Background: The nose is the most critical aesthetic element of the face and even the smallest loss of substance can create a deformity of concern. The forehead flap has been the workhorse for nasal reconstruction for centuries but requires multiple surgical steps and leads to prominent donor-site scarring. The nasolabial flap allows a single-step reconstruction with a donor-site scar concealed in the nasolabial crease but is conventionally designated for small defects involving the ala. Methods: The authors analysed all surgical records of patients undergone nasal reconstruction by nasolabial flap between May 2005 and December 2021 by the Plastic Surgery Unit of a major regional hospital in Lombardy. Defects were classified according to Burget's subunit principle and the 3-component approach. Reconstruction features and finesses were reported and analysed. Results: In the 16-year period under analysis, 378 patients with nasal defects of various aetiologies received nose reconstruction by nasolabial flap. All nasal subunits were involved; 20 patients had multisubunit defects. In all the cases the reconstruction with nasolabial flap, alone or combined with other solutions, was intended to be one-stage. Conclusions: The authors present several tips and tricks about preoperative planning and design, choice of the pedicle, flap harvesting and sculpting with preservation/restoration of grooves and convexities, conjoining multiple flaps, downsizing extensive defects by a rhinoplasty-like framework reduction. With a careful planning and refined technique, the range of application of the nasolabial flap can include defects involving any nasal subunit and larger and/or multisubunit defects.

BACKGROUND:Reconstruction of soft tissue defects of the acromioclavicular region represents a relatively uncommon but challenging event. Many muscular, fasciocutaneous, and perforator flaps have been described, including the posterior circumflex humeral artery perforator (PCHAP) flap based on the direct cutaneous perforator of the PCHA. This study aims to describe a variant of the PCHAP flap, based on a constant musculocutaneous perforator, by means of a cadaveric study and a case series.METHODS:A cadaveric study was conducted using 11 upper limbs. The perforator vessels originating from the PCHA were dissected and the musculocutaneous ones were identified and measured in their length and distance from the deltoid tuberosity. Besides, we retrospectively analyzed the posterior shoulder reconstruction conducted among 2 plastic surgery department (San Gerardo Hospital, Monza and Hospital Papa Giovanni XXIII, Bergamo) using the musculocutaneous perforators of the PCHA.RESULTS:The cadaver dissection showed the presence of a constant musculocutaneous perforator arising from the PCHA. The mean pedicle length is 6.10 ± 1.18 cm, and the musculocutaneous perforator pierces the fascia at a mean distance of 10.4 ± 2.06 cm from the deltoid tuberosity. In all the cadaver dissected, the perforator of interest divided into 2 terminal branches, anterior and posterior, nourishing the skin paddle.In our case series, the mean age of the patients was 66.7 years, the mean size of the defect was 46 cm 2 , the mean operating time was 79.3 minutes, the mean length of hospital stay was 2.7 days, and the complication rate was 28.6%.CONCLUSIONS:According to this preliminary data, the PCHAP flap based on the musculocutaneous perforator seems to be a reliable alternative in posterior shoulder region reconstruction.

The brisk remodeling in healthcare delivery observed after the COVID-19 outbreak led us to evaluate how the pandemic affected non-melanoma skin cancer's (NMSC) care and tumor burden. To address this topic, we set up a retrospective real-life multi-center study based on the cities of Bergamo and Varese, whose provinces were the worst hit in Italy by the pandemic. We analyzed medical and pathological data from patients that underwent surgery in the two months preceding the outbreak in Italy and compared them to those who did in the corresponding bimester of the following year, reaching 214 patients and 274 lesions. We observed a considerable and significant increase in NMSC's diameter, as well as in the proportion of squamous cell carcinomas. Both the average waiting time to obtain an evaluation visit and the average time in the surgical waiting list was shorter after the COVID-19 outbreak: the reason is that we evaluated and operated near-exclusive patients affected by high-priority lesions, who benefited from “fast-track” referrals. Conversely, less-concerning lesions were, and still are, left on hold, until they will become advanced enough to be labeled as “urgent”. Plastic surgery departments should evade as soon as possible from this downward spiral, in order to provide our patients with timely cancer care and to be able to treat all plastic surgery-requiring pathologies.

