Search

In conventional linear accelerators, to obtain flat profiles leading to uniform dose distribution in homogeneous medium, the flattening filter is usually applied on the beam path. In recent years, to obtain higher dose rates, there have been the options of flattening filter free (FFF) beams and it has been noticed that these have many advantages. The aim of this study was to clearly underline the advantages and the drawbacks of flattened filter free (FFF) beams in comparison with the flattening filter (FF) beams for different clinical contexts (planning target volumes locations).Two groups (planned with auto-planning VMAT, full and partial arcs) of eight patients each were analyzed: Group I (small planning target volume PTV, with average volume 48.9 ±44.4 cmUsing the 6MVFFF, the treatment delivery time was significantly reduced (p0.05). For larger PTVs, the number of MU increased by more than twice, and the p-value shown a significant difference (p= 0.008). The value of Dmax increased by 4%. On the contrary, for small volumes, the results were quite similar from 6MVFFF to 6MV except some differences in terms of MU.It is recommended to use 6MVFFF beam with small PTV volumes. Dose distributions are almost the same as with 6MV and there is a significant reduction of the treatment delivery time up to 57%. Due to the dose profile shape in FFF mode, the dose is lowered beyond the central axis for the FFF beams, and the additional MU allows the dose to be delivered away from the beam axis.

This study analyzed the challenges and benefits of the identification and promotion of a long-distance cycleway in high mountain areas with the aim of promoting Alpine eco- and geo-tourism. We also investigated the role of e-biking in discovering local geodiversity and geoheritage in a sustainable way. In particular, we focused on the path from Bormio to the Forni Glacier (Upper Valtellina, Italy), analyzed within the framework of the “E-bike” Interreg project. We performed a detailed analysis to select the points of environmental–geological interest (POIs), with a focus on geoheritage sites to increase the knowledge of the natural heritage of the area. Since these sites are widespread in the study area, within the frame of the “E-bike” project, we selected only the most exemplary ones, covering a wide spectrum of attractions, from a moving geosite (i.e., landslide) to a paradigmatic example of the effects of climate change (glacier). The “E-bike” path represents in its entirety a great opportunity to visit mountain and high-mountain landscapes, even for inexperienced mountain bikers, and to enjoy places rich in naturalistic and cultural values. Our interdisciplinary approach allows visitors to identify the sites of interest and export the structure of the project in different environmental and human contexts.

(1) Background: The role of the umbilical scar and its repositioning remains one of the most important surgical steps in the execution of any type of abdominoplasty, including those involving “inverted-t” or “fleur de lys” incisions. A consequence of this is a surgeon’s Hamletic dilemma: to keep or not to keep the original umbilical scar? (2) Methods: A retrospective observational study was conducted on all patients undergoing “T-inverted” abdominoplasty at the Department of Plastic Surgery of the Santa Maria alle Scotte University Hospital, Siena, between January 2018 and December 2020. Twelve months after the surgery we submitted to all patients the U-score questionnaire about their feelings about their umbilicus’s appearance. Patients could assign a score from 1 (very dissatisfied) to 4 (very satisfied) to each of the five items of the score. (3) Results: The average of the scores attributed by the nine patients in whom the navel was preserved is 13 (Range 10–17), while in patients on whom a navel reconstruction was performed, the mean score is 16.8 (Range 12–20). The mean score of patients with a reconstructed umbilicus is, therefore, statistically higher than that of the other group of patients (t-value = 3.88, p = 0.000374) with an average increase of 3.8 points. (4) Conclusions: We can state that the reconstruction of a new navel is the right answer to the Hamletic dilemma in patients having undergone vertical or anchor abdominoplasty.

