Francesca Maggiulli

Treatment of primary axillary hyperhidrosis with botulinum toxin type a: our experience in 50 patients from 2007 to 2010.

Background. Local injections of Botulinum toxin type A (BTX-A) are an effective and safe solution for primary bilateral axillary hyperhidrosis. Traditional treatments are often ineffective and difficult to tolerate. This study was performed to assess the efficacy and safety of Botulinum toxin type A in the treatment of these diseases and to evaluate the reliability of patients subjective rating in the timing of repeat injections. Methods. From 2007 to 2008, we included in the study and treated a total of 50 patients, and we used the Minors iodine test and the hyperhidrosis diseases severity scale as initial inclusion criteria and also for evaluating the followup, comparing to patients subjective rating. We used also a specific questionnaire to evaluate the level of pain, the onset of the effect, any eventual adverse effect of the treatment, the onset of compensatory hyperhidrosis, and the global grade of satisfaction. The data were analyzed using standard statistical methods. Results. 88% of patients were totally satisfied and all patients repeated the treatment during all the study. The symptom-free interval was in median 6 months with an average improving of HDSS of 1.5 points. In 86%, there was a complete accordance between the subjective patients demand of the repetition of the treatment and the positivity to Minor test and HDSS. No major side effects happened. Conclusion. Local injections of Botulinum toxin type A (BTX-A) result in an effective and safe solution for bilateral axillary primary hyperhidrosis for the absence of significant morbidity, side effects, and lack of efficacy or duration. The only defects are the need of repetition of the treatment and relative costs.

A case of facial lipoatrophy secondary to lupus profundus managed with lipofilling technique.

Facial lipoatrophy is one of the most difficult complication in the patients with lupus profundus. In this paper, we present a case of a 55-year-old woman affected by lupus profundus, with a grade V lipoatrophy, treated with lipofilling technique. No complications were observed and results at 12 months were stable, natural, and symmetric.

Chimeric anterolateral thigh free flap for reconstruction of complex cranio-orbito-facial defects after skull base cancers resection

Complex cranio-orbito-facial defects after skull base cancers resection entail a functional and esthetic reconstruction. The introduction of endoscopic assisted techniques for excision surgery with the advances in reconstructive surgery and anesthesiology allowed to improve the management of such critical patients. We report a series of chimeric anterolateral thigh (ALT) flaps used to reconstruct complex cranio-orbital-facial defects after skull base surgery. A retrospective review of patients that underwent cranio-orbito-facial reconstruction using a chimeric ALT flap from March 2013 to October 2015 at a single tertiary care referral Institute was performed. All patients were affected by locally-advanced malignant tumor and the resulting defects involved the skull base in all cases. The ALT flaps were perforator-based flaps with different components: fascia, skin and muscle. The different flap territories had independent vascular supply and were independent of any physical interconnection except where linked by a common source vessel. Ten patients were included in the study. Three patients underwent adjuvant radiotherapy and to chemotherapy. The mean hospitalization time was 21 days (range, 8-24 days). One failure was observed. After a mean follow-up of 12.4 months, 3 patients died of the disease, 2 are alive with disease, while 5 patients (50%) are currently alive without evidence of disease. Chimeric ALT flap is a reliable and versatile reconstructive option for complex cranio-orbito-facial defects resulting from skull base surgery. The chimeric flap composed of different territories proved to be adequate for a patient-tailored three-dimensional reconstruction of the defects as well as able to resist to the postoperative adjuvant treatments.

Massive de-gloving thigh injury treated by vacuum therapy, dermal regeneration matrix and lipografting

Frequently lower limb injuries are caused by road and work accidents. The young age of those affected coupled with the anatomical and functional peculiarities of this part of the body with regards to social life during adolescence make the treatment of the leg wound complex and challenging. We present two cases of young girls, victims of serious road accidents who were treated initially with frequent wound washings, vacuum therapy to stimulate granulation tissue, then dermal regeneration matrix (INTEGRA ® ) and split-thickness skin grafts. After one year, both patients treated with lipofilling have shown improved cosmetic results allowing a new social life.

Sandwich Fascial Anterolateral Thigh Flap in Head and Neck Reconstruction: Evolution or Revolution?

Introduction: The anterolateral thigh perforator flap (ALT) represents the workhorse for most reconstructive efforts in the head and neck regions. The main advantages of this flap are its versatility, the length of the pedicle, and the low morbidity of the donor site. The major drawback is the bulkiness of this flap with the frequent need for secondary revisions. To overcome this, we have developed a novel way to harvest and inset the ALT, called the sandwich fascial ALT flap (SALT). Methods: All patients undergoing head and neck reconstruction using the SALT flap from January 2013 to March 2016 were included in this retrospective analysis. The SALT flap was harvested as a composite flap including the superficial fascia, the subscarpal fat, and the deep fascia. At the recipient site, the flap was inset with the deep fascia facing out. A split thickness skin graft (± dermal substitute) was used to cover the deep fascia and the pedicle. Results: Eleven patients were included: 8 cases of orbital exenteration, 1 case of forehead reconstruction, and 2 cases of palatal reconstruction after radical maxillectomy. Flap survival was 100%. One patient required an early take back for venous thrombosis. The reconstruction was effective in all cases, allowing a prosthetic rehabilitation when required. Donor-site morbidity was minimal. Conclusions: The reconstruction of head and neck defects with a bulky fasciocutaneous ALT flap might not be the best option in every case. The SALT flap could represent a valid alternative for selected cases, with encouraging functional and cosmetic outcomes.

