Topography of the deep branch of the ulnar nerve between genders: a cadaveric study with potential clinical implications.

The lack of meticulous knowledge concerning the topographical anatomy of the deep branch of the ulnar nerve (DUN) may pose difficulties, leading to a delay or a misdiagnosis of a DUN injury. Identification of the DUN is quite difficult without precise anatomical landmarks as reference points. The current study investigates the topography of the DUN between genders, taking as a reference point a well-known landmark, the Kaplan line, used in hand surgery for carpal tunnel release. Twenty-two (15 males and 7 female) fresh frozen adult cadaveric hands were dissected by using magnifying loupes (3.5 and 5.0 x). We marked values proximal to the Kaplan line as positive (+), while we marked distal ones as negative (-). The mean distance DUN-Kaplan line was 1.69 ± 4.45 mm. In male hands, the mean distance was 4.17 ± 1.88 mm, distal to the Kaplan line, while in females, the mean distance was -4.92 ± 0.69 mm proximal to the Kaplan line. Gender dimorphism was detected, with higher statistically significant values in male hands (p = 0.001). Cadaveric studies of the DUN topography, course, and distribution pattern are uncommon. The current study provides an accurate description of the DUN topography, taking the Kaplan line as a reference point, emphasizing gender differences. The DUN is located distally in males and proximally in females. Knowledge of these predictable anatomical relations may help hand surgeons intraoperatively when dealing with a DUN lesion, because of hand trauma or during the decompression of the DUN.

Novel three-dimensional acellular dermal matrix for prepectoral breast reconstruction: First year in review with BRAXON® Fast.

Implant-based breast reconstruction is part of breast cancer treatment, and increasingly optimized reconstructive procedures exploit highly biocompatible materials to ensure enhanced aesthetic-functional results. Acellular dermal matrices (ADMs) are collagen-based materials that made prepectoral implant placement possible, thanks to their bioactive antifibrosis action. Recently, the first three-dimensional ADM, BRAXON® Fast, has been produced. Its 3D design represents the technological evolution of BRAXON® ADM, a flat collagen matrix, and allows for a time-saving complete wrapping of the synthetic prosthesis, thus creating a total biological interface on the implant with patient's tissues. Here, we report our experience on the first 23 eligible patients who received BRAXON® Fast-assisted prepectoral reconstruction. On a total of 27 breasts, the overall complication rate was 11.1%, including one minor seroma (3.7%), one case of necrosis (3.7%), and one implant removal due to infection. As new-generation devices, 3D ADMs showed an effective performance, allowing to reduce the overall exposure time for implant preparation and providing an optimal safety profile.

A Novel Phantom and a Dedicated Developed Software for Image Quality Controls in X-Ray Intraoral Devices.

BACKGROUND: Periodic quality control (QC) procedures are important in order to guarantee the image quality of radiological equipment and are also conducted using phantoms simulating human body. OBJECTIVE: To perform (QC) measurements in intraoral imaging devices, a new and simple phantom was manufactured. Besides, to simplify QC procedures, computerized LabView-based software has been devised, enabling determination of image quantitative parameters in real time or during post processing. MATERIAL AND METHODS: In this experimental study, the novel developed phantom consists of a Polymethyl methacrylate (PMMA) circular insert. It is able to perform a complete QC image program of X-ray intraoral equipment and also causes the evaluation of image uniformity, high and low contrast spatial resolution, image linearity and artefacts, with only two exposures. RESULTS: Three raters analyzed the images using the LabView dedicated software and determined the quantitative and qualitative parameters in an innovative and accurate way. Statistical analysis evaluated the reliability of this study. Good accuracy of the quantitative and qualitative measurements for the different intraoral systems was obtained and no statistical differences were found using the inter-rater analysis. CONCLUSION: The achieved results and the related statistical analysis showed the validity of this methodology, which could be proposed as an alternative to the commonly adopted procedures, and suggested that the novel phantom, coupled with the LabView based software, could be considered as an effective tool to carry out a QC image program in a reproducible manner.

A Meta-analysis On Evidence Of Platelet-rich Plasma for Androgenetic Alopecia.