(1) Background: The increase in the number of bariatric surgery procedures has led plastic surgeons to look for new approaches to improve outcomes of body-contouring surgeries. A major concern in brachioplasty is the scarring process. Here, we propose a novel technique to minimize the incidence of pathological or unsatisfactory scars from brachioplasty. A video of the entire procedure is provided. (2) Methods: From January 2016 to August 2020, we performed the "Jaws" brachioplasty on 16 post-bariatric patients. We evaluated the effectiveness of the technique through pre- and postoperative assessments by patients and surgeons, the Vancouver Scar Scale, and the detection of major and minor complications within 12 months of follow-up. (3) Results: Thirteen patients were female and three were male, with a mean age of 32.5 ± 6.8 years (range: 22-47 years). The BODY-Q© Arms Section scores improved significantly, with no incidence of major or minor complications over 1 year of follow-up, and favorable aesthetic outcomes. (4) Conclusions: We believe that the "Jaws" technique is a valid contribution to post-bariatric surgery, as it aims to solve specific aesthetic problems of scarring from brachioplasty. The small number of patients does not allow the comparison of our original technique to others previously described in the literature.

There are many instances in which sacrificing the umbilicus is unavoidable. Umbilical reconstruction (umbiliconeoplasty) is an important surgical procedure to complete the abdomen’s reconstruction and to give again a pleasant cosmetic appearance. To provide a complete overview of all surgical techniques for umbiliconeoplasty described in the literature. PubMed database was queried using ‘umbilical and reconstruction’, ‘umbilicus and reconstruction’, ‘navel and reconstruction’, ‘umbiliconeoplasty’, ‘neo-omphaloplasty’ or ‘umbilicaneoplasty’ to select the papers dealing with the reconstruction of the umbilicus. Sixty different techniques for the reconstruction of the missing umbilicus were described in 77 papers. Local skin flaps and the purse-string suture technique were the most frequently described techniques. The Three flaps technique, the Four flaps technique and the 2 Lateral rectangular pedicle lateral flaps technique were the most popular local flap techniques. Indications ranged from congenital pediatric defects to reconstruction during abdominoplasty. Several surgical techniques were described for umbilicus reconstruction. While there is not a universal algorithm for the choice of the technique, the surgeon may decide which technique to use based on other surgeons’ experiences reports. 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 .

Background Chronic wounds are one of the most important challenge for regenerative surgery. Plastic surgeon can use fat graft to increase wound healing because its growth factors can enhance tissue regeneration. In a recent study, the authors evaluated a reduction of pain in a cohort of patients submitted to breast reconstruction with breast implant and lipofilling, putting into evidence that growth factors in fat graft can reduce post-surgical pain. The aim of this work is to evaluate ultra-filtered fat graft potential in reducing pain in chronic wounds. Patients and methods Fifty new patients with chronic wounds of different etiology were recruited for this study and divided into two groups: A, treatment and B, control. Twenty-five patients per group. Negative pressure therapy dressing was applied after surgical debridement. Three days later patients in group A received ultrafiltered fat graft. Pain was evaluated with preoperative Visual Analogic Scale, repeated twice a day for 14 days and finally 21 days from procedures. Results In group A (treated patients), pain was lower. These data were confirmed even after 7 days. The overall statistical analysis of the average of all values (SD 1.72) confirmed that the differences were significant at the 95% with the Chi-square test and analysis of variance (P value Conclusions The ultra-filtered fat graft placed on the wound bed and edges was effective in reducing pain in chronic wounds. The reduction of pain was statistically significant.

Breast ptosis is characterized by severe volumetric deficiency of the upper pole, excess of skin in the lower pole and descent of the nipple-areola complex (NAC). Mastopexy, also known as breast lifting, is the surgical operation aimed to reshape the ptotic breast. Recurrence of breast ptosis after mastopexy is common but to the best of our knowledge no study before has measured it.The aim of this study was to measure the recurrence of breast ptosis after mastopexy in a prospective study.Female patients affected by unilateral or bilateral moderate or severe breast ptosis were enrolled in the study. All the patients underwent mastopexy performed only with the removal of skin excess following a Wise pattern. The jugular notch-nipple distance was measured before surgery, immediately after surgery and after 1, 3, 6 and 12 months.Ten patients were included in the study, four underwent unilateral mastopexy and six underwent bilateral mastopexy. The lifting of the NAC, measured in the immediate post-operative period, ranged from 3 to 8.5 cm, with an average value of 6.3 cm. This lifting, one year after surgery, ranged from 2 to 7 cm, with an average value of 4.6 cm. The percentage loss of the NAC lifting one year after surgery compared to the immediate post-operative time ranged from 12.5 to 41.7%, with an average value of 27.5%.In our case series, the lifting of the NAC obtained immediately after surgery showed an average loss of 27.5% one year after surgery. Even if limited by the low number of patients included, this pilot study is eye-opening on a very common phenomenon that occurs after mastopexy. The patients should be informed about the possible recurrence of the breast ptosis.

