"Just Pulse it!" Introduction of a conservative implant salvage protocol to manage infection in pre-pectoral breast reconstruction: Case series and literature review.

Post-operative implant infection is generally rare after breast augmentation, but it can occur in up to 35% of cases in post-mastectomy breast reconstruction. Standard treatment consists in the administration of antibiotics, implant removal, and delayed prosthesis replacement leading to multiple operations, with a negative impact on patient's clinical, economical, and psychological outcomes. There is little information published in the literature on the management of periprosthetic infection following pre-pectoral reconstructions. Capsule's removal from a pre-pectoral plane brings the risk of excessive tissue thinning and the compromise of skin flaps viability. In this preliminary multi-center case series, eight patients diagnosed with implant infection following oncological mastectomy and two-stage heterologous pre-pectoral breast reconstruction underwent the same protocol, consisting in tissue expander removal and conservative surgical revision supplemented by an antibiotate pulse lavage of the pocket surface. All patients achieved a successful infection resolution with immediate prosthesis replacement switching the temporary expander to definitive implant. No additional surgical revision was registered during follow-up. The intermittent irrigation is meant to disrupt the biofilm structure and restore antibiotic susceptibility. Moreover, pulse lavage allows the cleansing of the prosthetic capsule, thus avoiding the vascular stress associated with subcutaneous capsulectomy. To the best of our knowledge, this is the first series reporting on the use of Pulsavac in periprosthetic infection following pre-pectoral breast reconstruction, in an attempt to set the basis for an alternative conservative protocol to manage breast implant infection. A thorough literature review on pulse lavage in breast surgery was carried out.

Clinical Characteristics of Severe COVID-19 Patients Admitted to an Intensive Care Unit in Lombardy During the Italian Pandemic.

Italy was one of the worst affected European countries during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. More than 50% of Italian cases occurred in the northern region of Lombardy, where the saturation of health services between March and April 2020 forced hospitals to allocate patients according to available resources. Eighteen severe coronavirus disease 2019 (COVID-19) patients were admitted to our hospital needing intensive support. Given the disease fatality, we investigated the patients' characteristics to identify mortality predictors. We counted seven deaths from multiple organ failure, two from septic shock, and two from collapsed lungs. The maximum case fatality was observed in patients who contracted SARS-CoV-2 in hospitals. The fatal outcome was associated with the following baseline characteristics: polymorbidity (OR 2.519, p = 0.048), low body mass index (OR 2.288, p = 0.031), low hemoglobin (OR 3.012, p = 0.046), and antithrombin III (OR 1.172, p = 0.048), along with a worsening of PaO2/FiO2 ratio in the first 72 h after admission (OR 1.067, p = 0.031). The occurrence of co-infections during hospitalization was associated with a longer need for intensive care (B = 4.511, p = 0.001). More information is needed to inform intensive care for patients with severe COVID-19, but our findings would certainly contribute to shed some light on this unpredictable and multifaceted disease.

Donor Site Wound Healing in Radial Forearm Flap: A Comparative Study Between Dermal Substitute and Split-Thickness Skin Graft Versus Full-Thickness Skin Graft Primary Coverage.

ABSTRACT: Radial forearm flap (RFF) is one of the most used flaps in reconstructive surgery. Despite its versatility and effectiveness, the donor site is affected by aesthetic and functional issues. In the group of techniques described to improve the donor site morbidity, dermal substitutes offer a valid approach in the wound management. A bilayered bioresorbable dermal substitute (Hyalomatrix) was used to provide the primary coverage of the RFF harvest site followed after 3 weeks by a split-thickness skin graft placement. In this study, 37 patients underwent RFF donor site reconstruction and subjected to a minimum follow-up of 1 year. The dermal substitute was applied on 15 patients, and their outcomes were compared with the data achieved by 22 patients submitted to immediate reconstruction with autologous full-thickness skin graft. Results were documented by digital photographs, the visual analog scale, the Vancouver Scar Scale, and the Disabilities of the Arm, Shoulder, and Hand questionnaire. Data were analyzed and compared through statistical analysis. Total wound coverage was achieved in 4 to 6 weeks, and no tendon impairments were reported in the dermal substitute group. In our experience, the use of the dermal substitute is a valuable mean to minimize RFF donor site morbidity with excellent functional and aesthetic outcomes.

SARS-CoV-2 Aiming for the Heart: A Multicenter Italian Perspective About Cardiovascular Issues in COVID-19.

