Nerve Capping Techniques for Neuroma Management: A Comprehensive Literature Review

BACKGROUND/AIM OF THE STUDY

Nerve capping is a method of neuroma treatment or prevention that consists of the transplantation of a proximal nerve stump into an autograft or other material cap, after surgical removal of the neuroma or transection of the nerve. The aim was to reduce neuroma formation and symptoms by preventing neuronal adhesions and scar tissue. In this narrative literature review, we summarize the studies that have investigated the effectiveness of nerve capping for neuroma management to provide clarity and update the clinician's knowledge on the topic.

METHODS

A systematic electronic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria was performed in the PubMed database combining "neuroma," "nerve," "capping," "conduit," "treatment," "management," "wrap," "tube," and "surgery" as search terms. English-language clinical studies on humans and animals that described nerve capping as a treatment/prevention technique for neuromas were then selected based on a full-text article review. The data from the included studies were compiled based on the technique and material used for nerve capping, and technique and outcomes were reviewed.

RESULTS

We found 10 applicable human studies from our literature search. Several capping materials were described: epineurium, nerve, muscle, collagen nerve conduit, Neurocap (synthetic copolymer of lactide and caprolactone, which is biocompatible and resorbable), silicone rubber, and collagen. Overall, 146 patients were treated in the clinical studies. After surgery, many patients were completely pain-free or had considerable improvement in pain scores, whereas some patients did not have improvement or were not satisfied after the procedure. Nerve capping was used in 18 preclinical animal studies, using a variety of capping materials including autologous tissues, silicone, and synthetic nanofibers. Preclinical studies demonstrated successful reduction in rates of neuroma formation.

CONCLUSIONS

Nerve capping has undergone major advancements since its beginnings and is now a useful option for the treatment or prevention of neuromas. As knowledge of peripheral nerve injuries and neuroma prevention grows, the criterion standard neuroprotective material for enhancement of nerve regeneration can be identified and applied to produce reliable surgical outcomes.

The Use of Botulinum Toxin in Raynaud Phenomenon: A Comprehensive Literature Review

BACKGROUND

Raynaud phenomenon (RP) is a vasospastic condition of the digits that can be primary or secondary to systemic disease. Symptoms are triggered by cold or stress and can cause pain and skin color changes. The chronic ischemia may lead to necrosis, ulceration, and amputation. There are no Food and Drug Administration-approved treatments and cases refractory to pharmacologic and surgical treatments are difficult to control. Local botulinum toxin injections have been increasingly used in the treatment of Raynaud disease and have shown promising results.

AIM OF THE STUDY

To examine the outcomes, techniques, and complications of botulinum toxin use for the treatment of Raynaud disease.

METHODS

The PubMed database was queried using "botulinum toxin" AND "Raynaud phenomenon" as title key words. Preferred reporting items for systematic reviews and meta-analysis criteria were used. Additional articles were selected while reviewing the references of the articles from PubMed. No time restrictions were followed. Articles of all languages were included. Articles were analyzed for study type, demographics, diagnosis/inclusion criteria, treatment methods, outcome measures, length of follow-up, results, and complications. A positive outcome was defined as subjective improvement in symptoms and/or improvement in the outcome measures. A poor outcome was defined as harm done to the patient by the injection that would not have occurred otherwise.

RESULTS

Forty-two clinical studies describing the use of botulinum toxin for Raynaud's phenomenon were found. A total of 425 patients with primary or secondary Raynaud's were treated, with ages ranging from 14 to 91 years. There were 342 women and 81 men, with a female-to-male ratio of 38:9. Outcomes were positive in 96.2% of patients. There were 14.2% of the studies that reported 3.5% of all patients showing no subjective improvement. A single study reported a poor outcome for 1 patient. There were 40.5% of the studies that reported complications, affecting 20.2% of all patients. The most frequently reported complication was transient hand weakness, affecting 44.2% of patients with complications and 8.9% of total patients. Weakness resolved in hours to months after injection. Pain at the injection site lasting minutes to days was reported in 40.7% of patients with complications, and 8.2% of total patients.

CONCLUSIONS

Botulinum toxin treatment for RP is effective. Complications are minor and self-limiting.

Recent Advances in Breast Cancer Diagnosis, Treatment, Psychology, Management, and Reconstruction

Breast cancer is the second most common cancer in women after skin cancer [...].

Recurrence of breast ptosis after mastopexy - a prospective pilot study

BACKGROUND

Breast ptosis is characterized by severe volumetric deficiency of the upper pole, excess of skin in the lower pole and descent of the nipple-areola complex (NAC). Mastopexy, also known as breast lifting, is the surgical operation aimed to reshape the ptotic breast. Recurrence of breast ptosis after mastopexy is common but to the best of our knowledge no study before has measured it.

PURPOSE

The aim of this study was to measure the recurrence of breast ptosis after mastopexy in a prospective study.

MATERIALS AND METHODS

Female patients affected by unilateral or bilateral moderate or severe breast ptosis were enrolled in the study. All the patients underwent mastopexy performed only with the removal of skin excess following a Wise pattern. The jugular notch-nipple distance was measured before surgery, immediately after surgery and after 1, 3, 6 and 12 months.

RESULTS

Ten patients were included in the study, four underwent unilateral mastopexy and six underwent bilateral mastopexy. The lifting of the NAC, measured in the immediate post-operative period, ranged from 3 to 8.5 cm, with an average value of 6.3 cm. This lifting, one year after surgery, ranged from 2 to 7 cm, with an average value of 4.6 cm. The percentage loss of the NAC lifting one year after surgery compared to the immediate post-operative time ranged from 12.5 to 41.7%, with an average value of 27.5%.

