were included in the prospective study. They reported a significant improvement in body image (p < 0.001), satisfaction with the abdomen (p < 0.001), and sexual functioning (p = 0.009). Functionally, improvements were recorded with regard to visualization of the genitalia (36%), hygiene maintenance of the pubic area (32%), sex life (48%), genital sensitivity (24%), and urinary continence (4%). Patient satisfaction was very high. There were no major complications. The retrospective study included 80 patients between 2010 and 2021, with a mean follow-up time of 18 months. No major complications were noted. CONCLUSION: Monsplasty is a simple and fast procedure that can truly bring an added value to the patient's satisfaction and functional outcomes. It can be incorporated in both esthetic and reconstructive abdominoplasties and should be a standard component of the procedure for cases with mons ptosis grade 2 or higher. EVIDENCE BASED MEDICINE LEVEL: Level II.

A new oncoplastic technique with immediate nipple reconstruction for central breast tumors using Würinger's septum-based flap.

INTRODUCTION: Centrally located breast tumors represent a challenge for both oncological and reconstructive surgeons, mainly due to the necessity of nipple-areola complex (NAC) removal. We describe an original oncoplastic solution utilizing a displacement flap technique with immediate nipple reconstruction. METHODS: Since 2008, we developed an oncoplastic technique using a septum-based island flap for the reconstruction of central breast defects, including the NAC. This technique is based on the Würinger's septum which is centered around the intercostal perforators. A retrospective study was performed collecting data on patient characteristics, oncological features, and outcomes. Patient satisfaction was reported using a Likert scale. RESULTS: Reconstruction was successfully realized in 15 patients (14 immediate and one delayed post-lumpectomy correction). In immediate surgery, the excision margins were all free of tumor. Minor complications occurred in three patients; one small area of skin necrosis was managed by secondary intention, and two cases of partial nipple necrosis were treated by debridement under local anesthesia. Contralateral symmetrization surgery was performed on nine patients. Patient satisfaction scored high. CONCLUSION: In comparison with the previous oncoplastic techniques used for reconstructing central defects, the septum-based island flap has increased flexibility, provides better projection, and can be combined with immediate NAC reconstruction.

Schwannoma Arising from the Deep Motor Branch of the Ulnar Nerve - A Case Report and Review of Literature.

Schwannomas of the ulnar nerve in the hand are uncommon and those arising from the deep motor branch of the ulnar nerve (DMBUN) are rare. We were able to find only five reports of a schwannoma of the DMBUN. We report a schwannoma arising from DMBUN beyond the Guyon canal and summarise the literature on schwannomas involving the DMBUN. Level of Evidence: Level V (Therapeutic).

Anatomic study of the profunda artery perforators by multidetector CT scanner and clinical use of the banana-shaped flap design for breast reconstruction.

BACKGROUND: The profunda artery perforator (PAP) flap is a well-known free flap for breast reconstruction. However, a reproducible perforator mapping system has yet to be developed. METHODS: The PAP perforators were localized by CTA using a novel X-Y axis system. Flap dimensions were based on the CTA images and localized PAP-perforators. Perioperative findings and postoperative outcomes were analyzed. RESULTS: A total of 70 lower limbs and 180 PAP perforators were evaluated. An average of 2.78 ± 1.22 and 2.22 ± 0.96 perforators were seen, in the right and left legs, respectively, and were divided in five clusters (PAP1-PAP5) based on their location on the Y-axis. The course of the perforators was noted as well as the average diameter at the origin. The overall average diameter was 1.99 ± 0.86 mm. A banana-shaped PAP-flap was harvested in 10 patients. The mean operative time was 278 min, pedicle length 76 ± 12 mm, and mean flap weight 247 g. No major complications were seen. CONCLUSION: The PAP flap can be mapped by CTA in a reproducible way. The X and Y axes are based on fixed anatomic landmarks and may form the basis for a banana-shaped flap design of the PAP-flap.

Case Report of Two Patients With COVID-19 and Sacral Pressure Injuries Associated with Pyoderma Gangrenosum.

ABSTRACT: During the COVID-19 pandemic, an increasing number of patients have been admitted to the ICU with severe respiratory complications requiring prolonged supine positioning. Recently, many case reports have been published regarding dermatologic manifestations associated with COVID-19. However, there is little information about the clinical features of these manifestations. Pyoderma gangrenosum (PG) is an ulcerative noninfectious inflammatory disease of the skin. In at least 50% of the cases, the etiology is unknown. Nevertheless, PG is associated with many systemic diseases. In this article, the authors report two critically ill patients with COVID-19 who developed sacral ulcers during their recovery in the ICU. These ulcers had an atypical course and were exacerbated by surgical debridements. Accordingly, providers suspected PG, which was confirmed by the clinical evolution of the ulcers and biopsies taken from the wounds. To the best of the authors' knowledge, no previous articles have reported sacral pressure injuries associated with PG in patients with COVID-19. Providers should suspect PG in patients with COVID-19 who develop nonhealing pressure injuries.

The "ART" of facial filler injections: Avoid, recognize, and treat hyaluronic acid-induced complications.