Despite being especially used in its solid form, silicone is still injected as a liquid filler for breast contouring in many countries. Here, we present a rare case of a woman with silicone pneumonitis and extended breast scarring after breast silicone injection. Because of evidence of a restrictive syndrome due to the thoracic extensive scarring tissue and the high demand of oxygen therapy, as jointly agreed with the pulmonologists, we decided to perform a surgical asportation of the scarring tissue and covering with microsurgical flap. We chose the deep inferior epigastric perforator flap mainly because of the large amount of skin that is possible to use, the good skin texture matching, and the possibility of double team working without changing patient’s position.

We performed one of the most extensive study in scientific literature (3,957 excisions, 2,358 patients) about basal cell carcinoma (BCC) focusing on the behavioral patterns,1 the risk factors associated to incomplete excisions,2 and the following preferred surgical management.2 The data about each patient and each surgery were carefully organized in a Microsoft Office Excel 2003 (Microsoft Corporation, One Microsoft Way, Redmond, WA 98052-6399 USA) database. The long time lapse (from January 1992 and September 2007) of the study and the huge number of considered variables (gender, age at first intervention, months waited by the patient before undergoing a plastic surgeon’s examination, date of biopsy when performed, histological subtype after biopsy, depth of infiltration after biopsy, date of surgery, anatomical site, size, surgical technique of repair, histological subtype after surgery, depth of infiltration after surgery, complete vs incomplete excision, margins involvement, multiple lesions treated in the same surgical session, and primary vs recurrent BCC) unavoidably lead to spotted missing information of our database, due substantially to desultory incomplete clinical folders. Furthermore, patient clinical folder does not include post-surgical treatment (chemotherapy, radiotherapy, etc) and surgery performed in other hospitals. We resolve to undertake the Recall Activity, which consist in phoning and questioning all the patients that have been taken into care by Plastic Surgery Department of Riuniti Hospital in Bergamo (Italy), to decrease the number of the omitted data. Accordingly to our knowledge, the scientific literature does not provide any other example of Akin task with this purpose. During the review of patients’ clinical folders, we set aside a column to gather their respective telephone number that we found on the frontispiece. We collected the phone numbers (2,358) of all the patients who had undergone BCC excision (one or more) at Plastic Surgery Department of Riuniti Hospital in Bergamo (Italy) between January 1th, 1992 and August 31th, 2007. The Recall Activity started on December 1th, 2007 and took about seven weeks in which the phone calls were made continuously between 8.30 a.m. and 7.00 p.m. by the same person (Codazzi). After a first round of phone calls, we proceeded with a second round trying to contact patients who did not answer at first instance. We administered the same questionnaire to each patient with this approach: (i) Personal presentation of the interviewer (Codazzi); (ii) Explanation of the reasons of the call; and (iii) 1. Department of Plastic Surgery, University of Turin, San Giovanni Battista Hospital, Turin, Italy 2. Department of Plastic Surgery, ASST Monza – San Gerardo Hospital, Monza, Monza-Brianza, Italy 3. Department of Plastic Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy

BACKGROUND:Rhinoplasty is considered the most challenging chapter of plastic surgery due to its variability and the continuing evolution of surgical maneuvers. Worksheets became essential to unequivocally record surgical steps and to demonstrate their reciprocal effects/interactions during the follow-up period. After 1989, no other software was created to upgrade the Gunter Rhinoplasty Diagrams, the forefather and benchmark of the rhinoplasty "virtual" worksheet maker. METHODS:The authors built a new standard three-dimensional nasal framework model in STL format. All the basic components were modified to simulate the interaction among sutures, grafts, and the most common maneuvers performed during rhinoplasty. The authors created a total of 669 (99 built-in units and 285 unilateral units) three-dimensional figures which can be selected by the surgeon from among 230 options. The interface for the surgeon is Bergamo 3D Rhinoplasty Software. RESULTS:Bergamo 3D Rhinoplasty Software is made up of the database section, which gathers all the patient's personal information and documents, and the surgery section, which groups multiple selection lists in 10 surgical areas. Eighty percent of the options modify the original shape of the three-dimensional model. Several options help the surgeon to tailor the final result and to export it both in desktop software and in a real three-dimensional printed model. CONCLUSIONS:Bergamo Rhinoplasty Software revolutionizes the concept of patient and surgical data storage. Furthermore, the immediacy of three dimensions facilitates communication with patients, allows case sharing with colleagues, simplifies teaching, and encourages the surgeon's self-analysis and professional growth. Customization of the original model and of the maneuvers is the main limitation of the software, because of the currently existing technology in 2014.

