Lymphatic Patterns in the Superficial Circumflex Iliac Artery Perforator Flap.

BACKGROUND: Lymphedema is a chronic condition, characterized by fluid buildup and tissue swelling and is caused by impairment of the lymphatic system. The lymph interpositional flap transfer technique, in which lymph flow is restored with a flap that includes subdermal lymphatic channels, is an option for surgical reconstruction. The superficial circumflex iliac artery perforator (SCIP) flap can be used for this purpose. This study aimed to describe and characterize the lymphatic patterns within the vascular territory of the SCIP flap. METHODS: This cross-sectional multicenter study involved 19 healthy volunteers aged ≥18 years of both sexes assessing the bilateral SCIP flap zone. Superficial lymphatic patterns were evaluated at 4-, 14-, and 24 minutes after indocyanine green (ICG) lymphography injection. Standardized procedures were implemented for all participants in both hospitals. RESULTS: The linear pattern was predominant bilaterally. The median number of lymphatic vessels and their length increased over time. Most lymphatic vessels in the SCIP flap were oriented toward the inguinal lymph node (ILN). However, the left SCIP zone lymphatic vessels were directed opposite to the ILN. CONCLUSION: The two sides SCIP zones were not significantly different. The primary direction of the bilateral lymphatic vessels was toward the ILN, although only single-side lymphatic vessels were in the opposite direction. These findings emphasize the importance of assessing lymphatic axiality and coherent lymphatic patterns prior to undertaking the SCIP as an interposition flap, to ensure effective restoration of lymphatic flow.

Factors influencing final rendering in areola tattoo reconstruction: a statistical analysis.

BACKGROUND AND AIM: Reconstruction of the nipple-areola complex announces the end of breast reconstruction process, sometimes difficult to live for the patient, and significantly improves the perception of body image. In literature there are no studies addressing the possible influencing factors of the final rendering of areola reconstruction with tattoo. The aim of the present study was to evaluate all the factors which could influence the yield and the final result of the nipple areola complex pigmentation. METHODS: 97 patients who underwent areolar tattooing between January 2018 and February 2020 were retrospectively reviewed. Breast reconstruction timing and personal history, as well as surgical details were recorded. RESULTS: Mean age was 52 years old (range 29-71), almost the totality of cases was women including even 2 men (one with Poland syndrome and one post mastectomy). 27 patients needed bilateral tattooing. 22 had history of adjuvant radiotherapy, 16 received neoadjuvant chemotherapy and 4 adjuvant chemotherapy. In the logistic regression analysis, radiotherapy resulted a risk factor for retattooing (p<0.05) while the autologous breast reconstruction resulted a protective factor for retattooing. Neo - and adjuvant chemotherapy were not statistically significant. CONCLUSIONS: Tissue thickness, sex, reconstructive technique and history of radiotherapy could influence the final result in areola reconstruction with tattoo, and must be taken into account to obtain the best result, knowing when the pigmentation has to be repeated.

Sub-Muscular Direct-to-Implant Immediate Breast Reconstruction in Previously Irradiated Patients Avoiding the Use of ADM: A Preliminary Study.

BACKGROUND: The aim of this paper is to present a preliminary experience of sub-muscular primary direct-to-implant (DTI) breast reconstruction without acellular dermal matrix (ADM), after salvage mastectomy for local recurrence following prior irradiation. METHODS: A retrospective investigation was performed on a prospectively maintained database of breast reconstruction cases at our institution between January 2015 and December 2020. We considered only immediate DTI breast reconstructions without ADM following radiotherapy and salvage mastectomy for local recurrence, with at least a 12-month follow-up. RESULTS: The study considered 18 female patients with an average of 68 years. According to the BREAST-Q questionnaire, all patients reported high levels of "satisfaction with outcome" with good "psychosocial wellness" and "physical impact" related to the reconstruction. The aesthetic evaluation showed a significant difference between the VAS score gave by the patient (mean 6.9) and the surgeon (mean 5.4). No implant exposure occurred in this series. In terms of complications, four patients (22%) suffered from wound dehiscence and were managed conservatively. Three patients (17%) required primary closure in day surgery following superficial mastectomy flap necrosis. Late capsular contracture was seen in seven patients (four Baker stage II and three Baker stage III, totally 39%); however, no patient was willing to undergo implant exchange. CONCLUSIONS: DTI breast reconstruction following prior irradiation can be considered as an option in patients who are not good candidates for autologous breast reconstruction. Our general outcomes compared favorably with literature data regarding the use of staged procedures, with acceptable complication rates and levels of patient satisfaction.

Filler-induced complications of the lips: 10 years experience with intralesional laser treatment and refinements.

