A Retrospective Comparative Analysis of Latissimus Dorsi (LD) Flap Versus Thoracodorsal Artery Perforator (TDAP) Flap in Total Breast Reconstruction with Implants: A Pilot Study.

BACKGROUND: In breast surgery, an autologous flap combined with implant may reduce the risk or repair the soft-tissue defects in several cases. Traditionally, the preferred flap is the myocutaneous latissimus dorsi (LD) flap. In the perforator flap era, the evolution of LD flap is the thoracodorsal artery perforator (TDAP) flap. The aim of this study is the comparison between LD flap and TDAP flap with implants in terms of early complications and shoulder function. METHODS: We performed a retrospective cohort study in accordance with the STROBE guidelines. Between January 1 2015 and January 1 2020, 27 women underwent a unilateral total breast reconstruction with LD or TDAP flap combined with an implant at our institution. 15 women were operated with LD flap and 12 with TDAP flap. The most frequent indications for intervention were results of mastectomy and radiation-induced contracture. We evaluated several data in terms of clinical and demographical characteristics, operative and perioperative factors, and follow-up variables. We assessed shoulder function through the Disability of the Arm, Shoulder and Hand Questionnaire (DASH). RESULTS: The rate of complications was significantly lower in the TDAP group compared with the LD group (16.7% vs 60.0%, p = 0.047. Table 3). Although the small sample size limited further detailed statistical analyses, we particularly noticed no cases of donor site seroma in the TDAP group, as compared with four in the LD group. Patients in the TDAP group had an ∼11-point lower mean DASH score compared with the LD group (9.8 vs 20.5). This difference was statistically significant (p = 0.049). CONCLUSIONS: TDAP flap seems to be a reliable technique for soft-tissue coverage in total breast reconstruction with implants. In comparison with the traditional LD flap, it could be a more favorable option in terms of less complications and better quality of life.

Technological characterization of vaginal probiotic lactobacilli: resistance to osmotic stress and strains compatibility.

AIMS: The aim was to evaluate the osmotic stress resistance of vaginal beneficial probiotic strains, their growth kinetics and parameters when growing in salt-added culture media, and their compatibility to go further in the design of a probiotic formula for reconstitution of vaginal microbiome in women. METHODS AND RESULTS: The resistance to osmotic stress of the lactobacilli was evaluated by determining their growth in MRS (as control) added with NaCl (2-8%). The most resistant strains were Lactobacillus gasseri CRL1509, L. rhamnosus CRL1332 and L. reuteri CRL1327 selected by statistical approaches and growth parameters. Electron microscopy was applied to determine changes. They maintain probiotic properties and viability. Some strains showed incompatibility, then they cannot be included in multistrain formulas. CONCLUSIONS: The resistance to different salt concentrations in vaginal lactobacilli is strain-specific, because the behaviour is different in strains identified into the same species. The resistance is not related to the metabolic groups. SIGNIFICANCE AND IMPACT OF THE STUDY: The resistance and survival to extreme osmotic resistance is one of the specific requirements of beneficial bacteria after the technological processes for their inclusion in probiotic formulas, in a way to express their beneficial characteristics and exert the effect on the host.

Very Early Development and Recognition of Coronary Involvement in a Febrile Infant with Typical Signs of Kawasaki Disease.

Kawasaki disease (KD) is an acute, self-limited, inflammatory disease affecting medium-sized arteries and particularly the coronary arteries in about 25% of untreated cases. KD is a clinical diagnosis based on the presence of ≥5 days of fever and the presence of ≥4 of the 5 principal clinical criteria. We described, for the first time to our knowledge, a case of a very early development (on day 1) of typical KD with transient coronary involvement, diagnosed on day 2 of disease and treated with aspirin and steroids on day 3, with complete resolution of clinical signs and coronary involvement.

Soft-tissue defects of the Achilles tendon region: Management and reconstructive ladder. Review of the literature.