The editors and the publisher gratefully acknowledge the excellent work provided by our reviewers over the past year. The quality of the journal is definitely dependent upon the review process. The work performed by our reviewers is essential for the increasing interest of our journal within the plastic surgery arena in Europe and elsewhere. We have a common interest in making the European Journal of Plastic Surgery an even better one as well as a leading plastic surgery journal. We wish you a happy and prosperous 2016!

Background: Rhinoplasty is considered the most challenging chapter of plastic surgery due to its variability and the continuing evolution of surgical maneuvers. Worksheets became essential to unequivocally record surgical steps and to demonstrate their reciprocal effects/interactions during the follow-up period. After 1989, no other software was created to upgrade the Gunter Rhinoplasty Diagrams, the forefather and benchmark of the rhinoplasty “virtual” worksheet maker. Methods: The authors built a new standard three-dimensional nasal framework model in STL format. All the basic components were modified to simulate the interaction among sutures, grafts, and the most common maneuvers performed during rhinoplasty. The authors created a total of 669 (99 built-in units and 285 unilateral units) three-dimensional figures which can be selected by the surgeon from among 230 options. The interface for the surgeon is Bergamo 3D Rhinoplasty Software. Results: Bergamo 3D Rhinoplasty Software is made up of the database section, which gathers all the patient’s personal information and documents, and the surgery section, which groups multiple selection lists in 10 surgical areas. Eighty percent of the options modify the original shape of the three-dimensional model. Several options help the surgeon to tailor the final result and to export it both in desktop software and in a real three-dimensional printed model. Conclusions: Bergamo Rhinoplasty Software revolutionizes the concept of patient and surgical data storage. Furthermore, the immediacy of three dimensions facilitates communication with patients, allows case sharing with colleagues, simplifies teaching, and encourages the surgeon’s self-analysis and professional growth. Customization of the original model and of the maneuvers is the main limitation of the software, because of the currently existing technology in 2014.

