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Since the establishment of the major Trauma Network in England, the treatment of patients with severe injuries (such as open fractures of the lower limb) has been concentrated into specialized trauma centers with greater resource consuption and cost increase.

Breast conserving surgery has been reserved for patients with favorable proportion between tumor dimensions and breast size. Introduction of local flaps from the lateral thoracic region has widened the indications for breast conserving surgery, by allowing surgeons to perform wider excisions, thus yet be able to ensure tumor-free surgical margins and a good aesthetic result. We have used lateral intercostal perforator flaps and flaps harvested on the lateral thoracic artery and lateral thoracic artery axial flap in patients with small breasts and an unfavorable tumor to breast size proportion. From May 2015 to October 2016, 19 patients with breast tumors have been treated with BCS and immediate volume replacement reconstruction by pedicle perforator flaps from the lateral thoracic region. In 15 patients lateral intercostal artery perforator flaps or lateral thoracic artery perforator flaps were used after quadrantectomy or wide local excision, in 3 patients as volume replacement after mastectomy and in 1 patient after mastectomy following previous augmentation mammoplasty. In all patients, good breast symmetry was achieved, with no major complications. Fibrosis of the flap and residual breast parenchyma, with volume reduction were noticed after postoperative radiotherapy in thin patients or flaps with little subcutaneous fat. Perforator flaps from the lateral thoracic region should become the gold standard for reconstructions after breast conserving surgery involving less than 20% of the breast volume or after mastectomy in patients with small breasts. The operating procedure is safe, quick and allows sparing of the latissimus dorsi muscle and thus minimal donor site morbidity, as well as an excellent aesthetic result.

Breast reconstruction is increasingly present in the treatment of breast cancer. It may be accomplished with implants or autologous tissues. This cross-sectional study evaluates patients satisfaction and quality of life in women after successful autologous or implant breast reconstruction.109 women who successfully underwent breast reconstruction between 2007 and 2016 were included. The patients completed the BREAST-Q questionnaire at follow-up visits. Additional data were collected retrospectively from the hospital charts regarding complications, smoking, chemotherapy, radiotherapy, unilateral or bilateral reconstruction, BMI and comorbidities. Mann-Whitney U Test was applied to evaluate differences between the autologous breast reconstruction group (n = 50) and the implant breast reconstruction group (n = 59).Women with a successful autologous reconstruction were significantly more satisfied with their reconstructed breasts than women with successful alloplastic breast reconstruction as measured by the BREAST-Q breasts module (p = 0. 00596), psycho-social well-being module (p=0.04) and sexual well-being module (p=0.00068). Furthermore, there is a higher degree of satisfaction in patients who have not undergone radiotherapy, with no complications and with a normal BMI for implant reconstruction group as well as in non-smokers, and bilateral reconstructions for flap reconstruction group.The findings of our study are in agreement with the data found in the literature, attributing greater satisfaction with physical, mental and social wellbeing, as well as with elements having repercussion on sexual wellbeing, to autologous breast reconstruction.Autologous breast reconstruction leads to higher patient satisfaction than implant breast reconstruction. This study may help patients and medical teams in their decision-making process regarding breast reconstruction. This pilot study opens several questions that need further investigations in a larger prospective studyKeywords: Breast reconstruction, breast-Q, satisfaction, implant, autologous tissue.

Rhinophyma is a disfiguring condition etiologically related to rosacea and due to hypertrophy of the sebaceous glands of the nose. It leads to a progressive thickening of the skin up to the development, in some cases, of severe deformities that result in significant functional deficits and serious cosmetic damage. We report a case of giant rhinophyma consisting of 2 large masses that interfered with feeding and respiration of the patient, and we describe the surgical treatment by resection with electrosurgery and razor-thin saline jet (Versajet Hydrosurgery System). This combined approach is simple and effective for the treatment of severe cases of rhinophyma.Il rinofima è una condizione deturpante dovuta ad un ipertrofia delle ghiandole sebacee del naso eziologicamente correlata alla rosacea. Essa porta ad un progressivo ispessimento della cute fino allo sviluppo, in alcuni casi, di gravi deformità che determinano importanti deficit funzionali nonché gravi danni estetici. Noi riportiamo un caso di rinofima gigante composto da 2 grosse lobulazioni che interferivano con l’ alimentazione e la respirazione del paziente e ne descriviamo il trattamento chirurgico mediante resezione con elettrobisturi e rimodellamento con bisturi ad acqua Versajet Hydrosurgery System. Questo approccio combinato risulta semplice ed efficace per il trattamento di casi gravi di rinofima.