CONCLUSION

In our case series, the lifting of the NAC obtained immediately after surgery showed an average loss of 27.5% one year after surgery. Even if limited by the low number of patients included, this pilot study is eye-opening on a very common phenomenon that occurs after mastopexy. The patients should be informed about the possible recurrence of the breast ptosis.

What is Beauty?

PURPOSE

In the current study, the authors attempt to thoroughly investigate the concept of beauty from different perspectives in different historical periods and offer their personal thoughts about it.

METHODS

The authors performed a comprehensive and across-the-board literature review about 'beauty', including beauty from a philosophical perspective, beauty perception by human mind, beauty from a biopsychological perspective, beauty of the face, body and breast, models of beauty and beauty in cosmetic surgery.

RESULTS

From Plato to modern neuro-psychological studies, the concept of beauty has always been a theme for adamant debates and passionate thoughts. Different aspects of beauty, from intellectual to pure physical, have received a tremendous amount of attention. The true definition of the concept of beauty is still ambiguous, and there is not a unanimous explanation for it. It seems that the definition of beauty differs in every individual's mind and over the history of humankind.

CONCLUSION

Although beauty is a very important concept and the seek for achieving it is a very natural behavior, one must remember that the importance of beauty should not overshadow the fact that every human being is made up of similar internal organs. We strongly encourage the reader to look beyond the hedge, to be aware that each of us is made up of internal organs, beyond the external appearance. Level of Evidence V 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 Table of Contents or online Instructions to Authors www.springer.com/00266.

Leonardo da Vinci: the Lady with an Ermine enigma

"Lady with an Ermine" (1489-1490) is an oil on walnut portrait by the Italian artist Leonardo da Vinci. The portrait's subject is Cecilia Gallerani, the favorite mistress of Ludovico Sforza, known as "il Moro", Duke of Milan. It was painted around the time of Cecilia's pregnancy with Ludovico's illegitimate son. Leonardo's paintings are famous for hiding mysteries; thus, the truth about the "Lady with an Ermine" is still unclear. However, the solution to this enigma could be more evident than expected. Our hypothesis is that Cecilia might have suffered from pregnancy-induced Cushing syndrome.

Umbilical Reconstruction Techniques: A Literature Review

BACKGROUND

There are many instances in which sacrificing the umbilicus is unavoidable. Umbilical reconstruction (umbiliconeoplasty) is an important surgical procedure to complete the abdomen's reconstruction and to give again a pleasant cosmetic appearance.

OBJECTIVES

To provide a complete overview of all surgical techniques for umbiliconeoplasty described in the literature.

METHODS

PubMed database was queried using 'umbilical and reconstruction', 'umbilicus and reconstruction', 'navel and reconstruction', 'umbiliconeoplasty', 'neo-omphaloplasty' or 'umbilicaneoplasty' to select the papers dealing with the reconstruction of the umbilicus.

RESULTS

Sixty different techniques for the reconstruction of the missing umbilicus were described in 77 papers. Local skin flaps and the purse-string suture technique were the most frequently described techniques. The Three flaps technique, the Four flaps technique and the 2 Lateral rectangular pedicle lateral flaps technique were the most popular local flap techniques. Indications ranged from congenital pediatric defects to reconstruction during abdominoplasty.

CONCLUSIONS

Several surgical techniques were described for umbilicus reconstruction. While there is not a universal algorithm for the choice of the technique, the surgeon may decide which technique to use based on other surgeons' experiences reports.

LEVEL OF EVIDENCE III

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 .

Management of skin damage of health workers' face: the role of plastic surgery in the time of Pandemic

Background and aim:

The Sars-Cov-2 virus is characterized by a being highly contagiousness, and this is the reason why massive use of personal protective equipment is required by medical and paramedical staff of the COVID-19 dedicated departments. The aim of this manuscript is to describe and share our experience in the prevention and treatment of the personal protective equipment related pressure sores and other skin alterations in the medical and paramedical staff.

Methods:

All healthcare workers with PPE-related skin damages were registered at time 0. Age, sex, profession, type of skin damage, diseases and possible drugs were registered.

Results:

Two strategies were employed: the first strategy was to immediately treat the skin and the second one was to prevent pressure wounds formation both in already affected healthcare workers and the recurrence in healed staff. Three weeks after the two strategies were used, the incidence rate PPE-related skin damage was reduced in a statistically significant way.

Conclusions:

Proper management helps in reducing the incidence of pressure ulcers related to personal protective devices in Covid-19 Units. Skin prevention and hydration, have been obtained achieved by using products applied at home, autonomously.

Histoplasmosis of the Upper Extremities: Clinical Case, Treatment Algorithm, and Systematic Review

Background: Histoplasmosis of the upper extremities is extremely rare, and there is no consensus in its management. The aim of this study was to present a case report and literature review of histoplasmosis in the upper extremities to provide the best treatment recommendation and to increase awareness of this disease. Methods: A systematic review of the literature was performed in PubMed, MEDLINE, and EMBASE databases with the search terms "(Tenosynovitis AND histoplasmosis)" OR "(Upper limbs AND histoplasmosis)" OR "(Upper extremities AND histoplasmosis)" OR "((finger OR arm OR hand OR forearm OR wrist) AND histoplasmosis)." Manuscripts were included in the study if they described diagnosis of histoplasmosis in the bone, joint, synovia, or tendons of the upper extremities. Results: In all, 14 manuscripts and 15 cases of histoplasmosis of the upper extremities from 1992 to 2015 met the inclusion criteria. Eight (53.3%) patients were diagnosed with tenosynovitis, 5 (33.3%) with osteomyelitis, 1 (6.7%) with carpal tunnel syndrome, and 1 (6.7%) with joint wrist abscess. Immunosuppression, travel history, previous diagnosis with histoplasmosis, and persistent symptoms may suggest infectious causes. Surgery and medical treatment together are recommended to optimize outcomes compared with single treatment alone. Conclusions: Histoplasmosis of the upper extremities may have various clinical presentations, including tenosynovitis, osteomyelitis, carpal tunnel syndrome, and joint wrist abscess. The type of surgical approach may depend on the etiology of disease. Increased awareness and knowledge of the clinical signs, symptoms, and effective treatment modalities will help decrease possible complications, such as tendon rupture and functional impairment of the upper extremities.

