Aesthetic Surgery Tourism: An Opportunity or a Danger?

BACKGROUND: Medical and surgical tourism is a rapidly growing phenomenon in post-pandemic Europe. The exodus of patients abroad to perform surgery, especially cosmetic treatments, is spreading recently in industrialized countries. In the social media era, the ease of access to advertising about surgical procedures and their costs favors traveling. However, the information given is not always punctual, and there is often a lack of patient awareness about the risks related to the procedures. METHODS: The objective of the manuscript is to investigate, through clinical examples, the path that a patient operated on in a non-European country must face once he returns home. From the availability and translation of clinical documentation to the problems encountered in revision surgeries. RESULTS: Thirteen cases of surgical tourism, patients who presented to our department with surgical complications, are investigated. Adverse events occurring during medical treatment abroad raised medico-legal and appropriateness issues, as well as concerns regarding the follow-up of patients. CONCLUSIONS: The current literature confirmed the high complication rate: It affects individual patients and the native country's healthcare systems. Therefore, patients must learn more about the dangers of traveling abroad for surgery. Education initiatives in the patient's home country might help achieve this. 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 .

Silver nanoparticle dressing: The knowledge of advantages and limits improves the indications in clinical practice.

Silver nanoparticle dressings have gained popularity recently as a way to treat challenging wounds. Notwithstanding the properties of Ag-NPS (silver nanoparticles) described by several articles, there is a lack of clinical studies that guide healthcare professionals to specific and conscious use. In this case series, Ag-NPS dressing was tested on a randomized group of 10 patients with complex wounds requiring conservative treatment. Each case was analysed, recording the patient's history, the peculiar characteristics and the progressive changes in the wound. The wound bed and the quality of the peri-wound skin improved and a decrease in signs of infection was observed. The application of the dressing was simple and comfortable for the patient and it was appreciated for its sealing ability. A few capacity restrictions showed up: those should be read as elements to improve the indications for this peculiar dressing. The thin tissue matrix of the Ag-NPS dressing does not allow for massive absorption and also performs poorly in reducing little exudate. The reduction in wound width is also limited: reconstructive surgery was required in half of the enrolled patients to achieve wound healing.

The Effect of Adjuvant Radiotherapy on One- and Two-Stage Prosthetic Breast Reconstruction and on Autologous Reconstruction: A Multicenter Italian Study among 18 Senonetwork Breast Centres.

Purpose: In modern breast cancer treatment, a growing role has been observed for breast reconstruction together with an increase in clinical indications for postmastectomy radiotherapy (PMRT). Choosing the optimum type of reconstructive technique is a clinical challenge. We therefore conducted a national multicenter study to analyze the impact of PMRT on breast reconstruction. Methods: We conducted a retrospective case-control multicenter study on women undergoing breast reconstruction. Data were collected from 18 Italian Breast Centres and stored in a cumulative database which included the following: autologous reconstruction, direct-to-implant (DTI), and tissue expander/immediate (TE/I). For all patients, we described complications and surgical endpoints to complications such as reconstruction failure, explant, change in type of reconstruction, and reintervention. Results: From 2001 to April 2020, 3116 patients were evaluated. The risk for any complication was significantly increased in patients receiving PMRT (aOR, 1.73; 95% CI, 1.33-2.24; p < 0.001). PMRT was associated with a significant increase in the risk of capsular contracture in the DTI and TE/I groups (aOR, 2.24; 95% CI, 1.57-3.20; p < 0.001). Comparing type of procedures, the risk of failure (aOR, 1.82; 95% CI, 1.06-3.12, p=0.030), explant (aOR, 3.34; 95% CI, 3.85-7.83, p < 0.001), and severe complications (aOR, 2.54; 95% CI, 1.88-3.43, p < 0.001) were significantly higher in the group undergoing DTI reconstruction as compared to TE/I reconstruction. Conclusion: Our study confirms that autologous reconstruction is the procedure least impacted by PMRT, while DTI appears to be the most impacted by PMRT, when compared with TE/I which shows a lower rate of explant and reconstruction failure. The trial is registered with NCT04783818, and the date of registration is 1 March, 2021, retrospectively registered.

Mutable Collagenous Tissue Isolated from Echinoderms Leads to the Production of a Dermal Template That Is Biocompatible and Effective for Wound Healing in Rats.

