Saturday, August 29, 2026

Essential ‘Human’ Features of the Cyber-Physical Nurse

Introduction

A cyber-physical ‘nurse’ is an emergent technological entity to support care in present day hospitals and nursing homes. It is important to outline its essential ‘human’ features in order to make it resemble a human nurse, and at the same time, relieve her from heavy, difficult and harmful tasks (Li [1]). ‘Nurse’ is a well established category of a helping profession, essential in every treatment and rehabilitation centre as well as in home care. A category is being deJined, according to (Mervis [2]), by its deep, essential features, whereas evident features, like feathers of a bird, for example, are called ‘characteristic’ for not ‘being essential’ to the bird category. In a similar way it is a challenging task to attempt and define the humanoid robot as an emergent category. If we imagine the ‘perfect’ robotic nurse, it will probably be a cyber-physical agent, who is best described as 4P - ‘pleasant, patient, polite and powered’. The ability to lift and help the patient is one of the essential features of the nursing profession (‘powered’). In addition to it, the other ’essential feature’ of the nurse therefore, is defined as being capable of displaying empathy in its communication with the patient (‘pleasant, patient, polite’) (Pepito, et al. [3]).

Levels of Analysis of the Behaviour of the Cyber-Physical Nurse

The interaction with a humanoid robot can be analysed on three levels in parallel - physical, social and/or psychological. The physical level analysis is based on understanding the interactions in the physical world. It is possible to implement algorithms, which predict behaviour in response to behaviour (Dimitrova [4]). A nurse assistant robot RoNA is described in (Hu, et al. [5]). RoNA is a robotic nurse with enhanced manipulator abilities being able to lift the patient and help with tasks of moving the body in space during rehabilitation. The social abilities of the robot are more limited. The social level analysis has to be based on understanding features of the social dynamics during the interaction, which is a more complicated diagnostic task on behalf of the artificial intelligence algorithms of the robot than predicting behaviour in response to behaviour. A popular social robot used in healthcare is Pepper, as described, for example, in (Van der Putte D, et al. [6]). Pepper can take the task of interviewing the patients and, in this way, relieving the human nurse to focus on caring for the emotional needs of the patients. The important aspect is to implement algorithms imitating pleasant and polite attitude to the patient., since the humanoid robot does not get bored or irritated by the response of the patient. At the same time it can perform face and emotion recognition and, based on this, predict behaviour in response to attitude. Why is it inappropriate to implement a psychological level of analysis? This issue was discussed in (Dimitrova [7]): “The psychological level of ‘predicting behavior in response to opinion’, in our view, is the “uncanny” case.

Whenever people react as if they feel that the behavior of the robot is guided not just by attitude (social level), but by opinion (psychological level), by some kind of awareness like the one produced by a ‘gaze sensor’, we expect to observe the ‘uncanny valley’ phenomenon. Robots need synthetic sensors like the ‘gaze sensor’ but they need not reinstate situations where the human ‘gaze sensor’ is on. They can rather reinstate feelings of positive attitude, friendliness, trust and compassion. Special questionnaires, distinguishing feelings close to perception of attitude from perception of opinion in human-robot interaction need to be designed to explore the validity of this hypothesis (p. 2)”. Patients in hospitals and care centres are being constantly monitored by surveillance systems integrated in the physical environment, including in robotic systems. When speaking of robots acting intelligently like humans, it was proposed in (Jamisola [8]) to endow them with the ability to ‘feel the gaze’ of a person by the robot, very much the way the human feels that someone is staring at them.

This would make the interaction more contextually relevant, according to the author. Elaborating on this idea, it was proposed in (Dimitrova, 2016) to deploy a number of similar high level synthetic sensors, not existing in nature, but mimicking complex subjective phenomena such as ‘affection’ detection in the patient (p. 27). Why affection? It is a fundamental feeling, which is not a basic emotion, but a high level emotional state of the human subject, which develops throughout the lifetime and underlines the relations of the patient, especially in old age, with their closest people - family and friends. It is important to maintain the memory and understanding of the state of affection in order to boost the overall effect of the rehabilitation. Social robots have to be able to deal not only with possible outbursts of negative emotions on behalf of the patient, but, more importantly, to invoke memories of affectionate moments of their life. The design of such a sensor is not an easy engineering task, yet it is possible to achieve it and to endow the cyber-physical nurse with it. This ability would be an ‘essential’ characteristic feature of the cyber-physical nurse of the future.

