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Patients presenting breast actinic damage or implant-related complications require an autologous approach to breast reconstruction. However, when they are not good candidates for microsurgical procedures, alternative solutions must be sought. Latissimus dorsi (LD) is a workhorse flap in breast reconstruction, but often the amount of skin and volume achievable are insufficient. Taking inspiration from the Kiss flap concept, the authors hereby describe the "Kiss" LD flap to achieve totally autologous breast reconstruction.A prospective service evaluation of all patients who underwent breast reconstruction with Kiss LD flap between 2018 and 2020 was performed. Patient demographics and operative variables were recorded, together with early and late complications. Patient satisfaction and quality of life were registered using the latest BREAST-Q reconstruction module, which includes specific LD scales. The questionnaire was administered to patients preoperatively and six months postoperatively.Thirty patients underwent total autologous breast reconstruction with Kiss LD flap. Breast cancer and breast sarcoma resection were followed by reconstruction. The timing of reconstruction was immediate in 3 cases and delayed in 27 cases. No major complications nor total flap loss were registered. BREAST-Q scores postoperatively were significantly higher than the preoperative ones in every domain (p0.0001) except for the physical well-being of back and shoulder, where the scores differed slightly and non-significantly (p=0.05).The Kiss LD flap allows to harvest a large amount of skin to restore the breast envelope and a considerable volume to reconstruct the breast mound in a completely autologous procedure.

Immediate single stage breast reconstruction is a challenging procedure with the goal of improving the quality of life of patients with breast cancer. The aim of this study is to evaluate using the BREAST-Q patient satisfaction, body perception and quality of life after direct-to-implant breast reconstruction comparing unilateral and bilateral reconstructions.In this study we enrolled 56 women who underwent mastectomy and immediate single-stage direct-to-implant (DTI) breast reconstruction at Campus Bio-Medico University of Rome between 2013 and 2020. One year after surgery they were administered electronically the BREAST-Q post-operative module.Our two cohorts of patients consisted in 34 women who received unilateral nipple-sparing mastectomy and DTI breast reconstruction and 22 women who underwent bilateral nipple-sparing mastectomy and DTI breast reconstruction. Twenty-four of the 34 patients belonging to the unilateral group responded to the questionnaire (70.5%), while in the bilateral group responders were 16 out of 22 (72.7%). The BREAST-Q scores were compared between the two groups: patients undergoing bilateral mastectomy and breast reconstruction showed higher scores in every BREAST-Q domain compared to patients undergoing unilateral mastectomy and breast reconstruction with a statistically significant difference in the Satisfaction with breast (P = 0.01), Sexual well-being (P = 0.03), and Satisfaction with implants (P = 0.01) domains.Patients undergoing bilateral DTI breast reconstruction have a favorable postoperative surgical cosmetic outcome with a better patient's body image perception and a higher post-operative level of satisfaction compared to unilateral DTI reconstruction after nipple-sparing mastectomy.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 Evidence in literature about the best reconstructive approach after melanoma resection is controversial, with some authors advocating that tissue rearrangement flap techniques might hinder the early detection of local relapses. The aim of the present study is to evaluate oncological, aesthetic, and functional outcomes following melanoma reconstruction using pedicled perforator-based flaps. Methods The authors reviewed all patients affected by melanoma treated during a 6-year period. Demographic data, tumor characteristics, and operative variables were evaluated. Locoregional recurrence was assessed with clinical and radiological follow-up. One-year postoperatively patients rated on a 5-point Likert scale the aesthetic and functional outcomes of the procedure. Three blind observers examined preoperative and 1-year postoperative photographs and rated the aesthetic outcome of the reconstructive procedure. Results One-hundred sixty-five patients were treated with wide excision and delayed reconstruction, including pedicled perforator-based flaps in 70 patients (group A) and primary closure in 95 patients (group B). Mean Breslow thickness was 2.972 and 2.189 mm in group A and B, respectively. There was no statistically significant difference in locoregional recurrence (chi-squared test, p = 0.8333; Fisher's exact test, p > 0.9999) between the two groups. Group A reported a higher satisfaction with both the aesthetic (mean rating 4.390 in group A and 4.094 in group B) and functional (mean rating 4.732 in group A and 4.170 in group B) outcomes of the procedure, the latter being statistically significant (p = 0.0006). Conclusion This series suggests that pedicled perforator-based flaps provide optimal aesthetic and functional outcomes in melanoma reconstruction without impairing the locoregional control of the disease.

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.

Background The anterolateral thigh (ALT) flap represents a workhorse in reconstructive microsurgery but its use in a free style fashion as perforator-based flap has yet to be popularized. We describe our experience with lateral circumflex femoral artery (LCFA) sparing perforator-based ALT flaps for thigh reconstruction after oncological resection in a case series of 24 consecutive patients. Methods Twenty-four patients underwent thigh reconstruction with 25 perforator-based ALT flaps between 2014 and 2020. Defect etiology was related to skin cancer, melanoma, and sarcoma resection in 3, 7, and 14 cases respectively. Mean defect size was 15 × 8 cm. Six months postoperatively, patients were asked to rate on a 5-point Likert scale the aesthetic and functional outcomes of the reconstructive procedure. Results Eight flaps were advanced in a V-Y fashion (33.3%), whether 16 flaps (66.7%) were rotated in a propeller fashion. The average flap size was 19 × 8 cm, while mean operative time was 197.2 min. Donor sites were always closed by primary intention. Minor complications were registered in 5 cases and managed conservatively. Overall patients' satisfaction was high, with mean aesthetic and functional ratings of 4.46 and 4.21 respectively. Conclusions LCFA sparing perforator-based ALT flaps proved to be a versatile and reproducible solution to address thigh reconstruction after oncological resection according to the different topographical sub-units involved.

