- OBJECTIVE: Lichen sclerosus is a chronic, inflammatory, progressive skin disease predominantly affecting anogenital areas. Vulvar lichen sclerosus (VLS) is one of the most common conditions treated in vulvar clinics; most patients report distressing symptoms of itching, burning, stinging, and pain (particularly during or after sexual intercourse). A preliminary, prospective, single -center study was performed to investigate the efficacy of hyaluronan hybrid cooperative complex (HCC) comprising high and low molecular weight hyaluronic acid to treat menopausal women with VLS. PATIENTS AND METHODS: Patients (N = 30) received two HCC injections at 32 mg/ml (one month apart). At baseline and one and six months after treatment, patients completed validated psychometric questionnaires to assess their self-reported pain, itching, and dryness using the Visual Analogue Scale (VAS) and sexual function by the Female Sexual Function Index (FSFI). RESULTS: After treatment with HCC, no side effects or complications were reported. VAS scores showed a trend towards reduced pain and itching intensity, and there was a statistically significant reduction in median VAS score for dryness at follow-up vs. baseline (p=0.038). For sexual function, there was a statistically significant improvement in lubrication (p=0.001) and orgasm (p=0.001) FSFI domains. CONCLUSIONS: Overall, this preliminary study demonstrated the promising efficacy of HCC in menopausal women with VLS without side effects.

The management of skin cancer presents challenges in reconstructive surgery to achieve the best patient outcome and rapid wound healing. The most used antiseptic in pre and post operative care is Povidone Iodine solution. However, valid antiseptic alternatives should be considered. The primary endpoint of our study was to achieve the best healing in patients receiving fluorescein solution versus two comparator arms (Eosin and Povidone-Iodine).182 patients were enrolled and divided into three randomized groups according to the type of antiseptic solution received: Fluorescein (n = 63), Eosin (n= 60), and Povidone-Iodine (n = 59). To assess the endpoint of our study the ASEPSIS score was used to objectively evaluate graft healing. Results of the ASEPSIS score for each group were analyzed. The comparison demonstrated that there was no statistically significant difference among the three groups regarding the endpoint of our study, thus between fluorescein and povidone-iodine (p = 0.89), eosin and fluorescein (p = 0.54), and eosin and povidone-iodine (p = 0.81). Patients responded positively to the use of the Fluorescein antiseptic solution, although no more than the others. This study suggests that this type of antiseptic can be successfully used in skin graft management.

Dear Editor, A letter to the Editor re: 'Infective complications of cosmetic tourism: A systematic literature review'Journal of Plastic, Reconstructive & Aesthetic SurgeryPreviewDear Editor, Full-Text PDF

Pseudoangiomatous stromal hyperplasia (PASH) of the breast is a rare and benign medical condition in which the breast tissue is affected by an abnormal myofibroblastic proliferation, which mimics a low-grade sarcoma angiomatous proliferation. PASH usually presents itself either as a palpable mass or as an incidental diagnosis during breast specimens' histological examination. A few cases have been reported in the literature of a diffuse form of breast PASH syndrome in which the clinical presentation is a bilateral form of gigantomastia without palpable masses. In such cases, the optimal surgical management is still debated due to a significant risk of relapse after breast reduction. Mastectomy seems to be the endpoint of this condition in relapsing cases. Recent studies report a good outcome with a Tamoxifen regimen when surgery cannot be performed, supporting a hormonal component for the etiology of the condition. This study reports on an extremely rare case of bilateral, rapid, and severe PASH in a young patient, presenting as a truly disabling gigantomastia that forced the patient to use a wheelchair due to the excessive breast weights (25 kg the right breast and 21 kg the left). We describe her complicated medical history, her diagnosis, and our course of treatment.

Background: Necrotizing fasciitis is a rare and potentially life-threatening soft tissue infection, even more so when associated with fungal causative agents. Onset has been identified in nosocomial settings following elective surgery, but not in esthetic surgery. Case presentation: We here present a case of necrotizing fasciitis related to Candida albicans infection which occurred in an immunocompetent patient who received a cosmetic breast augmentation mastopexy combined with a Brazilian Butt Lift using autologous fat grafting. The case was managed with aggressive wound exploration and debridement. Treatment was delayed by the diagnostic challenge and the difficulty in identifying the causative agent, but the patient fully healed and recovered once the C. albicans was isolated in culture tests and appropriate antimycotic treatment was implemented. Conclusion: Considerations should be made regarding the possibility of implementing an antimycotic option for first-line empirical treatment despite the rarity of fungal etiology because of the threat of diagnostic delay and worse outcome.