Conclusion

This opinion article argues in favour of the design of high level synthetic sensors, not existing in nature, but mimicking complex subjective phenomena such as ‘affection’ detection for implementation in humanoid robots for healthcare. These sensors form essential features of the sociality of the care robots in order to help the patients improve better and faster during medical treatment and rehabilitation. Especially important would be the ‘affection detection’ to bring the emotions of the patient to a positive state by the cyber-physical system.

BJSTRAngelaRoy

Friday, August 28, 2026

Improvement in Severe Liver Injury Related to Anorexia Nervosa with Antioxidant Therapy

Introduction

Presentations of anorexia nervosa (AN) are commonly associated with acute derangement in liver function tests (LFTs). Up to 75% of patients hospitalised with anorexia nervosa demonstrate a relatively mild increase in serum values of hepatocellular enzymes, including alanine aminotransferase (ALT) and aspartate aminotransferase (AST), typically to less than five times the upper limit of normal, with a much smaller proportion of patients displaying more severe liver injury [1]. The cause of the LFT derangement is linked to nutritional status, with studies demonstrating that the magnitude of rises in serum ALT and AST values is inversely correlated to body mass index (BMI) [1]. Research into the mechanism of liver injury in AN has shown that autophagy plays a significant role [2]. Autophagy is a lysosomal catabolic pathway for degrading cytoplasmic protein and damaged organelles to make them available for recycling. This is a process by which organisms can self-supply nutrients and energy during periods of starvation. Whilst this process is initially protective, when periods of starvation are prolonged, such as in AN, autophagy can lead to an acute liver injury, characterised electrochemically by severe glycogen depletion and a reduced number of mitochondria and endoplasmic reticula [2].

In health, autophagy is regulated by the hormones, insulin and glucagon, and amino acids, principally leucine. Autophagy is prevented by antioxidant defense mechanisms. In the setting of nutritional deficiency and depleted antioxidant defenses leading to oxidative stress, there is increased propensity to liver injury secondary to autophagy [1]. This has led to calls to investigate the possible therapeutic potential of antioxidant therapy in patients with AN [3]. This case series reports the first clinical experiences with antioxidant therapy in patients with severe liver injury related to AN, based on intravenous infusion of the glutathione precursor, N-acetylcysteine, demonstrating that such treatment is associated with significant improvements in parameters of liver injury.

Materials and Methods

We report three severely malnourished patients with AN, managed at a University Teaching Hospital (all female, aged 19 years, 23 years and 27 years, respectively; BMI values 12, 12 and 13, respectively), who presented on a total of seven occasions with nausea, jaundice and severe hepatocellular-type liver injury related to AN (mean serum ALT level 2,974 U/L ± 448 U/L {SEM}, normal <45 U/L; mean serum AST level 3,009 U/L ± 739 U/L {SEM}, normal <45 U/L; mean bilirubin level 62 micromol/L ± 5 micromol/L {SEM}, normal <25 U/L and mean international normalized ratio {INR} 1.8 ± 0.2 {SEM}, normal 0.8-1.1). Alternative causes of liver injury were excluded based on negative laboratory tests for viral (hepatitis A virus, hepatitis B virus, hepatitis C virus, hepatitis E virus, Epstein-Barr virus, cytomegalovirus, herpes simplex virus, varicella zoster virus, parvovirus), parasitic (Toxoplasmosis gondii), metabolic (haemochromatosis, alpha-1-antitrypsin deficiency, Wilson’s disease) and immune-mediated (autoimmune hepatitis) aetiologias and liver ultrasound, which demonstrated normal liver echogenicity and blood flow without focal liver abnormality or features of biliary obstruction. Serum paracetamol values were undetectable and a urinary drug screen for amphetamines and cocaine was negative on all occasions. There was no history of other potentially hepatotoxic drug exposure.