The mutable collagenous tissue (MCT) of echinoderms possesses biological peculiarities that facilitate native collagen extraction and employment for biomedical applications such as regenerative purposes for the treatment of skin wounds. Strategies for skin regeneration have been developed and dermal substitutes have been used to cover the lesion to facilitate cell proliferation, although very little is known about the application of novel matrix obtained from marine collagen. From food waste we isolated eco-friendly collagen, naturally enriched with glycosaminoglycans, to produce an innovative marine-derived biomaterial assembled as a novel bi-layered skin substitute (Marine Collagen Dermal Template or MCDT). The present work carried out a preliminary experimental in vivo comparative analysis between the MCDT and Integra, one of the most widely used dermal templates for wound management, in a rat model of full-thickness skin wounds. Clinical, histological, and molecular evaluations showed that the MCDT might be a valuable tool in promoting and supporting skin wound healing: it is biocompatible, as no adverse reactions were observed, along with stimulating angiogenesis and the deposition of mature collagen. Therefore, the two dermal templates used in this study displayed similar biocompatibility and outcome with focus on full-thickness skin wounds, although a peculiar cellular behavior involving the angiogenesis process was observed for the MCDT.

Litigation Cases After Post-Bariatric Surgery: Lesson from the Past.

BACKGROUND: Due to the high demand of post-bariatric surgeries, the number of litigation cases is rapidly growing. Even if surgical mistakes still represent one of the main causes of medico-legal issues, many disputes depend on what happens in the post-operative course. In this article we analyzed the litigation cases that occurred in our Plastic Surgery Department, the current literature about medico-legal disputes and the importance of the doctor-patient relationship. PATIENTS AND METHODS: The medical records of 788 post-bariatric surgeries, the post-operative complications and the related litigation cases from January 2015 to December 2019 were collected, analyzed and compared. RESULTS: We performed 380 abdominoplasties, 28 torsoplasties, 65 breast reductions, 99 mastopexies, 94 brachioplasties, 52 thighplasties, 65 liposuctions and 5 facelifts between 2015 and 2019. Eight patients complained of medical issues and claimed for litigation. Despite in all cases the judges highlighted the risk of consent misinterpretation, the payout was granted only in one case. CONCLUSION: Post-bariatric patients often mistake their preoperative condition and consider body contouring procedures as an aesthetic surgery treatment. Patients should be therefore clearly informed about the complexity of body contouring procedures after massive weight loss, which should never be compared to aesthetic surgery. Surgeons should always promote the communication with their patients and build a strong and trustworthy relationship. This attitude will allow to deal more easily with complications and, in the worst situations, with medico-legal litigations. 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 .

Safety of autologous fat grafting in breast cancer: a multicenter Italian study among 17 senonetwork breast units autologous fat grafting safety: a multicenter Italian retrospective study.

BACKGROUND: Autologous fat grafting (AFG), defined as the re-implant to the breast of fat tissue from different body areas, has been firstly applied to esthetic plastic surgery and then has moved to reconstructive surgery, mainly used for scar correction and opposite breast altering. Nevertheless, due to the potentially unsafe stem-like properties of adipocytes at the tumoral bed level, no clear evidence of the procedure's oncological safety has been clearly documented at present. PATIENTS AND METHODS: We retrospectively collected data of early breast cancer (BC) patients from 17 Italian Breast Units and assessed differences in terms of locoregional recurrence rate (LRR) and locoregional recurrence-free survival (LRFS) between patients who underwent AFG and patients who did not. Differences were analyzed in the entire cohort of invasive tumors and in different subgroups, according to prognostic biological subtypes. RESULTS: With a median follow-up time of 60 months, LRR was 5.3% (n = 71) in the matched population, 3.9% (n = 18) in the AFG group, and 6.1% (n = 53) in the non-AFG group, suggesting non-inferiority of AFG (p = 0.084). Building Kaplan-Meier curves confirmed non-inferiority of the AFG procedure for LRFS (aHR 0.73, 95% CI 0.41-1.30, p = 0.291). The same effect, in terms of LRFS, was also documented among different biological subtypes (luminal-like group, aHR 0.76, 95% CI 0.34-1.68, p = 0.493; HER2 enriched-like, aHR 0.89, 95% CI 0.19-4.22, p = 0.882; and TNBC, aHR 0.61, 95% CI 0.12-2.98, p = 0.543). CONCLUSIONS: Our study confirms in a very large, multicenter cohort of early BC patients that, aside the well-known benefits on the esthetic result, AFG do not interfere negatively with cancer prognosis.