Breast remodeling following breast-conserving surgery (BCS) and radiation therapy (RT) is challenging and often burdened by complications due to irradiated tissue atrophy. The authors present a case–control study to compare the central mound mastopexy (CMM) to more conventional techniques, applying it to different patterns of skin excision. A variation of the original central mound technique is presented separately addressing glandular and cutaneous deformities. Between 2012 and 2018, 17 consecutive patients presenting defects following unilateral BCS and RT underwent breast remodeling with CMM technique. Immediate and long-term complications together with patient-reported outcomes were evaluated and compared to a matched control group of sixteen patients who underwent superior pedicle mammoplasty. Two independent plastic surgeons reviewed pre- and postoperative photographs and rated the cosmetic outcomes on a visual analog scale from 1 to 5. In the study group, different patterns of skin excision, i.e., inverted-T pattern (41.2%), circumareolar (23.5%), skin-sparing type V (17.65%), omega (11.77%), and J (5.88%), were used to correct various breast deformities, and a decisional algorithm was developed. No major complications were registered. Retraction recurrence rate was higher in the control group (p = 0.037). Cosmetic results were considered more satisfying in the CMM group by both patients (4.18 vs 3.00, p

Abdominal wall reconstruction represents a complex challenge for plastic surgeons, given the variable range of clinical situations requiring restoration of abdominal wall integrity. When significant myofascial defects are encountered, repair with either a synthetic or biological mesh is indicated, both of which have advantages and drawbacks. Taking inspiration from Gillies' fourth commandment of plastic surgery- Thou shalt not throw away a living thing -an innovative technique to obtain a vascularized autologous mesh from the tissues usually discarded during abdominal contouring procedures was conceived. The authors describe how to maximize the use of perforator flaps derived from abdominoplasty excision patterns in abdominal wall reconstruction to simultaneously obtain restoration of abdominal wall integrity and improvement of the abdominal contour.

In conducting this study, it was our presumption that lipofilling is a necessary and simultaneous adjunct to lifting the middle third of the face in patients with negative lower eyelid vectors, enabling satisfactory and enduring aesthetic results. Eligible patients met the following criteria: (1) primary midface lift in subperiosteal plane; (2) negative inferior eyelid vectors at preoperative baseline; (3) postoperative monitoring for ~ 2 years; (4) standard pre- and postoperative photo-documentation; (5) proficiency in Italian language; and (6) signed consent for study participation. Informed consent pertaining to photography allowed for subsequent publication. Pertinent patient data were also collected as follows: age, sex, duration of follow-up, type of surgical procedure, related secondary procedures, quantity of fat injected, nature of incision, and patient satisfaction level. Complete randomness was thus conferred during computer-assisted patient assignment to one of two study arms: midface lift only (group 1) or midface lift plus facial lipofilling as a concurrent operation (group 2). All patients completed Italian versions of the FACE-Q module, which were issued by e-mail approximately 2 years postoperatively. Two plastic surgeons reviewed all postoperative photographs of treated patients and rated outcomes on a scale of 1–5. Statistical analysis was powered by standard software expressing categorical data as numbers and percentages and quantitative data as means ± standard deviations. Between January 2016 and March 2018, a total of 56 patients (women 48; men 8) subjected to primary midface lifts in subperiosteal plane at our Plastic Surgery Department met all criteria for study enrollment. Mean patient age was 56.5 years (range 40–70 years), and the mean follow-up period was 2.1 years (range 2–5 years). Differences in postoperative FACE-Q scoring by the two groups were significant (p

A patient affected by a voluminous synovial sarcoma of mediastinum received radical surgery, resulting in injury of both phrenic nerves. Because of the cancer location, reconstruction of the left phrenic nerve was not possible, so to prevent the patient's ventilator dependence, the right phrenic nerve was reconstructed via an autograft from the residual proximal stump of the contralateral one. In 3 months, the right hemidiaphragm function showed a full recovery, documented by ultrasonographic and radiographic assessment of diaphragmatic excursion, and the patient was weaned from mechanical ventilation. When a nerve autograft is indicated, the sural nerve still remains the criterion standard, because of the low morbidity of the donor site and ease of harvesting; however, in particular situations, such as in this unique case, the choice of an orthotopic graft may offer promising results.