Following an observation period of 24 hours whilst awaiting the results of the diagnostic laboratory screen for alternative aetiologias of severe liver injury, patients were managed with an intravenous infusion of N-acetylcysteine, 150 mg/kg as a loading dose over 30 minutes and then 150 mg/kg given over 24 hours for a total of 5 days, as used in the management of acute liver failure regardless of aetiology [4]. Laboratory markers (ALT, AST, bilirubin and INR) were measured on days minus 1 and 0 (observation period) and then on days 1, 3, 5 (N-acetylcysteine treatment period) and then on days 7, 14, 21 and 28 (post-treatment observation period).

Results

Patient 1 experienced four episodes of severe hepatocellular damage related to AN (Figure 1), whilst Patient 2 experienced two such episodes (Figure 2) and Patient 3 experienced one episode (Figure 3). Serum markers of hepatocellular damage, namely ALT and AST, each increased during an initial 24-hour period of observation prior to the commencement of N-acetylcysteine treatment in all three patients (Figures 1-3). By contrast, commencement of N-acetylcysteine treatment was consistently associated with rapid reductions in serum ALT and AST values, with AST levels typically falling more quickly than ALT levels (Figures 1-3). Statistically significant improvements in ALT and AST levels occurred during the 5-day N-acetylcysteine treatment course, with further statistically significant improvements occurring to day 28, by which time serum ALT and AST values had normalized (Figures 4 & 5). In the two patients with more than one clinical presentation (four subsequent presentations occurring 20 days, 25 days, 43 days and 62 days, respectively, following prior N-acetylcysteine treatment), the magnitude of serum ALT and AST disturbances at subsequent presentations was consistently lower than those found at initial presentation, implying that prior N-acetylcysteine treatment remained partially protective during this time period (Figures 1 & 2).

Figure 1: Markers of hepatic necrosis (serum levels of alanine aminotransferase {ALT} and aspartate aminotransferase {AST}; normal <45 U/L) in relation to intermittent treatment with N-acetylcysteine (NAC) for five days in Patient 1.

Figure 2: Markers of hepatic necrosis (serum levels of alanine aminotransferase {ALT} and aspartate aminotransferase {AST}; normal <45 U/L) in relation to intermittent treatment with N-acetylcysteine (NAC) for five days in Patient 2.

Figure 3: Markers of hepatic necrosis (serum levels of alanine aminotransferase {ALT} and aspartate aminotransferase {AST}; normal <45 U/L) in relation to treatment with N-acetylcysteine (NAC) in Patient 3.

Figure 4: Statistical analysis of serum levels of alanine aminotransferase (ALT) (normal <45 U/L) in relation to treatment with N-acetylcysteine for 5 days and then followed to Day 28.

Figure 5: Statistical analysis of serum levels of aspartate aminotransferase (AST) (normal <45 U/L) in relation to treatment with N-acetylcysteine for 5 days and then followed to Day 28.

Improvement in hepatocellular injury during N-acetylcysteine treatment was accompanied by statistically significant improvements in the hepatic functional parameters, serum bilirubin and INR, with further statistically significant improvements occurring to day 28, by which time serum levels of these hepatic functional parameters had also normalized (Figures 6 & 7). All three patients remained recalcitrant to re-feeding during the seven presentations, with negligible increases in caloric intake above baseline despite specialist liaison psychiatry input. BMI values remained low throughout the seven periods of N-acetylcysteine treatment in all three patients. An improved nutritional intake leading to improvement in BMI eventually did occur in all three patients and no further instances of severe liver injury developed following this during 90 days of follow-up (Figures 1-3). N-acetylcysteine treatment was well-tolerated by all three patients during all seven treatment exposures, with no instances of any untoward effects.

Figure 6: Statistical analysis of serum levels of bilirubin (normal <25 micromole/L) in relation to treatment with N-acetylcysteine for 5 days and then followed to Day 28.

Figure 7: Statistical analysis of international normalised ratio (INR) values (normal 0.8-1.1) in relation to treatment with N-acetylcysteine for 5 days and then followed to Day 28.