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.

Complete Implant Wrapping with Porcine-Derived Acellular Dermal Matrix for the Treatment of Capsular Contracture in Breast Reconstruction: A Case-Control Study.

BACKGROUND: Capsular contracture (CC) represents one of the most common complications in breast reconstruction surgery, impairing final result and patients' well-being. The role of acellular dermal matrixes (ADM) has been widely described for the treatment and prevention of contracture. The aim of the study was to evaluate the efficacy and safety of complete implant coverage with porcine-derived ADM in preventing CC limiting complications. In addition, patients' reported outcomes were evaluated in order to define the role of ADM in improving sexual, physical and psychosocial well-being and satisfaction. METHODS: 42 patients who underwent surgical treatment of 46 contracted reconstructed breasts from May 2018th to May 2019th were collected in the two groups (ADM group vs. Control group). RESULTS: The ADM group showed lower rate of CC recurrence and a higher rate of implant losses and minor complications. A significant difference was observed in red breast syndrome (27.3% in the ADM group vs. absent in control the group) and skin ulceration rates (18.2% in the ADM group vs. 4.18% in the control group). As for patients' perceived outcomes, the ADM group showed a statistically significant higher postoperative Satisfaction of Breast Scale score compared to the control group. In addition, a significant difference was observed in the improvement of Physical Well-Being of the Chest Scale and the Satisfaction of Breast Scale after surgery, in favor to the ADM group. CONCLUSION: Complete implant coverage with ADM may reduce the risk of CC recurrence in breast reconstruction. An accurate patient selection allows minimizing complications improving patient well-being and satisfaction. 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 .

The Cyberball task in people after obesity surgery: preliminary evaluation of cognitive effects of social inclusion and exclusion with a laboratory task.

BACKGROUND: Social cognition and temperamental and interpretative styles could play a role in the outcome of bariatric surgery. This study aims to assess preliminary evidence about how obesity surgery patients evaluate social inclusion and exclusion through a ball-tossing game called Cyberball, looking at the influence of early maladaptive schemas. METHODS: Thirty-four patients with a history of obesity surgery interventions and 44 controls were recruited for this study. A psychological evaluation was performed before and after the Cyberball task with self-report questionnaires. RESULTS: In the ostracism condition, significant differences were seen across all the patients' fundamental psychological needs with less perceived ostracization (p = 0.001) even if they recognized less interaction via fewer ball tosses than controls. Moreover, the ostracism paradigm resulted in patients experiencing a higher urge to binge (p = 0.010) and a higher urge to restrain (p = 0.012) than controls. Looking at differences due to the Cyberball paradigm applied, clear differences emerged only between controls subgroups at the specific self-report scales applied, corroborating the reduced perception of the exclusion. As evidenced by the schema domains, the study found a connection between the impaired limits-schema domain and the drive to binge. CONCLUSION: The results show that obesity surgery patients reported different effects of the Cyberball task than controls. Different possible interpretations are discussed, and future directions for studies are exposed, both for the evaluation of social interactions effects and in the assessment of the role of specific cognitive schemas. LEVEL OF EVIDENCE: Level III: evidence obtained from well-designed cohort or case-control analytic studies.

Publisher Correction: Reprogramming normal cells into tumour precursors requires ECM stiffness and oncogene-mediated changes of cell mechanical properties.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Reprogramming normal cells into tumour precursors requires ECM stiffness and oncogene-mediated changes of cell mechanical properties.

Defining the interplay between the genetic events and microenvironmental contexts necessary to initiate tumorigenesis in normal cells is a central endeavour in cancer biology. We found that receptor tyrosine kinase (RTK)-Ras oncogenes reprogram normal, freshly explanted primary mouse and human cells into tumour precursors, in a process requiring increased force transmission between oncogene-expressing cells and their surrounding extracellular matrix. Microenvironments approximating the normal softness of healthy tissues, or blunting cellular mechanotransduction, prevent oncogene-mediated cell reprogramming and tumour emergence. However, RTK-Ras oncogenes empower a disproportional cellular response to the mechanical properties of the cell's environment, such that when cells experience even subtle supra-physiological extracellular-matrix rigidity they are converted into tumour-initiating cells. These regulations rely on YAP/TAZ mechanotransduction, and YAP/TAZ target genes account for a large fraction of the transcriptional responses downstream of oncogenic signalling. This work lays the groundwork for exploiting oncogenic mechanosignalling as a vulnerability at the onset of tumorigenesis, including tumour prevention strategies.

