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Ex-obese patients present with redundancy of abdominal skin and soft tissue due to massive weight loss (MWL). The plastic surgeon can restore the body shape through body contouring procedures. Hence the need to adequately direct patients to body contouring by identifying suitable candidates exists. Our work aims to retrospectively analyze the abdominoplasty complications in our case series to identify associated risk factors and evaluate the effect of combined procedures on abdominoplasty outcomes.We retrospectively investigated predictive factors of abdominoplasty procedure complications on 213 MWL patients who received abdominoplasty with and without rectus sheath plication, abdominal liposuction, and other body contouring procedures. We identified risk and protective factors with univariate and multivariate regression analysis. Furthermore, we assessed the impact of additional procedures on the complication rates.The overall complication rate was 49.8% (26.8% minor complications; 23% major complications). The delayed wound healing rate was 27.7%, and the revision surgery rate was 25.8% (14.7% early revision; 14.2% late revision). These results were compared with literature reports. Several negative predictors emerged as non-modifiable (advanced age, diabetes mellitus, surgical mode of weight loss) or modifiable (preoperative obesity and body mass index (BMI); active smoking; preoperative anemia; use of fibrin glue or quilting sutures). Performing rectus sheath plication improved most of the outcomes. Liposuction of hypochondriac regions and flanks led to increased safety and reduced the risk of surgical dehiscence and delayed wound healing, in contrast to epimesogastric liposuction. The other combined body contouring procedures did not worsen the outcomes, except for poor scarring.Our findings encourage us to continue associating rectus sheath plication, liposuction, and other body contouring surgeries with abdominoplasty. We emphasize the importance of proper patient selection, particularly with regard to anemia, before body contouring surgery in the interests of offering safe surgery and satisfactory results. Further studies are needed to investigate how the optimal BMI cut-off and abstinence from smoking (in terms of time) before surgery reduce postoperative complications.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 https://www.springer.com/journal/00266 .

Lateral lumbar defects are rarely encountered and difficult to manage because of the limited reach of loco-regional flaps and the unfavorable position of recipient vessels for microsurgical transfer. The purpose of this report is to describe the innovative application of an extended latissimus dorsi (LD) flap with propeller ascending design in the field of lumbar reconstruction, reviewing current reconstructive options accepted for lateral lumbar defect. A 68-year-old male patient underwent wide full thickness resection for a solitary hepatocellular carcinoma metastatic lesion arising in the left lumbar region, resulting in an extensive soft-tissue defect (20 x 13 cm) with deep structures exposure. An extended LD flap with propeller ascending orientation was obliquely designed, with the distal third of the skin island laying over the trapezius muscle. The skin paddle measured 34 x 9 cm. The flap, including a cuff of proximal LD muscle spared by the oncological resection and a fasciocutaneous superior extension, underwent 90°clockwise rotation on the main thoracodorsal artery perforator and further caudal advancement allowed by section of the LD cranial tendinous insertion. The rotation-advancement movement allowed tension-free flap insetting, while donor site was closed by primary intention. The post-operative course was uneventful without any complications registered. At 12-months follow-up, a satisfactory result and a stable coverage were achieved. Due to the surgical complexity traditionally associated with the repair of defects located in the lumbar region, the case reported may help to provide a new alternative solution to extend the indications of local flaps in similar cases and simplify such reconstructions.