Postmastectomy radiation therapy (PMRT) has a primary role in the treatment of locally advanced breast cancer; however, the most appropriate timing of irradiation in immediate tissue expander breast reconstruction (ITEBR) still remains unknown.A retrospective review was performed on all women undergoing mastectomy and retropectoral ITEBR at Campus Bio-Medico University Hospital in Rome, Italy, between 2010 and 2019. The patients were categorized into three cohorts: patients undergoing PMRT with the tissue expander (TE) in situ, patients with PMRT delivered to the permanent implant (PI), patients who were not administered RT. Complications and failure rates were analysed and compared. Potential predictors of adverse outcomes were analysed.Over 10 years, 183 patients underwent retropectoral ITEBR (55 PMRT-TE, 50 PMRT-PI, 78 no-PMRT). The three groups were well matched with respect to patient- and treatment-related factors (p 0.05), with the exception of neoadjuvant chemotherapy and irradiation. The mean follow-up was, respectively, 4.58, 7 and 5.75 years. Radiotherapy either to the TE or to the PI was independently associated with failure and conversion to autologous procedures (p 0.0001). Failure rate was significantly higher when TE was irradiated (p = 0.03). PMRT was associated with severe capsular contracture development (p 0.00001), the odds being higher when irradiation was delivered after implant exchange (p = 0.04). Increased BMI was significantly associated with failure.When PMRT is delivered to the TE, the risk of failure is higher (OR 2.77); when the PI is irradiated, reconstruction will more likely be affected by severe capsular contracture (OR 2.7). However, considering that the overall risk of severe capsular contracture correlated to PMRT is higher than failure, we believe that irradiation should be delivered to the TE. Performing a proper capsuloplasty at the time of implant exchange, indeed, allows to correct the deformities related to radiation-induced capsular contracture. Patients with unfavourable outcomes after TE placement and RT, instead, can be directly switched to autologous reconstruction.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 .

Basal cell carcinoma (BCC) is the most common skin cancer, and it can be easily treated by surgery or by various other physical modalities and topical chemotherapy. For metastatic, locally advanced BCC and for cancers that cannot be removed by surgery, systemic drugs known as hedgehog pathway blocker are used. High-frequency ultrasound (HFUS) is a non- invasive technique used in diagnosis of some skin cancers. It has proven potentially useful for BCC management. In this study we used high frequency ultrasounds to evaluate BCCs' thickness and the correlation with dermoscopic features.We examined 86 basal cell carcinomas with dermoscopy and with high-frequency ultrasound. The main patterns identified by ultrasound were linear, ellipsoid and non-specific or undefined. Patients were divided by sex and age. The BCCs were grouped by anatomic location. Finally, we recorded specific dermoscopic features of BCCs noting their presence/absence in lesions overall and in each of four quadrants. Then the lesions were excised, and histological examination was made with definition of tumor thickness (in mm).In our study, two main echographic patterns were described: linear, associated with superficial BCC, and ellipsoid, found primarily in nodular variants. However, a small percentage of lesions have otherwise non-specific patterns. We observed a significant correlation between echographic tumor thickness and histotype. We observed high concordance between histological tumor thickness and ultrasounds. Also, dermoscopic criteria as large branching and blue ovoid nests were significantly associated with heightened histologic and echographic assessments of tumor thickness.Our study confirmed the utility of ultrasound in the diagnosis of BCCs and for the first time we have correlated ultrasounds' patterns with dermoscopy and tumor thickness.

Introduction The purpose of this study is to determine if there is a better quality of life with one of the two techniques and if the results are in line with those already present in the literature. The hypothesis from which we started is to demonstrate that cancer patients who undergo a deep inferior epigastric perforator flap (DIEP) breast reconstruction surgery are more satisfied and have a higher level of quality of life compared to those subjected to an intervention of reconstruction with prosthesis. Materials and Methods All patients undergoing reconstruction from January 2010 to July 2018 were eligible for inclusion. This is a retrospective cohort study carried out using the patients of two plastic surgery departments who have undergone monolateral or bilateral implant-based or DIEP flap breast reconstruction. We administered BREAST-Q questionnaire electronically almost 2 year after surgery. Patients were divided into two groups: implant-based and autologous breast reconstruction with DIEP flaps. Baseline demographics and patient characteristics were analyzed using a Students t-test (continuous variables) or Chi-square/Fisher’s exact test (categorical variables). Mean standard deviation BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. The linear regression model was applied to all BREAST-Q score with all predictor factors. Results Of the 1125 patients involved, only 325 met the inclusion criteria and were enrolled in this study; specifically, 133 (41%) DIEP and 192 (59%) prosthetic reconstructions. We summarized the results of the principal scales of BREAST-Q module: satisfaction with breast, psychosocial well-being, satisfaction with outcome, and sexual well-being in which the autologous group was always more satisfied. We reported results of all linear regression models with higher values for the DIEP group independently from predictors. Conclusion This is the first study performed on the Italian population that compares autologous surgical techniques with the implantation of breast implants. In this population, DIEP is considered the technique that leads to the highest satisfaction in all BREAST-Q scores. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Introduction This study aims to analyze whether there is any patient- or treatment-related factor that can influence patients' body perception after mastectomy and autologous or implant-based breast reconstruction. Materials and methods This retrospective cohort study included patients who underwent immediate implant-based or DIEP flap breast reconstruction. Predictive factors analyzed included chemotherapy, radiotherapy, hormone therapy, body mass index, age, type of mastectomy, and follow-up length. The BREAST-Q was administered postoperatively almost 2 years from the last surgical procedure. Mean BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. A linear regression model was applied to all BREAST-Q scores with all predictor factors. Results In total, 325 patients were enrolled in this study (133 DIEP flap and 192 implant-based reconstructions). The DIEP flap reconstruction group with a previous nipple sparing mastectomy showed the highest scores. Patients with a longer follow-up were less satisfied than the ones with a shorter follow-up, which could be considered as an assessment of the outcome. No significant difference was reported between patients who underwent radiotherapy, chemotherapy or hormone therapy and those who did not. Furthermore, age and BMI had no influence on patient satisfaction. Conclusion This study is the first that groups a large number of patients and analyzes predictive factors of long-term satisfaction of patients undergoing breast reconstruction. This can be regarded as a pilot study to raise the awareness of everyone's clinical practice to predict the attitude that patients have after surgery and to prepare them in the best possible way. 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 the Table of Contents or the online Instructions to Authors www.springer.com .