Background: Cosmetic tourism has increased dramatically over the years. We performed a systematic review of the literature to find reports of infective complications following cosmetic surgery, focusing on epidemiology, clinical, and surgical management. In addition, we identified cosmetic tourism trends in terms of mobilization from the country of origin and travel destinations. Methods: A search on PubMed, Embase, and Web of Science was performed between March and August 2022. The search was not restricted based on study date. Only English manuscripts were assessed. Reviews, short communications, letters, and correspondences were excluded after reviewing their references for potentially relevant studies. Articles related to non-cosmetic surgeries were also excluded from the study. Results: We identified 152 articles, of which 31 were duplicates and 47 were excluded based on title/abstract assessment. Three non-English manuscripts, 13 reviews, 12 letters to the editor, and 10 articles that did not feature clinical cases were also rejected. Thirty-six articles were included for analysis. We found 370 patients with infective complications following cosmetic surgery. The severity of complications was stratified according to the Clavien-Dindo classifi- cation. Most reports were from the United States (56.5%), followed by Switzerland and the United Kingdom. Travel destinations included the Dominican Republic (34.3%), Turkey, and Colombia. Conclusion: Infective complications commonly occurred after abdominoplasties in patients who underwent cosmetic surgeries in Latin America or Asia. Most infective complications re- quired management with surgical procedures that involved the administration of local, regional, or general anesthesia. Gluteal augmentations were the fourth most common cosmetic procedures; however, they were associated with the highest number of severe cases, which required intensive care treatment.& COPY; 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The thoracodorsal (TD) vessels represent a complex vascular system that offers a variety of pedicled and free flaps. Variations of the classical latissimus dorsi (LD) flap have been developed to overcome its major drawbacks. The thoracodorsal artery perforator (TDAP) flap described by Angrigiani represents one of these options. Other techniques have been defined as “muscle-sparing” latissimus dorsi (MSLD) due to the preservation of the LD muscle and the TD nerve, in whole or in part. Nevertheless, the term “muscle sparing” has also been applied to the descending branch LD (DB-LD) flap which requires the denervation of the LD muscle. According to our knowledge, there are no articles in the literature reviewing and comparing the reconstructive options based on the TD vessels. We performed a systematic search in PubMed, Web of Science, and Cochrane databases to perform a literature review and meta-analysis about the reconstructive options based on the TD vessels. The primary outcome of interest was the percentage of flaps developing a specific early complication, i.e., hematoma of the donor site, seroma of the donor site, partial flap loss, total flap loss, wound dehiscence, and wound infection. Moreover, we analyzed the outcomes and complications of our cases, comparing the MSLD flaps, the DB-LD flaps, and the TDAP flaps. According to both our casuistry and the literature, the three techniques can be considered safe in terms of early donor site complications. According to the literature, MSLD has been shown to develop partial flap necrosis more frequently than the TDAP flap.

In the last few years, tuberculosis (TB) infections resurfaced in Europe. Despite its growing incidence, muscoloskeletric localization and in particular hand involvement represents a rare presentation of TB, representing only 1-2% of cases. We report the case of a 64-year-old man, presenting to our department with hand swelling and fever. The unclear radiological findings demanded a surgical exploration that revealed the presence of caseous necrotic material. Cultural samples con-firmed Koch bacillus presence over infected by a Staphylococcus aureus. No other systemic signs of tuberculosis were found. TB hand infections are clinical entities difficult to recognize and to diagnose, especially in absence of systemic symptoms. TB must be suspected whenever compatible clinical and intraoperative findings are recognized, to avoid se-vere chronic morbidities or dissemination of the disease.

Neonatal purpura fulminans (NPF) is a rare entity due to a deficiency in anticoagulant protein C or S that leads to the development of disseminated intravascular coagulation with formation of microvascular thrombi and skin and soft tissue necrosis. Three forms of NPF are described: congenital, infectious and idiopathic. Acute infectious purpura fulminans (AIPF) is related to sepsis. Group B Streptococcus spp. is the most frequent pathogen involved in the development of AIPF in newborns. The clinical severity varies according to the underlying cause. The mortality rate of AIPF ranges from 10% to 50%. Limbs are involved more frequently than other areas. Skin lesions may present early as petechial rashes, which rapidly progress to larger ecchymoses. Later in the course, hemorrhagic bullae may form, which contribute to the classic hard eschars characteristic of NPF. Differential diagnosis with necrotizing fasciitis should be performed. Treatment of NPF should be multidisciplinary. Plastic surgeons are frequently involved in the management of soft tissue defects. Surgical treatment consists in early debridement or amputation in more critical cases and subsequent reconstruction by using skin grafts, pedicled or free flaps. Medical research is now focused on bioengineering solutions that can provide better aesthetic and functional outcomes while minimizing surgical sequelae. The aim of this editorial is to present the available options and the state-of-the-art research and scientific advances in local wound care and surgical management of AIPF.