Discussion

This case series demonstrates for the first time that, in patients with AN and severe liver injury, treatment for five days with the antioxidant, N-acetylcysteine, a glutathione precursor, is associated with statistically significant improvements in markers of hepatocellular damage, namely serum ALT and AST levels, as well as statistically significant improvements in the hepatic functional indices, bilirubin and INR. Statistically significant improvements were found to occur during the 5-day treatment period, with further statistically significant improvements occurring to day 28, by which time all indices had normalized. Improvements in liver injury in AN associated with N-acetylcysteine therapy could not be ascribed to natural history, as serum ALT and AST values were found to increase during an initial 24-hour observation period prior to the commencement of antioxidant therapy in all three patients. Neither could any of the improvements in serum ALT, AST, bilirubin and INR values associated with N-acetylcysteine treatment be attributed to an improvement in nutritional status, as caloric intake remained similar to baseline and BMI remained unchanged throughout the treatment and subsequent post-treatment observation periods. An improved nutritional intake leading to improvement in BMI eventually did occur in all three patients and no further instances of liver injury developed following this during a follow-up period of 90 days, in keeping with the notion that liver injury associated with AN is related to a critical reduction in BMI [1].

Importantly, N-acetylcysteine therapy was well-tolerated by our patients, with no instances of side-effects. It has been proposed that treatment with N-acetylcysteine be limited to 5 days in patients with severe liver injury, as its anti-inflammatory effects resulting from inhibition of nuclear factor kappa B expression may predispose to infection in the setting of functional immuneparesis evolving beyond this time [5]. The findings of our study are particularly pertinent, therefore, in that a 5-day treatment duration was found to be sufficient to promote normalization of serum ALT, AST, bilirubin and INR values in patients with severe liver injury associated with AN, while no instances of infection ensued.

Conclusion

We conclude that antioxidant treatment with the glutathione precursor, N-acetylcysteine, is a safe and effective treatment for severe liver injury in patients with AN. Our clinical findings suggest that inadequate antioxidant defense mechanisms likely play a key role in the pathogenesis of severe liver damage associated with AN.

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Wednesday, August 26, 2026

Ductal Prostate Cancer Presenting as a Giant Cyst- Case Report

Introduction

Prostatic cysts are relatively uncommon and without typical clinical presentation. That is why urologists generally do not think about them while making the diagnosis of the patients. Very often they are found incidentally during the ultrasound examination and pose significant diagnostic and treatment challenges.

Case Presentation

A 78-years old man presented with symptoms of incontinence and hematuria-from 2years. The hematuria was intermittent, macroscopic and painless, without clots –obviously not profuse because the level of hemoglobin was normal. The incontinence was neither stress nor urge and also not profuse. The digital rectal examination revealed an enlarged prostate-painless, soft and smooth, protruding to the rectum. The ultrasound showed normal kidneys and bladder –below the bladder a cyst was found 50/51mm diameter with thick irregular wall (shown in Figure 1). A normal prostate was visible on some planes with the cyst situated behind and to the left of the prostate. PSA level was 15.8 ng/ml.

MRI (shown in Figure 2) revealed enlarged prostate 80/56/53 mm. and more than 50% of the volume of the prostate was occupied by a cyst (slightly to the left side) with thick irregular wall. The MRI suggested a malignant condition but no PI-RADS evaluation was given. There were no signs of trans-capsular extension of the tumor. Some pelvic lymph nodes were enlarged up to 12 mm. Urethrocystoscopy was performed-nothing abnormal was found. Part of the left lobe was resected and the cyst was opened-the liquid inside was clear, with many papillary growths from the cyst wall. A biopsy from the growths was taken-the pathological result was ductal cancer, Gleason score 4+4. After the biopsy the symptoms (hematuria and incontinence) disappeared and the cyst was invisible on the ultrasound (shown in Figure 3). 1 week later the symptoms appeared again. The ultrasound (shown in Figure 4) revealed that the cyst was again visible, although smaller than before. No treatment was applied and gradually (within several weeks) the incontinence and hematuria disappeared, the cyst was completely invisible on the ultrasound. The patient chose hormonal therapy (LHRH-agonist) for the prostate cancer which is now administered-PSA was 0.58 ng/ml 4 weeks after the start of the therapy.

Figure 1: The prostatic cyst at the initial presentation.

Figure 2: MRI image of the cyst.

Figure 3: The cyst after the TURP.

Figure 4: The cyst 1 week after the TURP.

