Postoperative care in finger replantation. Our case-load and review of the literature

OBJECTIVE: Technical success of a finger replantation depends on several factors such as surgical procedure, type of injury, number of segments amputated, amputation level and individual patient factors. Among early complications that can occur in this type of surgery the onset of venous or arterial thrombosis is the most dreaded. Local irrigating solutions, oral and intravenous anticoagulants, thrombolytic agents, plasma expanders, vasodilating, and antiaggregant drugs are routinely used in patients undergoing microvascular procedures, but currently there is only a non-standardized practice based on anecdotal personal experience. MATERIALS AND METHODS: The aim of our study is to review selected literature relating to perioperative therapy in microsurgical digital replantation. We also report our case-load of 16 patients with finger avulsion describing our particular protocol for postoperative anticoagulation and restoration of fluid and electrolyte balance. RESULTS: Following our daily pharmacological protocol, the postoperative course of the replanted fingers was uneventful. The survival rate for finger replantations performed was 100% (n = 16) with no need for surgical revisions. CONCLUSIONS: The association Dextran-40/Heparin/fluids in the proposed standardized pro-weight pharmacological protocol is an optimal postoperative prophylactic/therapeutic plan to reduce the incidence of endovascular thrombosis after replantation, so ensuring high rate of success in microvascular surgery

Invited response on: dual-plane retro-pectoral versus pre-pectoral dti breast reconstruction. An italian multicenter experience

Invited Response on: Dual-Plane Retro-Pectoral Versus Pre-pectoral DTI Breast Reconstruction: An Italian Multicenter Experienc

Intraoperative ultrasound and oncoplastic combined approach: an additional tool for the oncoplastic surgeon to obtain tumor-free margins in breast conservative surgery—a 2-year single-center prospective study

In case of breast postoncologic reconstructive surgery when an oncoplastic approach is adopted and volume replacement with glandular flap mobilization is performed, tumor-positive margins may create a significant problem. We present our experience with intraoperative ultrasound as an adjunctive tool to guide breast surgeons to improve margin-free management of neoplastic breast lesions in patients undergoing oncoplastic surgery

Postoperative care in finger replantation: our case-load and review of the literature

OBJECTIVE: Technical success of a finger replantation depends on several factors such as surgical procedure, type of injury, number of segments amputated, amputation level and individual patient factors. Among early complications that can occur in this type of surgery the onset of venous or arterial thrombosis is the most dreaded. Local irrigating solutions, oral and intravenous anticoagulants, thrombolytic agents, plasma expanders, vasodilating, and antiaggregant drugs are routinely used in patients undergoing microvascular procedures, but currently there is only a non-standardized practice based on anecdotal personal experience. MATERIALS AND METHODS: The aim of our study is to review selected literature relating to perioperative therapy in microsurgical digital replantation. We also report our case-load of 16 patients with finger avulsion describing our particular protocol for postoperative anticoagulation and restoration of fluid and electrolyte balance. RESULTS: Following our daily pharmacological protocol, the postoperative course of the replanted fingers was uneventful. The survival rate for finger replantations performed was 100% (n = 16) with no need for surgical revisions. CONCLUSIONS: The association Dextran-40/Heparin/fluids in the proposed standardized pro-weight pharmacological protocol is an optimal postoperative prophylactic/therapeutic plan to reduce the incidence of endovascular thrombosis after replantation, so ensuring high rate of success in microvascular surgery

Acral lentiginous melanoma. A retrospective study

Background: Acral lentiginous melanoma (ALM) carries one of the worst prognoses among other subtypes. This malignant tumor is found on the distal limbs and is usually detected at late stages. Hereby, the authors present their experience on this melanoma subtype. Methods: A retrospective study was conducted. Data were extracted from patients’ medical records and from phone interviews. Results: A total of 43 patients were included in the study. The main signs and symptoms disclosed by the patients were bleeding (41.9%), size greater than 6 mm (41.9%), change in size (37.2%), change in shape (30.2%), rise above the surface of the skin (27.9%), change in color (20.9%), irregular borders (16.3%), and inflammation (16.3%). The first healthcare professional consulted was a general practitioner or a dermatologist in the majority of cases (88.3%). Only 44.2% of the patients were sent by their first physician for a biopsy, whereas 30.3% were sent by the 2nd physician. 14 patients underwent biopsy within 1 month from the first appointment with a physician, while 20 patients within 3 months and 9 patients within 6 months. Only 7 patients sought medical attention in the first 3 months; 21 patients sought medical care between 3 months and one year from the appearance of the lesion, while the remaining 15 patients waited more than a year. Conclusions: One of the major issues found in ALM is represented by the diagnostic delay; this may be due to either the patients or the physicians’ failure to recognize warning signs

Deep sternal wound infection following cardiac surgery. A comparison of the monolateral with the bilateral pectoralis major flaps

Deep sternal wound infections are a serious complication following sternotomy for cardiothoracic surgery. “Conventional” treatment provides debridement and secondary closure or closed catheter irrigation. The combination of the Negative Pressure Therapy with flap coverages is an accepted technique and one or both Pectoralis Major muscles could be chosen. A multistep protocol was adopted. One hundred and sixty seven patients were treated with the combination of Negative Pressure Therapy with the Pectoralis Major muscle flap: 86 monolateral flap and 81 bilateral flap reconstruction. The main complications (hematoma, seroma, dehiscence, and re-infection), the need for re-intervention, mortality rates, Intensive Care Unit, and hospitalisation time were assessed. The mono-pectoralis group had fewer complications and need for revision, with a shorter hospital stay. A statistically significant difference emerged for the hematoma rate (P =.0079). Monolateral flap should to be preferred because with the same coverage effectiveness, it guarantees the saving of controlateral muscle with its functionality and the possibility of its use in case of failure. Furthermore, as the technique is less invasive, it can be reserved for more fragile patients