BACKGROUND: Platelet-rich plasma (PRP) treatment has gained popularity among different surgical specialities for improving various conditions. Androgenetic alopecia (AGA) is a common disorder, with possible psychosocial implications. Plastic surgeons have increased the practice of PRP injections for hair restoration. A meta-analysis on this topic was performed comparing local injection of PRP versus control to investigate the efficacy of local PRP injections in AGA. METHODS: We performed a systematic literature search. The increase in number of hairs was the primary outcome. Secondary outcomes were the increase of hair thickness and the percentage increase in hair number and thickness. RESULTS: Seven studies involving 194 patients were retrieved and included in the present analysis. A significantly locally increased hair number per cm2 was observed after PRP injections versus control (mean difference [MD] 14.38, 95% confidence interval [CI] 6.38-22.38, P < 0.001). Similarly, a significantly increased hair thickness cross-section per 10-4 mm2 (MD 0.22, 95% CI 0.07-0.38, P = 0.005) favoring PRP group. The pooled results did not show a significant percentage increase in hair number (MD 18.79%, 95% CI - 8.50-46.08, P = 0.18), neither hair thickness (MD 32.63%, 95% CI - 16.23-81.48, P = 0.19) among patients treated with PRP. CONCLUSION: Local injection of PRP for androgenic alopecia might be associated with an increased number of hairs in the treated areas with minimal morbidity, but there is clearly a lack of scientific evidence on this treatment modality. Further studies are needed to evaluate the efficacy of PRP for AGA.

Platelet-rich plasma for androgenetic alopecia: Does it work? Evidence from meta analysis.

INTRODUCTION: The use of platelet-rich plasma (PRP) has increased among different surgical specialities for the treatment of various conditions. Androgenetic alopecia is a common condition, with severe attendant psychosocial implications. PRP injections for hair restoration have become a popular practice among plastic surgeons. We performed a meta-analysis comparing local injection of platelet-rich plasma versus control to evaluate this issue in order to investigate the effectiveness of PRP local injections for androgenetic alopecia. METHODS: A systematic literature search was performed. Primary outcome was the increase in number of hairs. Secondary outcomes were the increase in hair thickness and the percentage increase in hair number and thickness. We performed random-effect analysis. RESULTS: Six studies involving 177 patients were retrieved and included in the present analysis. A significantly locally increased hair number per cm2 was observed after PRP injections versus control (mean difference (MD) 17.90, 95%CI 5.84-29.95, P=.004). Similarly, a significantly increased hair thickness cross section per 10-4  mm2 (MD 0.22, 95%CI 0.07-0.38, P=.005) favoring PRP group. The pooled results did not show statistically significant differences in percentage increase in hair number (MD 24.12%, 95%CI -12.76-60.99, P=.20) and hair thickness (MD 32.63%, 95%CI -16.23-81.48, P=0.19) among patients treated with PRP. CONCLUSIONS: Local injection of PRP for androgenic alopecia might be associated with an increased number of hairs and some hair thickness improvement in the treated areas with minimal morbidity. The results of this meta-analysis should be interpreted with caution as it consists of pooling many small studies. Larger randomized studies can verify this perception.

3D Volumetric Modeling and Microvascular Reconstruction of Irradiated Lumbosacral Defects after Oncologic Resection.

BACKGROUND: Locoregional flaps are sufficient in most sacral reconstructions. However, large sacral defects due to malignancy necessitate a different reconstructive approach, with local flaps compromised by radiation and regional flaps inadequate for broad surface areas or substantial volume obliteration. In this report, we present our experience using free muscle transfer for volumetric reconstruction, in such cases, and demonstrate three-dimensional (3D) haptic models of the sacral defect to aid preoperative planning. METHODS: Five consecutive patients with irradiated sacral defects secondary to oncologic resections were included, surface area ranging from 143-600 cm2. Latissimus dorsi (LD)-based free flap sacral reconstruction was performed in each case, between 2005 and 2011. Where the superior gluteal artery was compromised, the subcostal artery (SA) was used as a recipient vessel. Microvascular technique, complications, and outcomes are reported. The use of volumetric analysis and 3D printing is also demonstrated, with imaging data converted to 3D images suitable for 3D printing with Osirix software (Pixmeo, Geneva, Switzerland). An office-based, desktop 3D printer was used to print 3D models of sacral defects, used to demonstrate surface area and contour and produce a volumetric print of the dead space needed for flap obliteration. RESULTS: The clinical series of LD free flap reconstructions is presented, with successful transfer in all cases, and adequate soft-tissue cover and volume obliteration achieved. The original use of the SA as a recipient vessel was successfully achieved. All wounds healed uneventfully. 3D printing is also demonstrated as a useful tool for 3D evaluation of volume and dead space. CONCLUSION: Free flaps offer unique benefits in sacral reconstruction where local tissue is compromised by irradiation and tumor recurrence, and dead space requires accurate volumetric reconstruction. We describe for the first time the use of the SA as a recipient in free flap sacral reconstruction. 3D printing of haptic bio-models is a rapidly evolving field with a substantial role in preoperative planning.