Discussion

The incidence of prostatic cysts can be as high as 7.9%-most of them are benign [1]. Usually they are asymptomatic; the most common presenting symptoms (if there are at all) are usually difficult urination (including retention), frequency and urgency [2]. In our case the patient presented with leakage of clear liquid from the urethra between the normal urinations- the patient called this incontinence but it is also possible that it was a leakage of the intracystic fluid. There was also hematuria-probably also from the intracystic cavity because the cystoscopy showed completely normal urothelium. These symptoms imply a possible connection (although not visible) between the cystic cavity and the urethral lumen. Midline cysts are usually benign and congenital-sometimes associated with infertility [3] – examples include Mullerian duct cysts, prostatic utricle cysts, ejaculatory duct cysts, ductus deferens cysts [4-6]. In our case the cyst was lateral and the patient was elderly. Possible lateral cystic lesions are cystic degeneration of benign prostatic hyperplasia, prostatic retention cyst, seminal vesicle cyst, diverticular prostatitis, prostatic abscess, parasitic prostatic cyst and cystic prostatic carcinoma [7,8].

The ultrasound provided the initial diagnosis of a prostatic cyst and PSA measurement and MRI raised the suspicion that the cyst was malignant – namely the presence of irregular wall with internal enhancing solid components suggests cancer. Unfortunately, from the MRI no PI-RADS assessment was given - probably because of the highly unusual presentation of the tumor. Therapeutic options for managing prostatic cysts include transrectal aspiration with or without sclerotherapy, transurethral marsupialization and open surgery [9-11]. Also, a CT- guided biopsy for histological diagnosis is described in the literature [12]. We opted for a transurethral resection of the prostate because the papillary growths inside of the cyst were considered to be malignant. With opening of the cyst (in fact a transurethral marsupialization) the resectoscope entered the cystic cavity and some papillae were taken for histology. The inracystic fluid was clear which is not typical for carcinomas. The pathological examination initially was inconclusive-second review by a more experienced pathologist was necessary to establish the diagnosis of the tumor.

The pathological result was ductal cancer which is relatively rare (shown in Figures 5-7). Also immunohistochemistry was used (shown in Figure 8) with High-Molecular-Weight cytokeratin-no staining of myoepithelial cells was observed. The literature review showed that in most cases (nine out of ten cases) the pathological finding is acinar-type prostatic adenocarcinoma- only in one case a ductal component was reported [12]. Actually most cases of prostate cancer with cyst formation were pseudocysts with haemorrhage – not true cystic prostatic carcinomas. Only 17% of the cystic tumors were derived from degeneration of a retention cyst [13]. The patient chose hormonal therapy (instead of radical prostatectomy) because of his advanced age. 1 year after the operation PSA is still 0 and on the ultrasound the cyst is invisible – despite the fact that ductal prostate cancer is associated with worse prognosis compared with the typical adenocarcinoma, including overall survival and cancer-specific survival [14].

Figure 5: Hematoxylin and eosin staining, x40 magnification.

Figure 6: Hematoxylin and eosin staining, x200 magnification.

Figure 7: Hematoxylin and eosin staining, x400 magnification.

Figure 8: Immunohistochemistry with HMW cytokeratin.

Conclusion

Prostatic cysts are relatively uncommon with varying clinical presentation. Ultrasound is very valuable for the initial diagnosis. PSA and MRI are performed in order to exclude a tumor. In many cases the TURP is a possible treatment and provides the final (pathological) diagnosis.

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Monday, August 24, 2026

Use of a Dermal Regeneration Template in the Multi- Flap Reconstruction of a Total Upper and Lower Eyelid Defect

Introduction

Eyelid defects are congenital, traumatic or, more often, consequences of tumor excision, mainly non-melanoma skin cancer that generally affects the lower lid and the medial or lateral canthus while the upper eyelid is involved in less than 10% of cases. Basal cell carcinoma is the most common type of non-melanoma skin cancer [1]. Several therapeutic options such as irradiation, cryotherapy and topical application of anti-metabolites like 5-Fluorouracil, are used for the treatment of non-melanoma skin cancers. However, the most common radical approach is surgical excision. On the other hand, it is very difficult to find a tissue that can adequately cover the eyeball [2,3]. Several surgical techniques, ranging from the use of local, pedicled or free flaps, to the use of simple or composite grafts, have been proposed in the available literature; however, none of these techniques have been proven to be clearly superior to the other [2-4].The Dermal Regeneration Template (DRT; IntegraⓇ Dermal Regeneration Template, Integra LifeSciences Corporation, Plainsboro, N.J., U.S.A.), which was commercialized in the 1980s, is now an important tool employed in a broad spectrum of cases, from the treatment of scar contractures to the reconstruction of soft tissues loss due to trauma or cancer removal in all anatomical sites. In this report, we describe the first surgical case of a multilayered composite mucosal graft and flaps reconstruction of wide eyelid defects covered by using a DRT for the upper eyelid.