Abstract Introduction In breast surgery, an autologous flap combined with implant may reduce the risk or repair the soft-tissue defects in several cases. Traditionally, the preferred flap is the myocutaneous latissimus dorsi (LD) flap. In the perforator flap era, the evolution of LD flap is the thoracodorsal artery perforator (TDAP) flap. The aim of this study is the comparison between LD flap and TDAP flap with implants in terms of early complications and shoulder function. Methods We performed a retrospective cohort study in accordance with the STROBE guidelines. Between January 1 2015 and January 1 2020, 27 women underwent a unilateral total breast reconstruction with LD or TDAP flap combined with an implant at our institution. 15 women were operated with LD flap and 12 with TDAP flap. The most frequent indications for intervention were results of mastectomy and radiation-induced contracture. We evaluated several data in terms of clinical and demographical characteristics, operative and perioperative factors, and follow-up variables. We assessed shoulder function through the Disability of the Arm, Shoulder and Hand Questionnaire (DASH). Results The rate of complications was significantly lower in the TDAP group compared with the LD group (16.7% vs 60.0%, p = 0.047. Table 3). Although the small sample size limited further detailed statistical analyses, we particularly noticed no cases of donor site seroma in the TDAP group, as compared with four in the LD group. Patients in the TDAP group had an ∼11-point lower mean DASH score compared with the LD group (9.8 vs 20.5). This difference was statistically significant (p = 0.049). Conclusions TDAP flap seems to be a reliable technique for soft-tissue coverage in total breast reconstruction with implants. In comparison with the traditional LD flap, it could be a more favorable option in terms of less complications and better quality of life.

Prosthesis-based techniques are the predominant form of breast reconstruction worldwide. The most performed surgical technique involves the placement of the expander in a partial submuscular plane. The coverage of the implant remains a difficult management problem that can lead to complications and poor outcomes. The use of the serratus fascia flap may be the best choice to create a subpectoral pocket for the placement of a tissue expander, with excellent results in terms of morbidity and cost-effectiveness. A total of 20 breast reconstructions with the inferolateral coverage with the serratus fascia were performed. Patients demonstrated a low overall complication rate (9.5%), such as seroma and infection, with complete resolution during the follow-up and no major complications. The US examination of the soft tissues over the implant reported thickness measurements that demonstrated a good coverage over the inferolateral area. Our study shows that using the serratus fascia flap to create a pocket with the pectoralis major for the placement of the tissue expander is an effective technique during two-stage breast reconstruction. The resulting low rate of morbidity and the US findings collected reveal the safety of this procedure. Its success relies on appropriate patient selection and specific intraoperative technique principles.

Capsular contracture is one of the most common complications of implant-based breast augmentation. Despite its prevalence, the etiology of capsular contracture remains controversial although the surface texture of the breast implant, the anatomical position of the prosthesis and the presence of bacterial biofilm could be considered trigger factors. In fact, all medical implants are susceptible to bacterial colonization and biofilm formation. The present study demonstrated the presence of microbial biofilm constituted by cocci in a breast implant obtained from a patient with Baker grade II capsular contracture. This suggests that subclinical infection can be present and involved in low grade capsular contracture.

Sir: We read with great interest the article entitled “Impact of Evolving Radiation Therapy Techniques on Implant-Based Breast Reconstruction” (Plast Reconstr Surg. 2017;139:1232e–1239e).1 The authors performed a retrospective study in which they compared the complication rate of 533 nonirradiated reconstructions and 125 irradiated reconstructions. This study showed that the irradiation group was significantly more likely to experience later complications (such as capsular contracture) than the nonirradiated group (30.9 percent versus 20.2 percent; p = 0.05). Within the irradiated group, complication rates did not vary significantly between patients with tissue expanders versus patients with implants except in the development of capsular contracture (tissue expander group, 12.7 percent; implant group, 35.7 percent; p = 0.06). The authors evaluated the radiation dose to the skin, 1 cc of skin, to the breast, body, and tissue expander/implant, and demonstrated that only the first two radiation doses are associated with significantly increased complication rates. In accordance with the authors, we think that the role of skin damage is crucial in the development of complications.2 For this reason, in our practice, we usually perform fat grafting after radiotherapy.3 Fat injection helps to prevent and avoid skin damage by increasing tissue thickness and promoting tissue healing because of the presence of mesenchymal stem cells and growth factors. The development of capsular contracture may be also linked to radiation-induced alteration of biomaterials (implants).4 Therefore, the prevention of implant damage is carried out by performing radiation therapy on the expander and not on the definitive implant fallowed by multiple sessions of fat grafting performed before the time of expander-implant exchange.5 We believe that achieving a breast reconstruction with a nonirradiated implant is safer. This is confirmed by both our clinical results and biomaterial analysis; however, further clinical and experimental studies are necessary to confirm our preliminary results. DISCLOSURE The authors have no potential conflict of interests and have not received funding for this work. None of the authors received any funds or has any financial interests to disclose. Federico Lo Torto, M.D.Paola Parisi, M.D.Donato Casella, M.D.Giuseppe Di Taranto, M.D.Department of General and Plastic SurgeryPoliclinico Umberto I“Sapienza” University of RomeRome, Italy Emanuele Cigna, Ph.D.Department of Translational Research and New Technologiesin Medicine and SurgeryPisa UniversityPisa, Italy Diego Ribuffo, M.D.Department of General and Plastic SurgeryPoliclinico Umberto I“Sapienza” University of RomeRome, Italy