Clinical Case of Acute Non-Traumatic Hand Compartment Syndrome and Systematic Review for the Upper Extremity

Background: While trauma to the upper extremity is known to cause acute compartment syndrome (ACS), nontraumatic causes of ACS of the upper extremity are rare. Nontraumatic ACS of the upper extremity can lead to adverse outcomes if not recognized early. There are limited reports of spontaneous ACS published in the literature. The aim of this comprehensive systematic review is to increase awareness among plastic surgeons and hand surgeons of this acute event and provide an algorithmic approach to management in the acute setting through an illustrative case example. Methods: A comprehensive systematic review of published literature was conducted in the Medline/PubMed database with the search terms, "compartment syndrome," "extremity," "spontaneous," "nontraumatic," and "atraumatic" without timeframe limitations. Articles were identified and included in this review based on ACS localization in the upper extremity and etiology of nontraumatic, spontaneous origin. Results: Sixteen publications and 19 total cases of nontraumatic ACS of the upper extremity from 1993 to 2016 met our search criteria. A bleeding disorder was the etiology in three cases, systemic anticoagulation in three cases, infection in six cases, and unknown in three cases. The remaining four cases included systemic sclerosis, Ehlers-Danlos syndrome, rhabdomyolysis, and McArdle disease. Conclusions: Nontraumatic causes of ACS of the upper extremity include infection, anticoagulation therapy, and bleeding disorders. Even though trauma is the most common cause of ACS, clinicians should be aware of these other potential causes of ACS in the nontraumatic setting. Appropriate medical and surgical intervention should be done to avoid potential adverse outcomes.

Taking care of healthcare workers during COVID-19 pandemic: does plastic surgery have a role?

Background:

The massive use of personal protective equipment is required by the medical and paramedical staff of the COVID-19 dedicated departments. This often causes painful pressure injuries. The aim of this study is to value the use of anesthetic cream and collagen veil masks for the treatment of pain. We also evaluated the possible psychological impact on healthcare workers involved in the emergency, which is currently a hot topic in the worldwide literature.

Materials and Methods:

We applied lidocaine idrochloride 5% cream and a collagen veil mask respectively before and after each work shift. We evaluated the improvement of pain symptoms through VAS assessments. We used a modified Maslach burnout inventory as well to evaluate the psychological impact of our treatments on healthcare workers.

Results:

A significant reduction of pain was detected within the first 3 days, but this was not significant over the long period (10 days). Otherwise, we saw a significant improvement of the psychological assessment (p<0,05).

Conclusions:

Parameters such as pain or psychological stress are not objective, but, anyway, our data show a reduction of pain due to continuative PPE wearing and a significant improvement of psychological wellness of healthcare workers from two different countries, a finding which should not be undervalued by all the health caregivers not directly involved in COVID-19 pandemic. (www.actabiomedica.it)

Unveiling Charles II, the last King of the Habsburg Spanish Empire, in a portrait by Juan Carreño de Miranda (1685)

PURPOSE

Charles II (1661-1700) was the last King of the Habsburg dynasty. He was physically and mentally disabled and died at just 39 years old. Here, the authors attempt to investigate the correlations between his signs and symptoms and the physical appearance on the painting.

METHODS

Charles II has been portraited by Juan Carreño de Miranda in a painting that may provide precious information about his premature death.

RESULTS

It has been suggested that inbreeding beside other endocrinological disorders were of the major causes responsible for illness and ultimately his death.

CONCLUSION

Possible endocrinological diseases have been hypothesized.

Oil injection for cosmetic enhancement of the upper extremities: a case report and review of literature

Here the authors report a case of complications occured after injection of a site enhancement oil in the upper extremity for cosmetic muscles’ volume enhancement and a literature review on the topic. The medical and sports communities should be aware of the secondary effects of site enhancement oils use, which could bring to severe complications. (www.actabiomedica.it)

Treatment of COVID-19 in Pregnancy with Hydroxychloroquine and Azithromycin: a case report

The combination of hydroxychloroquine (HCQ) and azithromycin could represent a suitable treatment for SarS-CoV-2 positive pregnancies. The authors report one of the first cases of COVID-19 positive pregnant woman successfully treated with HCQ in April 2020. (www.actabiomedica.it)

Nipple-Areola Complex Reconstruction

The reconstruction of the nipple–areola complex is the last step in the breast reconstruction process. Several techniques have been described over the years. The aim of this review is to provide clarity on the currently available reconstructive options.

Disparities in Access to Autologous Breast Reconstruction

Background and objectives: This study aimed to determine if age, race, region, insurance, and comorbidities affect the type of breast reconstruction that patients receive. Materials and methods: This analysis used the Florida Inpatient Discharge Dataset from 1 January 2013 to 30 September 2017, which contains deidentified patient-level administrative data from all acute care hospitals in the state of Florida. We included female patients, diagnosed with breast cancer, who underwent mastectomy and a subsequent breast reconstruction. We performed an χ² test and logistic regression in this analysis. Results: On the multivariable analysis, we found that age, race, patient region, insurance payer, and Elixhauser score were all variables that significantly affected the type of reconstruction that patients received. Our results show that African American (odds ratio (OR): 0.68, 95%CI: 0.58–0.78, p < 0.001) and Hispanic or Latino (OR: 0.82, 95%CI: 0.72–0.93, p = 0.003) patients have significantly lower odds of receiving implant reconstruction when compared to white patients. Patients with Medicare (OR: 1.57, 95%CI: 1.33–1.86, p < 0.001) had significantly higher odds and patients with Medicaid (OR: 0.61, 95%CI: 0.51–0.74, p < 0.001) had significantly lower odds of getting autologous reconstruction when compared to patients with commercial insurance. Conclusions: Our study demonstrated that, in the state of Florida over the past years, variables, such as race, region, insurance, and comorbidities, play an important role in choosing the reconstruction modality. More efforts are needed to eradicate disparities and give all patients, despite their race, insurance payer, or region, equal access to health care.

