Giant thigh lipomas: from a case report to a guide for the surgical approach.

The issue of international migration and health has received increased attention since its rise due to empirical studies on the immigrant paradox. Less examined has been research focused on countries in the Global South with growing immigrant population share and contentious debates on implications. Using data from the longitudinal National Income Dynamics Study (NIDS) (2008-2017) and panel logistic regression this study focused on evaluating whether reported physical health, mental health, and life satisfaction are all associated with immigrant status in South Africa. Accounting for several sociodemographic factors, results emanating from analysis showed no significant evidence of association between overall immigration status and self-reported health or life satisfaction. This however did not apply to depression as immigrants were found to be significantly less likely to report depressive level scores. Interestingly, preference to migrate was also found to be significantly associated with depression, and life satisfaction. Further evaluation amongst racial groups showed that African immigrants are also significantly more likely to report better health than non-immigrant counterparts. This study argues for the need of contextualisation of the immigrant paradox as evidence thereof varies dependent on specific outcomes and communities. The importance of other associated social determinants of wellbeing is also highlighted since gender, race, age, class, education, relationship status, location, and behavioural factors were found to be significantly associated with wellbeing. Policies should thus be aimed at reducing structural inequalities in broad whilst also introducing social programmes that reduce behavioural or lifestyle activities that have negative implications on wellbeing.

Combined Double-breasted Full-thickness Abdominal Flap Plication and Acellular Dermal Matrix in Prune-belly Syndrome Reconstruction.

Background: Reconstruction of the abdominal wall in patients with prune-belly syndrome (PBS) following previous intra-abdominal procedures is a challenging problem with a high incidence of revision due to persistent bulging or herniation. The abdominal wall flaccidity not only produces a severe psychological and aesthetic discomfort for the patient but often determines functional disabilities, including inability to cough properly, impaired bowel and bladder function, and delay in posture and balance. Methods: The authors describe three cases of reconstruction of abdominal wall using a modified double-breasted abdominoplasty fascial plication with additional acellular dermal matrix interposition and review the literature for innovations in the use of abdominal repair for reconstruction of these difficult cases. Results: Three children with PBS at a mean age of 7.3 years achieved successful reconstruction of the abdominal wall, using the modified double-breasted abdominoplasty fascial plication with acellular dermal matrix interposition. Patients underwent previous procedures, including orchiopexy in two patients and bilateral nephrectomy in one patient. No postoperative complications have been found, apart from superficial skin dehiscence along the abdominal incision treated conservatively in one child. At mean follow-up of 42 months (range 28-56 months), no patient presented incisional hernia, persistent or recurrent fascial laxity with abdominal bulging. All patients achieved significant aesthetic and functional improvements, including children's ability to cough, spontaneous gain of abdominal tonus, balance, and ambulation. Conclusion: Modification of the original vertical, two-layer plications of the deficient abdominal interposing biological mesh has the purpose of improving strength, aesthetics, and function of the abdominal wall in pediatric patients with PBS.

The Overwhelming Postsplenectomy Sepsis: Role of Plastic Surgeon.

The overwhelming post-splenectomy infection (OPSI) is a feared late complication of splenectomy, with high morbidity and a mortality rate of up to 50%. Although the management of this syndrome is the duty of clinical physicians, the interest of plastic surgeons in OPSI is related to the injury that can occur in tissues with an end circulation, such as the limb extremities, nasal tip, and lips. In the management of OPSI, surgical techniques are not highlighted. The role of the plastic surgeon can be fundamental for the prevention of further extension of the necrotic tissue, improving as much as possible the vascularization around it. Moreover, a critical role in the management of OPSI is avoiding superinfection of the necrotic areas by combining different techniques and methods, such as surgical debridements, negative pressure wound therapy, and conservative treatment. Last but not least, functional and aesthetic restoration of the injured parts is of paramount importance for the final outcome. In this article, we describe the management of two unvaccinated patients with necrosis of the extremities after OPSI.

Microsurgical training in vein anastomoses: the use of systemic heparin in a rat model.