INTRODUCTION: Defects of the Achilles tendon region represent a challenge for reconstructive surgeons. Several options are available but there is still no reconstructive ladder for this specific and tricky area. An up-to-date reconstructive ladder according to local and general conditions is proposed based on our multicentre experience and an extensive review of the English literature on PubMed. MATERIALS AND METHODS: An extensive review of the English literature was performed on PubMed using the following key-words: "Achilles region", "heel", "soft-tissue reconstruction", "flaps", "grafts" and "dermal substitutes". RESULTS: A total of 69 complete papers were selected, covering the last thirty years' literature. Although most of the studies were based on limited case-series, local and general conditions were always reported. A comprehensive reconstructive ladder of all the available reconstructive techniques for the Achilles region has been created based on our personal multicentre experience and the results of the literature review. CONCLUSIONS: The reconstructive ladder is a concept that is still a mainstay in plastic surgery and guides decisions in the repair strategy for soft tissue defects. The optimal solution, according to the experience of the surgeon and the wishes of the patient, is the one that implies less sacrifice of the donor site. Perforator flaps should be the first-line option for small-to-moderate defects; the distally-based sural flap is the most reported for moderate-to-large defects of the Achilles region, and free flaps should be reserved mainly for complex and wide reconstructions.

Tibialis anterior muscle needle biopsy and sensitive biomolecular methods: a useful tool in myotonic dystrophy type 1.

Myotonic dystrophy type 1 (DM1) is a neuromuscular disorder caused by a CTG repeat expansion in 3'UTR of DMPK gene. This mutation causes accumulation of toxic RNA in nuclear foci leading to splicing misregulation of specific genes. In view of future clinical trials with antisense oligonucleotides in DM1 patients, it is important to set up sensitive and minimally-invasive tools to monitor the efficacy of treatments on skeletal muscle. A tibialis anterior (TA) muscle sample of about 60 mg was obtained from 5 DM1 patients and 5 healthy subjects through a needle biopsy. A fragment of about 40 mg was used for histological examination and a fragment of about 20 mg was used for biomolecular analysis. The TA fragments obtained with the minimally-invasive needle biopsy technique is enough to perform all the histopathological and biomolecular evaluations useful to monitor a clinical trial on DM1 patients.

A sneaky surgical emergency: Acute compartment syndrome. Retrospective analysis of 66 closed claims, medico-legal pitfalls and damages evaluation.

BACKGROUND: Acute compartment syndrome (ACS) is a clinical condition with potentially dramatic consequences, therefore, it is important to recognise and treat it early. Good management of ACS minimises or avoids the sequelae associated with a late diagnosis, and may also reduce the risk of malpractice claims. The aim of this article was to evaluate different errors ascribed to the surgeon and to identify how the damage was evaluated. MATERIALS AND METHODS: A total of 66 completed and closed ACS cases were selected. The following were analysed for each case: clinical management before and after diagnosis of ACS, imputed errors, professional fault, damage evaluation and quantification. Particular attention was paid to distinguishing between impairment because of primary injury and iatrogenic impairment. Statistical analyses were performed using Fisher's exact test and Pearson's correlation. RESULTS: The most common presenting symptom was pain. Delay in the diagnosis, and hence delay in decompression, was common in the study. A total of 48 out of 66 cases resolved with the verdict of iatrogenic damage, which varied from 12% to 75% of global capability of the person. A total of $394,780 out of $574,680 (average payment) derived from a medical error. CONCLUSIONS: ACS is a clinical emergency that requires continuous clinical surveillance from both medical and nursing staff. The related damage should be evaluated in two parts: damage deriving from the trauma, so that it is considered inevitable and independent from the surgeon's conduct, and damage deriving from a surgeon's error, which is eligible for an indemnity payment.

Posterior tibial artery perforator flaps for coverage of Achilles region defects.

BACKGROUND: Defects of the Achilles tendon region still represent a tricky issue in lower limb surgery. Among the several reconstructive possibilities, local propeller perforator flaps have gained popularity in the last decade. MATERIALS AND METHODS: We report our experience with eight patients affected by small-to-moderate soft-tissue defects of the Achilles tendon region, who underwent surgical reconstruction with local flaps based on posterior tibial perforator branches. RESULTS: All patients healed successfully in terms of aesthetic and functional aspect. In only one case a transient venous congestion was observed and this resolved spontaneously. CONCLUSIONS: Although the surgical technique requires much care and skill, including an extremely gentle dissection of perforator vessels, local propeller flaps should be considered the first-line choice for reconstruction in small-to-medium size soft-tissue defects in the Achilles region.