Adipose-derived stem cells in wound healing of full-thickness skin defects: a review of the literature. J Plast Surg Hand Surg 2020;54:263-279. [PMID: 32427016 DOI: 10.1080/2000656x.2020.1767116]

The complex process of wound healing can be delayed in circumstances when the natural niche is extremely altered. Adipose-derived stem cells (ADSC) seem to be a promising therapy for these type of wounds. We aim to describe the studies that used ADSC for wound healing after a full-thickness skin defect, the ADSC mechanisms of action, and the outcomes of the different ADSC therapies applied to date. We performed a review by querying PubMed database for studies that evaluated the use of ADSC for wound healing. The Mesh terms, adipose stem cells AND (skin injury OR wound healing) and synonyms were used for the search. Our search recorded 312 articles. A total of 30 articles met the inclusion criteria. All were experimental in nature. ADSC was applied directly (5 [16.7%]), in sheets (2 [6.7%]), scaffolds (14 [46.7%]), skin grafts (3 [10%]), skin flaps (1 [3.3%]), as microvesicles or exosomes (4 [13.3%]), with adhesives for wound closure (1 [3.3%]), and in a concentrated conditioned hypoxia-preconditioned medium (1 [3.3%]). Most of the studies reported a benefit of ADSC and improvement of wound healing with all types of ADSC therapy. ADSC applied along with extracellular matrix, stromal cell-derived factor (SDF-1) or keratinocytes, or ADSC seeded in scaffolds showed better outcomes in wound healing than ADSC alone. ADSC have shown to promote angiogenesis, fibroblast migration, and up-regulation of macrophages chemotaxis to enhance the wound healing process. Further studies should be conducted to assure the efficacy and safety of the different ADSC therapies.

Resolution of Keratoacanthoma Type Squamous Cell Carcinoma Following Intralesional Therapy With Methotrexate

Keratoacanthoma is considered a variant of squamous cell carcinoma prone to spontaneous involution, but it may also rapidly grow and invade surrounding tissues. Herein, we report a case of keratoacanthoma-type squamous cell carcinoma that resolved after intralesional therapy with methotrexate.

Paget disease of the breast: A national retrospective analysis of the US population

BACKGROUND

Paget's disease of the breast is rare. The National Cancer Database (NCDB) is one of the largest tumor databases in the United States.

METHODS

We queried the NCDB to identify male and female patients with Paget's disease of the breast who were treated from January 1, 2004, through December 31, 2015. No age limitations were applied. Descriptive statistical analysis and survival analysis were performed.

RESULTS

We analyzed the demographic, disease, and treatment characteristics of 7,191 patients with Paget's disease of the breast. The median (range) age was 64 (20-90) years. Only 2.1% of patients were men, and 85.4% were white. The most common treatment was complete mastectomy (65.3%), followed by partial mastectomy (30.3%). Tumor destruction was performed in 0.1% of patients, and 4.3% of patients did not undergo any surgery. We examined survival in the subset of 6,864 patients who were treated surgically with complete mastectomy or partial mastectomy. The 5-year survival rate after surgery was 82.5% (95% CI, 81.1%-83.9%). Factors associated with shorter survival were older age, black race/ethnicity, higher tumor grade, regional lymph node metastasis, higher cancer stage, metastatic cancer, and larger tumor size.

CONCLUSIONS

Paget's disease of the breast usually affects patients older than 60 years, and the most common treatment is complete mastectomy. The 5-year overall survival rate of patients with Paget's disease of the breast is greater than 80% but is lower among older and black people.

Breast cancer in women: a descriptive analysis of the national cancer database

Background and aim of the work:

Breast cancer is the most common cancer in women in the United States. National Cancer Database (NCDB) is one of the largest tumor databases of the United States. This study aimed to evaluate the features of breast cancer in women from a large updated database.

Methods:

We describe and analyze the frequencies and percentages of the clinical and pathological features of women diagnosed with breast cancer registered in NCDB, in a period from 2004 to 2015.

Results:

A total of 2,423,875 women were diagnosed with breast cancer between 2004 and 2015. The nationally representative analysis demonstrated that the incidence of breast cancer among women increased over the years. Upper-outer quadrant was the most frequent primary tumor site, and the intraductal carcinoma was the most frequent histology. The prevalence of breast cancer increased with age. The most frequent grade at diagnosis was grade II. Broadly, invasive characteristics were noted more frequently in younger patients. Left and right breast were affected with almost the same frequency, with a slight predominance of the left breast. The most frequent surgical treatment was a partial mastectomy. Reconstruction with implant was the most frequent choice. Post-mastectomy radiation therapy was administered in the majority of patients.

