Search

E-cadherin (CDH1 gene) germline mutations are associated with the development of diffuse gastric cancer in the context of the so-called hereditary diffuse gastric syndrome, and with an inherited predisposition of lobular breast carcinoma. In 2019, the international gastric cancer linkage consortium revised the clinical criteria and established guidelines for the genetic screening of CDH1 germline syndromes. Nevertheless, the introduction of multigene panel testing in clinical practice has led to an increased identification of E-cadherin mutations in individuals without a positive family history of gastric or breast cancers. This observation motivated us to review and present a novel multidisciplinary clinical approach (nutritional, surgical, and image screening) for single subjects who present germline CDH1 mutations but do not fulfil the classic clinical criteria, namely those identified as—(1) incidental finding and (2) individuals with lobular breast cancer without family history of gastric cancer (GC). This manuscript was supported by the Italian Ministry of Health (Project Code GR-2016-02361655) and was partially supported by the Ricerca Corrente and 5 × 1000 funds.

Split-thickness skin graft is one of the most used procedures in plastic surgery. This procedure involves numerous painful dressings at the donor site. α-Tocopherol acetate has anti-oxidative and anti-inflammatory properties and it can reduce the local bacterial growth, thereby promoting wound healing. We designed a prospective study to evaluate the effects of two different kinds of dressings at skin graft donor sites. A total of 30 patients were subjected to daily dressings with α-tocopherol acetate oil and traditional moist gauzes (group 1). Another 30 patients were subjected to dressings every 4 days with α-tocopherol acetate oil and silicone-vitamin E gauzes (group 2). Healing time, infection rate, patient's pain perception and costs were evaluated in both the groups. No statistically significant difference was found in terms of healing time. The infection rate was slightly different in the two groups. Significant reduction of pain perception was detected in group 2. In the same group, significant reduction in the total cost of the treatment was also observed. α-Tocopherol acetate oil and silicone-vitamin E gauzes may represent a safe, simple, painless and inexpensive method for improving skin graft donor site healing.

Capsular contracture is one of the most frequent complications following breast augmentation where the capsule begins to squeeze or contract upon itself. The incidence of this phenomenon varies between 0.5 and 30 %, according to the experience of the plastic surgeon. The authors discuss the use of periprosthetic fat transfer in capsule contracture following breast reconstruction. Lipofilling fits well with the breast tissue over time and it adapts to the patient in a very natural way following weight and structural changes. There is still a lack of standardization in the techniques used, but trends towards time management and simplification of technique are appearing. Two cases are described.