This randomized controlled study aimed to analyse the long-term results of thin-skinned patients who underwent rhinoplasty. All the included study patients had the following characteristics: underwent primary rhinoplasty for functional and/or cosmetic problems, were thin-skinned, had been followed for almost 2 years, underwent both standard pre- and post-operative photography, had a good understanding of the Italian language, and had signed a consent form for inclusion in the study. The patients were randomly divided into 4 groups as follows: group 1, camouflage of the dorsum by diced cartilage; group 2, camouflage of the dorsum with lipofilling; group 3, camouflage of the dorsum by a temporal fascia graft; and group 4 (control group), without camouflage of the dorsum. Patients answered the Italian version of the FACE-Q rhinoplasty module. The Obagi skin pinch test was used to measure nasal skin thickness. We compared pre- and post-operative patient satisfaction with the appearance of their nose between the 4 patient groups by the Chi-squared test for unpaired data. Two plastic surgeons reviewed all the post-operative photographs of the study patients and rated the photographs on a scale of 1 to 5. A total of 101 patients who underwent primary rhinoplasty between January 2016 and March 2018 in our department of plastic surgery and satisfied the inclusion criteria were enrolled in this study. The mean patient age was 38.5 years. The mean follow-up time was 2.5 years. The differences between the preoperative and post-operative FACE-Q values for group 1 were significant (P

The objectives of this study are: (1) comparison of long-term outcomes after correction of severe gynecomastia using different techniques; (2) apply the Italian version of the BODY-Q; (3) present the role of intercostal perforator flap (ICAP) after massive weight loss for correction of severe gynecomastia. Between January 2008 and March 2016, we performed surgical correction of bilateral severe gynecomastia in 80 men (160 breasts) following massive weight loss. Patients answered the Italian version of BODY-Q postoperative module. All patients had experienced substantial weight loss (> 30 kg), presented with bilateral severe tissue ptosis of the breast, follow-up of almost 2 years and had a good understanding of the Italian language, and signed consents were included in the study. The sample was studied about age, BMI, comorbidity, bariatric surgical procedure, follow-up, type of post-bariatric surgical procedure, complications and secondary procedures. We performed 487 severe gynecomastia corrections from 2008 to 2016; 80 patients adhered to the inclusion criteria and formed our study group. This cross-sectional study compared three cohorts: 52 access using a circumareolar scar, 18 with an inframammary fold scar, 10 with an inframammary fold scar using intercostal perforator flaps. There were 16 secondary procedures in group one, 2 in group two and 1 in group three. We compared the secondary procedures of group 1 with the other groups, and we obtained a significant difference with a P = 0.04. The mean patient age was 36.5 years, and the average body mass index was 27.5 kg/m2 at the time of surgical correction of gynecomastia. From the BODY-Q analysis, the group of patients undergoing adenomammectomy with inframammary fold scar using intercostal perforator flaps has achieved significantly better results regarding the satisfaction with chest, psychosocial function, satisfaction with outcome and better body image. This is the first study that used the BODY-Q to analyze the correction of severe gynecomastia following massive weight loss with long-term results. The use of this patient-reported outcome measure underlined that the intercostal artery perforator flap, used in the correction of severe gynecomastia following massive weight loss, is a safe and effective technique with good outcomes and high patient satisfaction. 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 .

Introduction Many techniques have been described to treat full thickness nasal defects. The authors introduce the bipaddle chimaeric forehead flap (BCFF), a new alternative technique to achieve simultaneous lining and cutaneous reconstruction in case of full thickness hemi-nasal defects, presenting surgical details and applications for its clinical use. Patients and methods From June 2015 to April 2017, 10 patients presenting with oncological full thickness defects involving nasal sidewall and/or nasal ala were reconstructed with the BCFF technique. Mean age was 69.4 years. The chimaeric flap was composed of 2 paddles (cutaneous and periosteal), nourished by a single supratrochlear pedicle, which were used to independently reconstruct the deficient cutaneous and mucosal layers of the nose. Cartilage grafts were used in 8/10 patients. Results Mean surgical time was 114 minutes. An intermediate thinning operation was performed in 3 out of 10 patients. All the flaps survived with no partial necrosis or cartilage exposure observed. Viability and mucosalization of the periosteal paddle was documented both intra-operatively (during the 2nd stage of the operation) and postoperatively (with fiberoptic rhinoscopy performed 3 months after the procedure). Clinical follow-up period ranged from 4 to 24 months postoperatively. The final result was judged sufficient, good and excellent in 1, 5, and 4 cases, respectively. Conclusions The BCFF technique may be a new alternative approach to address full thickness hemi-nasal defects with no extra donor site morbidity, allowing primary placement of structural cartilage grafts and immediate definition of the nasal subunits to be reconstructed.

