IntroductionThe completion of nipple-areola complex (NAC) reconstruction is increasingly regarded as an essential final step in breast reconstruction. As the perineal skin of Asian females is commonly hyperpigmented, we investigated its use for areolar reconstruction in conjunction with a nipple-sharing procedure and evaluated surgeon- and patient-reported outcomes.Materials and MethodsThis retrospective review focused on NAC reconstructions performed on patients with unilateral breast reconstruction. This study analyzed 15 cases in which NAC reconstruction was performed as a secondary procedure following initial breast reconstruction. The employed technique involved the "nipple-sharing" approach complemented by a full-thickness skin graft harvested from the perineum. Key metrics for assessment included patient age, type of initial breast reconstruction, complication rates, and parameters such as color, symmetry, projection, and overall satisfaction, which were evaluated using a 5-point Likert Scale by both patients and overseeing physicians.ResultsThe series showed that all 15 NAC reconstructions yielded positive aesthetic outcomes. The take of full-thickness skin graft for areolar reconstruction was 100%. However, there were instances of minor to partial loss of the nipple graft in 7 cases after the removal of the tie-over dressing 7 days after operation. Nipple height showed no statistical significance (P = 0.167) compared to the normal side after 2 years of follow-up. Satisfaction levels regarding surgical outcomes were high among all patients.ConclusionsThe study concludes that NAC reconstruction using the 'nipple-sharing' technique, combined with perineal skin grafting, is a reliable and effective method for the Asian population after long-term follow-up.

Scapholunate (SL) ligament injuries, if not properly treated, can compromise wrist biomechanics, leading to instability, scapholunate advanced collapse (SLAC) and progressive osteoarthritis. Depending on the severity of the injury, current repair techniques include either arthroscopic or open surgical approaches; however, the limited vascularization of the region often represents an obstacle to optimal ligament healing. This study aims to assess the feasibility of using a vascularized fascial flap based on the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) for biological augmentation of the scapholunate ligament. Five previously injected cadaveric upper limbs were dissected and flap dimensions, including length, width, and pedicle length, were measured using a millimeter-calibrated ruler by two independent operators. All flaps provided sufficient coverage, and the vascular pedicle length allowed tension-free positioning without vascular kinking. These findings demonstrate that a 1,2 ICSRA-based fascial flap is anatomically feasible for scapholunate ligament augmentation. It should be noted that this is a purely cadaveric study, and the technique has not yet been tested in vivo. The results suggest potential surgical applications, providing a vascularized biological option that may enhance ligament healing in future clinical studies.

Background:During the past 4 decades, the anterolateral thigh (ALT) flap has evolved into a cornerstone of reconstructive microsurgery. Since its first description in 1984, advances in perforator dissection and flap design have broadened its applications. Commemorating the 40th anniversary of the ALT flap, this review outlines key anatomical, technical, and clinical milestones that have shaped its evolution and enduring significance. Methods:A narrative review of clinical studies on the ALT flap was conducted, focusing on human, English-language publications from the past 40 years. Studies were selected based on relevance, innovation, and clinical impact. Data were extracted on technique, anatomy, and applications to highlight key advancements in flap evolution. Results:From 2712 articles screened, 138 met the inclusion criteria. Key advancements were categorized into anatomy and perforator patterns, composite and functional flap variants, vascular modifications, refinements in flap thickness, and novel applications with imaging integration. Conclusions:After 4 decades, the ALT flap remains a cornerstone in reconstructive microsurgery due to its reliable anatomy, design versatility, and low donor-site morbidity. Ongoing advances in imaging and surgical planning are expected to further optimize outcomes and expand its applications across complex reconstructive challenges.

Significant weight loss often results in severe deformities affecting multiple body regions, negatively impacting patients’ social and personal lives. Many massive-weight-loss patients (MWLP) seek treatment for multiple anatomical areas. Combining procedures in a single surgical session offers perceived benefits such as a single recovery period, reduced costs, and faster patient satisfaction. However, the associated risks and reliability require further evaluation. This study compares the safety and reliability of combined body-contouring procedures versus single procedures performed in a staged approach. A retrospective study was conducted on 1182 MWLP patients undergoing body-contouring surgery. Patients were divided into four groups: Group A (single procedure, 389 patients), Group B (two procedures, 312 patients), Group C (three procedures, 272 patients), and Group D (four procedures, 209 patients). Medical records were reviewed for complications and patient satisfaction (BODY-Q). A total of 2665 procedures were performed with follow-up ranging from 12 to 34 months (mean 14.2 months). Overall complication rates were 3.6 www.springer.com/00266 .