Conclusions:

To the authors’ knowledge, the current study is the largest descriptive analysis to date on the clinical and pathological features of breast cancer in a population-based database. The increase in incidence over the years indicates an important need for etiologic research and innovative approaches to improve breast cancer prevention. (www.actabiomedica.it)

Lymphaticovenular anastomosis for breast cancer-related upper extremity lymphedema: a literature review

Breast cancer-related lymphedema is a long-term condition that affects almost half of breast cancer survivors. Clinical studies have looked at the benefits of lymphaticovenular anastomosis (LVA) for the treatment of upper extremities lymphedema after breast cancer, however, there is still controversy if it improves lymphedema. This study aimed to analyze the studies and outcomes related to LVA for breast cancer-related lymphedema. A PubMed/Medline search was performed using "lymphovenous bypass", "upper extremity lymphedema", "arm lymphedema after breast cancer treatment", and "lymphaticovenular anastomosis" as key words. Only English articles reporting outcomes after LVA were included. We found 22 articles that met the inclusion criteria. Positive outcomes were found in 21 studies with an objective volume reduction and subjective symptoms relief after LVA. This literature review concluded that LVA has demonstrated a significant decrease in upper extremity volumes and an improvement in subjectively reporting symptoms in breast cancer-related lymphedema patients.

Chronic Tenosynovitis of the Upper Extremities Caused by Mycobacterium kansasii : A Clinical Case and Systematic Review of Literature

Background  Chronic tenosynovitis of the upper extremities caused by Mycobacterium kansasii ( M. kansasii ) is uncommon, but symptoms may overlap with other more common diseases. Late diagnosis and treatment can lead to disfiguration of structures and rupture of tendons, resulting in worse cosmetic outcomes after reconstruction. Methods  We present a clinical case and literature review of M. kansasii in patients with chronic tenosynovitis of upper extremities. PubMed was queried for cases of upper extremities tenosynovitis caused by M. kansasii . The keywords " M. kansasii ," "tenosynovitis" and synonyms were used for search in different combinations. Manuscripts, with no specific data or another condition, where the infection was not located in the upper extremities, were reviews, or not in English, were excluded from the study. Results  We described 23 reported cases of tenosynovitis of the upper extremity caused by M. kansasii . An immunosuppressed state was present in eight (34.8%) cases, and 12 (52.2%) patients received immunosuppressive treatment. A long-time period between the first appearance of symptoms and the definitive diagnosis was identified (median: 7 months, interquartile range: 9). The most frequent symptoms were local swelling (65.2%), pain (56.5%), mass effect (26%), and stiffness (13%). Tendon rupture was found in three (13%) patients as a complication of the disease. Moreover, seven (30.4%) patients underwent previous surgeries to try to relieve the symptoms before definitive diagnosis was achieved. Conclusion M. kansasii is an important differential causal pathogen for tenosynovitis of the upper extremities. Although rare, raising awareness about this infectious disease is imperative to avoid inadequate management and hazardous aesthetic sequelae.

Wide Excisional Surgery in Invasive Melanoma Treatment: Factors Driving Non-compliance With National Guidelines

BACKGROUND/AIM

Margin size during wide excisional surgery for invasive melanoma treatment have been established by national guidelines. This study identified factors associated with wider than recommended excisional margins and its impact on survival.

PATIENTS AND METHODS

The National Cancer Database was queried to identify patients with primary invasive melanoma. Statistical analysis was performed using univariate and multivariate analysis. Overall survival was compared using Kaplan-Meier method.

RESULTS

A total of 26,440 patients were included in the analysis. Melanomas located on the trunk were more likely to be treated using wider than recommended excisional margins for certain Breslow depth groups (p<0.05), while the opposite was true for those being treated in an academic/research program (p<0.05). The practice of taking wider than recommended margins was not associated with improved survival.

CONCLUSION

Tumor location and facility type influence non-compliance with the National Comprehensive Cancer Network guidelines. Lack of survival benefit in patients with wider excisional margins seems to support guideline recommendations.

Residual Tumor on Wide Excisional Margins After Treatment of Invasive Melanoma

BACKGROUND/AIM

The surgical management of invasive melanoma has been debated for many years and recommended excisional margins have been established. We aimed to describe the factors and survival related to the presence of residual tumor in patients with invasive melanoma lymph nodes negative.

PATIENTS AND METHODS

We performed a retrospective study by querying the National Cancer Database from 2004 to 2015. Associations were tested using a multivariate analysis. Overall survival was compared using the Kaplan-Meier method.

RESULTS

A total of 26,440 patients met the inclusion criteria. For Breslow depth groups ≤1 mm and >2 mm, older age and location in the head and neck were factors associated to residual tumor in margins (p<0.05), whereas only location in the head and neck was associated to residual tumor for patients with Breslow depth between 1.01-2.00 mm (p<0.05).

CONCLUSION

Knowledge of the factors associated with the residual tumor will help establish a patient-centered management and decrease the recurrence of disease.

A giant keratoacanthoma of the cheek

Keratoacanthoma (KA) is a cutaneous tumor arising on sun-exposed skin and characterized by self-limiting growth and involution. We reported a case of a 92-year-old man presented a 4.5x3.5 cm nodular lesion with a central keratin-filled crater on his left cheek. We performed surgical excision and histopathological examination revealed a keratoacanthoma with perineural invasion. A close follow-up was carried out. (www.actabiomedica.it).

High-pressure injection injury: a case report and systematic review

High-pressure delivery devices for paint and other substances can lead to severe injuries of the hand without immediate surgical debridement. We present a case of a high-pressure paint gun injury treated surgically with full resolution of function. A systematic review of the literature details outcomes of similar injuries.

What Factors Define Limb Salvage or Amputation Surgery in Osteosarcoma of the Upper Extremities?

BACKGROUND/AIM

Controversy exists between performing limb salvage or amputation to treat osteosarcoma of the upper extremities. Our aim was to review the characteristics associated with limb amputation due to osteosarcoma of the upper extremities.

PATIENTS AND METHODS

A descriptive study was performed by querying the National Cancer Database from January 1, 2004 to December 31, 2015. Statistical analysis was performed using chi-squared test and a multivariate logistic regression model.