Fournier gangrene (FG) is a deadliest condition affecting genitoperineal area in predisposed patients. A late diagnosis, thus a delayed surgical treatment, leads often to death. LRINEC score and CT scan can help in suspect, despite definitive diagnosis needs surgical exploration and histological findings. Furthermore, FG determines wide defects of genitoperineal area, thus reconstructive surgery is pivotal to restore form and function of the affected patient. Aim of this article is to discuss the use of posteromedial thigh (PMT) fasciocutaneous flap in FG reconstruction, based on authors' personal experience. A case report of a 63-year-old obese and diabetic man is presented. Two PMT flaps (10 x 17cm2) were harvested to cover a complete scrotal defect (20 x 40cm2), while penis integuments defect was treated with a two-staged surgery (dermal substitute application and skin graft). Follow-up at 4 months showed a successful outcome of PMT flaps reconstruction, with preservation of testes vitality, despite one of the flaps developed distal necrosis that was treated with further debridement and skin graft. The authors experience is followed by the decision-making process based on a literature review that led to the choice to use PMT flaps to achieve reconstruction. Furthermore, alternative flaps to treat FG, each of them with pros and cons, are discussed, despite there is not a gold standard treatment and every option must be tailored to the patient. KEY WORDS: Fournier gangrene, Genital reconstruction, Infection, Necrotizing fasciitis, Posteromedial thigh flap, Perineum reconstruction.La gangrena di Fournier è una condizione letale che interessa l’area genitoperineale in pazienti predisposti. Una diagnosi tardiva, dunque un ritardo nel trattamento chirurgico, conduce spesso alla morte del paziente. Il LRINEC score e l’esame TC può aiutare nel sospettare tale condizione, ma la conferma diagnostica necessita l’esplorazione chirurgica e l’esame istologico. Inoltre, la gangrena di Fournier determina ampi difetti dell’area genitoperineale, dunque la chirurgia ricostruttiva è importante nel ripristino della forma e della funzione nel paziente affetto. Lo scopo di questo articolo è discutere l’utilizzo del lembo fasciocutaneo posteromediale di coscia nella ricostruzione degli esiti della gangrena di Fournier in base all’esperienza personale degli autori. È dunque presentato un case report di un uomo di 63 anni, affetto da obesità e diabete che ha sviluppato una gangrena di Fournier in seguito ad una infezione scatenata da ripetuti autocateterismi. Due lembi posteromediali di coscia (10x17cm2) sono stati prelevati per coprire un difetto scrotale totale (20x40 cm2), mentre i tegumenti del pene sono stati trattati con una chirurgia a due step (sostituto dermico e successivamente innesto di cute). Il follow-up a 4 mesi ha mostrato un outcome soddisfacente della ricostruzione con lembi posteromediali di coscia, con la preservazione della vitalità dei testicoli, nonostante uno dei lembi abbia sviluppato una necrosi distale che è stata trattata con ripetuti debridement e innesto di cute successivo. La descrizione dell’esperienza degli autori è seguita dalla spiegazione dell’algoritmo decisionale del trattamento, basato su una revisione della letteratura che ha portato a scegliere i lembi posteromediali di coscia per ottenere la ricostruzione. Inoltre, altri lembi alternativi per trattare la gangrena di Fournier, sono discussi, considerando per ciascuno di essi vantaggi e svantaggi, e che non esiste ad oggi un gold standard di trattamento e ogni opzione deve essere valutata in base alle caratteristiche del singolo paziente.

Background Due to the great impact of bariatric surgery on the overweight epidemic, the number of post-bariatric body-contouring procedures is constantly increasing worldwide. The portable incisional negative pressure wound therapy (piNPWT) is a promising medical device for accelerating wounds closure and controlling post-operative complication, which have been shown promising results in post-bariatric population. We aimed to evaluate the role of piNPWT in optimizing wound healing and controlling post-operative complications after a post-bariatric brachioplasty. Patients and Methods 26 post-bariatric female patients who underwent a brachioplasty followed by either a piNPWT (14 cases) or a standard wound treatment (12 controls) were analyzed. The number of post-operative dressing changes, the rate of local post-operative complications (re-operation, hematoma and serosa development, dehiscence and necrosis), the time to dry as well as the scar quality and hospitalization length were evaluated. Results None of the patients prematurely stopped treatment with piNPWT due to intolerance. The piNPWT patient group showed a significant lower healing time as well as a significant reduction of the number of post-operative dressing changes and hospital stay. Despite the scarring process was excellent from the functional point of view in the long term, we noticed a higher rate of hyperchromic scarring at 90 days after surgery. Conclusion The piNPWT is a cost-effective and user-friendly medical tool that increase and promote wound healing. We suggest the use of this device in post-bariatric patients who undergo a brachioplasty, especially if there is the need to minimize the number of post-operative dressing changes. Level of Evidence IV 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 Table of Contents or the online Instructions to Authors www.springer.com/00266.