Reconstructive management of degloving trauma of male external genitalia using dermal regeneration template: A case report

Traumatic injuries of male external genitalia are rare and not usually life threatening; however, they can have psychological repercussions. The reconstructive management of these lesions is challenging and articulated. We report the case of a 38-year-old farmer suffering from a degloving wound on the external genitalia. The first reconstructive step used to treat the wound was the incorporation of a dermal regeneration template (Integra(®)) and accordingly partial-thickness skin grafts and local flaps. The follow-up 16 months after the first treatment was satisfying; sexual function had been restored.

FRAIL scale as a predictor of complications and mortality in older patients undergoing reconstructive surgery for non‑melanoma skin cancer

The aim of the present study was to determine the association between preoperative frailty and the onset of surgical complications in patients diagnosed with massive non-melanoma skin cancer subjected to plastic and reconstructive surgery. A retrospective analysis was performed on a cohort of 587 patients with non-melanoma skin cancer, selected on the basis of specific inclusion criteria, who were subjected to plastic and reconstructive surgery between 2005 and 2014. Frailty was scored using the FRAIL index, whereas postoperative complications were classified according to Clavien-Dindo criteria. By binary logistic regression, the odds and probabilities of complications were calculated as a function of increasing values of the FRAIL index. Two different logistic models were created, comparing absent/mild (Clavien grades 1st and 2nd) vs. moderate/severe complications or mortality (Clavien grades 3rd-5th; model A), or absent/mild/moderate complications (Clavien grades 1st-3rd) vs. severe complications or mortality (Clavien grades 4th and 5th; model B). The FRAIL index was an accurate predictor of surgical complications or mortality, with significant odds ratios and goodness of fit. In model A, FRAIL scores 4 and 5 were the most critical predictors of moderate/severe complications or mortality (37 and 94% probability, 0.6 and 17.3 odds, respectively), compared to score 3 (2% probability, 0.02 odds) or lower. In model B, FRAIL score 5 was the most critical predictor of severe complications or mortality, as it was associated with a 74.6% probability and 2.93 odds for these events. In conclusion, increasing FRAIL scores were associated with worsening surgical outcomes for patients with non-melanoma skin cancer undergoing plastic/reconstructive surgery. A low rate of surgical complications was observed in pre-frail and frail patients up to FRAIL score 3.

A Novel Surgical Technique to Correct Intrareolar Polythelia

Polythelia is a rare congenital malformation that occurs in 1-2% of the population. Intra-areolar polythelia is the presence of one or more supernumerary nipples located within the areola. This is extremely rare. This article presents 3 cases of intra-areolar polythelia treated at our Department. These cases did not present other associated malformation. Surgical correction was performed for psychological and cosmetic reasons using advancement flaps. The aesthetic and functional results were satisfactory.

Short-Term Effects of Radiotherapy Postquadrantectomy on Internal Mammary Artery and Vein

When a tumor local recurrence occurs a possible approach can be a mastectomy with simultaneous breast reconstruction with autologous tissue. The area involved by tangential radiation portals includes also the internal mammary artery and veins, considered by the most part of plastic surgeons to be the best recipient vessels for a free flap in breast reconstruction. Internal mammary vessels receives low but not necessary insignificant doses during whole breast irradiation; arteries and veins are traditionally considered quietly resistant to the irradiation but limited data on the flux in mammary vessels after radiotherapy are available. The goal of our study (37 patients from September 2011 to February 2012) was to evaluate modifications in vascular parameters of the flux at ultrasonography in the internal mammary chain after adjuvant radiotherapy that could influence the choice of the autologous surgical technique (free or pedicled flap) and the choice of the recipient vessels in breast reconstruction. Based on the results of our study, we would recommend avoiding an irradiated recipient site when no irradiated recipient vessels are available; a preoperative ultrasound evaluation is recommended in patients underwent whole breast irradiation.

A New Algorithm for The Surgical Management of Defects of the Scalp

Scalp reconstruction is a daily challenge for plastic surgeons. The authors propose their algorithm for reconstructive surgery after ablative surgery. They considered not only the size defect but also the anatomical defect and the clinical condition of the patient to achieve the best choice for reconstruction. During the two-year period, a total of 86 procedures were performed on 78 patients. We used five different techniques for reconstruction, including primary closure, graft, local or free flap, and a dermal regeneration template. No statistical difference of complication was observed in the different groups. We consider our algorithm a useful improvement in the management of the defect at the vertex.