RESULTS

A total of 777 patients diagnosed with osteosarcoma of the upper extremities who underwent surgery met the inclusion criteria. Patients between 61 and 80 years were less likely to undergo limb amputation. Moreover, facilities located in the South Atlantic region, and stage IV of the disease were factors independently positively associated with amputation.

CONCLUSION

Patients in facilities located in the South Atlantic region and those with stage IV disease were more likely to undergo amputation.

Influence of Facility Characteristics on Access to Breast Reconstruction: A 12-Year National Cancer Database Analysis

BACKGROUND/AIM

This study aimed to analyze facility characteristics contributing to disparities in breast reconstruction access in the United States.

PATIENTS AND METHODS

Data from January 1, 2004, to December 31, 2015 were extracted from the National Cancer Database on patient, facility and treatment, and tumor characteristics. A total of 858,594 patients met the inclusion criteria of the study, including 553,517 (64.5%) patients who underwent mastectomy only (without breast reconstruction) and 305,077 (35.5%) patients who received breast reconstruction (implants or autologous tissue).

RESULTS

Multivariate analysis showed that the odds of reconstruction were higher in Integrated Network Cancer Programs and Academic/Research Programs compared to Community Cancer Programs. Patients treated in the South, Midwest, and West regions had lower odds of reconstruction. Interestingly, patients treated in more than one Commission on Cancer facility had a higher likelihood of reconstruction.

CONCLUSION

Facility characteristics and location impact on access to breast reconstruction.

Eyelid Melanoma in the United States: A National Cancer Database Analysis

BACKGROUND

Eyelid melanoma (EM) is a rare condition that accounts for <1% of all cutaneous melanomas. In this analysis, patients diagnosed with EM in the United States were compared to those with other melanomas in the head and neck.

METHODS

The National Cancer Database was used to select patients with head and neck melanoma from 2004 to 2015.

RESULTS

A total of 137,233 patients met the criteria of the study. Among them, 2694 were diagnosed with EM (2%) and 134,539 in other head and neck locations (98%). Regarding the patients with EM, the mean age was 68.56 years (standard deviation 14.04). A greater number of them were treated in Academic/Research Programs (53.6%), insured by Medicare (55.7%), tumor in situ (52.2%), stage 0 (49%), and without ulceration (75.9%). The mean time to treatment commencement was 18.96 days for EM compared to 14.4 days for other melanoma in the head and neck regions (P < 0.001). There was a greater proportion of EM in female patients (odds ratio [OR] 2.371 [2.191-2.566], P < 0.001), compared to male; age greater than 80 years (OR 1.622 [1.360-1.934], P < 0.001) compared to 0 to 49 years. Moreover, EM was an independent predictor for treatment in Academic/Research Programs (OR 1.258 [1.160-1.365], P < 0.001) and diagnosis at autopsy (OR 1.414 [1.083-1.847], P = 0.011) compared to other melanoma in the head and neck region.

CONCLUSION

These novel findings have the potential to guide clinical decision making in head and neck melanoma management.

Factors that Influence Chemotherapy Treatment Rate in Patients With Upper Limb Osteosarcoma

BACKGROUND/AIM

Chemotherapy is the mainstay treatment of osteosarcoma. The purpose of this study was to elucidate the factors that affect the rate of chemotherapy treatment of osteosarcoma patients.

MATERIALS AND METHODS

We queried the National Cancer Database for bone cancer patients. We included patients diagnosed with osteosarcoma of the upper extremities regardless of age and sex. With bivariate and multivariate models, we analyzed the demographic, facility, and tumor-specific characteristics, comparing the group that received chemotherapy with those that did not.

RESULTS

Female patients (OR=0.567; 95%CI=0.337-0.955), non-White patients (OR=0.485; 95%CI=0.25-0.939), and patients with government insurance (OR=0.506; 95%CI=0.285-0.9) had lower odds of receiving chemotherapy treatment than male, white, and privately insured patients. Patients with stages II (OR=4.817; 95%CI=2.594-8.946) and IV disease (OR=0.457; 95%CI=1.931-10.286) had higher odds of receiving chemotherapy than those with stage I disease.

CONCLUSION

Age, sex, race and insurance affected the rate of chemotherapy treatment in patients with upper limb osteosarcoma.

Survival Disparities in Male Patients With Breast Cancer

BACKGROUND/AIM

We evaluated factors associated with mortality among men with breast cancer.

MATERIALS AND METHODS

We used the National Cancer Database to identify men with breast cancer and evaluated factors associated with mortality, using a Cox regression model.

RESULTS

Black patients experienced an increased risk of death from any cause compared to white patients [hazard ratio (HR)=1.19, 95%CI=1.05-1.37]. Patients with government insurance had a greater risk of death compared to privately insured patients (HR=1.57, 95%CI=1.41-1.75). When compared to patients with an income of >$46,000, those with an income <$30,000 presented an increased risk of death (HR=1.35, 95%CI=1.14-1.60). Finally, patients treated at a comprehensive community cancer program (HR=1.129, 95%CI=1.021-1.248), community cancer program (HR=1.164, 95%CI=1.010-1.343), or integrated network cancer program (HR=1.216; 95%CI=1.056-1.401) experienced elevated risk of death compared to those treated at academic/research-programs.

CONCLUSION

Race, insurance, income, education, and facility type are associated with the risk of mortality in male patients with breast cancer.

Osteosarcoma of the Upper Extremities: A National Analysis of the US Population

BACKGROUND/AIM

Osteosarcoma of the upper extremities is rare, and characteristics in this location have not been described before. We aimed to analyze the characteristics and survival rate of osteosarcoma of the upper extremities.

MATERIALS AND METHODS

A retrospective cohort study was performed by querying the National Cancer Database. Statistical analysis was performed using a multivariate logistic regression model and Kaplan-Meier log-rank tests for survival.

