Lymphedema is a chronic disabling condition affecting a growing number of patients worldwide. Although lymphedema is not life-threatening, several reports underlined detrimental consequences in terms of distress, pain, functional impairment, and infections with a relevant decrease in quality of life. Currently, there is no cure, and the therapeutic management of this condition aims at slowing down the disease progression and preventing secondary complications. Early diagnosis is paramount to enhance the effects of rehabilitation or surgical treatments. On the other hand, a multidisciplinary treatment should be truly integrated, the combination of microsurgical and reductive procedures should be considered a valid strategy to manage extremity lymphedema, and rehabilitation should be considered the cornerstone of the multidisciplinary treatment not only for patients not suitable for surgical interventions but also before and after surgical procedures. Therefore, a specialized management of Plastic Reconstructive Surgeons and Physical and Rehabilitative Medicine physicians should be mandatory to address patients’ needs and optimize the treatment of this disabling and detrimental condition. Therefore, the aim of this review was to characterize the comprehensive management of lymphedema, providing a broad overview of the potential therapy available in the current literature to optimize the comprehensive management of lymphedema and minimize complications.

The nose represents the most common site for the presentation of cutaneous cancer, especially in sun-exposed areas: ala, dorsum, and tip. Even the smallest loss of substance can create aesthetic and psychosocial concerns for patients; therefore, surgeons who perform nasal reconstruction should be strictly confident with the pertinent surgical anatomy in order to tailor the procedure to the patient’s condition and needs. Radical tumor excision and satisfactory aesthetic and functional results are primary targets. Restoring the original shape is the goal of any reconstruction: appropriate reshaping of three-dimensional geometry, proper establishment of symmetry, and excellent color and texture match to the adjacent structures are paramount features. Multiple options exist to re-establish functional and aesthetic integrity after surgical oncology; nevertheless, the management of nasal defects can be often challenging, and the gold standard is yet to be found. The current goal is to highlight some of the more common techniques used to reconstruct cutaneous defects of the nose with a specific focus on decision making based on the aesthetic subunit and defect size. The authors attempt to share common pitfalls and offer practical suggestions that they have found helpful in their clinical experience.

Background: Implant-based reconstruction is the most performed breast reconstruction, and both subpectoral and prepectoral approaches can lead to excellent results. Choosing the best procedure requires a thorough understanding of every single technique, and proper patient selection is critical to achieve surgical success, in particular when dealing with prepectoral breast reconstruction. Methods: Between January of 2014 and December of 2018, patients undergoing mastectomy and eligible for immediate prepectoral breast reconstruction with tissue expander or definitive implant, were selected. The Prepectoral Breast Reconstruction Assessment score was applied to evaluate patient-related preoperative and intraoperative risk factors that could influence the success of prepectoral breast reconstruction. All patients were scored retrospectively, and the results obtained through this assessment tool were compared to the records of the surgical procedures actually performed. Results: Three hundred fifty-two patients were included; 112 of them underwent direct-to-implant immediate reconstruction, and 240 underwent the two-stage procedure with temporary tissue expander. According to the Prepectoral Breast Reconstruction Assessment score, direct-to-implant reconstruction should have been performed 6.2 percent times less, leading to an increase of 1.4 percent in two-stage reconstruction and 4.8 percent in submuscular implant placement. Conclusions: To date, there is no validated system to guide surgeons in identifying the ideal patient for subcutaneous or retropectoral breast reconstruction and eventually whether she is a good candidate for direct-to-implant or two-stage reconstruction. The authors processed a simple risk-assessment score to objectively evaluate the patient’s risk factors, to standardize the decision-making process, and to identify the safest and most reliable breast reconstructive procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Background and Objectives: Conservative treatment represents an essential pillar of lymphedema management, along with debulking and physiologic surgeries. Despite the consistent number of treatment options, there is currently no agreement on their indications and possible combinations. When dealing with unusual lymphedema presentation as in the genitalia (Genital Lymphedema—GL), treatment choice becomes even more difficult. The authors aimed to present their targeted algorithm of single and combined treatment modalities for rare GL in order to face this paucity of information. Materials and Methods: Data were collected from a prospectively maintained database since January 1983, and cases of GL that were managed in the authors’ department were selected. Only patients that were treated in the authors’ institution and presented a minimum follow-up of 3 months were admitted to the current study. Results: From January 1983 to July 2021, 19 patients with GL were recruited. All the patients were male, and their ages ranged from 21 to 73 years old (average: 52). Ten cases (52.6%) presented with ISL (International Society of Lymphology) stage I, five (26.3%) were stage II and four (21.1%) were stage III. GL was managed with conservative treatment (12 cases), LVA (LymphaticoVenous Anastomosis) (3) or surgical excision (4). In a mean follow-up of 7.5 years (range: 3 months—11 years), no major complications occurred, and all cases reached improvements in functional and quality of life terms. Conclusions: Contrary to the predominant thought of the necessity to avoid surgery in unusual lymphedema presentations such as GL, they can be managed using targeted multimodal approaches or by adapting well-known procedures in unusual ways to achieve control of disease progression and improve patients’ quality of life.

Extensive skin defect represents a real problem and major challenge in plastic and reconstructive surgery. On one hand, skin grafts offer a practical method to deal with skin defects despite their unsuitability for several complicated wounds. On the other hand, negative pressure wound therapy (NPWT), applied before skin grafting, promotes granulation tissue growth. The aim of the study is to evaluate the improvement in wound healing given by the merger of these two different approaches. We treated 23 patients for large wounds of multiple factors. Of these, 15 were treated with the application of V.A.C.® Therapy (KCI Medical S.r.l., Milan, Italy), in combination with skin grafts after a prior unsuccessful treatment of 4 weeks with mesh skin grafts and dressings. Another 8 were treated with only mesh skin graft. Pain reduction and wound area reduction were found statistically significant (p<0.0009,p<0.0001). Infection was resolved in almost all patients. According to our study, the use of the negative pressure wound therapy over mesh skin grafts is significantly effective especially in wounds resistant to conventional therapies, thereby improving the rate of skin graft take.