Oncoplastic conservative surgery for breast cancer: long-term outcomes of our first ten years experience

The main goal of oncoplastic breast surgery (OBS) is to optimize cosmetic outcomes and reduce patient morbidity, while still providing an oncologically-safe surgical outcome and extending the target population of conservative surgery. Although the growing number of reported experiences with oncoplastic surgery, few studies account for the long-term outcomes

Oncological safety of stromal vascular fraction enriched fat grafting in two-stage breast reconstruction after nipple sparing mastectomy: long-term results of a prospective study

OBJECTIVE: Autologous fat transfer (AFT) is commonly used to treat implant palpability and prevent fibrosis and thinning in mastectomy skin flaps. A major limit to this procedure is volume retention over time, leading to the introduction of fat enrichment with stromal vascular fraction (SVF+AFT). Oncological concerns have been raised over the injection of an increased concentration of progenitors cells (ASCs) in the SVF. The aim of the study is to evaluate the long-term cancer recurrence risk of SVF+AFT cases compared to AFT, in patients undergoing Nipple Sparing Mastectomy (NSM). PATIENTS AND METHODS: A prospective study was designed to compare three groups of patients undergoing NSM followed by SVF+AFT, AFT or none (control group), after a two-stage breast reconstruction. Patients were strictly followed-up for at least 5-years from the second stage reconstructive procedure. Loco-regional and systemic recurrence rate were evaluated over time as the primary outcome. Logistic regression was used to investigate which factors were associated with recurrence events and independent variables of interest were: surgical technique, age above 50 years old, lympho-vascular invasion, oncological stage, adjuvant or neoadjuvant chemotherapy, adjuvant radiotherapy and adjuvant hormone therapy. RESULTS: 41 women were included in G1 (SVF+AFT), 64 in G2 (AFT), and 64 in G3 (control group). Loco-regional recurrence rate was 2.4% for G1, 4.7% for G2, and 1.6% for G3. Systemic recurrence was 7.3%, 3.1%, and 3.1%, respectively. Among the variables included, there were no significant risk factors influencing a recurrence event, either loco-regional or systemic. In particular, SVF+AFT (G1) did not increase the oncological recurrence. CONCLUSIONS: Our data suggest that both centrifuged and SVF-enhanced fat transfer have a similar safety level in comparison to patients who did not undergo fat grafting in breast reconstruction after NSM

Extended latissimus dorsi kite flap (eld-k flap). Revisiting an old place for a total autologous breast reconstruction in patients with medium to large breasts

Background: The latissimus dorsi (LD) flap represents one of the most reliable methods for autologous breast reconstruction. However, in many patients, the exclusive use of this technique may not guarantee the restoration of an adequate volume and projection. We report our experience with the extended latissimus dorsi kite flap (ELD-K flap), an alternative surgical approach to maximize the volume of the fleur-de-lis pattern LD flap, for total autologous breast reconstruction. Methods: Between 2016 and 2018, 23 patients were subjected to mastectomy and immediate autologous reconstruction with "extended latissimus dorsi kite flap" (ELD-K flap), technique that employs an extended version of the LD musculocutaneous flap, based on the skeletonized thoracodorsal pedicle and a trilobate skin incision with an inferiorly based vertical branch. The BREAST-Q questionnaire was administered preoperatively, and one year after surgery to evaluate the quality of life results of the patients. BREAST-Q latissimus dorsi module was also provided. Results: Average body mass index was 29.7 kg/m2 (range 25–40 kg/m2). Mild complications occurred in only six cases, and eight patients underwent treatment to improve the donor site scar outcome. Patients indicated high scores in quality of life measures with an increase in all BREAST domains from the preoperative to the postoperative period. A statistically significant increase (p < 0.05) was noted in: “overall satisfaction with breasts” (p < 0.05), “psychosocial well-being” (p < 0.05), “physical impact of the surgery” (p < 0.05). Within the LD module, participants reported a mean score of, respectively, 73.8 and 67.9 for “satisfaction with back” and “satisfaction with shoulder and back function” domains. Conclusions: The extended incision allows the recruitment of additional tissue to provide enough volume to complete the reconstruction without implants. The isolation of the vascular pedicle allows for extreme freedom and mobilization of the flap, ensuring adequate filling of the breast. ELD-K flap may expand the indications for a total autologous LD immediate breast reconstruction, representing an additional and reliable alternative in selected cohorts of patients. 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

The role of component separation in the treatment of severe diastasis recti abdominis: a new indication for a known technique.

Objective: Diastasis of the rectus abdominis muscle (DRAM) is a widening of linea alba, it also could be accompanied by abdominal bulging. DRAM is often a cause of quality-of-life impairment, especially when it is of large dimensions. Repair with direct rectus plication is the most common treatment for Diastasis Recti Abdominis (DRA), but it can result in high recurrence rates. The authors aimed to show their results in applying the component separation technique in wide DRA cases. Patients and methods: From January 2015 to July 2018, 43 patients with DRA ≥ 10 cm at 3 cm over the umbilicus have been treated with component separation technique associated to panniculectomy. A biologic mesh was positioned onlay in cases of weakness along the semilunaris lines. Results: DRA repair was achieved in all cases. All patients completed the 1-year follow-up and no recurrence nor major complication were registered. Minor complications were observed in 12 (27.9%) cases. Conclusions: This is the first study describing the component separation technique use in cases of DRA without hernia, associated to abdominoplasty surgery. Preliminary results were encouraging, but larger series are required