Surgical excision of Infantile Haemangiomas: a technical refinement to prevent bleeding complications.

PURPOSE: The aim of the study is to improve operative speed and precision of haemangiomas excision. CASE-REPORT: haemangioma is a common affection of the 8% of the population during the neonatal period. In complicated cases and involution sequelae surgical treatment is the first choice. The Authors propose a surgical refinement to prevent intraoperative bleeding. METHODS: several suture stitches were placed around the hemangioma. The edges of the lesion became more defined, thus allowing accurate excision. RESULTS AND CONCLUSIONS: Haemangiomas are characterized by rich blood supply. Surgery is often hindered by massive bleeding and Temporary placement of full-thickness sutures, surrounding the hemangioma, allowed a noticeable improvement in hemostasis precision and greater definition of the margins of the hemangioma.

Limb trauma: the use of an advanced wound care device in the treatment of full-thickness wounds.

This is an observational case series of 15 patients with full-thickness traumatic wound defects treated with a dermal substitute. There were 8 male and 7 female patients with a mean age of 36.6 years. Eight patients had trauma to the lower limbs and 7 were of the upper limbs, with the average lesion size 104.4 cm(2) (range 6-490 cm(2)). The time to complete healing had a mean average time of 26.8 days (range 16-60 days). All patients went on to successful repair with 6 patients requiring a second application of the substitute and 5 patients needing split thickness skin grafts. Infection was recorded in one patient.

A 'migrant' mass of the forehead: diagnosis and treatment.

BACKGROUND: Primary cutaneous large B-cell lymphoma, leg type, is a rare and aggressive neoplasm as defined by the World Health Organization/European Organisation for Research and Treatment of Cancer classification of cutaneous lymphomas. In some cases this disease may simulate other forms of benign or malignant solid tumours. MATERIAL: We present a case of a 74-year-old man showing a quickly 'migrant' mass on his forehead. First skin biopsy, ultrasound and magnetic resonance images were not significant. A deeper biopsy revealed a pathology consistent with a primary cutaneous diffuse large B-cell lymphoma leg type. RESULTS: The patient was successfully treated with only local radiotherapy (total dose: 32.4 Gy). At 1-year follow-up there were no recurrences. DISCUSSION: To the best of our knowledge, this is the second case of a primary cutaneous diffuse large B-cell lymphoma leg type developed as a quickly 'migrant' lesion. In contrast with the first report, our case developed in a non-leg site. From these two cases, we should bear in mind that aggressive and quickly migrant cutaneous or subcutaneous masses might mask a lymphomatous disease.

Failure by congestion of pedicled and free flaps for reconstruction of lower limbs after trauma: the role of negative-pressure wound therapy.

Lower limb reconstruction with pedicled or free flaps can be commonly compromised by venous insufficiency. This complication often leads to partial/complete flap necrosis and increases the risk of superinfection. Negative-pressure wound therapy (NPWT) is known to increase local blood flow, decrease edema, promote tissue granulation, and reduce the likelihood of soft tissue infection. This study aims to evaluate the effectiveness of NPWT in the treatment of congested pedicled and free flaps of the lower limb after reconstructions in lower limb traumas. A retrospective analysis was performed on four congested (pedicled and free) flaps on the lower limbs. NPWT was applied in all cases after partial flap debridement. NPWT was able to improve and resolve tissue edema and venous insufficiency, avoid further flap necrosis, and promote granulation. On NPWT removal, a split-thickness skin graft was applied on the wound, achieving complete and uneventful healing. NPWT is a useful instrument in managing flaps affected by venous insufficiency in lower limb reconstruction, although larger studies are necessary to better define the effectiveness and indications of NPWT in this setting.

Giant congenital melanocytic naevi: review of literature.