Background:Single-stage direct-to-implant (DTI) reconstruction, particularly the prepectoral technique, has become prominent due to its reliable outcomes and shorter operative time. This approach spares the pectoralis major muscle, reducing postoperative pain and morbidity, and ensuring quicker recovery. However, limitations such as patient comorbidities and tumor characteristics can limit feasibility, leading to complications and high reconstructive failure rates. In such cases, switching to autologous or 2-stage approaches becomes necessary. This study introduced an innovative acellular dermal matrix-free dual-plane DTI hybrid reconstruction using a reverse submammary adipofascial perforator flap for small-volume breasts. Methods:A prospective noncontrolled cohort study was conducted from January to April 2024, enrolling 10 breast cancer patients eligible for DTI reconstruction. Data collected included preoperative clinical characteristics, intraoperative surgical data, and postoperative outcomes, including complications and patient satisfaction measured using BREAST-Q version 2.0. Breast aesthetics was also evaluated by 12 independent observers at minimum 3 months follow-up. Results:The surgical technique involved a dual-plane pocket with a reverse submammary adipofascial perforator flap, harvested from the inframammary fold, anchored to the pectoralis major muscle for inferolateral pole coverage of the breast implant. Results showed 1 major complication requiring surgical revision and 1 minor skin flap necrosis managed conservatively. All patients reported good satisfaction with their reconstruction results, supported by positive aesthetic evaluations from observers. Conclusions:This acellular dermal matrix-free, dual-plane DTI hybrid technique seems safe and effective for small-volume breasts. It offers a viable alternative for selected cases, warranting further investigation with larger cohorts and longer follow-ups.

Background and objective Conservative mastectomy is burdened by possible necrosis of the breast skin and nipple-areola complex, particularly among patients with macromastia and severe ptosis undergoing heterologous reconstruction. It is well known that anterior fifth intercostal artery perforator plays a critical role in nipple-areola complex blood supply. Our study investigates outcomes of large or ptotic breasts, undergoing immediate prepectoral direct-to-implant breast reconstruction covered by dermoadipose flap based on the fifth anterior intercostal artery perforator. Methods We conducted a retrospective study on 70 consecutive patients who underwent skin-reducing mastectomy, with or without nipple preservation, using an inverted T-pattern. Setup of a dermo-adipose flap with an inferior pedicle, based on the anterior intercostal artery perforator of the fifth intercostal space was performed, according to preoperative Doppler ultrasound. Immediate breast reconstruction was performed using Microthane implants. We assessed rate of mastectomy flap necrosis (Mayo Clinic Classification), at 12 months follow up, pre- and postmastectomy satisfaction with breast, physical well-being of the chest with BREAST-Q questionnaire, and spinal pain using the McGill Pain Questionnaire. Results No complications such as hematoma, seroma, or implant infections occurred. Ischemic complications were observed in 11 cases (13.9%), however, only in one case was implant removal necessary. Satisfaction with breast appearance, chest physical well-being, and the pain rating index all significantly improved postoperatively. Conclusions Direct to implant reconstruction using the inferiorly pedicled flap based on the AICAP is a reliable and reproducible technique that offers favorable results with low complication rates in large or ptotic skin reducing mastectomies.