Silodosin is a selective alpha-1 adrenergic receptor antagonist approved for the treatment of lower urinary tract symptoms associated with benign prostatic hypertrophy. Adverse events include retrograde ejaculation, dizziness, diarrhea, vasodilator symptoms, and postural hypotension. Skin adverse reactions to silodosin such as eruption, purpura, and jaundice are uncommon. This article reports a case of unusual silodosin-related skin rash, Naranjo score 5, which regressed after applying combined intense pulsed light (IPL)/fractional CO2 laser/chemical treatments and drug interruption. Level of evidence: Level V, risk/prognostic.

Background A-T plasty has long been a workhorse for defects located around the eyebrow or in the upper and lower lip. It allows like-with-like reconstruction with placement of the scars in natural creases or subunit junctions. In this article, the authors describe their refined technique to specifically address moderate to large size defects of the frontotemporal, preauricular, and zygomatic regions. Materials and methods Thirty consecutive patients underwent reconstruction with the extended A-T plasty at our institution after skin cancer excision. Mean age at surgery was 63 years (range, 39-87 years). Mean defect size was 5.2 × 4.7 cm. The defects were located in the frontotemporal (13), upper preauricular (10), and zygomatic (7) facial subunits. Results Mean operative time was 65 minutes. Three (10%) patients suffered from delayed healing at the T junction, with no impairment in the long-term follow-up. All the other flaps healed uneventfully with optimal long-term cosmetic and functional restoration. Follow-up ranged from 3 months to 3 years (mean, 19 months). Conclusions The basic principles of the A-T plasty were applied to design large advancement-rotation flaps incorporating frontotemporal and preauricular cervicofacial skin. The resulting extended A-T plasty proved to be a simple, reliable, and reproducible technique to resurface, in a "like with like" fashion, moderate to large defects located in the frontotemporal, preauricular and zygomatic facial subunits.

The treatment of a tuberous breast deformity has changed over the years, with a large variety of procedures described. However, maintaining a long-lasting breast contour is an ongoing challenge. The aim of this study was to evaluate the long-term results of tuberous breast corrections, focusing on the incidence of secondary procedures and patient satisfaction. Forty-six patients who underwent correction of a tuberous breast deformity from 2000 through 2013 were considered. Age, degree of deformity, asymmetry, BMI, pregnancy, first surgical technique used, complications and further surgical procedures were evaluated. Statistical analysis was conducted to identify predicting factors for multiple procedures. Patient satisfaction was evaluated with BREAST-Q. Eighty-eight breasts were treated: 57 breasts underwent implant-based corrections, whereas 31 breasts underwent autologous procedures. A multi-step procedure was initially planned in 7 breasts only, and 41 breasts underwent secondary procedures: 33 out of 53 breasts (62.3%) were re-operated in the implant-based group, whereas 8 out of 28 breasts (28.6%) were re-operated in the autologous group. Statistical analysis showed a correlation between the number of procedures and young age (P = 0.0253) and between the number of procedures and the primary surgical technique (P = 0.0132). The BREAST-Q evaluation suggested that patient satisfaction was comparable. The question of time is one of the main issues in breast surgery. The management of tuberous breast deformities requires a customized strategy considering all parameters to improve the longevity of the result in the long term. 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 Despite of the widespread use of 180-degree propeller flaps in the field of soft tissue reconstruction, less information are available in the current literature to standardize the use of propeller flaps with reduced degrees of rotation.The authors report their experience with propeller flaps with reduced rotational angles reviewing clinical applications and outcomes of the technique in a series of 40 consecutive reconstructions. PATIENTS AND METHODS Forty elective defects of various etiologies located in different regions of the body (head and neck, trunk, buttocks and perineum, extremities) were reconstructed with less than 180 degrees rotated propeller flaps. The technique was applied to patients presenting with a strong audible perforator detected in close proximity to the wound and the defect located in a position adjacent to the axis of the chosen perforasome. RESULTS Defect size ranged from 2 × 2 to 15 × 9 cm. Flap dimensions ranged from 5 × 2 to 21 × 10 cm. The flaps were based on 1 (34) or 2 (6) perforators and were mobilized with an angle of rotation of 45, 90, and 135 degrees in 7, 24, and 9 patients, respectively. Mean operative time was 105 minutes. All flaps survived postoperatively. In only 4 cases (10%) partial flap necrosis was registered. All flaps achieved adequate and durable reconstruction with excellent contour, with a follow-up ranging between 6 months and 2 years. CONCLUSIONS Propeller flaps with reduced rotational angles represent a safe and versatile option to reconstruct soft tissues defects at different anatomical sites.