Radial and anterolateral thigh flaps in head and neck surgery

surgical mandibular reconstruction with free flaps

Performing osteotomies with piezoelectric bone scalpel is also possible with bones of larger diameter/thickness. At the same time, adjacent soft tissues are not in danger from cutting or thermal damage, reducing the risk of damaging neurovascular structures - which is of primary importance in hand and reconstructive microsurgery. These features contribute to the safety and easy execution of the procedure. The resulting bony cut is precise and permits immediate and safe bone fixation. Osteotomy of bones of >1 cm thickness takes 20-30% longer than when using a conventional oscillating saw, though the increased safety of the procedure more than compensates for this. Three cases are presented, illustrating of the use of Genera Ultrasonic for cutting bones of major thickness (metacarpal, fibula and rib) without any complication. Because of its selectivity for bony tissue, precision and ability to protect soft tissues we also advocate the use of the Genera piezoelectric bone scalpel in hand and reconstructive microsurgery.

Abdominal donor site flaps and in particular DIEAP (Deep Inferior Epigastric Perforator), are becoming the gold standard for autologous breast reconstruction. The use of this flap has been limited by concerns over vascular anatomy of the abdominal wall. An accurate preoperative evaluation of the location, size and course of perforator vessels is essential. For this purpose, Computed Tomographic Angiography (CTA) has become increasingly adopted, as it has been shown to improve operative outcomes and decrease operating times. We present our experience of using CTA of the abdomen as part of our standard preoperative assessment of the patients who will undergo autologous breast reconstruction with DIEAP flap. From January 2007 to July 2009, 37 patients underwent immediate or delayed breast reconstruction with DIEAP flap, of these 35 were studied preoperatively with CTA. Moreover, in the first stage of the study we compared CTA with other techniques, such as unidirectional Doppler probe and twodimensional Color Doppler. CTA has been shown to be the most accurate modality for perforator mapping, with high sensitivity, high specificity and high correlation with intraoperative findings. Our experience with CTA has been highly beneficial. CTA may guide operative technique and improve perforator selection in every cases, decreasing surgical times and complication rate. Moreover, in difficult cases such as comorbidities or previous abdominal surgery, it can guide the selection of the most appropriate operation.

In the following paper we exposeour last two year experience on treatment of chronic cutaneous wounds.

Damage to the weightbearing surface of the foot is a challenge for the reconstructive surgeon. The aim is to reconstruct the skeletal tripod and soft tissue, allowing the patient to walk normally. We report the case of a patient admitted with an acute right foot open fracture of the second, third, fourth, and fifth metatarsal bones. After debridement of all nonvital tissues, the patient required reconstruction of the metatarsal heads (third, fourth, and fifth) plus soft tissue coverage. We then performed a reconstruction with a free osteocutaneous fibular flap, insetting the bone perpendicular to the long axis of the metatarsal bones. This configuration allowed the reconstruction of the foot skeletal tripod. A second free flap, a thin radial forearm flap, was added during the revision surgery to improve the venous drainage of the skin paddle of the fibular flap and avoid tension after skin closure. At 1-year follow-up, the patient was able to walk entirely weightbearing on the forefoot, returning to her previous employment with no limitation in physical and recreational activities. To our knowledge, this is the first description of the use of a chimeric osteocutaneous fibular flap, oriented transversely, to reconstruct a complex bone/soft tissue defect after a traumatic loss of multiple metatarsal heads.