Background: Huriez syndrome is a rare hereditary skin disorder marked by early-onset sclerodactyly, hyperkeratosis of the palms and soles, and nail dysplasia. A key concern is the early and aggressive development of cutaneous squamous cell carcinoma (SCC), typically affecting the dorsal aspects of the hands. Methods: This narrative review summarizes clinical features, genetic aspects, and oncologic implications of Huriez syndrome. A systematic search was conducted in PubMed and Scopus, including English-language articles published up to May 2025. Relevant case reports and small case series were analyzed. Results: Seven patients (58.3%) underwent multiple surgeries due to recurrent or bilateral disease. Six patients (50%) required amputations, including finger, hand, and arm amputations, with no foot amputations reported. Reconstruction after oncological resection was performed in six patients (50%) using skin grafts (3), pedicled flaps (2), or free flaps (1). Amputation was mainly for advanced disease, with radial forearm flaps used for reconstruction. All flaps remained disease-free. Five cases (41.6%) had a history of local recurrence. Conclusions: The early diagnosis of Huriez syndrome is crucial to enable the surveillance and timely treatment of SCC. A multidisciplinary team including dermatologists, oncologists, plastic surgeons, and geneticists is recommended. Further research is needed to clarify genetic mechanisms and develop early detection strategies to improve outcomes.

INTRODUCTION:Nowadays, physicians have tools to prevent breast cancer-related lymphedema (BCRL) but there is no consensus on when to apply them. The authors analysed patient- and treatment-related risk factors to create the LyBra score, to identify patients that may benefit the most from BCRL preventive interventions. MATERIALS AND METHODS:Patients were selected from cases of breast cancer treated from January 2019 to July 2022. Inclusion criteria were age above 18, breast cancer diagnosis and surgical treatment with lymph-node biopsy or axillary dissection. Recurrent cancers, inflammatory cancer, previous axillary surgery, bilateral cases and patients with primary lymphedema were excluded. Selected cases were assessed with the LyBra Score. Numerosity and distribution of expected BCRL were compared to the BCRL registered during the minimum follow-up of 2 years. RESULTS:During an average 41 months follow-up (range, 24-62), 131 cases (14 %) of BCRL were registered in the total 933 patients included in the study. According to LyBra score, expected BCRL cases were 149 (16 %), slightly higher but with no statistical significance. The major incidence of BCRL (40 cases in 47 patients) was registered in the high-risk group that included 5 % of the study population. A ROC curve was used to determine the diagnostic performance of the LyBra score and the AUC was 0.78 corresponding to a good discriminating ability. CONCLUSION:By sorting patients into risk groups, the LyBra score offers a solution to the actual dilemma of timing and indication of the modern preventive-BCRL microsurgeries.

Background The increasing popularity of Large Language Models (LLMs) in various healthcare settings has raised questions about their ability to provide accurate and reliable information. This study aimed to evaluate the informational value of Large Language Models responses in aesthetic plastic surgery by comparing them with the opinions of experienced surgeons. Methods Thirty patients undergoing three common aesthetic procedures—dermal fillers, botulinum toxin injections, and aesthetic blepharoplasty—were selected. The most frequently asked questions by these patients were recorded and submitted to ChatGpt 3.5 and Google Bard v.1.53. The answers provided by the Large Language Models were then evaluated by 13 experienced aesthetic plastic surgeons on a Likert scale for accessibility, accuracy, and overall usefulness. Results The overall ratings of the chatbot responses were moderate, with surgeons generally finding them to be accurate and clear. However, the lack of transparency regarding the sources of the information provided by the LLMs made it impossible to fully evaluate their credibility. Conclusions While chatbots have the potential to provide patients with convenient access to information about aesthetic plastic surgery, their current limitations in terms of transparency and comprehensiveness warrant caution in their use as a primary source of information. Further research is needed to develop more robust and reliable LLMs for healthcare applications. Level of Evidence I 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 .

