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.

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Introduction:The anterolateral thigh (ALT) flap is considered a workhorse reconstructive option; however, it is encumbered by its bulkiness that can result in poor final outcome and need for revision surgery. The aim of the present study was to compare the standard cutaneous ALT free flap and sandwich fascial ALT (SALT) free flap, raised harvesting between the Scarpa's fascia and the crural fascia, for distal extremity soft tissue reconstruction, including pre-intra-and post-operative considerations and outcomes.Patients and methods: A retrospective review of medical records from 2013 to 2018 of 24 patients who underwent distal extremity reconstruction with standard fasciocutaneous ALT flap (13 patients) and SALT flap (11 patients) was performed. The mean defect dimensions were 12 × 6.5 cm in group 1 and 12 × 6 in group 2. Surgical outcomes and quality of life were assessed (through the upper extremity functional scale and the lower extremity functional scale questionnaires. Results:The mean flap dimensions were 13.1 × 7.1 in group 1 and 14.1 × 7.8 in group 2, the overall flap success rate was 100% (one microvascular venous thrombosis occurred in group 1), no statistically significant difference was recorded regarding microvascular thrombosis (one patient in group p = .369) and infections (one patient in group 1, p = .36) while a statistically significant difference was presence regarding the number of secondary/debulking procedures (6 patients vs. 0) (p = .0076) and the quality of life perception showed an overall better perception in group 2 with statistical significant difference (p = .03). Conclusion:The SALT flap represents a valid option, as showed through our preliminary data, when a thin and robust reconstruction is required when dealing with distal extremities soft tissue reconstruction.

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Introduction:Much attention has been directed towards understanding the phenomena of angiogenesis and lymphangiogenesis in wound healing. Thanks to the manifold dermal substitute available nowadays, wound treatment has improved greatly. Many studies have been published about angiogenesis and cell invasion in INTEGRA®. On the other hand, the development of the lymphatic network in acellular dermal matrix (ADM) is a more obscure matter. In this article, we aim to characterize the different phases of host cell invasion in ADM. Special attention was given to lymphangiogenic aspects.Materials and Methods:Among 57 rats selected to analyse the role of ADM in lymphangiogenesis, we created four groups. We performed an excision procedure on both thighs of these rats: On the left one we did not perform any action except repairing the borders of the wound; while on the right one we used INTEGRA® implant. The excision biopsy was performed at four different times: First group after 7 days, second after 14 days, third after 21 days and fourth after 28 days. For our microscopic evaluation, we used the classical staining technique of haematoxylin and eosin and a semi-quantitative method in order to evaluate cellularity counts. To assess angiogenesis and lymphangiogenesis development we employed PROX-1 Ab and CD31/PECAM for immunohistochemical analysis.Results:We found remarkable wound contraction in defects that healed by secondary intention while minor wound contraction was observed in defects treated with ADM. At day 7, optical microscopy revealed a more plentiful cellularity in the granulation tissue compared with the dermal regeneration matrix. The immunohistochemical process highlighted vascular and lymphatic cells in both groups. After 14 days a high grade of fibrosis was noticeable in the non-treated group. At day 21, both lymphatic and vascular endothelial cells were better developed in the group with a dermal matrix application. At day 28, lymphatic endothelial cells had organized themselves, engineering the pseudocylindrical structure better disposed in the ADM group than in the control group, and the lymphatic cells were detectable inside the vessels’ lumen in this group.Conclusion:This study has made it possible to demonstrate the absolute importance of an ADM in proper wound healing and has shown better definition of both the qualitative and quantitative aspects of lymphangiogenesis compared to the second intention healing. A major grade of organization of the extracellular matrix and a minor grade of fibrosclerosis in ADM allowed a well-structured morphologic and functional development of the endothelial and lymphatic vascular structures. This study hopes to represent a clinical basis for a wider use of ADM in lesions where lymphatic complications are common.

Background The nose is a functionally complex organ with also a critical role in aesthetics. For reconstruction of full thickness nasal defects, multiple stages are needed and there is risk for resorption resulting in residual deformity. The aim of this report was to develop and evaluate a new method for full thickness total/subtotal nose reconstruction using the medial femoral condyle free flap (MFCFF) in combination with a paramedian forehead flap. Methods Between November 2015 and January 2018, eight patients (four males, four females) mean age 52 years (range 40–73 years) undergoing a total/subtotal nasal excision and subsequential reconstruction with MFCFF plus paramedian forehead flap were enrolled. Six cases were squamous cell carcinomas while two were basal cell carcinomas. The MFCFF was stabilized, with the periosteum as inner layer, with plates and a paramedian forehead flap was used as external skin coverage. All patients were evaluated for with postoperative nasal endoscopy and CT scan. A postoperative questionnaire was given 6 months after surgery. Results The mean MFCFF size was 2–3.8 cm × 2.25–2.5 cm with a mean pedicle length of 6.3 cm (range 4.1–9.4 cm). The postoperative period was uneventful. The mean follow‐up was 16 months, no bone displacement or resorption was observed at the CT scan, no evidence of nasal stenosis occurred. All patients had a satisfying aesthetic evaluation and a good subjective nasal function. Conclusions In this series, the MFCFF in combination with the paramedian forehead flap appeared to provide a valid subtotal nose reconstruction, allowing for the recreation of all the three nasal layers and maintaining the nose projection and airway patency in the long term.

Summary:The nose is a functionally complex organ implicated in breathing, olfaction, and phonation, with a critical role also in the aesthetic appearance of a person. This latter aspect should be carefully considered whenever a total or subtotal rhinectomy is performed for resection of locally advanced nasal cancer. To reconstruct large nasal defects, several techniques were described, including the use of cartilaginous grafts, bony grafts, local flaps, and free flaps. In cases of extensive full-thickness resections, free flaps probably represent the most adequate option. The aim of this report is to present the functional and aesthetical outcomes of a reconstruction of the nose after rhinectomy, using the medial femoral condyle free flap associated with the forehead flap.