The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the high fatality rate of coronavirus disease 2019 (COVID-19) have been putting a strain on the world since December 2019. Infected individuals exhibit unpredictable symptoms that tend to worsen if age is advanced, a state of malnutrition persists, or if cardiovascular comorbidities are present. Once transmitted, the virus affects the lungs and in predisposed individuals can elicit a sequela of fatal cardiovascular consequences. We aim to present the pathophysiology of COVID-19, emphasizing the major cellular and clinical manifestations from a cardiological perspective. As a roaming viral particle or more likely via the Trojan horse route, SARS-CoV-2 can access different parts of the body. Cardiovascular features of COVID-19 can count myocardial injuries, vasculitis-like syndromes, and atherothrombotic manifestations. Deviations in the normal electrocardiogram pattern could hide pericardial effusion or cardiac inflammation, and dispersed microthrombi can cause ischemic damages, stroke, or even medullary reflex dysfunctions. Tailored treatment for reduced ejection fraction, arrhythmias, coronary syndromes, macrothrombosis and microthrombosis, and autonomic dysfunctions is mandatory. Confidently, evidence-based therapies for this multifaceted nevertheless purely cardiological COVID-19 will emerge after the global assessment of different approaches.

Effects of Prophylactic Lipofilling After Radiotherapy Compared to Non-Fat Injected Breasts: A Randomized, Objective Study.

BACKGROUND: Patients who are suffering from invasive breast cancer may require post-mastectomy radiation therapy (PMRT). PMRT improves outcomes in breast cancer patients in terms of locoregional recurrence. Preliminary studies indicate that fat injections reduce post-radiation damage of soft tissue and implants. OBJECTIVES: The aim of this study was to demonstrate the safety and effectiveness of prophylactic fat injections on radiated implanted breasts. METHODS: The authors randomly assigned 60 female patients to either Group A or B. Group A patients received 3 breast fat injections, according to Coleman's technique, after radiotherapy and before expander removal with definitive implant insertion. Group B patients underwent surgery without lipofilling. At each surgical operation, skin biopsies were performed in a specific breast area to evaluate adipose tissue thickness, and a statistical analysis of the thickness variations was performed with the Wilcoxon's sum test. Disability was assessed according to the Late Effects of Normal Tissues-Subjective Objective Management Analytic scale. RESULTS: The study demonstrates a qualitative and quantitative improvement about tissues after fat injection. This is highlighted by the significant increase in thickness after lipofilling. CONCLUSIONS: The study, which is based on both clinical and histological findings and is supported by the comparison of a control group with a 1-year follow-up, demonstrates that fat injections reduce tissue radio damage, improving reconstructive surgery outcomes and quality of life.

EA-DIVA score (Enhanced Adult DIVA score): A new scale to predict difficult preoperative venous cannulation in adult surgical patients.

INTRODUCTION: Providing peripheral intravenous access is one of the most commonly performed technical procedures in hospitals and it is mandatory for all patients undergoing surgery. Obtaining peripheral intravenous access may be difficult and this may cause delays in patient management, increased risk of adverse events and hospitalization costs. The aim of this study is to develop and validate a scale to identify patients at risk of peripheral difficult intravenous access, applicable to any adult patient undergoing surgery. METHODS: A monocentric, observational study was conducted on adult surgical patients between September 2015 and April 2016. The primary outcome was the identification of parameters that could detect peripheral difficult intravenous access. Several parameters were taken into consideration, including patient details, healthcare professionals, and setting. The sample data were randomly divided into two subsets: a multivariate analysis was performed on the first one to define the Enhanced Adult DIVA score; the second subset was used for its validation. RESULTS: We included 1006 patients (607 in the derivation, 399 in the validation cohorts respectively). The peripheral intravenous access was difficult in 127 patients (12.6%). The EA-DIVA score was devised with a score ranging from 0 to 12. The receiver operating characteristic (ROC) curve area under the curve (AUC) in the validation subset was 0.94. The validation study suggested a cut-off score of 8, which maximizes sensitivity (85.5%) and specificity (89.2%) in detecting difficult peripheral intravenous access, with a positive predictive value of 56% and a negative predictive value of 97.5%. DISCUSSION: The EA-DIVA score is a simple tool to identify patients at high risk of peripheral difficult intravenous access. Its implementation is recommended in order to optimize peripheral intravenous access procedures.

Skin cancers and dermal substitutes: Is it safe? Review of the literature and presentation of a 2-stage surgical protocol for the treatment of non-melanoma skin cancers of the head in fragile patients.