RESULTS

A total of 991 patients were diagnosed with osteosarcoma of the upper extremities. Most tumors were osteogenic and osteoblastic (66.8%), larger than 8 cm (47.9%), high grade (64.3%), lymph node-negative (7.9%), and without metastasis to lungs (39.0%). Osteosarcomas of the hand and wrist were less likely to be high-grade when compared to osteosarcomas of the forearm, arm, and shoulder.

CONCLUSION

The results of this study help us to approach patients promptly and avoid total amputation, increasing functionality and prognosis of the disease.

Desmoplastic Melanoma: Clinical Characteristics and Survival in the US Population

Objective

Desmoplastic melanoma (DM) is a rare variant of invasive malignancy of the skin pigmented cells. We present a comprehensive study reporting on US demographics, disease characteristics, and survival, to contribute to the current knowledge and raise awareness of this rare disease.

Materials and methods

The demographics of DM patients diagnosed from January 1, 2004, to December 31, 2015, were obtained by querying the National Cancer Database. The characteristics of DM were compared with common malignant melanoma (CMM) using univariate and multivariate regression models. Five-year overall survival (OS) curves were estimated using Kaplan-Meier analyses and the Cox proportional regression model.

Results

Our query found 5,895 patients diagnosed with DM and 292,939 patients with CMM. DM tended to present at an older age, a more advanced stage, and with a Breslow depth greater than 4 mm at diagnosis (P<.05). The Kaplan-Meier survival analysis demonstrated a five-year OS for DM and CMM of 75% and 76%, respectively, without any statistical difference (P=.07). Cox regression analysis demonstrated that age at diagnosis and comorbidities were independent predictors of five-year OS for DM (P<.001).

Conclusions

Older age, advanced stage, and higher Breslow depth were found to be independent positive factors associated with DM.

Ultra-high-frequency Ultrasound to Assess Nerve Fascicles in Median Nerve Traumatic Neuroma

A traumatic neuroma is a major cause of persistent neuropathic pain. Diagnostic imaging tools are critical to the success of surgical treatment. Ultra-high-frequency ultrasound is a novel technology that can generate frequencies up to 70 MHz, assessing structures up to 30 μm. We report a unique case of intraoperative use of ultra-high-frequency ultrasound to provide detailed imaging of nerve fascicles, facilitating surgical excision of the mass.

Urethrovaginal space during the third trimester of pregnancy is not related to vaginal orgasm

Introduction:

Sexologists have described the urethrovaginal space (UVS) as a region of the body involved in the female orgasm. Recently certain authors have described the UVS via ultrasound (US). Pregnancy is associated with a myriad of physiological, anatomical and biochemical changes. To measure the UVS thickness in the third trimester of pregnancy and to investigate the relationship between the UVS thickness and the presence of vaginal orgasm.

Material and Methods:

Sexually active pregnant patients in the third trimester were included. We measured the UVS via US. Each patient compiled a modified female sexual function index (FSFI) questionnaire and was categorized in group with or without vaginal orgasm. Association between vaginal orgasm and UVS thickness was evaluated via t-test and ROC curve analysis.

Results:

UVS thickness resulted greater than 15 mm (average) in the third trimester, and was not related to the presence of vaginal orgasm (p>0.05). Conclusion: UVS thickness is high in the third trimester of pregnancy but it is not related to the presence of vaginal orgasm. (www.actabiomedica.it)

Complications associated with brachioplasty: a literature review

Background:

Paralleling the growth of bariatric surgery, the demand for post-bariatric body-contouring surgery is increasing. Weight loss is the main cause, although not the only one, that drives patients to arm lift surgery. Several surgical techniques have been proposed over the years. Our aim was to consider the complications and outcomes according to the performed technique, through a wide review of the literature.

Methods:

A search on PubMed/Medline was performed using “brachioplasty”, “upper arm lifting”, and “techniques” as key words. Embase, Medline (OvidSP), Web of Science, Scopus, PubMed publisher, Cochrane, and Google Scholar were searched as well. As inclusion criteria, we selected the clinical studies describing techniques of brachioplasty. We excluded the papers in which complications related to brachioplasty were not specified. We also excluded literature-review articles.

Results:

We found 27 studies from 1995 to 2015. Overall, 1065 patients were treated. Different techniques were applied. Complications were observed in 308/1065 patients (28.9%). The most frequent complications were hypertrophic scarring, seroma and hematoma. Surgical revision rate ranged from 0 to 21 percent. Nerve damage occurred in a modest percentage of patients (16/1065, 1.5%). No major complications, such as thromboembolism and sepsis, were observed.

Conclusions:

Brachioplasty is a safe surgical procedure. All the brachioplasty techniques showed positive outcomes, in term of patients’ satisfaction and clinical results. Nevertheless, minor complications occurred in a high percentage of patients, regardless the performed surgical procedure. Patients should be informed about the possible formation of hypertrophic scars and nerve injuries. (www.actabiomedica.it)

Melanoma in situ mimicking a Lichen planus-like keratosis

The incidence of melanoma has steadily increased over the past three decades. Melanoma in situ (MIS), defined as melanoma that is limited to the epidermis, contributes to a disproportionately high percentage of this rising incidence. Amelanotic melanoma presents as an erythematous macule or plaque and may initially be misdiagnosed as an inflammatory disorder. We report a case of amelonatic MIS raised on non-sun-exposed skin, inducing a lichen planus-like keratosis as inflammatory reaction, which clinically masked the melanoma. (www.actabiomedica.it)

A case of extramammary inguinal Paget disease in a male patient: surgical treatment with an abdominal advancement cutaneous flap

Extramammary Paget disease (EMPD) is a rare neoplasm. The clinical case of a 55-year-old man with a two-year history of a pruritic, painless erythematous skin rash on the inguinal region and scrotum is described. After a delay due to improper diagnosis and improper treatments, the patient came to the attention of the Division of plastic surgery. He underwent a punch biopsy and the pathology report came back as EMPD. Surgical excision was carried out, and an abdominal advancement cutaneous flap was performed for the defect repair. This is the first description of a reconstruction after surgical removal of inguinal EMPD with a flap of this type and we think that this type of treatment can be useful and reliable for disease localization in the groin area, especially for patients that present an excess of abdominal skin.