The most effective dissection technique for elevating flaps in body contouring is still controversial, particularly in high-risk massive weight loss (MWL) patients. LigaSure (Medtronic, Dublin, Ireland) is an energy device commonly used among different surgical specialties to reduce morbidity and improve outcomes. The aim of this study is to investigate the effectiveness of LigaSure Impact and LigaSure Small Jaw in body contouring after MWL compared with conventional technique.Patients who underwent abdominoplasty, mastopexy, brachioplasty and thigh lift after MWL at a single center from 1 December 2018 to 1 March 2020 were retrospectively reviewed. In each procedure patients were divided into two groups according to the dissection technique: LigaSure group and monopolar electrosurgery group. Patients characteristics, perioperative details and postoperative complications were evaluated.Fourty-five patients underwent abdominoplasty, twenty-six mastopexy, twenty brachioplasty and sixteen medial thigh lift. Using LigaSure, operative time was longer in abdominoplasty and thigh lift, but shorter in mastopexy and brachioplasty. Although not statistically significant, the amount of blood and serum recorded from drains in the first 36 hours was reduced in LigaSure groups. Additional analgesic intake was reduced with LigaSure as well as postoperative subjective pain. In all body contouring procedures statistically significant difference was found in days of hospital stay favoring LigaSure groups. Complications occurred most frequently in control groups compared to LigaSure groups.LigaSure Impact and LigaSure Small Jaw may be beneficial in improving outcomes because they might reduce fluids drainage, analgesics intake, hospital stay and postoperative complications.

(1) Background: The increase in the number of bariatric surgery procedures has led plastic surgeons to look for new approaches to improve outcomes of body-contouring surgeries. A major concern in brachioplasty is the scarring process. Here, we propose a novel technique to minimize the incidence of pathological or unsatisfactory scars from brachioplasty. A video of the entire procedure is provided. (2) Methods: From January 2016 to August 2020, we performed the “Jaws” brachioplasty on 16 post-bariatric patients. We evaluated the effectiveness of the technique through pre- and postoperative assessments by patients and surgeons, the Vancouver Scar Scale, and the detection of major and minor complications within 12 months of follow-up. (3) Results: Thirteen patients were female and three were male, with a mean age of 32.5 ± 6.8 years (range: 22–47 years). The BODY-Q© Arms Section scores improved significantly, with no incidence of major or minor complications over 1 year of follow-up, and favorable aesthetic outcomes. (4) Conclusions: We believe that the “Jaws” technique is a valid contribution to post-bariatric surgery, as it aims to solve specific aesthetic problems of scarring from brachioplasty. The small number of patients does not allow the comparison of our original technique to others previously described in the literature.

Autologous fat grafting (AFG), defined as the re-implant to the breast of fat tissue from different body areas, has been firstly applied to esthetic plastic surgery and then has moved to reconstructive surgery, mainly used for scar correction and opposite breast altering. Nevertheless, due to the potentially unsafe stem-like properties of adipocytes at the tumoral bed level, no clear evidence of the procedure’s oncological safety has been clearly documented at present. We retrospectively collected data of early breast cancer (BC) patients from 17 Italian Breast Units and assessed differences in terms of locoregional recurrence rate (LRR) and locoregional recurrence-free survival (LRFS) between patients who underwent AFG and patients who did not. Differences were analyzed in the entire cohort of invasive tumors and in different subgroups, according to prognostic biological subtypes. With a median follow-up time of 60 months, LRR was 5.3% (n = 71) in the matched population, 3.9% (n = 18) in the AFG group, and 6.1% (n = 53) in the non-AFG group, suggesting non-inferiority of AFG (p = 0.084). Building Kaplan–Meier curves confirmed non-inferiority of the AFG procedure for LRFS (aHR 0.73, 95% CI 0.41–1.30, p = 0.291). The same effect, in terms of LRFS, was also documented among different biological subtypes (luminal-like group, aHR 0.76, 95% CI 0.34–1.68, p = 0.493; HER2 enriched-like, aHR 0.89, 95% CI 0.19–4.22, p = 0.882; and TNBC, aHR 0.61, 95% CI 0.12–2.98, p = 0.543). Our study confirms in a very large, multicenter cohort of early BC patients that, aside the well-known benefits on the esthetic result, AFG do not interfere negatively with cancer prognosis.