Non-melanoma skin cancers (NMSC) represent the most common skin tumours of the head region. We describe the use of dermal substitute in a 2-stage surgery protocol for selected fragile patients to remove NMSC of the head region. A review of the literature focusing on dermal substitutes' safety after skin tumours excision is provided. A total of 45 fragile patients with NMSC in the head region were selected and scheduled for the 2-stage surgical protocol. The first stage consisted of traditional surgical excision and immediate coverage with Hyalomatrix (Fidia Advanced Biopolymers, Abano Terme, Italy). After histology confirmed diagnosis and clearance of the margins, full-thickness skin autografts were performed. All of the patients reached complete tumour excision and wound healing. No local recurrences were registered during 24 months follow up. The 2-stage surgical therapeutic-diagnostic-reconstructive approach represents a less stressful and oncologically safe surgical protocol in selected fragile patients. When patients cannot tolerate invasive and long surgical procedures, general anaesthesia, and long hospitalisation, skin grafting following temporary skin substitute coverage can achieve oncological clearance and provide good functional and aesthetic results. The use of dermal substitutes represents a valid alternative surgical option in cases of ASA III, fragile patients non-eligible for complex reconstructive surgery. To our knowledge, this is the first paper reviewing literature focusing on dermal substitutes' applications and safety after skin tumour excision.

Tuberous breast and predisposition to breast deformity in consanguineous.

Tuberous breast deformity is a pathologic condition of the breast consisting of a constricting ring at the breast base, reduction in the volume of the breast parenchyma, and herniation of breast tissue through the nipple-areola complex with areola enlargement. This pathology is generally congenital and has an unknown etiopathogenesis. We report the first observation of tuberous breast deformity in consanguineous. This report suggests the potential role of a genetic base in the development of this deformity. Between May 2008 and March 2011, we observed six female patients from two different families, aged between 18 and 55 years, affected by tuberous breast deformity. The breast deformity was characterized by breast asymmetry in all six cases. Four patients underwent surgery to correct the deformity. Standardized objective measurements of breast and chest were taken. A Visual Analog Scale was used to evaluate patients' and physicians' satisfaction. The first three patients were consanguineous; two were first cousins, and the third was second cousin with one of the above. The other three patients were also from the same family: two sisters and their mother. According to Von Heimburg's classification, the patients presented different degrees of breast deformity. In all operated cases, a good esthetic result with a high satisfaction (average visual analog scale score 9) was achieved. The results remained stable over time and no revisions were needed after the 1-year follow-up. The possibility of a parental consanguinity for breast deformities such tuberous breast has never been described in the literature. This report suggests the possible genetic role in the development of tuberous breast deformity. Further studies and genetic tests are required to prove this hypothesis.

Surgical treatment of nasal non-melanoma skin cancer in elderly patients using dermal substitute.

CONCLUSIONS: The nose is often involved by non-melanoma skin cancer (NMSC) and the increase in the incidence of such tumors, the morbidity and treatment-related costs represent a significant burden to healthcare systems. A bioresorbable dermal substitute (Hyalomatrix®) has been used for immediate dermal coverage and nose restoration after excision of infiltrating nasal NMSCs in elderly ASA III patients. Further studies on dermal substitutes are needed to improve benefit to patients. OBJECTIVE: Surgical treatment of nasal non-melanoma skin cancer (NMSC) in elderly patients. MATERIALS AND METHODS: Ten elderly ASA III patients with nasal defects after resection of infiltrating NMSC were reconstructed in a two-stage strategy. The surgical protocol targeted an initial wide tumor excision and apposition of a dermal induction template (Hyalomatrix®) and successive full thickness skin autograft. Results were documented by photography, visual analog scale for patient satisfaction, and Vancouver scar scale for evaluation of final graft characteristics. RESULTS: All patients were tumor-free during the 2 years follow-up. The procedure achieved acceptable nose reshaping and graft scarring evolution. Patient satisfaction was good-to-high.

The use of the Alexis(®) device in breast augmentation to improve outcomes: a comparative randomized case-control survey.