Vacuum-assisted closure (VAC) therapy is a sophisticated system that maintains a closed, humid, sterile and isolated environment. Wound infection is considered a relative contraindication. The objective of this study is to extend the indications for VAC therapy to include infected wounds by demonstrating its ability to increase the antibiotic concentration in the damaged and infected tissues. Patients who presented with ulcers infected with daptomycin-sensitive bacteria were eligible to be enrolled in this prospective study. They were given antibiotic therapy with daptomycin with a specific protocol. A biopsy of the lesion was carried out to detect tissue concentration of the drug at time 0. Afterwards, the patients were subjected to VAC therapy. At the end of VAC therapy, a second lesion biopsy was performed and analysed to detect tissue concentration of the drug at time 1. A control group was enrolled in which patients followed the same protocol, but they were treated with traditional dressings. Fisher's exact test was used to compare the two groups. The results highlighted a significant increase in the concentration of antibiotics in the study group tissue; the improvement was sensibly lower in the control group. Statistical differences were not found between the two groups. The preliminary analysis of the data showed an important increase of antibiotic concentration in the tissue after VAC therapy. Despite the encouraging data, it is necessary to broaden the sample of patients and perform the same study with other antibiotics.

Purpose This study aims to evaluate the safety and efficacy of autologous aspirated and purified fat tissue injected percutaneously into the knee joint for the treatment of symptomatic osteoarthritis (OA). Methods We reviewed 30 patients, who received an autologous percutaneous fat injection for the treatment of knee OA, from January 2012 to March 2015. Mean patients' age was 63.3 ± 5.3 years (range, 50–80 years). Body mass index was 25.1 ± 1.7. Clinical evaluation was based on pain visual analog scale (VAS) and WOMAC score for functional and subjective assessment. We also noted the adverse reactions and the consumption of nonsteroidal anti-inflammatory drugs in the posttreatment period. Results All patients reported improvements with respect to pain: average VAS was 7.7 ± 1.2 at baseline, 5.2 ± 0.2 at 1-month follow-up, and 4.3 ± 1 at 3-month follow-up. A slight deterioration (5.0 ± 1.1) was evidenced at 1 year. Total WOMAC score was 89.9 ± 1.7 at baseline, 66.3 ± 1 at 1 month, 68.6 ± 1.7 at 3 months, and 73.2 ± 1.8 at 12 months of follow-up. Conclusion Our preliminary findings suggest that autologous percutaneous fat injections are a valid treatment option for knee OA. Level of Evidence Level IV, therapeutic case series.

AIM Congenital genitalia anomalies are a spectrum of malformation, difficult to classify because similar or identical phenotypes could have several different aetiology; therefore it's essential to assess an efficient diagnostic algorithm for a quick diagnosis and to develop an efficient therapeutic strategy. The aim of this study is to underline the importance of imaging in case of ambiguous genitalia due to its high sensitivity and specificity in detecting internal organs and urogenital anatomy. MATERIAL OF STUDY We report a case of a young girl affected by a complex genitor-urinary malformation with an initial wrong anamnesis that led to a tricky diagnosis. RESULTS Imaging techniques - especially Magnetic Resonance Imaging (MRI) - together with karyotype, hormones and physical investigations, offered complete and reliable informations for the best surgical treatment of our patient. CONCLUSION Karyotype, hormones investigation, and radiological examinations are the main criteria considered in the diagnostic iter. Ultrasonography (US) is the primary modality for the detection of the presence or absence of gonads and müllerian derivatives, whereas Cystourethrography can define urethral and vaginal tract or the presence of fistulas. In our experience MRI, due to its multiplanar capability and superior soft tissue characterization, proved to be useful to provide detailed anatomic information.

The origin of the muscolocutaneous latissimus dorsi flap dates back to 1906 when Igino Tansini, an Italian surgeon, described a procedure to reconstruct the mastectomy defect. After a detailed study of Tansini's original description and drawings, new insights about the pedicle of its compound flap have been found, showing that it has the same pedicle of the scapular flap. In the end, Tansini's flap should be more correctly considered as a compound musculocutaneous scapular flap.