Seromas and hematomas are relatively common complications of a variety of surgical procedures. In plastic surgery, they may occur in the postoperative period of abdominoplasty or abdominal wall reconstruction, mastectomy or breast reconstruction, lymphadenectomy, or voluminous neoplasm excision. Furthermore, in our experience, seromas are particularly common in surgical procedures involving the use of biological substitutes [1]. Clinical treatment of seromas is usually performed by repeated evacuation by means of suction using an appropriately sized syringe (usually 10-50 mL in volume) according to the amount of fluid to be evacuated [2]. In some cases, an ultrasound examination can highlight the depth, volume, and extension of the fluid. In the case of seromas that are more than 100 mL in volume, the use of several syringes is necessary. Whenever a syringe is filled, it should be replaced or depleted by unplugging it from the hypodermic needle, thus exposing the patient to a high risk of infection. Therefore, negative pressure cannot be maintained continuously [3]. In order to avoid these issues, we have developed a new and simple method that allows us to reduce the material used and to minimize the risk of infection. This device involves the use of basic materials that are easily available in every hospital: a hypodermic needle, preferably a 20 G syringe needle, and high-vacuum Redon drainage. For this system, we used a high-vacuum Redon bottle (Drainobag 300V Lock, B-Braun, Melsungen AG, Germany); however, any kind of drainage can be used. First, it is necessary to make an oblique incision in the terminal portion of the rubber connector, taking care not to excessively shape the rubber in order to maintain the negative pressure. It is now sufficient to plug the connector into the needle hub to achieve the drainage system (Figs. 1, ​,2).2). Usually, an accurate plug between the needle and the connector is sufficient to maintain the negative pressure. To avoid disconnections, due, for example, to the stretching of the drainage tube, a plaster may be added to the connection. Fig. 1 Equipment for seroma drainage system: a 20 G hypodermic needle (alternatively a 21 G hypodermic needle or a needle cannula), high-vacuum Redon drainage, and a blade. Fig. 2 The assembled seroma drainage system. In the box, the system with the cannula needle. After pricking the skin and identifying the seroma, it is possible to open the drainage. The liquid will be drained from the drainage system without the use of different syringes. If a change of the drain site is necessary, simply close the Redon, prick the skin in another site, and reopen the drainage. It will suck the liquid without losing the negative pressure. This simple technique offers many advantages such as the availability of the required materials, lower risk of infection due to absence of material changing, a reduction in the risk of losing seromas (possible during the syringe changes), easier handling of the needle as compared to the whole syringe, a reduced number of devices with a decrease in costs, and higher accuracy of the drained fluid volume quantification. This easy drainage method can be used daily for both seromas and liquid hematomas. It is also possible to connect a cannula needle [4] as an alternative to the simple needle. This can be attached to the skin appropriately in order to obtain permanent aspiration. This technique appears to be more accurate and cheaper than traditional drainage methods and can be an excellent alternative in voluminous seroma drains.

Skin extender is a very useful method to repair wounds when oedema and skin retraction make a direct suture impossible. We have developed a new, simple and cheap way to prepare skin extenders based only on elastic vessel loops and metal clips stapler commonly used for skin suture and available in any operating room. This simple method can be performed both in the operating room and at the patient bedside, even under local anaesthesia, causes no bleeding and appears to be inexpensive and rapidly usable and should be made readily available in any hospital.