Hand-held Doppler (HHD) sonography and computerized tomography angiography (CTA) are the common assessment tools for deep inferior epigastric perforator (DIEP) flap preoperative planning. CTA is considered the gold standard method for preoperative perforator mapping but necessitates contrast medium and X-ray exposure. Dynamic infrared thermography (DIRT) does not have these drawbacks and allows the detection of hot and cold spots on a given body area. Our study aimed to compare DIRT, HHD, and CTA in perforator mapping for breast reconstruction using DIEP flap.From March to September 2020, 12 consecutive patients scheduled for DIEP flap breast reconstruction were preoperatively investigated with HHD, CTA, and DIRT. The patients' mean age was 53 and the mean BMI was 29.23 kg/mWe detected 178 perforators intraoperatively, 178 with CTA, 178 with DIRT, and 125 with HHD. The latter revealed a lower number of perforator vessels for each patient (10.42 ± 3.58), compared with CTA (14.83 ± 3.04) and DIRT (14.83 ± 4.76). DIRT resulted superior to HHD (p .05), while no statistically significant difference (p .05) was found between DIRT and CTA. We calculated a mean sensitivity of 93.87% for CTA, 69.02% for HHD, and 92.06% for DIRT.DIRT is a useful tool in the preoperative planning of DIEP flaps, as it provides information about the location of perforators and the hemodynamic properties of angiosomes. It is easy to use, and it does not involve ionizing radiation. DIRT could represent an innovative and promising implementation of CTA and HHD techniques for preoperative perforator mapping in DIEP breast reconstruction.

Background/aim Upper limb breast cancer-related lymphedema (BCRL) is a chronic and severe condition affecting a significant percentage of breast cancer survivors. Even though its physiopathology is well-known, there is no worldwide consensus on BCRL evaluation and a gold-standard treatment. This narrative review aims at providing a brief descriptive overview with regard to BCRL treatment modalities. Materials and methods We conducted a literature search within the PubMed database, and 33 articles out of 56 were selected, including reviews, systematic reviews, and meta-analyses aiming find the most updated evidence regarding BCRL treatment modalities. Results Physical exercise (aerobic exercise, resistance exercise, aquatic therapy), bandages, and intermittent pneumatic compression were shown to be most effective in BCRL patients, in terms of swelling reduction in the acute-intensive phase. Furthermore, physical exercise was beneficial also as a maintenance tool. Manual lymphatic drainage demonstrated efficacy in preventing secondary lymphedema if applied immediately after breast cancer surgery or in early phases of BCRL or as a maintenance tool. Complementary procedures such as acupuncture, reflexology, yoga and photo-biomodulation therapy did not show conclusive results in BCRL treatment. Surgery was shown effective in managing symptoms (liposuction), preventing (lymphaticovenular anastomosis) and treating BCRL (vascularized lymph node transfer). Conclusion BCRL is still a challenging condition either for breast cancer survivors and clinicians, deeply impacting patient functioning and quality of life. Due to the lack of globally accepted criteria in evaluating BCRL, to date a gold standard treatment for this widespread issue is still needed.