Improving physicians' communication skills and reducing cancer patients' anxiety: a quasi-experimental study.

AIMS AND BACKGROUND: This study is aimed at evaluating the effectiveness of a physician-centered communication skills training program on cancer patient anxiety levels. METHODS AND STUDY DESIGN: In this quasi-experimental study, physicians from 9 units of 5 general hospitals and 1 cancer research institute were recruited. The unit heads chose which physicians would attend the training program (treatment group) and which would not (control group). The effectiveness of the course was evaluated by assessing the evolution of state anxiety in a sample of cancer patients before and after clinical consultations. RESULTS: Thirty-eight physicians and 339 outpatients were assessed. Patients from the treatment and control groups did not differ in pre-examination anxiety or psychological distress levels. Patients examined by physicians from the treatment group displayed a higher decrease in state-anxiety levels compared with those examined by physicians from the control group. A higher proportion of high anxiety levels was found in women, in less educated patients, and in those with a high distress level. CONCLUSIONS: Our findings suggest the effectiveness of the communication skills training program with reference to patient anxiety levels. Given the potential gap between training and clinical impact, further studies investigating the effect of communication training on patient outcomes are needed.

Innervation of a prefabricated flap: a new experimental model.

INTRODUCTION: Flap innervation by neoaxonogenesis is a promising field of investigation. The authors evaluated the possibility of innervating an acellular collagen scaffold as component of a potential prefabricated flap. MATERIALS AND METHODS: Collagen matrix sheets were implanted around the femoral bundle of a murine model to produce two flaps on proximal and distal nerve stumps based on a flow-through model. After thirty days, nerve regeneration and integration into the collagen matrix were evaluated. The specimens were microscopically analyzed to study Schwann cell colonization and axonal integration with the matrix. Axonal count and density were assessed and statistically evaluated. RESULTS: Qualitative structural and ultrastructural evaluation indicated integration, with axonal fibers merged within the collagen matrix, along with a newly formed vascular network on the proximal flap. Wallerian degeneration occurred inside the distal chamber. Axonal count and density did not show statistically significant differences between the nerve inside the proximal flap and the control side. CONCLUSIONS: Innervation of an acellular matrix can be obtained by direct nerve stump implantation. The flow-through system was relatively easy to build and reliable to provide adequate blood supply. The collagen scaffold may be a promising support or further studies of preinnervated microsurgical flaps.

Segmental masseteric flap for dynamic reanimation of facial palsy.

The masseter muscle is one of the major chewing muscles and contributes to define facial contour. It is an important landmark for aesthetic and functional surgery and has been used for facial palsy reanimation or as source of donor motor nerve. We present an anatomic study to evaluate the possibility of using a muscle subunit for dynamic eye reanimation. Sixteen head halves were dissected under magnification to study the neurovascular distribution and determine safe muscle subunits; areas of safe/dangerous dissection were investigated. Once isolated, the arc of rotation of the muscular subunit was measured on fresh body to verify the reach to the lateral canthus. The patterns of neurovascular distribution and areas of safe dissection were identified; the anterior third of the muscle represents an ideal subunit with constant nerve and artery distribution. The muscle is too short to reach the lateral canthus; a fascia graft extension is needed. The information provided identified the main neurovascular branches and confirms the feasibility of a dynamic segmental flap. The need of efficient motor units for facial reanimation demands for different surgical options. A detailed anatomic description of the neurovascular bundle is mandatory to safely raise a functional motor subunit.

A functional magnetic resonance imaging paradigm to identify distinct cortical areas of facial function: a reliable localizer.

BACKGROUND: Irreversible facial paralysis can be surgically treated by importing both a new neural and a new motor muscle supply. Various donor nerves can be used. If a nerve supply other than the facial nerve is used, the patient has to adapt to generate a smile. If branches of the fifth cranial nerve are used, the patient has to learn to clench teeth and smile. Currently, controversy exists regarding whether a patient develops a spontaneous smile if a nerve other than the facial nerve is used. The authors postulate that brain adaptation in facial palsy patients can occur because of neural plasticity. The authors aimed to determine whether functional magnetic resonance imaging could topographically differentiate activity between the facial nerve- and the trigeminal nerve-related cortical areas. METHODS: A new paradigm of study using functional magnetic resonance imaging based on blood oxygen level-dependent signal activation was tested on 15 voluntary healthy subjects to find a sensitive localizer for teeth clenching and smiling. Subjects smiled to stimulate the facial nerve-related cortex, clenched their jaws to stimulate the trigeminal nerve-related cortex, and tapped their finger as a control condition. RESULTS: Smiling and teeth clenching showed distinct and consistent areas of cortical activation. Trigeminal and facial motor cortex areas were found to be distinct areas with minimal overlapping. CONCLUSIONS: The authors successfully devised a functional magnetic resonance imaging paradigm effective for activating specific areas corresponding to teeth clenching and smiling. This will allow accurate mapping of cortical plasticity in facial reanimation patients.