A 63-year-old man, unable to walk and a candidate for a knee prosthesis, was referred to u sfor a painful ulcer of the right knee of 12 months' duration. He denied any history of recent trauma or previous surgery. Physical examination revealed a 5.5 cm×4.0 cm ulcer of the medial aspect of the right knee (Fig. 1). An injection of paraffin oil into the knee 60 years before to treat a post-traumatic sequela was the only risk factor recorded during the medical history taking. There were no comorbidities such as diabetes, heart disease, or atherosclerosis. Doppler ultrasonography was performed in the lower extremities, but no peripheral arterial disease was found. The ulcer was painful, with smooth, erythematous, and indurated skin, but without exudates or edema. The bacteriological examination revealed no growth. The patient did not have any symptoms such as fever or lymphocytosis. Fig. 1 (A) Right knee at the time of admission. A 5.5 cm×4.0 cm ulcer was present, surrounded by smooth, erythematous, and indurated skin. (B) Radiography scan of the right knee. Soft tissue swelling and many dense, rounded, and streaky calcifications. ... Wide surgical debridement was performed. The specimen removed included a large piece of skin overlying the knee joint and the anterior aspect of the lower leg down to the ankle, and the underlying subcutaneous fat and skeletal muscle. Macroscopically, the typical lobulated fatty material mixed with scattered small nodules having a nearly transparent oily cut surface was not observed within the lesion. Histologically, sporadic vacuolated spaces of different sizes were detected within the adipose tissue with surrounding multinucleated giant cells and foamy histiocytes. There was no evidence of any paraffin, which had evidently been completely absorbed and replaced by dense fibrous connective tissue with an "embalmed-like" aspect. We concluded that the paraffin oil had been removed by macrophages during the long intervening period of time. This was confirmed by three sets of data: the histological results suggestive of an oleogranulomatous reaction to foreign material; the radiographic scan (Fig. 1); and the magnetic resonance imaging (MRI) examination showing irregular rounded and streaky calcifications, atypical opacities, fibrosis, and thickening of soft tissue with unusual architectural distortion of the lower limb. Once the tissue was debrided (Fig. 2), a temporary wound closure at the defect site was achieved by application of vacuum assisted closure therapy. Finally, a right anterolateral thigh free flap with end-to-end anastomosis to the anterior tibial vessels was performed to cover the tibia and a skin graft was placed over the knee (Fig. 2). Fig. 2 (A) Post-debridement view of the right lower limb and (B) at six-month follow-up after free right anterolateral thigh flap reconstruction. Paraffin oil was frequently used in the past to fill up defects in subcutaneous tissue [1]. This method has been abandoned because of several reports of serious local complications (formation of paraffinoma, inflammatory reactions, tissue necrosis, and sinus tract formation) and systemic complications (pulmonary and cerebral embolism) [2]. Although breast and facial paraffinomas are well-known and recognized complications of augmentation paraffin injections, only three patients, including the present case, have been reported to be affected by knee paraffinoma. In a 27-year-old man, a successful attempt was made to produce swelling and inflammation of a knee-joint to avoid military service. Since then, he has had attacks of painful swelling of the knee about once a year [3]. A 90-year-old man was reported to have a swollen, painful knee and a history of paraffin injections that had been present for more than 3 months [4]. He admitted self-injections of paraffin to his own knee in an attempt to avoid military service during the Second World War and experienced intermittent episodes of suppuration and fistula formation in the following years [4]. Our case is the first non-self-induced knee paraffinoma. Paraffinomas may present with different features, from a painless mass to a destructive ulcer simulating carcinoma [5]. Dense fibrosis causing streaky opacities and bizarre architectural distortion without erosions are the conventional findings on radiographic scan. Flocculent, amorphous, ring-shaped, or rounded calcifications may also be present within the involved tissues [2,5]. The plaque-like MRI signal intensity is low to intermediate on both T1-weighted and T2-weighted sequences, whereas the signal intensity of the round component is low on both T1-weighted and T2-weighted sequences and is markedly suppressed on the fat-suppression sequence. Our long experience in managing post-paraffin oil complications [1] allowed us to reach diagnoses by detailed medical inquiry, despite the aspecificity of the radiographic investigation and the long time interval between the primary injections and the symptoms. We would like to highlight the limits of diagnosis of paraffinoma affecting an unusual site such as the knee by means of radiological and histological examination without a relevant clinical history. This paper emphasizes the importance of collecting detailed clinical information because paraffinomas may develop in unusual sites even decades after primary injections and paraffin oil may not be found.

The closure of any circular or asymmetric wound results in puckering or excess of tissue known as dog ears. Tissue dynamics, wound geometry, surface contour, and surgical technique affect dog ear formation [1,2]. Despite good preoperative planning for skin management techniques including Burow's triangle, V-Y advancement flap, M-plasty [3], and S-plasty [4], and despite following intraoperative procedures including proper undermining of a shallow wound, proper 90° angle of the scalpel blade, precise suture placement, and removal of excess underlying fat, sometimes a dog ear occurs anyhow. Methods for correcting dog ears include excision of the excess tissue in the shape of a triangle, crescent or ellipse; excision of conical folds of tissue at the end of the wound in the same direction as the long axis of the original wound; and excision of the dog ear at a 120° angle to the long axis of the existing excision line in a shape resembling a hockey stick [5]. They are extensively described in the literature, but they all lead to wound extension. Only M-plasty allows for reduction in the scar's length but produces a double-tailed scar, so if the total length with the two tails is considered, the new scar is still longer than the original one. We have developed a new and easy technique for dog ear correction without extending the length of the original wound.

Summary: Lower-pole shaping of the breast is sometimes a difficult challenge when performing vertical mammoplasty. The problems mostly encountered are too large breast bases, persistent dog ears, which require long incision, and poor breast projection. We report a modification of the technique that we use in breast reduction so as to better shape the lower pole and to reduce revision surgery.