OBJECTIVE: To investigate whether the use of systemic heparin could be useful for vein microvascular anastomoses in microsurgical training on rats. DESIGN: Femoral end-to-end venous anastomoses were performed on both thighs of 40 wistar rats by two microsurgery trainees from October 2018 to February 2019 (80 anastomoses in total). We divided the rats into 2 groups of 20 specimens (40 femoral end-to-end anastomoses) each: group A received no heparin administration; group B received subcutaneous systemic heparin administration before starting dissection. We compared both vein patency after the procedures. RESULTS: Patency tests showed no difference between the two groups after 5 minutes. At the delayed test after 120 minutes, vein patency was significantly better in the systemic heparin group (85,0% vs 55,0%). Even though both trainees judged practicing on both groups very instructive, they found useful performing anastomoses when heparin was administrated. CONCLUSION: We suggest including the use of systemic heparin in microsurgery training programs, especially for the beginners. Systemic heparin administration in rat models is educative for trainees.

A functional "metacarpal-hand" after a firework injury obtained without any flap or toe-transfer.

A 37-year old male patient with a right-hand firework injury. An extreme hand reconstruction was performed. The second and third rays were sacrificed enlarging the first space. The diaphysis of the second metacarpal bone became a tubular graft to reconstruct the fourth metacarpal. The thumb consisted only in the first metacarpal bone. The result was satisfactory, according to the wishes and needs of the patient, a three-finger hand with an opposable thumb, obtained in only one surgical treatment and without using free flaps. The concept of an "acceptable hand" is related to the surgeon's and patient's opinions.

Efficacy of Vascularized Submental Lymph Node Transfer with Decongestive Therapy and Antibiotics for Early-Stage Lower Limb Filarial Lymphedema.

BACKGROUND: Filarial lymphedema (FLE) is the most common cause of secondary lymphedema, with endemic prevalence in developing countries. FLE traditionally has been managed with antibiotics and decongestive therapy (DCT) in the early stage or excisional surgery at the late stage. Results of vascularized lymph node transfer (VLNT) in postoncologic lymphedema have been encouraging, and VLNT is a widely accepted surgical treatment. The authors advocate that the combined treatment of antibiotics, DCT, and vascularized submental lymph node (VSLN) transfer could produce objective and subjective improvement of early-stage lower limb FLE. METHODS: Between January of 2019 and January of 2020, patients with early-stage lower-limb FLE who underwent VLNT were retrospectively reviewed. VLNT was harvested from the submental region in all patients. Outcomes were assessed using volume improvement, frequency of cellulitis, and lymphoscintigraphy, along with subjective scoring questionnaire. RESULTS: Three men and one woman with an average age of 27 years (range, 25 to 29 years) were included. Two patients presented bilateral lymphedema. One patient was lost at 3-month follow-up and not included in the analysis. Patients showed an initial decrease in circumferential measurements after antibiotics and DCT of 2074 ± 471 cc (39% ± 9%). At a mean follow-up of 12.3 ± 6.2 months, further improvement of limb volume of 2389 ± 576 cc (45% ± 10%) was achieved following VSLN transfer. Lymphoscintigraphy demonstrated dye uptake by the VLNT with reduced dermal backflow and none of the patients had episodes of postoperative cellulitis. Patients reported excellent outcome on subjective scoring (average score, 9 ± 1) and returned to their daily activities without wearing compression garments. CONCLUSION: The authors' early experience showed that VSLN transfer may represent an effective treatment option in the multimodal approach to early-stage lower limb FLE.

Secondary Autologous Fat Grafting for the Treatment of Chin Necrosis as a Consequence of Prone Position in COVID-19 Patients.