DEAR EDITOR Coleman classically described four phases in fat grafting including harvesting, refinement, transfer and placement. The harvesting phase can be simplified by using the “trap device” instead of the conventional 10-cc Luer-Lock syringes. The “trap device” for harvesting fat by Power Assisted Liposuction and Medinorm tank is a convenient, wholly sterile, time saving method to provide fat for lipostructure in various part of the body.1 The harvesting phase can be simplified by using Power-Assisted Liposuction (P.A.L.) instead of the conventional 10-cc Luer-Lock syringes.2 This study evaluated the trap device of P.A.L. in fat harvesting for lipofilling. MicroAire P.A.L.TM (MicroAire Surgical Instruments LLC, 1641 Edlich Drive Charlottesville, VA 22911) is an electric device for liposuction, composed of a motorized handle (mod. 600-E) connected to an aspiration cannula of varying size and types, a standard plastic tubing for fat aspiration, and an electric control console (mod. 1020). The P.A.L. produces oscillating reciprocal “to-and-fro” movements of the cannula tip2 with a 2,4 millimetres stroke and a 0 to 4500/min vibration range. We thought the same system would find ready application to fat harvesting if an efficient sterile fat trap could be fashioned. Thus, instead of directly connecting the plastic suction tube to a common aspirator, we deviced a trap composed of the reservoir of an “High Vacuum Wound Drainage System” of 600 cc (Medinorm Medizintechnik GmbH, Gewerbepark 7–9, D-66583 Spiesen-Elversberg, Germany) deprived of its two rubber caps. The P.A.L. tube was connected to the longest of the two beaks of the 600 cc reservoir by using the forefinger of a surgical glove as a gasket (both tube and beak were stiff and they otherwise would not fit one another); the other beak was directly connected with the tube of the customary aspirator. To avoid leaks and loss of suction, two small Opsites TM (Smith and Nephew, Inc 1450 E Brooks Rd Memphis, TN 38116) were used as an “insulating tape” around the two connections. The P.A.L. harvesting cannulas that we employed were a single-hole MicroAire of 3 mm in diameter (PAL-R300LS single-port) and a triple-hole MicroAire of 4 mm (PAL-R402LS Triport II) (Figure 1). Fig. 1 The trap device: the wider bore tube on right side brings fat from the P.A.L. handle to the reservoir, while the other smaller bore one on the left connected the tank to a common aspirator In a 38 years old patient (1.75 cm tall, weighing 57 kg, with a body mass index of 18.6) undergoing lipostructure for a severe pectus excavatum, we easily harvested high quality fat from both medial knees and the abdomen, after infiltration with 500 ml of a modified Klein formula (a dilution solution of 1% lidocaine, 50 ml), 1% adrenaline (1 ml) and 8,4% bicarbonate (2.5 ml) in 1000 ml of physiologic saline), 600 ml (13 ml per minute). After centrifugation according to Coleman, the pure yellow fat at our disposal was 400 ml that was two thirds of the initial harvested volume. The harvesting and refinement procedure took 40 minutes. An electric microair device was employed, with a relatively low vibration range of 0-1,350, as adjusted on the control console and on the handle. The P.A.L. device is gaining popularity in liposuction procedures. The oscillating movement of the cannula easily mimics, in a strainless and more controlled fashion, the work of a surgeon during traditional suction-assisted lipoplasty. The vibration allows easy penetration of even fibrous fat, while generating no thermal energy, thus no risk of cutaneous burns as compared with ultrasound liposuction.2 The rate of fat extraction is fast, while surgeon fatigue and intraoperative time are decreased, possibly also accounting in reduced intraoperative pain, postoperative edema and ecchymoses. Traditional difficulty in contouring certain areas (e.g. the periumbilical region) can be overcome by simply stabilizing the position of the cannula and allowing the reciprocating tip to remove fat.3 Drawbacks are an obvious learning curve (after performing eight or more cases of P.A.L., surgeons harvest 45% more fat per minute in comparison with traditional liposuction) and, of course, the price.4 Lipostructure by harvesting fat as described by Coleman1,5,6 is also rapidly gaining popularity worldwide, both as a stand-alone procedure and as an adjunct to other interventions, with wide both reconstructive and cosmetic indications. For instance, in our institution, we now add some form of lipofilling to practically any surgical step when reconstructiung a breast.1,5,6 It is to be noted that, especially for lipostructure in breast reconstruction, significant amounts of fat are often needed. The P.A.L. system can be used for harvesting fat by fashioning a trap as described above.5 Medinorm’s tank and the tubing system guarantee the sterility that would be lost when collecting the fat directly from the aspirator tank. Also, the whole system is latex allergen free. It also seems to us that the harvested fat is less bloody than what we usually see after manual liposuction that indeed the fat collected in the trap is already of almost pure yellow color. The low cost of the Medinorm drain of 600 ml reservoir (9 Euros) is an added bonus, with the possibility of replacing the reservoir with a new one when greater amounts of fat are needed, while other members of the team proceeded with refining the contents of the first bottle. Fat transfer from the trap to the 10 ml syringes that will then be inserted into the centrifuge takes a few seconds: after both tubes are removed from the bottle, the fat can simply be poured to fill each syringe. Additionally, this method preserves fat from ambient air exposure. Finally, it could be argued that this system is more traumatic to fat cells than the careful, low-pressure extraction via a Coleman harvesting cannula and a 10 ml syringe. We however believe that it is not so that the control rotating knob on the electric console directly administered (as shown by the number of blue light LEDs) the cannula top vibration range, while the hand piece allows further fine regulation of such range within the presaid parameters (for instance, three visible blue light LEDs administer a maximum cannula vibration range of 1,350 vibs/min; the hand piece can be then used, in proportion to digital pressure, to finely tune such range from 0 to indeed 1,350) (Figure 2). Fig. 2 Fat transfer from tank to syringes which will be centrifuged. We can conclude that the “trap device” for harvesting fat in P.A.L. liposuction is a convenient, wholly sterile, time saving method to provide fat for lipostructure in various part of the body. Time is saved and donor site morbidity minimized.