Effectiveness and safety of topical tacrolimus monotherapy for repigmentation in vitiligo: a comprehensive literature review

Thus far, several small studies and case reports on the use of topical immunomodulators in vitiligo have been published. We undertook a comprehensive literature review, searching for studies evaluating clinical response to tacrolimus topical therapy for vitiligo. A search was performed on PubMed/Medline using the term “vitiligo”, combined with “topical” and “ointment”. Our inclusion criteria were: use of tacrolimus ointment as monotherapy to treat vitiligo. We found 29 studies from 2002 to 2014. Overall, 709 patients were treated in 29 studies. Pooling the lesions, 50% repigmentation of vitiligo patches was never achieved before 2 months of treatment, with a peak after 6 months of therapy. The best results were obtained on lesions of the cephalic region, especially the face, with tacrolimus 0.1% ointment two times daily. The percentage of non-responsive patients ranged from 0% to 14%. Treatment was generally well-tolerated; only localized adverse effects were reported. Our objective was to verify the effectiveness and safety of tacrolimus ointment monotherapy. It has good efficacy and tolerability. At present, only small trials and case series are available in the literature. Further, standardized investigations on a larger number of patients are needed.

Fenestrated Adipofascial Reverse Flap: A Modified Technique for the Reconstruction of Fingertip Amputations

AIMS OF THE STUDY

Fingertip injuries can be treated in different ways, including shortening with primary closure, skin graft, and local or distant flaps. Several local flaps for the reconstruction of the amputated fingertip were described. We present our experience with a new concept of homodigital adipofascial reverse flap that avoids the second surgical stage and allows a complete and anatomically perfect reconstruction of nail bed, with preservation of the nail lamina.

MATERIALS AND METHODS

Between March 2014 and February 2015, five patients with digital amputations (distally to the nail matrix) were treated using the Fenestrated Adipofascial Reverse (F.A.R.) flap. The patients were evaluated measuring 2-point discrimination (2PD) value and range of motion of the distal interphalangeal joint (DIP). Scar evaluation was performed using the Vancouver Scar Scale (VSS).

RESULTS

All the flaps completely survived. A normal nail grow has been observed in first two-three months of post operatory follow-up. Length of the digits was preserved and good aesthetic as functional outcome were archive. The F.A.R. flap provided excellent coverage of fingertip defects and preserved finger length. After 1 year of follow, the mean static 2PD value at the reconstructed finger was 4.2 mm (range 3-5 mm), reconstructed fingers' mean range of motion for the DIP joint was 78 degrees and the VSS score ranged from 0 to 2 (mean score: 0.6). No complications were reported.

CONCLUSIONS

F.A.R. flap is one of the most useful techniques in order to achieve all the goals in fingertip reconstruction.

Superior Pedicle Mammaplasty without Parenchymal Incisions after Massive Weight Loss

BACKGROUND

After considerable weight loss, the breast suffers significant deformation. The ptotic breast is characterized by a lack of superior pole, tissue excess in the inferior pole, down-migration of nipple-areola complex (NAC) with redundancy of skin tissue. The authors describe a mastopexy technique based on a modulated and progressive reshaping, back rotation, and suspension of mammary gland parenchyma without parenchymal incisions.

METHODS

Forty-five patients with bilateral moderate or severe breast ptosis underwent mastopexy from January 2011 to January 2014 with complete detachment of breast from the pectoralis major muscle and the plication of parenchyma without any parenchymal incision. Patients were followed up for one year, reporting any complication, and measuring the jugulum-NAC distance. The outcomes were assessed by the patients as well as the surgical team.

RESULTS

The aesthetic outcomes were good or excellent in all patients. The new mammary contour and the distance between the jugular fossa and the nipple were stable during this time with a good filling of upper pole. No major complications were reported.

CONCLUSIONS

This technique gave good breast shape, long-term projection, and upper pole fullness, without parenchymal incisions. It restores breast shape and projection, especially in post-bariatric patients. A similar technique has not been described yet.

Synchronous and Metachronous Malignancies After Malignant Struma Ovarii in the SEER Database

BACKGROUND/AIM

Second primary tumors (SPTs) often occur, either synchronous or metachronous. Struma ovarii is a rare ovarian tumor represented by thyroid tissue in the ovary. Among other factors, production of thyroid hormones by the tumor or a shared genetic predisposition can further influence the development of SPTs. The occurrence of SPT, either synchronous or metachronous, following a long follow-up, has never been considered extensively.

PATIENTS AND METHODS

We analyzed the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2011 to follow-up all the cases of malignant struma ovarii in an effort of calculate the occurrence of SPTs in this cohort of patients.

RESULTS

We identified 21 patients with malignant struma ovarii in the period between January 1973 and December 2011. In a follow-up period of 219.57 person-years, 3 patients had SPT. One patient had synchronous thyroid sclerosing carcinoma, 1 patient had metachronous papillary adenocarcinoma with a latent time of 7 years and 1 patient had synchronous salivary ductal carcinoma.

CONCLUSION

Up to date, only thyroid synchronous tumors have been reported in the literature. A synchronous and a metachronous thyroid tumor, plus a synchronous salivary gland tumor, were found. A significant association between malignant struma ovarii and thyroid/salivary gland cancer is herein demonstrated.