BACKGROUND: Hyaluronic acid (HA) fillers are frequently used for cosmetic purposes as volumizers or as wrinkle fillers. One of the major advantages of hyaluronic acid use is the possibility to neutralize it by using hyaluronidase should complications occur. PATIENT: A case of a 21-year-old female patient is presented, in whom a hyaluronic acid injection-induced vascular occlusion was seen four days after the initial injection, with increasing pain and severe signs of ischemia. METHOD: Treatment consisted of an immediate hyaluronidase injection, supplemented with administration of acetylsalicylic acid, piracetam, low molecular weight heparin (LMWH), corticosteroids, analgesics, prophylactic antibiotics, application of topical nitroglycerin and warmth, smoking cessation, and hyperbaric oxygen therapy. RESULTS: The initial progress and evolution of the deformity with possible therapeutic options are being discussed. CONCLUSION: The "ART" (avoid, recognize, and treat) in handling filler complications is presented, as a new universal guideline for clinical aesthetic practitioners and injectors.

A pedicled split extended vertical deep inferior epigastric (s-vDIEP) flap and an adipo-dermal thigh local flap for the reconstruction of the medial thigh compartment after sarcoma resection: A case report.

Large upper medial thigh defects in prior irradiated tissue require challenging reconstructions. Several techniques have been reported to reconstruct this region and according to the literature, pedicled perforator flaps are the first reconstructive option. The anterolateral thigh flap is considered the gold standard, while surprisingly the pedicle deep inferior epigastric (DIEP) flap in vertical fashion has not been frequently employed, if compared with its muscular counterpart, the pedicle vertical rectus abdomins flap (vRAM). We report a case of a multilayered flaps reconstruction of the left medial thigh after an excision of a sarcoma involving the whole adductors compartment. A 75-year-old male patient underwent a free margins resection of the sarcoma. After the resection, a soft tissue defect of 24 cm × 14 cm × 14 cm spreading from the groin to the medial tuberosity of the tibia, was left. We performed a reconstructive technique based on a pedicled split extended vertical deep inferior epigastric (s-vDIEP) flap and an adipo-dermal thigh local flap in order to fill and cover the thigh defect. The s-vDIEP had 2 islands: a cranial de-epithelialized island to fill the dead space and a caudal for the skin closure. The postoperative follow-up was complicated by seroma formation and it was managed by sclerotherapy and at the 6 months follow-up the patient showed good cosmetic and functional outcomes with no sign of tumor relapse. Our result suggests that the proposed multilayered reconstruction may be employed for the restoration of large and deep upper medial thigh defects.

Lower medial thigh perforator (LMTP) propeller flap for reconstruction of soft tissue defects around the knee.

BACKGROUND: Skin and soft-tissue defects around the knee are common and their reconstruction is still challenging and argued. Thin, pliable and well-vascularized tissues are required in order to restore the aesthetic appearance of the knee and facilitate joint function. Historically local muscle flaps were employed for the upper third of the lower limb reconstruction; however, since their introduction, different perforator flaps have been proposed for this purpose. The aim of this report is to share our clinical experience with the pedicled lower medial thigh perforator (p-LMT) flap for the reconstruction of skin and soft tissue defects around the knee. PATIENTS AND METHODS: Between August 2013 and July 20, 2018, patients underwent pedicled LMT propeller flap reconstruction for defects around the knee. The subunits of the defects were the suprapatellar, the infrapatellar and patellar area and in two cases a full around the knee defect was reported. Cause of defects included trauma (13), tumor (4) and infection after knee operation (3) and defect sizes ranged from 4 × 3 cm2 to 7 × 8 cm2 . RESULTS: Flap sizes ranged from 4 × 9 cm2 to 6 × 16 cm2 . One to two perforators based on the superficial femoral artery or descending genicular artery were found between the septum of satorius and vastus medialis, or piercing the vastus medialis during dissection. All flaps were rotated 180° in propeller fashion. All the donor sites were primarily closed and no complication at the donor site was detected. In the two cases of the total knee soft tissue defect, a double pedicled flaps reconstruction was required. After a 6 months follow-up, all the patients in the series achieved a full range of motion. CONCLUSIONS: Fasciocutaneous flaps are currently the first reconstructive option for the soft tissue defects around the knee. The p-LMT flap reconstruction in this case series achieved good aesthetic and functional outcomes and this flap may be a valuable option for the reconstruction of the small to medium soft tissue defects around the knee.

Reconstruction of cranioplasty using the thoracodorsal artery perforator (TDAP) flap: A case series.