Due to the spread of the coronavirus disease 2019 pandemic, an increasing number of ill patients have been admitted to intensive care unit requiring mechanical ventilation. Although prone positioning is considered beneficial, long periods in this position may induce important complications, including pressure ulcers in high-risk and uncommon body areas. We report five cases of pressure ulcer necrosis of the chin in coronavirus disease 2019 patients as a consequence of mechanical ventilation in prone positioning using autologous fat grafting (AFG) as a secondary technique. A series of five patients with secondarily-healed chin necrosis treated by AFG between February and June 2020 were reviewed. All patients had been treated initially with surgical debridement followed by conservative treatment. Secondary AFG was performed to reduce patient's pain, improve chin contour-projection, and minimize cosmetic sequelae and scarring. Patient satisfaction was assessed using a five-point Likert scale (0-4). Vancouver scale was used to evaluate the chin scars clinically. The average amount of fat injected into the chin area was 8.1 ± 2.0 ml. At 6-month follow-up, all patients were mostly satisfied (average Likert-scale 3.2 ± 0.4). Based on the Vancouver scale, improvement of the chin scar from 9.5 ± 0.8 to 4.7 ± 0.8 was found. We report a positive experience with secondary AFG for correction of painful and unaesthetic scarring and contour abnormality following surgical debridement and secondary-intention healing of chin pressure ulcers.

Open release of stiff wrist: a medium to long term case series and literature review.

BACKGROUND AND AIM OF THE WORK: The authors reported a personal case series of open release of stiff wrists performed after previous internal osteosynthesis of distal radius fractures. METHODS: From a series of 16 patients operated by a single surgeon, 12 were evaluated at a mean 7.1 years follow-up (range 2.25 to 19 years), while 4 were lost at follow-up. The ROM in flexion-extension achieved at the final control was measured with a goniometer and compared to that recorded before surgery. The PRWHE questionnaire was administred at the last follow-up. RESULTS: The mean flexion improved from 25.5° to 42.3° and the extension from 15.75° to 43°. The mean PRWHE value was 32.9. CONCLUSIONS: Although arthroscopic release is increasingly used in clinical practice for its minimal invasinevess and warranty of fast recovery, open arthrolysis in post-traumatic stiff wrists appears to be an effective procedure, adaptable to all types of stiffness, that lets get good long lasting functional results.

Early venous congestion after diep flap breast reconstruction: case report of a successful management.

BACKGROUND AND AIM: More than 250 000 women estimated to be diagnosed with breast cancer in the USA every year. Mastectomy is primary treatment for more than a third of those with early-stage disease. Most of the patients undergoing mastectomy receive breast reconstruction. A number of. Surgical techniques have been described to reconstruct the breast. With autologous tissue breast reconstruction, the plastic surgeon uses patient's own tissues, taken from a different part of the body where there is an excess of fat and skin. Deep inferior epigastric perforator (DIEP) flap is the autologous breast reconstruction technique of choice in our department due to long lasting results, low donor site morbidity and positive patient reported outcomes have been described.   Case Report: We present the case of a 42-year-old woman who underwent neoadjuvant chemotherapy followed by left breast simple mastectomy, axillary lymph-nodes dissection and later adjuvant radiation therapy (RT). After conclusion of RT a DIEP flap breast reconstruction was performed. Nine-hours after the operation, signs of acute venous congestion were noted. The venous congestion was treated by a combined surgical and medical approach based on pedicle discharge and ICU resuscitation protocol. After take back surgery, the patient was tightly monitored in the intensive care unit where intravenous heparin infusion and leech therapy were performed for 2 days. Flap congestion resolved completely, and the patient was discharged.   Conclusions: Venous congestion is very difficult to treat due to its potential multifactorial nature. The most important step is to recognize this kind of emergency because irreversible microvascular damages will develop in 6-8 hours. Because of multiple causes of venous congestion a timely multidisciplinary approach is mandatory, to maximize flap salvage and success rates.

Photobiomodulation Therapy: A New Light in the Treatment of Systemic Sclerosis Skin Ulcers.