BACKGROUND: We present our experience in using a disposable wound retractor commonly used in abdominal surgery named Alexis(®) (Applied Medical Resources Corporation, Rancho Santa Margarita, CA, USA), during breast augmentation in order to improve outcomes, particularly final scar length. METHODS: Between January 2010 and November 2012, 40 patients undergoing breast augmentation with an inframammary approach were enrolled in the present study. Patients were randomly assigned to two groups: group 1 underwent breast augmentation with the standard technique; group 2 underwent breast augmentation by using the Alexis(®) (Applied Medical Resources Corporation) device. Patients were followed-up for a 12-month period. The time of surgery, the days of drain duration and the length of the incisions were recorded for both groups and statistical significance was evaluated with the Wilcoxon rank sum test. Also, final scar appearance was evaluated using a visual analogue scale (VAS). RESULTS: Patients in group 2 reported a lower incidence of hematomas and had shorter drain duration. The difference in scar length between the two groups was statistically significant (P<0.05). Surgeons and patients were mostly satisfied with the final appearance of the scar. CONCLUSIONS: The use of the Alexis(®) (Applied Medical Resources Corporation) device has proven useful in reducing the length of the inframammary incision. Interestingly, the increased visibility obtained with the use of the Alexis device allowed a better hemostasis, as suggested by the shorter drain duration and lower incidence of hematomas. However, its use prolongs the operative time, for which we recommend surgeons to allow themselves some time to become familiar with the device. LEVEL OF EVIDENCE: level I, evidence obtained from at least one properly designed randomized controlled trial.

Surgical treatment of a rare case of bilateral ptosis due to localized ocular amyloidosis.

We describe a rare case of a 31-year old woman with bilateral ptosis due to localized amyloidosis. She referred a nine-year history of ptosis and surgical treatment with frontalis suspension three years previously. Following complete ophthalmological examination and evaluation of the ptosis we carried out tarsal and fornix biopsy, which revealed accumulation of a weakly eosinophilic amyloid positive substance. We performed surgical correction using the levator aponeurosis-Müller's muscle complex re-adaptation technique and amyloid substance debulking in all the palpebral layers in the left eye. The material obtained was stained with hematoxylin-eosin, Congo Red, PAS and alpha-actin, which confirmed amyloid deposition. Successively, the right eye was operated in the same manner and entropion was managed by dissection and removal of amyloid from subconjunctival layers. Five years following surgery, the corrective procedure for ptosis was still effective. Surgical treatment of ptosis is very complex and requires precise indications. Appropriate management depends on the etiopathogenesis, accurate diagnosis, and clinical findings.

Retention of polyurethane foam fragments during VAC therapy: a complication to be considered.

Vacuum-assisted closure (VAC) therapy is a closed-loop, non-invasive active system, characterised by a controlled and localised negative pressure applied on porous polyurethane absorbent foams. It promotes healing of acute and chronic wounds. Therapeutic effects of VAC therapy have been proved and demonstrated; however, this method can have some disadvantages. Even if it is a quite versatile device, only qualified medical/paramedical personnel should use it in order to avoid possible complications that can occur after an improper application. In this report, 11 cases of foam-fragment retention within the wound are presented. This rare complication did not promote healing, but further hindered it. On the basis of our experience, it is mandatory to define the indications, benefits and limitations of VAC therapy.

Evidence-based evaluation technique to assess augmentation mammaplasty results: a simple method to objectively analyze mammary symmetry and position.

BACKGROUND: Despite the great variety of mammaplasty techniques, outcome assessment remains a challenging issue. OBJECTIVES: The authors devised an objective method to evaluate mammary symmetry based on statistical analysis of objective manual breast measurements and validated the method by applying it to results of a randomized controlled trial on the correction of breast asymmetry. METHODS: Sixty consecutive patients with hypoplastic breasts and small-volume asymmetry were enrolled in the study and randomly assigned to 1 of 2 groups. One group received a fixed-volume implant in 1 breast and an adjustable-volume implant in the other. The other group received 2 fixed-volume implants of different sizes. The differences in specific breast and chest measurements, obtained before surgery and during follow-up, were analyzed statistically with the Wilcoxon signed rank test. RESULTS: Correction of the asymmetry resulted in the reduction of the differences between left and right values for each specific breast measurement. Placement of an adjustable implant on 1 side yielded better symmetry than placement of 2 fixed-volume prostheses of different sizes. Patient and physician satisfaction was high for both groups. CONCLUSIONS: This objective analysis of clinical parameters enables comparing results for different patients in large clinical trials and for the same patient at different follow-up periods. LEVEL OF EVIDENCE: 3.

The use of cultured autologous oral epithelial cells for vaginoplasty in male-to-female transsexuals: a feasibility, safety, and advantageousness clinical pilot study.