Dear Editor Standardization of photography in plastic surgery is fundamental for pre-operative surgical planning, comparative post-operative assessment, and demonstration of surgical results.1 In rhinoplasty, slight changes in patient or camera position can lessen nasal hump, vary nose size, and alter skin tension.2 In order to prevent these common errors, photographic standardization with high- quality equipment (camera, lens, and lighting), consistent room set up and systematic patient position are mandatory.2 The authoritative Institute of Medical Illustrator3 published its guidelines about “Rhinoplasty and Septorhinoplasty Photography”: One of the most important concerns is about the use of standard viewfinder alignment grids to help finding both horizontal (Frankfurt and Reid planes first) and vertical reference planes during shooting. However, some cameras lack this grid at all and some other have grid with only four axes leaving focus point without reference lines. (Figure 1) Fig. 1 The commonest four axes grid leaves focus point without reference lines We thought about a new application of Opsite Flexigrid™ (Smith and Nephew Medical Limited, Hull, HU3 2BN, England) which is a transparent, adhesive film dressing, with a measurement grid (Figure 2). Fig. 2 Opsite Flexigrid™ 10x12 Cm An Opsite Flexigrid rectangle is tailored with scissors on screen camera dimensions (Figure 3). Fig. 3 Opsite Flexigrid™ is tailored with scissors on screen camera dimensions After removing the white back sheet (Figure 4), we turned on the camera and centered one of the grid intersections on camera viewfinder (Figure 5). The lines of the grid followed the main axes of the screen. Fig. 4 White back sheet is removed Fig. 5 Grid is positioned on camera screen The grid did not alter subject visibility and allowed the alignment of facial landmarks4in all conventional rhinoplasty pictures. This is a cheap (0.82 euro for 6x7 Cm sample, 2.04 for 10x12 Cm sample), quick and reversible way to mechanically add to digital camera a frequent lacking display option.

Basal cell carcinoma (BCC) is the most common skin malignancy. BCC generally has a clinical course characterized by slow growth, minimal local invasiveness, and a high cure rate. Occasionally, however, BCC behaves aggressively with deep tissue invasion, clinical recurrence, and regional/distant metastases. Surgical excision is uniformly indicated as a primary treatment. We carried out a retrospective study by selecting all patients operated for BCC in our Plastic Surgery Department between 1 January 1992 and 1 September 2007. The data collected were about 3,957 excisions performed on 2,358 individuals which is, to our knowledge, the largest population sample ever studied internationally. For this reason, we analyzed the most common BCC features generally reported in published papers so as to identify any difference compared to the data that we gathered in our series. From all of the collected data of the 2,358 patients and 3,957 excisions, 16 variables were drawn, which provided detailed information about patients’ status, biopsy when performed, surgery, and follow-up. All results concerning such variables are discussed. The results of our retrospective statistical analysis on a very large, single-center patient population sample are fully in line with what were previously published in the international literature.

Sir:FigureWe read with great interest the article entitled “Giant Basal Cell Carcinoma: 11-Year Follow-Up and Seven New Cases” by Manstein et al. (Plast Reconstr Surg. 2011;128:1105–1106), which is the update and integration of the case report previously published by the same authors.1 We wish to add the following comments. Our department recently reported one of the most extensive surveys in the published literature2 concerning basal cell carcinomas. A revision of our database from 1992 to 2007 shows 37 cases (18 female patients and 19 male patients) of giant basal cell carcinoma (lesions >5 cm at the greatest diameter),1 with the size of the tumors ranging from 5 to 18 cm (mean, 6.2 cm) and the site being prevalently extrafacial [21 of 37 (56.8 percent)] (Table 1).Table 1: Data for Patients with Giant Basal Cell CarcinomasIf clinical diagnosis is unclear, we prefer an incisional biopsy before final excision [17 of 37 (45.9 percent)]. For such reason, once the diagnosis of malignancy is confirmed, we will completely excise the lesion with larger margins than those (3 to 5 mm) commonly recommended.3 We agree with the authors that the use of split-thickness skin grafts is quick and practical, but we generally prefer the use of flaps [25 of 37 (67.6 percent)] over grafts [12 of 37 (32.4 percent)] because of better results with like-to-like tissue. The prevalent use of flaps does not seem to influence the extent of the excision, because we achieved complete excision margins at first surgery in 31 (83.8 percent) patients. In six patients (16.2 percent), a subsequent operation was required to achieve negative margins. As the authors write, metastatic basal cell carcinomas are extremely rare (0.003 to 0.55 percent).4 After a follow-up even longer than 15 years for some patients [seven of 37 (18.9 percent)], we have never diagnosed metastases from basal cell carcinoma, although we found a single case of perineural and another case of muscular invasion. Denis Codazzi, M.D. Stefano Bruschi, M.D. Maria Alessandra Bocchiotti, M.D. Department of Plastic Surgery, University of Turin, San Giovanni Battista Hospital, Turin, Italy Enrico Robotti, M.D. Department of Plastic Surgery, Riuniti Hospital, Bergamo, Italy DISCLOSURE The authors have no financial interest in this work.