Vacuum-assisted closure for the treatment of Fournier's gangrene.

BACKGROUND: Fournier's gangrene (FG) is a very aggressive necrotizing fasciitis involving subcutaneous fat and skin of scrotal and perineal regions. Vacuum-assisted closure (VAC) is a well-known method used to treat complex wounds. The authors for the first time enhance a multimodal strategy to treat the FG using VAC, reducing the number of surgical debridements, allowing a one-step surgical reconstruction with locoregional fasciocutaneous flap. METHODS: Six patients with the diagnosis of FG were reviewed retrospectively at our institution. All patients were affected by very extensive FG. The FG Severity Index (FGSI) was used to evaluate the prognosis of the case at admission. Following the acute phase (24-48 h), VAC was used to achieve wound cleaning and prepare the area to a single-stage reconstruction with superomedial thigh flap. Hyperbaric oxygen therapy was also used before final reconstruction. RESULTS: The average FGSI was 10.5, ranging from 8 to 12. All patients survived and were completely healed at the mean follow-up time of 9 months (range 3-30 months). CONCLUSIONS: VAC therapy is effective to clean and prepare the wounds, cutting off the fasciitis process and reducing the hospital stay and patient discomfort. Multidisciplinary treatment is mandatory during this devastating infection.

An anterior-lateral thigh perforator flap on a recipient brachial-radial vein graft for complex wound reconstruction: a case report.

A case of challenging microsurgical reconstruction of a difficult defect in a radiated upper limb is reported. A difficult wound, with tendon and bone exposition, developed on the dorsum of the forearm in a 76-year-old patient; she had been radiated since almost 50 years and her left hand had also been revascularized twice with venous grafts between the humeral artery and the superficial palmar arch. After failure of a local flap, an anterior-lateral thigh perforator flap was successfully transferred with end-to-side anastomoses on the arterialized venous graft. Up to date follow-up shows a good outcome. The Authors discuss the case and review the indications for microsurgical reconstruction in difficult wounds after radiation and ischemic limb conditions.

The use of sentinel node biopsy and selective lymphadenectomy in squamous cell carcinoma of the upper limb. Usefulness of sentinel node biopsy to avoid useless lymphadenectomies in high-risk upper limb SCC.

BACKGROUND: Squamous cell carcinoma (SCC) is the second most common skin cancer in humans. Because the incidence of metastasis from SCC of the skin is rare, regional lymphadenectomy is generally not recommended for the patients with clinically node-negative disease. However, in patients with an intermediate and high risk of metastasis, evaluation of the lymph nodes to detect the absence of metastatic nodal disease is a difficult task. PATIENTS AND METHODS: The authors reviewed the pertinent demographic and surgical data in a consecutive series of six patients with squamous cell carcinoma who underwent sentinel lymph node staging. The tumour size was greater than 2 cm (T2) and the patients had clinically non-palpable regional lymph nodes (N0). All nodes were examined using haematoxylin-eosin staining. Sentinel Lymph Node Biopsy (SLNB) and Selective Lymphadenectomy (SL) using preoperative lymphoscintigraphy and intraoperative radiolymphoscintigraphy and vital dye injections was used to identify the sentinel lymph node avoiding complete axillary node dissection. RESULTS: No false-negative results were observed. At a median follow-up of 10 months (mean 15 months), neither local or regional recurrences in sentinel node-negative basins have been noted. CONCLUSIONS: Sentinel node biopsy is a minimally invasive staging procedure useful in identifying occult regional lymph node disease in selected patients with squamous cutaneous malignancies of the arm. Furthermore sentinel lymph node histology is possibly the most important negative predictor of early recurrence and survival in patients with American Joint Committee on Cancer stage I and II squamous cell carcinoma. Although sentinel node-negative patients are a prognostically favourable group, this small series of patients demonstrates that further studies to verify these findings and develop formal guidelines are indicated