Giant congenital pigmented naevi is a great reconstructive challenge for the pediatric and plastic surgeons. Due to the increased risk of malignant transformation in such lesions, many procedures have been used to remove giant congenital naevi like dermoabrasion, laser treatment or surgical excision combined with reconstruction through skin expansion or skin grafting; among these, only a complete excision can offer an efficacious treatment. In our centre we use the "tissue expansion" technique in order to achieve a sufficient quantity of normal skin to perform a both staged and radical excision of these giant lesions.

Mammaplasties and medicolegal issues: 50 cases of litigation in aesthetic surgery of the breast.

BACKGROUND: Aesthetic surgery procedures are increasing all over the world, and so are related medicolegal questions and litigation cases. Aesthetic mammaplasties represent a very important part of this field and consequently many cases of error appear. Most of these errors lead to litigation from which plastic surgeons rarely can be exonerated. The aim of this article was to evaluate different errors ascribed to the plastic surgeon, the rate of cases in which professional responsibility has been identified, and the type of guilt imputed. METHODS: Each case is based on the evaluation of both documentation used by the judge and the relationships of two specialists involved in the assessment of the presumed error. In every case, problems complained about by the patient and the eventually related error of the surgeon were analyzed. Moreover, the eventual identification of professional responsibility, the quantified damage, and its possible reduction by another corrective operation were considered. RESULTS: The cases studied (N=50) were divided into 34 cases of augmentation mammaplasty, 11 cases of reduction mammaplasty, and 5 cases of mastopexy. Most of the problems complained about by patients were in the preoperative and intraoperative phases. In only 10% of the cases was the informed consent contested and an expected reduction of the damage was individuated in less than half of cases. CONCLUSIONS: The evaluation of aesthetic damage is a tricky question due to different aspects such as the psychological component or the frequent lack of adequate photographic documentation of the patient before the operation. Moreover, whenever possible reduction of the damage is proposed, the patient's willingness to undergo another operation, with all its related costs and benefits, must be considered.

Giant congenital nevi of the scalp and forehead treated by skin expansion.

Congenital giant melanocytic nevi of the scalp and forehead are rare lesions present at birth. These lesions are associated with risk of malignant transformation, but they primarily represent a psychological problem to both patient and parents and merit early excision and reconstruction. In this study we report our own experience: seven patients, aged 8 months to 9 years, with congenital pigmented nevi involving forehead and scalp, and a 4-year old patient with congenital pigmented nevus of periorbital region and nose were treated successfully with excision and expanded skin flap reconstructions. The mean expansion procedures were 2 (range, 1 to 3), with an average of 8,8 injections for each expansion procedure (range, 6 to 11). In only one patient simultaneous expanders were placed in the scalp and forehead. Follow-up ranged from 4 months to 15 years. We had no rupture, extrusion or infection of the skin expanders. Complications included eyebrow ptosis and asymmetry in two patients underwent correction at a final procedure. In our opinion tissue expansion is an excellent technique for the treatment of giant nevi of the scalp and forehead because it offers the best aesthetic and functional outcomes.

Birth-weight as a risk factor for cancer in adulthood: the stem cell perspective.

The 'stem cell burden' hypothesis represents a plausible explanation for the association between birth-weight and the risk of breast cancer in adulthood. The size of the overall stem cell pool would be expected to affect organ size and consequently birth-weight, making birth-weight a proxy for the overall number of fetal stem cells. As stem cells are self-renewing, the greater their number is at birth, the higher will be the chance that one of them will undergo carcinogenesis over the years. To investigate the correlation between birth-weight and stem cell burden, we examined the cord blood hematopoietic CD34+ stem cell population as an indicator of the overall fetal stem cell number. We measured both the CD34+ level (by flow cytometry) and the CD34+ proliferative potential (by the GM-CFU culture), in a sample of 1037 healthy newborn cord blood donors. We found that heavier babies had a significantly greater CD34+ stem cell concentration (p<0.001) and a higher GM-CFU number than lighter babies (p<0.001). Thus, a high birth-weight was positively associated with a high concentration of CD34+ stem cells and also with a qualitatively higher "stemness" of this pool. Therefore, our data support the theory that birth-weight reflects the number of fetal stem cells.

Increased frequency of immunoglobulin (Ig)A-secreting cells following Toll-like receptor (TLR)-9 engagement in patients with Kawasaki disease.