INTRODUCTION: Skin ulcers (SU) represent one of the most frequent manifestations of systemic sclerosis (SSc), occurring in almost 50% of scleroderma patients. SSc-SU are often particularly difficult to treat with conventional systemic and local therapies. In this study, a preliminary evaluation of the role and effectiveness of blue light photobiomodulation (PBM) therapy with EmoLED® in the treatment of scleroderma skin ulcers (SSc-SU) was performed. METHODS: We retrospectively analyzed 12 consecutive SSc patients with a total of 15 SU on finger hands. All patients were treated with adequate systemic therapy and local treatment for SU; after a standard skin ulcer bed preparation with debridement of all lesions, EmoLED® was performed. All patients were locally treated every week during 2 months of follow-up; SU data were collected after 4 weeks (T4) and 8 weeks (T8). Eight SSc patients with comparable SU were also evaluated as controls. RESULTS: The application of EmoLED® in addition to debridement apparently produced faster healing of SU. Complete healing of SU was recorded in 41.6% cases during EmoLED® treatment. Significant improvements in SU area, length, and width, wound bed, and related pain were observed in EmoLED® patients from T0 to T8. Control subjects treated with standard systemic/local therapies merely showed an amelioration of SU area and width at the end of the follow-up. No procedural or post-procedural adverse events were reported. CONCLUSIONS: The positive clinical results and the absence of side effects suggest that EmoLED® could be a promising tool in the management of SSc-SU, with an interesting role to play in the healing process in addition to conventional systemic and local treatments.

Piezoelectric Bone Surgery. Overview in Applications and Proof of Feasibility in Hand and Plastic Surgery.

PURPOSE: Piezoelectric bone surgery was already extensively used in a number of surgical procedures ranging from dental to maxillofacial surgery. The authors aimed to determine whether piezosurgery was suitable and advantageous for performing osteotomies in Hand and Plastic reconstructive surgery. METHODS: The authors overviewed a variety of applications for Piezosurgery® Device, from Mectron, in bone reconstructive surgery with over the last 8 years. An overall number of 156 bone cutting procedures in adults and children was described at the phalanges, metacarpal bones and distal radius level, as well as in bone graft harvesting and bone remodeling following carpal scaphoid nonunion, scapho-lunate bone-ligament-bone reconstruction and fibula free flap in maxillofacial defects. RESULTS: The consolidation rate was 87.5% in scaphoid nonunion grafting and fixation. Bone healing was achieved in all other cases. No intra-operative complications were recorded. CONCLUSION: Piezosurgery® allowed high precision in bone cutting as well as custom-made graft and surface roughness were obtained, while preserving nerves, vessels and tendons integrity. The instrument may be handling moved into the surgical space in absence of vibrations, with a clear view onto the bone. The mechanical and biological characteristics of the piezoelectrical effect perfected this technique as an effective and useful instrument in Hand and Plastic surgery. The selective bone cutting properties avoided injuries to the surrounding soft tissues and thermal damage of the bony cells. Best advantages were described in feasibility and flexibility for intra-articular osteotomies, custom-made grafts and reconstructive microsurgical techniques.

Systemic sclerosis cutaneous expression: Management of skin fibrosis and digital ulcers.

Systemic sclerosis is a connective tissue disease with cutaneous involvement. Clinical manifestations result from the balance of inflammations/autoimmunity process and fibrogenesis. Patients suffer from skin ulcers, non-ulcerative lesions including digital pitting scars, telangiectasias, subungual hyperkeratosis, abrasions, fissures, and subcutaneous calcinosis. A review about the pathophysiology of the disease, the physical examination of the patients, the instrumental assessment, and possible treatments is performed.

Digital Replantations: Comparison Veins Anastomoses first versus Arteries Anastomoses first.

PURPOSE: This retrospective study analyses the effect performing veins anastomoses before arteries anastomoses in digital replantation. PATIENTS AND METHODS: 38 adult patients with replantation of 12 thumbs and 39 fingers, in whom the veins anastomoses were performed prior to the arteries anastomoses, were compared with 29 patients with replantation of 9 thumbs and 30 fingers, in whom the arteries anastomoses were done first, with respect to the survival rate, total active motion, grip strength, and duration of the replantation. RESULTS: There was no significant difference between the two groups with respect to the survival rates, total active motion, and grip strength, while the duration of the replantation was significantly shorter in patients, in whom the veins anastomoses were performed prior to the arteries anastomoses (2 hours and 50 minutes versus 3 hours and 42 minutes; p < 0.001). CONCLUSION: Performing veins anastomoses before arteries anastomoses in digital replantations reduces the replantation time significantly without influencing the survival rate and the clinical outcome.