Complex injuries involving bones, tendons and soft tissues of the hand still represent a difficult challenge for reconstructive surgeons. Hereby, we present a case of a man suffering from a complex crush injury of the right hand that led to a wide three-dimensional defect with loss of two metacarpal bones, extensor tendons and skin. For composite hand defects, the most common surgical approach provides for a one-stage composite reconstruction or for an early restoration of bone and skin, with delayed tendon grafts. For the peculiarity of the defect, a one-stage reconstruction was not feasible. Hence, we opted for a two-stage reconstruction but the usual surgical steps have been inverted. First we secured tendon and skin restoration through a composite teno-cutaneous radial free flap. A month later, we reconstructed the two metacarpals with a modified Masquelet technique using fibular cortical graft. This strategy allowed the patient to start an early rehabilitation program and obtain a satisfactory recovery of his dominant hand. KEY WORDS: Composite flap, Hand trauma, Hand reconstruction, Microsurgery.I traumi complessi interessanti le ossa, i tendini e i tessuti molli della mano rappresentano ancora oggi una sfida impegnativa per i chirurghi ricostruttivi. Presentiamo in questo nostro lavoro un caso di un paziente affetto da un trauma complesso da schiacciamento della mano destra che ha causato un ampio difetto tridimensionale con la perdita di due ossa metacarpali, dei tendini estensori e della cute. Per i difetti compositi della mano, l’approccio chirurgico più comune consiste in una ricostruzione multi-tissutale in un unico o in due step successivi, rispettivamente dell’osso e della cute, e solo in seguito dei tendini. Per via della peculiarità del trauma in oggetto, una ricostruzione one-stage non è stata possibile. Pertanto si è optato per una ricostruzione in due step, invertendo tuttavia le procedure chirurgiche abituali . Primariamente si è proceduto alla ricostruzione dei tendini e della cute tramite un lembo libero microchirurgico radiale composito teno-cutaneo. Un mese dopo sono state ricostruite le due ossa metacarpali mancanti con la tecnica di Masquelet modificata utilizzando un innesto osseo corticale di perone. Questa strategia ha consentito al paziente di iniziare un programma di riabilitazione precoce e di ottenere un recupero soddisfacente delle funzioni della sua mano dominante.

Upper arm lift is a widespread body contouring procedure, but no globally accepted guidelines exist in selecting patients and, due to comorbidity and heterogeneity of them, it is difficult to identify predictive factors of good surgical outcome. The authors review the team's experience of 56 brachioplasty performed in massive weighs loss patients.Data of 56 consecutive arm lifts were reviewed for preoperative, perioperative and postoperative variables and outcomes (complications, scarring, wound healing, revision surgery, need for blood transfusion, satisfaction, etc.). Surgical technique and postoperative care are described. A statistical analysis was performed to identify relationship between possible predictive factors and outcomes. Furthermore, an evaluation of different employed wound management devices was conducted.Follow-up ranged from 6 to 36 months (mean 20.1 months). Outcomes summary is reported (overall complication rate 50%, poor scarring rate 25%, delayed wound healing rate 26.8%, revision surgery rate 37.5%, need for blood transfusion rate 8.9%, satisfaction rate 71.4%) and statistical investigation evidenced the role of prior plastic surgery BMI and the associated change in BMI before and after weight loss, just prior brachioplasty, and the modality of weight loss.The authors' technique resulted in positive outcomes overall, considering the difficulty in dealing with the problems of MWL patients. Based on our results, we aim to suggest to perform brachioplasty in patient with the lower achievable BMI (preferably30kg/m2) to reduce the negative effect of unmodifiable factors as diabetes, modality of weight loss, a wide ΔBMI, and other well-known negative predictive factors.