in a historical moment where there is an increasing use of beauty center, we report a case of necrotizing fasciitis occurred after a pedicure, with the aim of clarifying the safety of these aesthetic treatments.we discuss a case of left foot necrotizing fasciitis as consequence of removing a plantar callus. The patient is a 49 years old man; he is hypertensive, and diabetic not controlled. We report our experience showing the clinical manifestation and the tricky profile of the patient; then we reflect on the safety profiles of these aesthetic treatments.some bacterial infections of soft tissue after pedicure and manicure are reported in Literature. Mycobacteria seems to play a prevalent role, mostly after a peculiar practice of "fish pedicure". Our experience shows how the combination between a patient with complicated profile and poor hygienic measures can have catastrophic consequences.the aim of this article is to raise awareness on the serious consequences that can arise from banal aesthetic procedures. Furthermore, we want to recommend more control over these treatments performed in Beauty Salon, considering the large turnout of people, even clinically sensitive.

The development of research in genetic and biochemical fields has made it possible to investigate certain metabolic aspects of the microenvironment of chronic skin lesions, including altered cell signalling, highlighting its importance in determining the blockage of repair processes. The purpose of this prospective observational study is to evaluate the efficacy of a medical device consisting of a polyester scaffold enriched with an oleic matrix with controlled release of ROS in the management of LABC skin lesions. During the period from October 2018 to March 2020, 20 patients with locally advanced breast cancer were enrolled and ten were treated with the devices abovementioned. After 30 days of treatment all patients treated reported a general improvement in local conditions with reduction in ulceration area, exudate and odour. The results suggest that the application of these devices even in particular conditions (healthy and neoplastic tissue) does not lead to the onset of negative effects due to the release of ROS, though their role in tissue repair requires further study to fully understand their potential and increase the fields of application of the device by exploiting its modulation capabilities.

Skin is the most exposed surface of the human body, separating the microbe-rich external environment, from the sterile inner part. When skin is breached or its homeostasis is perturbed, bacterial, fungal and viral pathogens can cause local infections or use the skin as an entry site to spread to other organs. In the last decades, it has become clear that skin provides niches for permanent microbial colonization, and it actively interacts with microorganisms. This crosstalk promotes skin homeostasis and immune maturation, preventing expansion of harmful organisms. Skin commensals, however, are often found to be skin most prevalent and dangerous pathogens. Despite the medical interest, mechanisms of colonization and invasion for most skin pathogens are poorly understood. This limitation is due to the lack of reliable skin models. Indeed, animal models do not adequately mimic neither the anatomy nor the immune response of human skin. Human 3D skin models overcome these limitations and can provide new insights into the molecular mechanisms of microbial pathogenesis. Herein, we address the strengths and weaknesses of different types of human skin models and we review the main findings obtained using these models to study skin pathogens.

Skin is the most exposed surface of the human body, separating the microbe-rich external environment, from the sterile inner part. When skin is breached or its homeostasis is perturbed, bacterial, fungal and viral pathogens can cause local infections or use the skin as an entry site to spread to other organs. In the last decades, it has become clear that skin provides niches for permanent microbial colonization, and it actively interacts with microorganisms. This crosstalk promotes skin homeostasis and immune maturation, preventing expansion of harmful organisms. Skin commensals, however, are often found to be skin most prevalent and dangerous pathogens. Despite the medical interest, mechanisms of colonization and invasion for most skin pathogens are poorly understood. This limitation is due to the lack of reliable skin models. Indeed, animal models do not adequately mimic neither the anatomy nor the immune response of human skin. Human 3D skin models overcome these limitations and can provide new insights into the molecular mechanisms of microbial pathogenesis. Herein, we address the strengths and weaknesses of different types of human skin models and we review the main findings obtained using these models to study skin pathogens.