Microfragmented adipose tissue is associated with improved ex vivo performance linked to HOXB7 and b-FGF expression.

INTRODUCTION: Adipose tissue (AT) has become a source of mesenchymal stromal/stem cells (MSC) for regenerative medicine applications, in particular skeletal disorders. Several enzymatic or mechanical procedures have been proposed to process AT with the aim to isolate cells that can be locally implanted. How AT is processed may impact its properties. Thus, we compared AT processed by centrifugation (C-AT) to microfragmentation (MF-AT). Focusing on MF-AT, we subsequently assessed the impact of synovial fluid (SF) alone on both MF-AT and isolated AT-MSC to better understand their cartilage repair mechanisms. MATERIALS AND METHODS: MF-AT and C-AT from the same donors were compared by histology and qRT-PCR immediately after isolation or as ex vivo cultures using a micro-tissue pellet system. The in vitro impact of SF on MF-AT and AT-MSC was assessed by histological staining and molecular analysis. RESULTS: The main AT histological features (i.e., increased extracellular matrix and cellularity) of the freshly isolated or ex vivo-cultured MF-AT persisted compared to C-AT, which rapidly deteriorated during culture. Based on our previous studies of HOX genes in MSC, we investigated the involvement of Homeobox Protein HOX-B7 (HOXB7) and its target basic Fibroblast Growth Factor (bFGF) in the molecular mechanism underlying the improved performance of MF-AT. Indeed, both these biomarkers were more prominent in freshly isolated MF-AT compared to C-AT. SF alone preserved the AT histological features of MF-AT, together with HOXB7 and bFGF expression. Increased cell performance was also observed in isolated AT-MSC after SF treatment concomitant with enhanced HOXB7 expression, although there was no apparent association with bFGF. CONCLUSIONS: Our findings show that MF has a positive effect on the maintenance of AT histology and may trigger the expression of trophic factors that improve tissue repair by processed AT.

Safety of Reconstructive Microsurgery in the Elderly Population: a Multicentric Prospective Study.

BACKGROUND: Safety of reconstructive microsurgery in elderly patients is still a topic of debate, because no conclusive evidence exists that provides indications and risk evaluation in elderly patients. The purpose of this study, which the Italian Society for Plastic, Reconstructive, and Aesthetic Surgery (SICPRE) has promoted, is to evaluate the safety and the complication risk of elective reconstructive microsurgery in elderly patients as well as to identify patient- or procedure-related risk factors. The secondary aim is to evaluate the predictive role for complications of the Geriatric 8 score (G8). METHODS: A total of 194 consecutive patients from 18 centers, aged 65 or older, who received an elective microsurgical flap between April 2018 and April 2019 were prospectively evaluated. Patient-related, treatment-related, and outcomes data were recorded and statistically analyzed through multiple-adjusted logistic regression models. RESULTS: Our study showed an increased risk of complications and a longer hospitalization in patients aged ≥75 years with the American Society of Anesthesiologists (ASA) score ≥3 (or G8 score ≤11) as compared to patients >65 years of age and <75 years of age who undergo reconstruction with a microsurgical flap. Instead, flap survival did not significantly vary with age, but was associated only with ASA score ≥3 (or G8 score ≤11) and surgeries that last longer than 480 min; however, flap survival (92.3%) was slightly lower than that commonly reported for in the general population. CONCLUSIONS: Reconstructive microsurgery in the elderly is generally safe. The ASA score is easier and quicker than the G8 score and equally useful for risk stratification.

Breast Cancer-Related Lymphedema: Recent Updates on Diagnosis, Severity and Available Treatments.