Correction: Spatiotemporal distribution and speciation of silver nanoparticles in the healing wound.

Correction for 'Spatiotemporal distribution and speciation of silver nanoparticles in the healing wound' by Marco Roman et al., Analyst, 2020, 145, 6456-6469, DOI: 10.1039/D0AN00607F.

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.

Spatiotemporal distribution and speciation of silver nanoparticles in the healing wound.

The medical application of nanomaterials is growing fast. Amongst the most widely used, silver nanoparticles are antimicrobial agents whose key application is the care of burns and chronic wounds. Still, their absorption, distribution, metabolism and excretion behaviour in vivo has not yet been systematically investigated. We collected full-profile specimens of skin from four hospital patients with mid-to-deep thickness burns or equivalent skin wounds, treated with dressings containing silver nanoparticles or silver sulfadiazine. Synchrotron radiation µXRF/µXANES and laser ablation-ICP-MS were used to provide the first semi-quantitative/high resolution direct information on the spatiotemporal distribution and speciation of silver in vivo. The metal was rapidly released onto the wound surface, followed by a significant structure-dependent penetration into the damaged tissues. This was accompanied by sequential processes of metallic silver dissolution, chloride complexation, change to metal-thiol protein complexes, and final mobilization into deeper skin layers towards the vascular networks. Complete local clearance of silver was observed after 12 days of treatment in the case of full healing. The results provide a complete insight into the dynamics of silver in real human wounds, and a new basis for the design of innovative silver nanomaterials with optimal antibacterial efficacy and minimized risk for the patient.

32 Years of Ultrasonic-Assisted Lipoplasty (U.A.L.): From Aesthetic to Obesity.

In this article, we tried to take stock of the state of the art in ultrasonic-assisted lipoplasty focusing on its most recent technologic advances and in the newest clinical applications, such as overweight, obesity, breast surgery and regenerative medicine. Great space was devoted to the analysis and clarification of the most common myths and legends related to this intriguing technique.

White Adipose Tissue Expansion in Multiple Symmetric Lipomatosis Is Associated with Upregulation of CK2, AKT and ERK1/2.

Multiple symmetric lipomatosis (MSL) is a rare disorder characterized by overgrowing lipomatous tissue (LT) in the subcutaneous adipose tissue (SAT). What LT is and how it expands are not completely understood; previous data suggested that it could derive from brown AT precursors. In six MSL type I patients, we compared LT morphology by histological and immunohistochemistry (IHC) analysis, gene expression, by qPCR, kinase activity, by Western Blot and in vitro assay to paired-control SAT using AT from patients with pheochromocytoma as a human browning reference. In the stromal vascular fraction (SVF), we quantified adipose stem cells (ASCs) by flow cytometry, the proliferation rate, white and beige adipogenic potential and clonogenicity and adipogenicity by a limiting dilution assay. LT displayed white AT morphology and expression pattern and did not show increased levels of the brown-specific marker UCP1. In LT, we evidenced AKT, CK2 and ERK1/2 hyperactivation. LT-SVF contained increased ASCs, proliferated faster, sprouted clones and differentiated into adipocytes better than the control, displaying enhanced white adipogenic potential but not increased browning compared to SAT. In conclusion, LT is a white AT depot expanding by hyperplasia through increased stemness and enhanced white adipogenesis upregulating AKT, CK2 and ERK1/2, which could represent new targets to counteract MSL.

Dermatofibrosarcoma Protuberans on Tattooed Skin: A Case Report.

Dermatofibrosarcoma protuberans is an uncommon indolent fibroblastic skin tumor with a tendency for local recurrence. Its etiology is unknown, but there may be a link with vaccination sites, burn scars, and previous skin traumas. This report describes a curious case of dermatofibrosarcoma protuberans occurring secondary to a 16-year-old tattoo.