BACKGROUND: Complex defects resulting in ablation of the scalp, the calvaria, the dura, and the underlying brain are still challenging. These defects require cranioplasty to restore the bone cosmetic and functional roles and free-flap soft tissue reconstruction to prevent cranioplasty exposure and further infection. Different materials have been used in cranioplasty, while different free flaps have been proposed in those cases. In this article, we present a case series of cranioplasty reconstruction with thoracodorsal artery perforator flap (TDAP). PATIENTS AND METHODS: From April 2016 to January 2018, 5 patients underwent cranioplasty reconstruction using alloplastics and TDAP flap. Two patients underwent primary cranioplasty and 3 patients underwent secondary cranioplasty. The superficial temporal vessels were always dissected as recipient vessels. RESULTS: The flap sizes range from 40 to 80 cm2 (mean 57 cm2 ) and the maximum pedicle length was 12 cm (mean 10 cm). All the donor sites were closed primary with minimal morbidity. No postoperative complications were experienced. All the flaps provided stable coverage with an acceptable color match. The mean follow-up time was 4 months. CONCLUSIONS: Our data suggest that the TDAP may be employed in postcranioplasty reconstruction. The TDAP has more advantages compared to other flaps used in alloplastic reconstruction: a broad large surface, a long pedicle, and a thinner thickness.

Male breast cancer: Modified radical mastectomy or breast conservation surgery? A case report and review of the literature.

INTRODUCTION: Male breast cancer (MBC) is a rare disease that accounts for <1% of breast cancer cases. The most common treatment is modified radical mastectomy (MRM). Recently, breast conservative surgery (BCS) is getting popular for MBC treatment. We report a case and reviewed the literature to investigate whether emerging BCS can be considered as an alternative of a more radical surgery. PRESENTATION OF CASE: A 46 y.o. patient, presented with a painless left breast lump over a period of six months. The patient underwent a quadrantectomy at another institution. Pathology revealed an intraductal carcinoma in close proximity to the margins of excision. Adjuvant hormonal therapy was proposed to the patient, who refused and was referred to our Institution. We performed a MRM and a sentinel lymph node biopsy (SLNB). A contralateral breast liposuction and an adenectomy were also performed. The patient underwent also a nipple-areolar complex reconstruction. The patient didn't receive adjuvant therapy. DISCUSSION: Both oncological safety and satisfactory cosmetic outcomes are the goals of MBC treatment. No specific guidelines for MBC treatment have been proposed. MRM is currently the surgical gold standard of MBC (approximately 70% of all cases). Some authors reported that male BCS associated with radiation therapy is a feasible alternative MRM. Taking into account data from the literature and considering the previous surgery, in the case we report, we offered a MRM, SLNB and a contralateral breast symmetrization. CONCLUSION: MRM with SLNB and reconstruction of male breast asymmetry should be still considered as the treatment of choice of MBC.

A new mucosal propeller flap (deep lingual artery axial propeller): the renaissance of lingual flaps.

BACKGROUND: Lingual flaps provide ideal mucosal coverage for intraoral defects but traditionally require two surgical stages. The authors present an axial mucosal propeller flap for single-stage intraoral reconstruction. The flap includes the mucosa of the lateral side of the tongue, islanded on the deep lingual vessels. METHODS: Between 2011 and 2013, 23 patients underwent intraoral mucosal reconstruction with a deep lingual artery axial propeller flap after cancer resection in the cheek (n = 16), floor of the mouth (n = 2), retromolar trigone (n = 2), hard palate (n = 2), and soft palate (n = 1). Mean defect size was 19.5 cm. Preoperative and postoperative intraoral function was evaluated with the Functional Intraoral Glasgow Scale. RESULTS: The authors always achieved one-stage reconstruction with primary donor-site closure. The only complications were an infection treated conservatively and a late oronasal fistula caused by radiotherapy. All patients resumed an oral diet after 1 week and none required surgical revision. Mean 12-month postoperative Functional Intraoral Glasgow Scale score was better than the preoperative score (13.5 versus 12.8). CONCLUSIONS: The deep lingual artery axial propeller flap combines the advantages of the traditional lingual flap (i.e., reliable axial vascularization and like-with-like reconstruction) with those of a propeller flap (i.e., one-stage transfer of like tissue and extreme mobility) and has wider indications than a conventional lingual flap. The technique is fast and has low morbidity and good functional results, and the authors recommend it as a first-choice technique to reconstruct moderate to large intraoral defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Freestyle-like V-Y flaps of the eyebrow: a new outlook and indication of an historical technique.

The eyebrow region is of utmost importance for facial movement, symmetry, and the overall cosmetic appearance of the face. Trauma or tumor resection often leave scars that may dislocate the eyebrow producing an alteration both in static symmetry of the face and in the dynamic expressivity. The authors present a technique for eyebrow's defects repair using the remaining eyebrow advancement by means of a "freestyle-like" V-Y flap. In the past two years a total of eight consecutive patients underwent excision of skin lesions in the superciliary region and immediate reconstruction with this technique. On histology, six patients were affected from basal cell carcinomas, one from squamous cell carcinoma, and one from congenital intradermal melanocytic nevus. The pedicle of the flap included perforators from the supratrochlear, supraorbital, or superficial temporalis artery. Advancement of the entire aesthetic subunit that includes the eyebrow using a V-Y perforator flap was performed successfully in all cases achieving full, tension-free closure of defects up to 3.0 cm. "Freestyle-like" V-Y flaps should be considered as a first-line choice for partial defects of the eyebrow. The greater mobility compared to random subcutaneous flaps allows to reconstruct large defects providing an excellent cosmetic result.