Various vaginoplasty methods in male-to-female transsexuals have been described, but none is ideal. The use of cultured autologous oral epithelium to cover the neovagina walls is presented. Six patients were operated on. Complications encountered were one case of low-located rectovaginal fistula that was treated conservatively; one case of partial glans necrosis resulting in a scarred but sensitive clitoris; one case of large labia majora requiring reduction; and one case of short vagina requiring surgical revision with autologous cultured oral cells that was successful. All patients had adequate vagina, experienced sexual intercourse, and were satisfied with results. Autologous cultured oral epithelium transplantation is feasible, safe, and advantageous. Satisfactory neovaginas were provided; the procedure is relatively easy to perform and provides a thin, mucosa-lined neovagina with a sufficient amount of secretion.

Parosteal lipoma. Report of 15 new cases and a review of the literature.

The lipoma is the most common tumor of the body and can be found in virtually every tissue or organ. However, a parosteal lipoma is a rare benign fatty neoplasm having an intimate relationship to the periosteum. The incidence of this tumor is 0.3% of all lipomas. Over 150 cases of parosteal lipoma have previously been described in the literature. Owing to the rarity of this condition and the difficulties encountered in its diagnosis and treatment, we wish to report fifteen new cases of parosteal lipoma. We reviewed the clinical records of 15 patients who underwent surgery to remove a parosteal lipoma between November 2003 and July 2009. The diagnosis of a parosteal lipoma was made by the histological findings, the confirmation of fat content at Magnetic Resonance or Computed Tomography. Surgery in all the cases entailed resecting the tumor with parosteal excrescence. In three cases with hyperostosis, a further exeresis of the bone was performed. Parosteal lipomas are rare entities associated with periosteal involvement depending on their location. Current management should include computed tomographic scanning and magnetic resonance. Surgery, which is mandatory treatment, requires particular attention to ensure that any periosteal involvement is removed completely.

Association between abdominal separation and inguinal or crural hernias: our experience and surgical indications.

Abdominal wall weaknesses present several causative factors, both local and systemic and, as a consequence, abdominal hernias may develop in more than one site. Also, simultaneous hernia repair has been rarely reported in published reports. In the present study, the association of multiple weaknesses of the abdominal wall in patients undergoing conventional abdominoplasty or hernia repair were evaluated, and the advantages of simultaneous repair in a single operation are discussed. In a 3-year time period, all patients undergoing abdominoplasty or abdominal hernia repair were clinically and instrumentally evaluated for the association between median abdominal wall weakness and inguinal and/or crural hernias. The body mass index (BMI) was also considered and photographic documentation was taken before the operation and during the follow-up. When this association was confirmed, patients underwent contemporary correction of both conditions using an abdominoplasty approach. The presence of inguinal and/or crural hernias was observed in 10% of all patients undergoing conventional abdominoplasty and in 14.5% of patients with laparocele in the institution. The BMI was higher in patients with the association than in those without. Good aesthetic and functional results were achieved and the complication rate was low. The role of obesity as a triggering factor of abdominal wall weaknesses is confirmed by the higher BMI in patients with associated diseases. These observations remark the fact that the association between median abdominal wall weakness and inguinal or crural hernias should always be investigated. If this association is confirmed, it is preferable to treat both conditions simultaneously.

Scalp reconstruction using dermal induction template: state of the art and personal experience.

The loss of skin envelope is a frequent and costly problem in health care. This article provides an overview on the state of the art in scalp reconstruction with dermal substitutes, as well as our personal experience of ten critical patients with non-melanoma skin cancer of the scalp. These patients were treated in a two-stage procedure by wide tumor excision, apposition of a dermal induction template (Hyalomatrix®) and successive skin grafting. Four patients underwent subgaleal tumor excision with preservation of the periosteum and six patients en bloc tumor excision together with the external cortical bone. A 10×10 cm template was used in all patients. Two weeks after demolition surgery, we observed neodermis formation. Results were documented by comparative photography, visual analogue scale for patient satisfaction, and Vancouver scar scale for evaluation of final graft characteristics. Patients were tumor-free during follow-up. The procedure achieved good scalp reshaping and graft scarring evolution. Patient satisfaction was high. Hyalomatrix® was effective for oncological scalp reconstruction in critical patients. It prepared the wound bed for graft take while awaiting histological diagnosis and confirmation of margin clearance. Further studies on dermal substitutes are needed to improve benefit in patients.