Summary Background: The latissimus dorsi (LD) flap is reliable and versatile with many indications and low donor site morbidity. The aim of this study is to evaluate the long-term effects of LD flap on the shoulder function in patients undergoing delayed breast reconstruction. Methods: This case–control study enrolled women who underwent implant-based (IB) breast reconstruction, radical lymphadenectomy, and radiotherapy between 2006 and 2016. The study group included 72 women, with a history of severe capsular contracture, who received a secondary LD flap reconstruction. The control group consisted of a matched cohort of 80 patients with IB breast reconstruction. Shoulder function was assessed using the acromiohumeral interval (AHI) measurement in standard X-rays. The validated Western Ontario Shoulder Instability (WOSI) and BREAST-Q questionnaires were used to assess outcomes one year postoperatively and data were analyzed using Fisher's exact test and the Mann–Whitney test. Results: Out of 72 patients from the study group, 40 had valuable pre- and postoperative X-rays to measure the AHI. An AHI reduction was recorded only in 7/40 patients. From the WOSI analysis, no significant differences in shoulder function and back pain between the two groups were registered. BREAST-Q scores in the LD group were higher in most domains, including satisfaction with breasts and psychosocial well-being. However, the Mann–Whitney test showed no significant difference between the two groups (p > 0.05). Conclusion: LD flap, with detachment of its insertions from the humerus, does not seem to have a negative impact on back and shoulder function and is correlated with high patient satisfaction in breast reconstruction following radiotherapy.

INTRODUCTION Pedicled perforator flaps are widely used for soft tissue reconstruction, but evidence in literature about risk factors associated with complications is still controvert. The aim of this study is to evaluate risk factors and outcomes associated with pedicled perforator-based flaps harvested at different anatomical sites. PATIENTS AND METHODS Seventy-one propeller and 59 V-Y advancement flaps were performed to reconstruct defects of the face (24 cases), trunk (47 cases), and extremities (59 cases). Mean defect and flap area were 32.43 and 43.2 cm2 , respectively. The average age recorded was 66 years. We statistically analyzed whether patient and flap-related variables had an impact on flap vascular complications rate. Patients were asked to rate on a 5-point Likert scale the aesthetic and functional outcomes of the surgery. RESULTS Overall flap complications rate was 23.07%. Coronary heart disease was an independent risk factor for flap complications (p = .010), while hypertension was associated with a lower complication rate (p = .010). The increasing degree of pedicle rotation had a significant impact on the development of flap vascular complications (p = .008). Mean patients' aesthetic and functional ratings were 4.23 of 5 and 4.37 of 5, respectively. CONCLUSIONS We found a positive correlation between both coronary heart disease and increasing degree of pedicle rotation and complications. Other factors tested were not significantly associated with complications. Patients were overall satisfied with both the aesthetic and functional outcomes of the procedure. The decisional algorithm hereby suggested yields a 93.1% overall success rate and we believe it could be of help to plastic surgeons approaching soft tissue defects.

A multitude of options are traditionally used for the treatment of acne scars; however, newer treatment modalities are emerging to decrease the propensity for post-inflammatory hyperpigmentation and upregulate new collagen production. The aim of this study was to evaluate the efficacy of nanofat and platelet-rich plasma (PRP) infiltration alone and combined with fractional CO2 laser resurfacing to improve atrophic scars of the face. From March 2014 to June 2015, 30 patients with atrophic acne scars on the cheeks were selected for this study. Patients were evaluated pre- and postoperatively by physical examination, photographs and ultrasound with a 22-MHz probe to measure subcutaneous tissue thickness. All patients were treated with infiltration of nanofat plus PRP. The production of PRP was achieved using the RegenLab THT tube® method. In 15 randomly chosen patients, a fractional CO2 laser resurfacing at 15 W was also performed right after the infiltration. An Italian version of the FACE-Q postoperative module was administered to analyze each patient’s satisfaction and aesthetic perception of the result. The average preoperative thickness of subcutaneous tissue of patients from group A was 0.532 cm, while the average preoperative thickness of subcutaneous tissue of patients from group B was 0.737 cm. The average postoperative thickness of subcutaneous tissue was 1.201 cm in group A and 1.367 cm in group B. The improvement of thickness of subcutaneous tissue was 0.668 cm in group A and 0.63 cm in group B. We applied a t test on unpaired data, comparing the difference in thickness obtained with the treatment in both group A and in group B, with a p value =0.7289 (not significant). All patients in both groups had a treatment benefit, confirmed with FACE-Q postoperative module, but without a significant difference between the two groups. Subcutaneous infiltration with nanofat and PRP seems to be effective to improve atrophic scars, either alone or combined with fractional CO2 laser resurfacing. The FACE-Q module confirmed the impact of treatment of facial acne scars in social life and relationships. 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 .