Visceral adipose tissue has been linked with cardiovascular events. Visceral adiposity index (VAI) is a routinely applicable tool for evaluation of visceral adipose dysfunction and linked to 10 year-cardiovascular risk. No previous studies have evaluated the changes over time of the VAI in patients who underwent different types of bariatric surgery. We reviewed data of 42 patients who underwent laparoscopic sleeve gastrectomy (LSG) and 61 patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB). VAI, lipid profile, and several anthropometric variables were measured before and after 5 years following surgery. During the studied time period, the BMI was similar between LSG and LRYGB patients (34.1 vs 31.6; p = 0.191), but the percentage of total weight loss (%TWL) for LRYGB was significantly higher than LSG (31.3% vs 23.0%; p < 0.001). LRYGB patients had a significant improvement of all lipid parameters evaluated over time, while LSG patients experienced only a reduction in triglycerides (TG) levels and an increase in HDL cholesterol (HDL-C). VAI values were similar in the two groups at baseline as well at the last follow-up point (5-year VAI, LSG: 0.93, RYGB: 0.93; p = 0.951). At multivariate regression analysis, 5-year-%TWL was the only independent predictor of a greater amount of VAI reduction over time. Bariatric surgery, independent of the type of surgical procedure, decreases the cardiovascular disease (CVD) risks due to weight loss and improvement of lipid parameters. VAI could be a useful tool to better identify eligible patients for bariatric surgery and to determine the success of surgery.

Introduction: Acellular dermal matrix (ADM) were introduced in the early 2000s and more recently permitted new protocols for breast reconstruction allowing a short operative time with improved outcomes until the new muscle-sparing breast reconstruction proposed in 2014 using the Braxon® ADM. The aim of this research is to propose a technique to improve the aesthetic outcome using Braxon ADM with prepectoral implants. Materials and Methods: The enrolled patients were submitted to a nipple skin-sparing mastectomy leaving 1 additional centimeter of subcutis on the proximal part of the upper pole of the breast (see Surgical Technique). Aesthetic outcomes were compared to those obtained with traditional breast reconstruction with prosthesis and the Braxon ADM placed in the prepectoral space. Mean values of aesthetic outcomes were analyzed using the Student t test, and the κ test was used to analyze interobserver variability. Results: The overall aesthetic score was improved of 29.6% of the patients; in particular the most improved score was that for contour (+98.01%). Statistical significance was found for contour, upper pole definition, and total score average (p < 0.05).The κ test showed interobserver variability with a good level of agreement on contour (κ = 0.832). Conclusions: The proposed technique has allowed attainment of good results in terms of aesthetic outcomes. In a small sample we did not register any particular complications but we verified a better satisfaction on the evaluation of the aesthetic result (level of evidence: 3).

Peripheral nerve injury is commonly attributable to traffic and industrial accidents, natural disasters, and war damage. Destruction of nerve fibers results in denervation of targeted muscles, whic...

Reconstruction of the lower extremities has always been a challenge for Plastic Surgeons. The essential nature of the anatomical structures and the lack of usable excess tissues for reconstruction,...

Median and Ulnar nerve palsy is a devastating condition that compromise hand function. A procedure of tendon transfer may be helpful to restore the movements by linking palsy muscles to other muscles able to contract. Scientific discoveries and technological innovations have profoundly changed this kind of surgery; studies on sarcomeres, for example, changed the concept of tensioning. To date we know that muscle strength and its contraction capacity depends on many factors (not only tensioning) such as sarcomeres length, cellular cytoskeleton and extracellular matrix composition: all of these factors interact together and in a ways not still fully understood, determining the complex concept of "movement." Technology made possible the production of smaller and more complex prostheses so to open new frontiers for modulation of the tendon length during grasping. These devices, currently studied on computer models, on cadaver or on animals, behaved great impetus to research but are still not suitable for implantation in humans. Challenges are still numerous: for example obtain more biocompatible implantable device, find new surgical approach, new ways to obtain better results for this kind of patients.