Immediate breast reconstruction (IBR) with polyurethane (PU)-coated implants has usually been performed to mitigate the capsular contracture (CC) rate, particularly in patients requiring post-mastectomy radiotherapy (PMRT). This retrospective study aimed to evaluate the long-term outcomes of direct-to-implant (DTI) reconstruction using Microthane® PU-coated implants placed prepectorally without additional devices.A total of 143 consecutive patients underwent mastectomy, followed by IBR with Microthane® implants in the prepectoral position. Demographic and clinical data, including complications and CC incidence, were retrospectively collected. Statistical analyses comprised descriptive statistics, Kaplan-Meier survival curves, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire for patient-reported outcomes.Over a median follow-up of 4.5 years, 18.9 % of patients experienced at least one complication, with adjuvant radiotherapy being the only factor significantly associated with increased complications (p = 0.0229). Kaplan-Meier analysis indicated a complication-free survival rate of 57.85 % for the patient and 58.00 % for the implant, and a contracture-free survival rate of 79.46 % and 81.56 %, respectively. Severe CC (Baker grade III/IV) occurred only in 9.1 % of patients, including several who underwent adjuvant radiotherapy (p = 0.0215). These rates remain notably lower than those historically reported with textured implants. Moreover, DASH scores revealed minimal disability (an overall mean score of 8.17 %), reflecting favorable patient-reported outcomes.Microthane® breast implants in a prepectoral position demonstrated low CC rates and high patient satisfaction, even among those receiving radiotherapy, benefiting from all the prepectoral surgical approaches. In addition, this technique obviates the need for supplementary devices such as meshes or acellular dermal matrices (ADMs), thereby reducing costs, operative times, and potential complications.The large cohort size and substantial follow-up strengthen these findings. The results support prepectoral reconstruction with Microthane® implants as a safe and effective option in breast reconstruction, offering both aesthetic and functional benefits.

Background: The COVID-19 pandemic caused unprecedented delays in elective surgery, including breast reconstruction, prolonging expander retention beyond recommended timelines. Methods: We retrospectively compared patients who underwent two-stage expander-to-implant reconstruction before the pandemic (2011-2020) and during the pandemic (2020-2022). Clinical outcomes and patient-reported experiences were analyzed, and multivariate regression was used to adjust for confounders. Results: Expander retention was significantly longer in the pandemic cohort (481 vs. 280 days). Capsular contracture around the expander was markedly increased, with pandemic group assignment and prolonged expander retention emerging as independent predictors in multivariate analysis, while overall complication rates were unaffected. Patient-reported outcomes showed more functional limitations but paradoxically higher satisfaction with the definitive implant. Conclusions: Surgical delay selectively increased the risk of expander contracture without raising overall morbidity. Patient-reported findings highlight the dual impact of delay, with both greater burden and a potential "relief effect".

Background: Cutaneous squamous cell carcinoma (SCC) is the most common primary malignant tumor of the hand, and its aggressive nature can lead to significant morbidity, particularly when affecting critical structures like the thumb. SCC in this location may arise in the periungual area or the pulp and frequently presents with non-specific symptoms such as swelling, nail deformity, or discharge, features that closely mimic common benign conditions. Methods: A retrospective study analyzed patients with neglected or misdiagnosed SCC of the thumb treated at the Hand and Microsurgery Unit of the Jewish Hospital, Rome, between 2015 and 2025. Patient demographics, duration from symptom onset to diagnosis, initial misdiagnoses, and imaging findings (X-rays, MRI, CT scans, lymph node sonography) were reviewed. Surgical interventions, histopathological grading, and postoperative management were documented, with long-term follow-up focusing on disease progression and patient survival. Results: Sixteen patients were included in the study. The mean age at surgery was 73.6 years (range: 55-93 years), with a mean delay of 8.2 months from symptom onset to diagnosis in 87.5% of cases. Initial misdiagnoses included verruca vulgaris, onychomycosis, paronychia, and osteomyelitis. Imaging consistently revealed soft tissue involvement, bony invasion, and occasional metastasis. Surgical approaches ranged from wide resection to amputation, with thumb reconstruction in selected cases and hand amputation in severe presentations. Long-term follow-up (mean 4.6 years) showed high morbidity, a reduction in hand function and QoL, and a 50% mortality rate, with two cases due to metastatic disease (12.5%). Conclusions: Thumb SCC presents diagnostic and therapeutic challenges, exacerbated by late diagnosis and initial misdiagnoses. Multidisciplinary management involving early recognition, comprehensive imaging, appropriate surgical interventions, and vigilant follow-up is crucial for optimizing outcomes.