The goal of this study report is to define the “gender angle,” a new angle which represents the masculine or feminine nasal shape, for performing a gender-oriented rhinoplasty. The use of the “gender angle” in Caucasian patients will help the plastic surgeon in the search for a suitable nose for the patient’s face and above all for the search for maximum patient satisfaction. The study population was obtained from Caucasian patients who had undergone rhinoplasty between January 1986 and September 2016 at our department. Patients answered the Italian version of the FACE-Q outcome instrument on post-rhinoplasty satisfaction with their nose. Anthropometric measurements were taken retrospectively by AutoCAD for MAC on a photograph of the profile view taken postoperatively at the last follow-up. A total of 1774 (706 male and 1068 female) patients satisfied the inclusion criteria and were finally enrolled in this study. We identified a gender-specific angle ranging from 168° to 182° for the male nose and from 160° to 178° for the female nose. We subdivided all study patients into 3 ranges of angles as follows: male nose, range 1 = 168°–172°, range 2 = 173°–177°, range 3 = 178°–182°; female nose, range 1 = 160°–166°, range 2 = 167°–171°, range 3 = 172°–178°. All study patients completed the FACE-Q rhinoplasty postoperative module. Analysis was performed of the FACE-Q results and the angle obtained for each nose. The most satisfactory angle range for male patients was range 3 (P = 0.01) and for the female patients was range 2 (P = 0.01). The “gender angle” might be a parameter that effectively provides the optimal cosmetic result for male and female patients who undergo rhinoplasty. 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 .

The aim of this randomized controlled study was to analyze the long-term results of patients undergoing rhinoplasty because of severe septal deviation and to evaluate the stability of results. The study was performed with a randomized design. Patients were randomly divided into four groups: group 1, spreader flaps were used in combination with spreader grafts; group 2, spreader flaps were used alone; group 3, spreader grafts were used alone; and group 4, neither spreader flaps nor grafts flaps were used. Patients answered the Italian version of the FACE-Q rhinoplasty module. Anthropometric measurements were performed by AutoCAD for MAC. We determined the angle of deviation, and we compared the pre- and postoperative angles and compared patient satisfaction in the four groups using the Chi-squared test for unpaired data. Two plastic surgeons reviewed all the postoperative photographs of the study patients and rated the photographs on a scale of 1 to 5. A total of 264 patients who underwent primary rhinoplasty between January 2010 and September 2016 satisfied the inclusion criteria and were finally enrolled in this study. Anthropometric measurements revealed statistically significant differences (P

Background: The use of a transverse pattern for perforator flap design and its possible clinical applications in the field of lower leg reconstruction are previously unreported in the medical literature. The purpose of this report is to describe our clinical experience with the use of transversally oriented pedicled perforator flaps in lower leg reconstruction. Patients and methods: Seven patients underwent lower leg reconstruction with transversally oriented pedicled perforator flaps. Patients age ranged from 42 to 68 years. All defects resulted from skin cancer ablation. Defect sizes ranged from 9 3 5t o 53 2.5 cm. The technique was applied to patients presenting with vertically oriented, long, and narrow defects, not feasible for primary closure, with the only audible perforators detected at a significant distance from the wound. Results: All flaps were based on a single perforator vessel. One of them was converted to a perforator-plus peninsular flap design, which retained an additional source of blood supply from the opposite skin bridge. The flaps were always mobilized in V-Y fashion. Donor sites were always closed primarily. Flap dimensions ranged from 15 3 7t o 83 3.5 cm. Operative time ranged from 40 to 90 minutes. All flaps survived uneventfully. Follow-up ranged from 6 months to 2 years. All patients were satisfied with the surgical outcome. Conclusions: The use of transversally oriented pedicled perforator flaps proved to be a reliable alternative option to reconstruct small to medium size defects of the lower leg. V C 2015 Wiley Periodicals, Inc. Microsurgery 00:000‐000, 2015. Recent experimental studies on the microvascular architecture of perforator flaps have provided a clear anatomical basis for flap orientation in the lower extremity, 1 showing that the dominant distribution of linking vessels in this anatomical region follows the axiality of the limb and the course of superficial veins and nerves. 2 For this reason, perforator flaps should be ideally designed in parallel to the axis of the involved leg to capture the largest and most reliable vascular territory. Nevertheless, many situations exist in the clinical practice which lead the reconstructive surgeon to disregard these suggestions in favor of a pure free style approach, 3 thus adapting flap design to defect location, perforator position and adjacent expendable areas of soft tissue laxity. 4 What should the plastic surgeon do in such cases, when dealing with lower leg defects with no potential to be reconstructed with vertically oriented perforator based flaps? Is there any place in our armamentarium for the use of transversally oriented perforator flaps? Can they be considered a feasible option to reconstruct soft tissue defects of the lower leg? In this report we answer these questions presenting indications, clinical applications and outcomes of this particular flap design applied in a series of seven consecutive lower leg reconstructions.

Resurfacing of soft tissue defects consequent to skin cancer, melanoma, or sarcoma excision in different anatomical districts represents a difficult challenge for the plastic surgeon. Classic reconstructive procedures are frequently charged by unsatisfactory results. The introduction of perforator flaps in the clinical practice represented a revolution in the field of reconstructive plastic surgery. The technique further evolved with the introduction of the freestyle concept, allowing one to harvest a skin flap from any region of the body where an appropriate and detectable Doppler signal is present and to resurface soft tissue defects mobilizing the surrounding tissues, which present similar features compared with the recipient site in terms of color and texture, on a consistent vascular source and in a tension-free manner. The authors present their personal approach to the reconstruction of soft tissue defects after excision for a basal cell carcinoma involving the medial tibial region.