Breast cancer-related lymphedema (BCRL) represents a global healthcare issue affecting the emotional and life quality of breast cancer survivors significantly. The clinical presentation is characterized by swelling of the affected upper limb, that may be accompanied by atrophic skin findings, pain and recurrent cellulitis. Cardinal principles of lymphedema management are the use of complex decongestive therapy and patient education. Recently, new microsurgery procedures have been reported with interesting results, bringing in a new opportunity to care postmastectomy lymphedema. However, many aspects of the disease are still debated in the medical community, including clinical examination, imaging techniques, patient selection and proper treatment. Here we will review these aspects and the current literature.

Upper limb traumatic injuries: A concise overview of reconstructive options.

Different options for upper limb reconstruction are described in literature: advancement or rotation flaps, regional flaps and free flaps are the most common. Local and regional flaps can represent the reconstructive options for small defects while large wounds require the use of free flaps or distant pedicled flaps. In case of large wound, the use of free flaps rather than distant pedicle flaps is usually preferred. To choose the best reconstructive option, it is essential for the surgeon to have a general overview about the different methods. In this review the Authors will refer to the most commonly used methods to cover soft tissues injuries affecting the dorsum and the palm of the hand and the forearm (excluding fingers). The aim is to show all flap reconstructive options so as to support the inexperienced surgeon during the management of traumatic injuries of the upper limb.

The Challenges in restoration of extensor tendons function at the hand.

INTRODUCTION: The authors discuss challenges in extensor function restoration at the finger level following distal posterior interosseous or tendon complex injuries, according to the typologies of lesions or the specific patient requirements. MATERIALS: The authors report on two cases describing challenging resolutions. One patient with EDC lag from zone 6B to 8 requiring FCU prolonged with cadaveric grafts.  One young patient with distal posterior interosseous lesion requiring selective tendon transfers to EPL and EIP to restore selective and autonomous index extension. RESULTS: In both cases the main goals were obtained, achieving high index of patient satisfaction and excellent outcomes with the restoration of the extension of the fingers.  Conclusions: In distal posterior interosseous nerve lesion, high demanding patients may require selective function to restore fine motor skills, such as autonomous index extension. In extensor tendons loss of substance from zone 6 to 8, involving musculotendinous junction proximally and short remnants distally, by-pass tendon transfer prolonged with cadaveric grafts is required. The authors highlight the techniques available as escape plan according to the necessary solutions.

Standardization and Selection of High-risk Patients for Surgical Wound Infections in Plastic Surgery.

BACKGROUND: The aim of the present study was to show that the Infection Risk Index (IRI), based on only 3 factors (wound classification, American Society of Anesthesiologists score, and duration of surgery), can be used to standardize selection of infection high-risk patients undergoing different surgical procedures in Plastic Surgery. METHODS: In our Division of Plastic Surgery at Modena University Hospital, we studied 3 groups of patients: Group A (122 post-bariatric abdominoplasties), Group B (223 bilateral reduction mammoplasties), and Group C (201 tissue losses with first intention healing). For each group, we compared surgical site infection (SSI) rate and ratio between patients with 0 or 1 risk factors (IRI score 0 or 1) and patients with 2 or 3 risk factors (IRI score 2 or 3). RESULTS: In group A, patients with IRI score 0-1 showed an SSI Ratio of 2.97%, whereas patients with IRI score 2-3 developed an SSI ratio of 27.27%. In group B, patients with IRI score 0-1 showed an SSI ratio of 2.99%, whereas patients with IRI score 2-3 developed an SSI ratio of 18.18%. In group C, patients with IRI score 0-1 showed an SSI ratio of 7.62%, whereas patients with IRI score 2-3 developed an SSI ratio of 30.77%. CONCLUSIONS: Existing infection risk calculators are procedure-specific and time-consuming. IRI score is simple, fast, and unspecific but is able to identify patients at high or low risk of postoperative infections. Our results suggest the utility of IRI score in refining the infection risk stratification profile in Plastic Surgery.