Context Huriez syndrome is a rare de rmatological condition characterized by severe sclerotic and atrophic changes in the extremities (hands and feet) and an increased tendency to develop squamous cell carcinomas, with no established gold standard for the surgical treatment of these patients, who are difficult to manage due to the inability to perform reconstructions using local flaps. Clinical Case We report the case of a patient with severe Huriez syndrome who had developed SCC in both the hands and foot over time. After multiple surgeries at other centers, all resulting in recurrences, we planned wide excisions followed by reconstruction using distant flaps. The postoperative course for both reconstructive procedures was complication-free. Follow-up revealed not only an excellent reconstructive outcome but also highlighted the untapped potential of the flap in managing this condition: thanks to its independent vascularization, the flap remained unaffected by the surrounding diseased skin and significantly improved the scaly, atrophic appearance of the affected areas. Discussion Huriez syndrome is a dermatological condition characterized by a predisposition to developing squamous cell carcinomas. In these patients, it is essential to plan wide excisions that ensure oncological radicality. The reconstruction must be carefully planned, and microvascular flaps can be prioritized. Conclusion The radial forearm flap has proven effective for reconstruction in individuals with SCC associated with Huriez syndrome. The skin of the flap not only remained unaffected by the surrounding pathology but also induced a previously undescribed benefit on the diseased skin. This oncological-reconstructive approach could become the gold standard in treating these patients.

Background: Several studies have reported preliminary experiences with the anterior intercostal artery perforator (AICAP) flap for treating partial breast defects or breast implant exposure following reconstruction. As radiotherapy is commonly administered for breast cancer, some patients may present with heavily damaged skin flaps and chronic radiodermatitis. We describe new applications of a de-epithelialized AICAP flap, used in combination with an implant, for breast reconstruction when other treatment options are unavailable. Methods: A retrospective study was conducted, including all patients who underwent implant-based breast reconstruction with the aid of an AICAP flap. A literature review was also performed. Results: Between November 2022 and August 2023, four pedicled AICAP flaps were harvested in four patients. The indications were breast implant coverage in cases of chronic dermatitis of the mastectomy skin flaps (two unilateral flaps) and inferolateral coverage of partially submuscular expanders for immediate breast reconstruction (two unilateral flaps). All four flaps were based on one perforator. The mean harvesting time was 40 minutes. Complete flap survival was achieved, with no complications at the donor site. Conclusions: The AICAP flap is a safe and reliable technique for difficult cases of breast reconstruction when no other options are available. Moreover, this technique can easily provide additional coverage for the breast implant when needed.

Background/Objectives: The rising incidence of breast cancer has led to more mastectomies and increased demand for reconstruction. While retropectoral reconstruction with expanders is common, it has complications like postoperative pain and animation deformity. Prepectoral reconstruction, aided by advancements in biological and synthetic meshes, offers a promising alternative. Methods: This study prospectively evaluated the “Prepectoral Breast Reconstruction Assessment Score” on 20 patients undergoing mastectomy at Policlinico Umberto I, Rome, from July 2022 to February 2024. Patients with scores between 5 and 8 were included. The procedure involved the use of ADM (Acellular Dermal Matrix) or titanium-coated polypropylene mesh, followed by postoperative expansions and final implant placement after six months. Results: The mean age of patients was 51.85 years, with a mean BMI of 24.145 kg/m2. ADM was used in 15 cases and synthetic mesh in 5. Complications were one exposure of the expander, one superficial skin necrosis and one seroma. Statistical analysis showed a trend toward fewer complications with higher scores, though this was not statistically significant (p-value = 0.139). Conclusions: Prepectoral reconstruction with expanders is a viable option, offering benefits such as reduced operating time, better volume control, and a more natural breast contour compared to the retropectoral approach. Although the trend suggests fewer complications with higher assessment scores, further studies with larger samples are needed for confirmation.