The number of post-bariatric surgical procedures is increasing in time. Post-bariatric patients must be carefully evaluated preoperatively, and they must be considered a particular group of patients in plastic surgery. Aspiration is an occurrence in surgical patients that can cause transient pneumonitis but, in some cases, it can progress to severe clinical acute lung injury or in acute respiratory distress syndrome. The aim of this research is to underline a correlation between one anastomosis bypass-minigastric bypass (OAGB-MGB) and biliar or gastric aspiration. We performed an analysis of literature and a systematic review of our post-bariatric patients who underwent body contouring procedures which required general anaesthesia from 2013 to 2018 and divided them in two groups: OAGB-MGB group and other bariatric procedures in order to compare the rate of aspiration/pneumonia occurred in time. We collected 423 patients for 536 procedures and 9 complications. In the OAGB-MGB group, there was the highest rate of reflux/aspiration during anaesthesia induction (3.5%, 8 patients) compared with the other group (0.51%). Risk ratio of OAGB-MGB group vs other procedures is 7.054. Literature confirmed high risk of biliar reflux after OAGB-MGB procedure. This study underlined a significant correlation between OAGB-MGB and reflux/starting general anaesthesia in post-bariatric patients. In our experience we believe that it can be useful enlarge the pre-operatory fasting period and positioning a nasogastric tube during anaesthesia induction that can be performed moreover, in anti-Trendelenburg position, in order to prevent pulmonary aspiration.

“Vaginoplasty is the art of plastic repair of herniations of the urethra, bladder and rectum into the vaginal sheath”; Robert Toll defined the term “vaginoplasty” in his manuscript titled “VAGINOPL...

Marjolin's ulcer is an aggressive disease arising in chronic wounds and cutaneous scars. Corbo et al define Marjolin's ulcer an often overlooked or misdiagnosed tumor. We report a case of Marjolin's ulcer arose in a burn scar of a 51-year-old man who sustained a burn in childhood. A punch biopsy showed squamous cell carcinoma. The lesion was surgically removed with wide excision. The loss of substance was covered with a partial-thickness skin graft, harvested from the left thigh with dermatome. Histological examination confirmed a well-differentiated squamous cell carcinoma. Burn scars are the most commonly associated with these tumors, but other lesions may initiate this malignant transformation. The most common type of tumor reported in a Marjolin's ulcer is squamous cell carcinoma, but Pavlovic et al reported other malignancies.

To analyze temporal changes of B-type natriuretic peptide (BNP) used as index of heart remodeling in left-sided breast cancer patients after radiotherapy (RT) and its relationship with dosimetric parameters.BNP and dose-volume parameters for heart and ventricle were collected in 59 patients (median age 58.0 years) during a 1-year follow-up. Biochemical measurements were performed before the RT treatment (T0), at 15 days during RT (T(15day)), at the end of RT (T(endRT)), and then at 1, 3, 6, 9, 12 months (T1, T3, T6, T9 and T12). A logistical regression analysis was performed to identify demographic characteristics, dosimetric variables and risk factors associated with increased values of BNP.The ratio between the BNP value at T12 and the BNP value at T0 (BNP(T12)/BNP(T0)) increased significantly (p0.01). A significant association was found between the variation of BNP values after 1 year and the isodose received by 50% of the volume (D50% [Gy]) both to the heart (p = 0.03) and ventricle (p = 0.04).BNP plasma levels could provide additional information about subclinical RT-induced cardiotoxicity earlier than traditional ecocardiographic data.

Medial contouring of the thigh is frequently requested to improve appearance and function of medial thigh deformities, following massive weight loss or aging process. This surgical procedure can be associated with a significant rate of complications. Our aim was to consider the complications and outcomes according to the performed technique, through a wide and comprehensive review of the literature. A search on PubMed/Medline was performed using ′′medial thighplasty′′, ′′medial thigh lifting′′ and ′′technique′′ as key words. As inclusion criteria, we selected the clinical studies describing techniques of medial thighplasty. We excluded the papers in which complications related to medial thighplasty were not specified. We also excluded literature-review articles. We found 16 studies from 1988 to 2015. Overall, 447 patients were treated. Different techniques were applied. Complications were observed in 191/447 patients (42.72%). The most frequent complications were wound dehiscence(18.34%) and seroma (8.05%). No major complications, such as thromboembolism and sepsis, were observed. Minor complications occurred in a high percent of patients, regardless of the performed surgical procedure. Patients should be informed about the possible occurrence of wound dehiscence and seroma, as common complications associated with this surgical procedure.