Surgical site infection in implant-based breast reconstruction is a complication with variable incidence reported in the literature. Due to potential loss of implant and reconstruction, it can have a strong psychological impact on patients. Background and objectives: This study aimed primarily at analyzing the current status of the surgical site infection (SSI), (type, time of onset, clinical presentation, pathogens and management) in patients who underwent implant-based breast reconstruction at our Breast Unit. Secondarily, we wanted to establish whether introduction of a new, updated evidence-based protocol for infection prevention can reduce SSI in implant-based breast reconstruction. Materials and Methods: A single-center retrospective study was performed primarily to evaluate the incidence and features of SSI after implant-based breast reconstruction from 2007 to 2020. In June 2020, a protocol for prevention of SSI in implant-based breast reconstruction was introduced in clinical practice. Secondarily, a data analysis of all patients who underwent implant-based breast reconstruction in compliance with this protocol was performed after preliminarily assessing its efficacy. Results: 756 women were evaluated after mastectomy and implant-based breast reconstruction for breast cancer. A total of 26 surgical site infections were detected. The annual incidence of SSI decreased over time (range 0–11.76%). Data relating to infections’ features, involved pathogens and implemented treatments were obtained. Since the introduction of the protocol, 22 patients have been evaluated, for a total of 29 implants. No early infections occurred. Conclusions: Surgical site infection rates at our Breast Unit are comparable to those reported in the literature. The SSI rates have shown a decreasing trend over the years. No SSI has occurred since the introduction of the prevention protocol for surgical site infection in June 2020.

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Background:. Chest-wall contouring surgery (chest-wall reconstructive surgery) is often the first surgical procedure in female-to-male (FtM) gender reassignment surgery (GRS). The main goal of this procedure is to create an aesthetically pleasing male-like chest contour. No universally accepted algorithm exists for detection of the appropriate surgical technique. Also, there is no tool for objective evaluation of the quality of life and satisfaction of these patients after the operation. Methods:. This study involves a single-center clinical trial assessing the patients who underwent subcutaneous mastectomy in FtM GRS between 2003 and 2019. The selection of patients was based on the new “simplified” algorithm consisting of 2 different surgical techniques: the semicircular and the double-incision with free nipple grafting. The selection was based on 3 criteria: breasts size, breast ptosis, and skin elasticity. The outcomes and complication rates were collected and analyzed. The patients’ satisfaction and Quality of Life was assessed with a 5-point Likert scale questionnaire, specifically conceived for FtM patients. The aesthetic evaluation was performed using a 5-point Likert scale dealing with the 5 items featuring as the main goals of GRS. Results:. 184 mastectomies were performed in 92 FtM GRS patients. The overall reoperation rate was 11.9%. The patient survey revealed both a high satisfaction rate and a good aesthetic result (4.4/5). Conclusions:. The proposed algorithm facilitates the selection of the most suitable technique for top surgery. The patient satisfaction rate evaluated by the proposed Health-Related Quality of Life questionnaire confirmed the outcomes of the use of the algorithm. Further studies to validate the proposed evaluating tools are needed.

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Background In microsurgical reconstruction, vascular obstruction occurs in approximately 20% of patients. Close monitoring is central to their care. Clinical/Doppler detection of vascular obstruction could be enhanced by thermography. Methods A diagnostic test design included consecutive cases of hospitalized patients, ≥18 years old, who underwent surgery with free flaps. Two researchers separately evaluated patients with clinical/Doppler methods and thermographic camera hourly for 24 hours, every 2 hours for the next 24 hours, and then every 3 hours until discharge. The gold standard was visualization of thrombus or vascular obstruction during surgical reintervention. Sensitivity, specificity, positive/negative predictive value (PPV/NPV), and a delta temperature receiver operating characteristic (ROC) curve were calculated. Results A total of 2,364 tests were performed with a thermographic camera in 40 patients (31 females, 9 males) aged 50.12 ± 9.7 years. There were 28 deep inferior epigastric perforator, 5 anterolateral thigh, 3 radial, 2 scapular, 1 fibular, and 1 anteromedial thigh flaps included. Six (15%) had postoperative vascular obstruction (5 venous and 1 arterial). One flap developed partial necrosis and one total necrosis (overall survival 97.5%). ROC curve (area 0.97) showed the best results at ≥ 1.8°C of difference to the surrounding skin. Considering two consecutive positive evaluations, the sensitivity was 93%, specificity 96%, PPV 57%, and NPV 99%. The thermal imaging camera allows to identify the obstruction between 2 and 12 hours before the clinical method. Conclusion Utilizing a thermographic camera can reduce detection time of vascular obstruction by several hours in microvascular free flaps that include the cutaneous island. This method proves useful for early diagnosis of postoperative vascular obstruction.