BACKGROUND: The number of minimally invasive cosmetic procedures has steadily increased every year. In the last decade, the rates of filler injection reactions have also increased. This study presents our experience in the management and treatment of permanent filler complications to the lips. Undoubtedly, in these adverse reactions, the lips are the hallmark that most stigmatizes an unnatural look of the face. METHODS: One hundred and eighty-one patients (168 female and 13 male) with permanent filler complications to the lips were treated from September of 2009 to September of 2019 at the University Hospital of Modena. One hundred and thirty-five patients underwent intralesional laser treatment (ILT). Forty-six patients underwent a stab incision and drainage and 10 of these patients had solid and calcified nodules and therefore underwent a combined technique. Thirty-three patients underwent further cosmetic procedures. RESULTS: In 95% of patients there was a clinical improvement of which complete resolution in 38.7% and partial improvement in 34.2% of cases. Nine patients stopped the treatment because they were not satisfied. No patient was considered to have worsened after the treatment. Thirty-three patients underwent further treatments. CONCLUSIONS: A systematic combined approach between antibiotic therapy and treatments (ILT and a stab incision) represents the best therapeutic approach in dealing with permanent fillers complications to the lips. This treatment modality allows both the removal of the foreign material and the inflammatory reaction with low morbidity and little cosmetic disfigurement. Further cosmetic procedures may be applied to improve aesthetic appearance once most of the non-resorbable substance has been removed.

Surgical treatment of pressure injuries in children: A multicentre experience.

Pressure injuries (PI) are infrequent in paediatric patients, prevalence estimates ranging from 1.4% to 8.2%, and reaching values as high as 43.1% in critical care areas. They can be associated with congenital neurological or metabolic disorders that cause reduced mobility or require the need for medical devices. In children, most pressure injuries heal spontaneously. However, a small percentage of ulcers that is refractory to conservative management or is too severe at presentation (Stage 3 or 4) will be candidates for surgery. We retrospectively reviewed the clinical history of paediatric patients affected by pressure injuries from four European Plastic Surgery Centres. Information was collected from clinical and radiology records, and laboratory reports. An accurate search of the literature revealed only two articles reporting on the surgical treatment of pressure injuries in children. After debridement, we performed surgical coverage of the pressure injuries. We report here our experience with 18 children aged 1-17 years, affected by pressure injury Stages 3 and 4. They were successfully treated with pedicled (17 patients) or free flaps (1 patient). The injuries involved the sacrum (6/18 patients), lower limb (3/18 patients), thoracic spine (2/18 patients), ischium (3/18 patients, bilateral in one patient), temporal area (3/18 patients), hypogastrium (1/18 patients) and were associated to medical devices in three cases. Flaps were followed for a minimum of 19 months and up to 13 years. Only two patients developed true recurrences that were treated again surgically. Pressure injuries are infrequent in children and rarely need surgical treatment. Pedicled flaps have a high success rate. Recurrences, contrary to what is reported in the literature, were rare.

Reconstruction of upper limb soft-tissue defects after sarcoma resection with free flaps: A systematic review.

BACKGROUND AND OBJECTIVES: Upper limb preservation after soft tissue sarcoma (STS) surgical excision is now the accepted gold standard and it often requires reconstruction with free flaps. The purpose of this review is to summarize current literature on upper limb reconstruction with free flaps after STS resection. METHODS: A systematic review was performed in July 2019 in PubMed and MedLine Ovid databases according to the PRISMA guidelines. RESULTS: A total of 17 studies were included in the final analysis, with 132 patients. The most common diagnosis was Malignant Fibrous Histiocytoma. The most frequent timing of flap coverage was immediate. The success rate was almost always 100%. The length of follow-up was reported in 11 studies with a range of 2-187 months. The most commonly reported patient-centered outcome was the MSTS Score. Based on the evidence of the literature collected, we divided the upper limb into four parts (shoulder, elbow and arm, forearm and wrist, and hand) and described the most common and functional free flaps used for reconstruction after STS resection. CONCLUSIONS: Free flaps in the treatment of STS of the upper extremity have a good overall outcome, with a low postoperative complication rate. A wide array of free flaps is available for reconstruction, and the choice of flap is based on defect size, types of tissue required, postoperative functional goal, and surgeon preference. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.

Autologous Fat Grafting for the Oral and Digital Complications of Systemic Sclerosis: Results of a Prospective Study.

BACKGROUND: Systemic sclerosis is a connective tissue disease. Skin involvement of the mouth and hand may compromise function and quality of life. Autologous fat grafting has been described as a specific treatment of these clinical features. We report the results of our prospective study designed to treat and prevent skin complications in systemic sclerosis. MATERIALS AND METHODS: We treated 25 patients with mouth and/or hand involvement (microstomia, xerostomia, skin sclerosis, Raynaud's phenomenon and long-lasting digital ulcers) with autologous fat grafting, according to the Coleman's technique, around the mouth and/or at the base of each finger. The surgical procedures were repeated in each patient every 6 months for a total of two or three times. Clinical data were collected before the first surgery and again 6 months after each surgical procedure. Pain, skin thickness, saliva production and disability were assessed with validated tests. RESULTS: Overall we performed 63 autologous fat grafting sessions (either on the mouth, on the hands or on both anatomical areas). Results at 6 moths after the last session included improvement of xerostomia evaluated with a sialogram, reduction of the skin tension around the mouth and, in the hands, reduction of the Raynaud phenomenon as well as skin thickness. Pain was reduced while the perception of disability improved. Digital ulcers healed completely in 8/9 patients. CONCLUSIONS: Our results confirm the efficacy and safety of autologous fat grafting for the treatment of skin complications and digital ulcers due to systemic sclerosis. In addition, the patients' subjective well-being improved. Level of evidence V 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 .