The aim of this study was to measure patient satisfaction using the BREAST-Q reconstruction module in patients selected for lipofilling procedures after implant breast reconstructions. Seventy patients who underwent breast reconstruction with or without delayed lipofilling were enrolled between 2011 and 2015, and they completed BREAST-Q surveys. We administered the questionnaire electronically 6 months and 1 year after surgery. We divided patients into two groups. In group A, we included patients (46) who underwent secondary lipofilling almost 1 year after implant-based breast reconstruction; in group B (24), patients who underwent implant-based breast reconstruction without any lipofilling procedure. Statistical analysis was performed using descriptive and summary statistics to identify a central tendency between the two groups. All patients answered the postoperative BREAST-Q reconstruction module. The mean age of the patients was 41 years. Eleven of the 70 patients underwent a bilateral mastectomy. The mean follow-up was 2.5 years. The average amount of fat graft injected was 110 cc. In group A, there were two patients who had a complication: 1 infection and 1 intraoperative implant rupture. The average number of lipofilling procedures was 2.2. After further analysis of the questionnaire, we observed that patients in group A obtained significantly better postoperative results than patients from group B (control) regarding the following items: the ability to wear more fitted clothing; the reconstructed breast softness; symmetry (breasts of equal size relative to the other); reconstructed breast look and touch; amount of implant rippling perceived by the patients; and psychosocial well-being and physical well-being: chest and upper body. Our results are encouraging regarding the use of autologous fat grafting to improve cosmetic outcomes and to reduce postoperative pain after breast reconstruction. This is the first study that applied BREAST-Q to breast lipofilling to demonstrate better outcomes achieved by patients who underwent secondary lipostructures. 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 .

Many flaps have been described and are being used in the reconstruction of extensive tissue defects in the thoracic wall. The extended cutaneous thoracoabdominal flap, described in 2006, is an excellent option for chest wall reconstruction in patients with advanced breast cancer, being associated with a low morbidity rate and good functional results. The main disadvantage of this technique is the poor cosmetic outcome and the complete absence of a breast crease. We present the first case of a two-stage heterologous breast reconstruction after reconstruction using an extended cutaneous thoracoabdominal flap.

Background Free-style local perforator flaps can be harvested from any region of the body where an appropriate and detectable perforator vessel is present. Their use allows the surgeon to perform a "like with like" reconstruction by mobilizing surrounding tissues on a consistent vascular source. The authors report their experience with V-Y free-style perforator flaps in reconstruction of soft-tissue defects subsequent to skin cancer excision. Methods Forty elective defects in different regions of the body were reconstructed with V-Y advancement local perforator flaps raised in a free-style fashion. There were 23 male patients and 17 female patients. Mean age at surgery was 63 years. All defects resulted from skin cancer ablation. Mean defect size was 5×3.7 cm. Mean flap dimensions were 8.8×4.2 cm. The flaps were based on one (n=10), two (n=18), or three (n=12) perforators. Results Mean operative time was 93 minutes. Thirty-seven flaps (92.5 percent) healed uneventfully. In three flaps (7.5 percent), moderate venous insufficiency occurred, leading to partial flap necrosis that required surgical revision. In three cases (7.5 percent), the flap was converted to a rotation/hatchet perforator-based peninsular flap. Slight venous stasis was the most common postoperative finding registered (eight flaps; 20 percent). All flaps achieved adequate and durable reconstruction with excellent contour, with a follow-up ranging between 6 months and 2 years. Conclusion Free-style local perforator flaps advanced in V-Y fashion proved to be a valid and reliable solution to restore function and aesthetics of the operated site after skin cancer excision. Clinical question/level of evidence Therapeutic, IV.

Summary Background Different techniques are available to reconstruct scalp defects; however, when the cranium is exposed or the hairline compromised, the procedure may become quite challenging. The use of superficial temporal artery fascio-cutaneous flaps has been described mainly to restore the hair-bearing surface of the upper lip or the eyebrow but only few applications in the scalp have been reported. The authors present their experience with the use of superficial temporal artery island flaps to obtain durable coverage and excellent contour in anterior scalp reconstruction. Methods Thirty consecutive defects in the anterior scalp subunits (temporal = 14; parietal = 12; forehead = 4) were reconstructed with ipsilateral V-Y island flaps nourished by frontal and parietal branches of the superficial temporal artery. All defects resulted from skin cancer excision. Twenty-six flaps were based on the parietal branch. The frontal branch pedicle was used in only four cases to resurface defects in the forehead subunit. Glabrous skin flaps were harvested in six patients. Including a venous branch in the pedicle was not mandatory because the venous drainage of the flaps was provided by the perivascular fascial network. For this reason, a fascial pedicle around the artery, 2–3 cm in width, was maintained to minimise flap venous insufficiency. Results Twenty-nine flaps healed uneventfully (96.7% flap survival rate), providing stable coverage with a mean follow-up of 12 months. In the early postoperative time (up to 48 h), slight venous stasis was observed in 14 flaps (46.6%), but it resolved spontaneously within 1 week. Two flaps showed severe venous stasis, but in only one case (3.3%) it progressed to distal necrosis requiring surgical revision. No cases of alopecia or hairline distortion were postoperatively registered. Conclusions The use of superficial temporal artery island flaps, mobilised in a V-Y fashion, proved to be an elegant and reliable solution to resurface defects in the anterior scalp subunits in both hairy and bald patients.