Background: An increasing number of patients are using online in-formation regarding medical issues; however, the Internet is not subject to content ratings or filters. Unreliable information found on the web can heavily influence patients to the extent that it can lead to wrong decisions in the choice of treatment. In our daily experience we meet more informed patients and given the increasing use of polyurethane-coated implants in breast reconstruction in Europe, we wondered about the level of information available online. Our study aims to assess the quality of information available online on breast reconstruction with polyurethane-coated implants.Materials and Methods: Assuming that the most used search engines are Google and Yahoo, we used a search strategy to identify online information regarding prepectoral breast reconstruction with polyurethane-coated implants. The selected websites were di-vided into 5 groups (practitioners, hospitals, healthcare portals,professional societies, and encyclopedias), and the quality of information was assessed by using an expanded version of the Ensuring Quality Information for Patients (EQIP) tool, which is a checklist applicable to all existing types of information.Results: Fifty-six websites were selected and were categorized into 5 groups: 17 practitioners, 9 hospitals, 13 healthcare portals, 7 professional societies, 10 encyclopedias. The average score was 17 points (range: 12 - 25). We found 13 reliable websites with a score higher than 20 using the expanded version of the EQIP tool, whereas 43 were deemed unreliable, as they scored lower.Conclusion: Proper communication between surgeon and patient is crucial in the therapeutic choice, as the available online information presently is scarce and can lead to wrong decisions if not properly verified.(c) 2023 The Authors. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )

Background. In alloplastic breast reconstruction, the choice of implant positioning and the selection of periprosthetic devices is a critical and challenging decision. Surgeons must navigate between various biologic and synthetic meshes, including acellular dermal matrices (ADM). This study aimed to propose a simple selection tool for periprosthetic devices in prepectoral breast reconstruction. Methods. Patients scheduled for mastectomy followed by implant-based breast reconstruction between September 2019 and December 2023 were included. Preoperative risk assessments were performed using the Pre-Bra Score, and only those deemed suitable for prepectoral implant placement were selected. Mastectomy flap thickness was used as an independent criterion, and only cases with flap thicknesses less than 1 cm were included. Results. A total of 70 cases with an average flap thickness of 0.7 cm (range, 0.4-0.9 cm), as measured by preoperative contrast-enhanced spectral mammography (CESM), underwent prepectoral reconstruction with ADM covering the implant. Of these, 25 patients (35%) received direct-to-implant reconstruction, while 45 (65%) underwent two-stage reconstruction with a temporary tissue expander. Postoperative complications were recorded during a minimum follow-up period of 6 months. Over an average follow-up duration of 17.5 months (range 6-36 months), no major complications were observed. Minor complications occurred in seven patients: infection (1.28%), seroma (3.85%), and superficial skin necrosis (1.28%). Additionally, 21 patients (30%) experienced rippling, and secondary lipofilling was scheduled. Conclusions. The incidence of rippling was reduced by 40% through ADM in this patient subgroup, reducing the need for secondary aesthetic refinements.

Osteochondral lesions may be due to trauma or congenital conditions. In both cases, therapy is limited because of the difficulty of tissue repair. Tissue engineering is a promising approach that relies on designed scaffolds with variable mechanical attributes to favor cell attachment and differentiation. Human adipose-derived stem cells (hASCs) are a very promising cell source in regenerative medicine with osteochondrogenic potential. Based on the assumption that stiffness influences cell commitment, we investigated three different scaffolds: a semisynthetic animal-derived GelMA hydrogel, a combined scaffold made of rigid PEGDA coated with a thin GelMA layer and a decellularized plant-based scaffold. We investigated the role of different biomechanical stimulations in the scaffold-induced osteochondral differentiation of hASCs. We demonstrated that all scaffolds support cell viability and spontaneous osteochondral differentiation without any exogenous factors. In particular, we observed mainly osteogenic commitment in higher stiffness microenvironments, as in the plant-based one, whereas in a dense and softer matrix, such as in GelMA hydrogel or GelMA-coated-PEGDA scaffold, chondrogenesis prevailed. We can induce a specific cell commitment by combining hASCs and scaffolds with particular mechanical attributes. However, in vivo studies are needed to fully elucidate the regenerative process and to eventually suggest it as a potential approach for regenerative medicine.

This study investigates the interplay between plastic and reconstructive surgery patients and their respective caregivers in the Day Surgery Unit of Policlinico Umberto I, Rome, Italy. Utilizing a dual survey approach, we explored the role in patient safety and the challenges faced by caregivers during the perioperative period. This study, conducted at Policlinico Umberto I, covers all surgical procedures from October to December 2023, encompassing skin cancer removal, fat grafting, scar revisions, hand surgeries, and eyelid surgeries. Patient demographics reflect varying age distributions: 18-39 (4.9%), 40-59 (31.7%), 60-75 (34.1%), and over 76 years (29.3%).