The Persistent Sciatic Artery (PSA) is a rare congenital anomaly due to missed involution of embryo-fetal sciatic artery, which is the main blood supply to lower limb during embryonic development until superficial femoral artery (SFA) is formed. The PSA is frequently related to complications in adults like aneurysm and embolism. Here we present a case in which the discovery of a complete PSA resulted limb saving. In case of oncologic or trauma surgery, when no other options are available, the PSA can help in management of reconstructive surgery.A case of PSA was discovered during management of a patient affected by a soft tissue sarcoma of the lower limb. Tumor resection needed the femoral neurovascular bundle demolition to ensure radical surgery and subsequent vascular reconstruction, which failed due to complications.Despite failure reconstruction, a misdiagnosed type IIa PSA, replacing the role of the SFA, saved the lower limb from ischemia and subsequent amputation. Functional reconstruction was thus achieved with almost total recovery of lower limb function.In oncological and trauma surgery we recommend investigate the whole lower limb vascularization, from the pelvis to the foot, suspecting the PSA existence. Indeed, although it is always preferable to reconstruct the SFA system despite a complete PSA is present, due to its frequent complications, the PSA can represent a limb saving option.Computerized tomography angiography, Persistent sciatic artery, PSA, Superficial femoral artery, SFA fibromyxoid sarcoma.L’arteria ischiatica persistente (PSA) è una rara anomalia congenita causata dalla mancata involuzione dell’arteria ischiatica embrio-fetale, che rappresenta la principale fonte di apporto ematico all’arto inferiore durante lo sviluppo embrionale fino a quando l’arteria femorale superficiale (SFA) si sviluppa. La PSA è frequentemente associata allo sviluppo di complicanze negli adulti come aneurismi ed embolie. Presentiamo un caso in cui la scoperta di una PSA completa è risultata cruciale nel salvataggio di un arto. In caso di chirurgia oncologica o traumatologica, quando non sono disponibili altre opzioni, la PSA può essere d’aiuto nella gestione della chirurgia ricostruttiva. Un caso di PSA è stato scoperto durante la gestione di un paziente affetto da un sarcoma dei tessuti molli dell’arto inferiore. La resezione tumorale ha necessitato la demolizione del compartimento vascolonervoso femorale per assicurare la radicalità chirurgica e la successiva ricostruzione vascolare, che tuttavia è fallita per via di complicazioni. Nonostante il fallimento della ricostruzione, una PSA di tipo IIa non diagnosticata, vicariante il ruolo della SFA nella vascolarizzazione dell’arto inferiore, è stata in grado di salvarlo dall’ischemia e dall’amputazione. La ricostruzione funzionale è stata comunque ottenuta con un recupero quasi totale della funzione dell’arto inferiore. Nella chirurgia oncologica e traumatologica raccomandiamo l’esecuzione di accurato esame diagnostico di imaging per lo studio della vascolarizzazione dell’intero arto inferiore, dalla pelvi al piede, nel sospetto dell’esistenza di una PSA. Infatti, nonostante sia sempre preferibile ricostruire il sistema della SFA anche in presenza di una PSA completa, per via delle sue frequenti complicazioni, la PSA può comunque rappresentare un’opzione di salvataggio dell’arto.

Objective: To examine the difference between outcomes in the administration of concurrent endoscopic sinus surgery (ESS), septoplasty (SP), and rhinoplasty (RP) and concurrent ESS and SP in 1 single surgical session. Methods: Patients who underwent concurrent ESS and SP from September 2004 to July 2015 were identified. Furthermore, patients among them who underwent functional primary RP were selected. Subjects who had been administered concurrent ESS, SP, and RP (primary RP) were matched for sex, age, sinonasal surgical procedures for treatment of chronic rhinosinusitis with patients underwent concurrent ESS and SP, used as control subjects. A literature review was performed to find previous articles describing results of concurrent procedures among ESS, SP, and RP. Results: Twenty subjects, who underwent concurrent ESS, SP, and RP, were compared with a matched control group made of 20 patients who underwent concurrent ESS and SP, evaluating different postoperative outcomes (postoperative complications, postoperative improvement of respiratory symptoms, persistence of chronic rhinosinusitis symptoms 6 months to 1 year postoperative, need of revision surgery, satisfaction of the patient). Obtained P values showed that there was no statistically significant difference (P > 0.05) as regards the different outcomes, except for postoperative complications, increased because of the invasiveness proper of RP (P < 0.05). Conclusions: Therefore, execution of concurrent ESS, SP, and RP seems to be safe and effective, and additional RP does not modify postoperative outcomes of concurrent ESS and SP except for a little increase of postoperative complications, even if most of them had low impact on result of procedures.

Postbariatric surgery tries to correct physical defects and body deformities to which the alteration of collagen and elastic fiber ratio contributes, causing a particular horizontal laxity of the connective tissue, that leads to characteristic skin rolls, ptosis, and shape asymmetries.1 The combined execution of different surgical procedures represents a common practice in plastic surgery but patient safety always has to be considered2–5 and the accurate assessment of body mass index (BMI