Kawasaki disease (KD) is an acute vasculitis affecting mainly infants and children. Human B cells express Toll-like receptor (TLR)-9, whose natural ligands are unmethylated cytosine-guanine dinucleotide (CpG) motifs characteristic of bacterial DNA. The aim of this study was to clarify the pathogenesis of KD analysing the activation status of peripheral blood mononuclear cells (PBMC), focusing on B lymphocyte activation and functions. Ten patients and 10 age-matched healthy donors were recruited from the Bambino Gesù Hospital of Rome, Italy and enrolled into this study. We determined phenotype profile and immunoglobulin (Ig) production of PBMC from KD patients and age-matched controls. We found that the frequency of CD19(+) B lymphocytes and CD19(+) /CD86(+) activated B lymphocytes from KD patients during the acute phase before therapy was increased significantly. Moreover, B lymphocytes of acute-phase KD patients were more prone to CpG oligodeoxynucleotide (ODN) activation compared with the age-matched controls, as assessed by a significant increase of the number of IgA-secreting cells (SC). In the same patients we found a marked increase of IgM, IgG, interleukin (IL)-6 and tumour necrosis factor (TNF)-α production compared with the control group. In addition, in two convalescent KD patients, conventional treatment with intravenous immunoglobulin (IVIG) restored the normal frequency of CD19(+) B cells, the number of IgA-, IgM- and IgG-SC and the production of IL-6 and TNF-α. Our findings indicate that the percentages of peripheral B lymphocytes of acute-phase KD patients are increased and are prone to bacterial activation in terms of increased numbers of IgA-SC and increased production of IL-6 and TNF-α inflammatory cytokines. Thus, our data support the hypothesis of an infectious triggering in KD.

The pollicization of the index finger in the aplasia of the thumb.

UNLABELLED: We have examined 11 patients with aplasia of the thumb and we have treated by pollicization of the index finger. We have conducted a follow up of 5 years. The total absence of the thumb may be an isolated anomaly, but it is often associated with some other congenital malformation. The absent thumb is as an autosomal dominant pathology or may be sporadic. It is frequently observed in the Holt-Oram syndrome, Fanconi's anemia, and ring D chromosome abnormalities. It is occasionally observed in the Rothmund syndrome, trisomy, thalidomide embryopathology and other congenital syndromes. An absent radius is almost always associated with an absent thumb, except in thrombocytopenia radial aplasia (Fanconi's syndrome), where the thumb is present even when the radius is absent. The treatment in most cases of the absent thumb is to perform a pollicization of the index finger. Our isolated congenital absence of the thumb patients have been treated with pollicization as described by Buck-Gramcko works well. It is a beautiful operation for the congenitally deformed, aplastic, or missing thumb. Pollicization of the index finger gives good functional and cosmetic results which are maintained. CONCLUSIONS: The total absence of the thumb in the congenitally pathology gives the hand of the patient insufficient in the functional movement and no cosmetic. So the pollicization with the second index fined gives a good reconstruction for the neo-thumb. In our five years follow-up, the 11 young patients that were treated with the pollicization, they are satisfy and use the neo-thumb like normal thumb. In congenitally absent thumbs clearly support the fact that the pollicized digit is used by most patients and is not ignored or bypassed.

Second toe transplantation to reconstruct digits.

In congenital absence of fingers or in post-traumatic amputations of the thumb or fingers, reconstruction by microsurgical toe-to-hand transfer is becoming a common treatment for these difficult problems. In case of congenital absence of the thumb, fingers, or both, these transfers can provide acceptable growth, function and sensation of the transferred toes with a current success rate usually greater than 95%. The most commonly transplanted toe is the second toe, since it is the longest toe and combines all the useful characteristics of a finger (such as joint, a nail, sensitive pulp tissue, and the ability to growth) with a good reliable blood supply. In this article, we discuss the rationale for this treatment approach, by considering the indications to treatment, the patient's preoperatory assessment, and the long-term results. We also report a case of a 4-year-old female child, suffering from congenital partial absence of second finger of the left hand, who underwent reconstruction by transfer of the second toes of foot.