Clinical Case

A 64-year-old man was referred to our ophthalmoplasty outpatient clinic for the treatment of an ulcerated left-side eyelid lesion. The patient was a farmer and had fair skin; in addition to his senile age, both are risk factors for skin cancer. He was otherwise healthy and denied symptoms of fatigue, fever, night sweats, weight loss. He reported that the lesion had progressively grown over the previous two years and that he made copiously use of topical treatments as advised by his primary eye care physicians. An external examination revealed that the multifocal lesion involved the entire left upper eyelid, the medial and lateral canthi, and the lower eyelid. We also observed a central ulcer, many small translucent nodules with pearly outer margins, and a complete loss of eyelashes (madarosis) along the free margin of the upper eyelid. In the nose area, we observed a big crater-like lesion with irregular rolled edges that involved the region of the medial canthus, including both lacrimal puncta, lacrimal canaliculi and the medial canthal ligament. An ectropion, tylosis of the free lid margin, and a mold ulcer on the temporal border were noted on the lower lid (Figure 1A). Slit lamp examination revealed a deep and quiet anterior chamber, pseudophakia, and rare hard drusen in the posterior pole on ophthalmoscopy. Intraocular pressure was 17 mmHg bilaterally, and his visual acuity was 0.33 and 0.18 (LogMAR) in the right and left eyes, respectively. The locoregional lymph nodes of the lesion were non-palpable.

Figure 1:

A. Pre-operative clinical photograph.

B. Schematic drawing of the applied surgical procedure.

An incisional biopsy confirmed the clinical diagnosis of basal cell carcinoma. Thus, a complete, wide, free margin resection of the lesion was scheduled. After marking the lesion and the surgical plan (Figure 1B), the tumor was excised with a 3 mm safety margin under local infiltration anesthesia (2% lidocaine with epinephrine 1:200,000). Unfortunately, the extemporaneous biopsy results showed an excision margin involvement, leading to an unexpected excision of the entire lower lid. The complete excision of the basal cell carcinoma led to a full-thickness defect, which involved the upper and lower lids, the lateral and medial canthi, and the entire orbital skin (Zones I, II, III, IV, and V according to Spinelli HM et al., 1993). (Figure 2A) Therefore, in order to restore the integrity of the area, a combination of multiple surgical techniques that involve the use of complex flaps was required (Figures 2B & 2C).

Figure 2:

A. Intraoperative Results of Surgical Excision Waiting for Extemporaneous Biopsy.

B. Schematic drawing and section of the reconstruction plans.

A dovetail-shaped glabellar flap, dissected up to the subcutaneous fat layer, was used to reconstruct the tissue defect in the medial canthal area. An oral mucosal graft was split and used to reconstruct the posterior lamella of the superior and inferior eyelids; thereafter, it was sutured to the remnant conjunctiva. The inferior-anterior lamella and the lateral canthus were reconstructed by using a Mustardé flap [5]. According to Brusati et al. [6], we completed the reconstruction of the anterior layer of the upper eyelid with a forehead galeal flap covered through DRT trimmed to the external surface of the flap size (5x3 cm). Then, a complete suture of the multilayered new free margins was performed to assure corneal protection. (Figure 3) After three weeks, the tarsorrhaphy and the DRT outer silicone layer were removed. A thin epidermal autograft taken from the contralateral eyelid skin was then placed over the new well-vascularized dermis. Intraoperative and early postoperative complications did not occur, and the scar healed well. Furthermore, the patient did not complain of epiphora that interfered with his daily life. The mucosal grafts, although hard to examine, showed good viability and no insertion problems. No local recurrence was reported during the 12 months of follow-up. Upper lid motility was limited but present, maintaining the ability to fully close the eye; no ectropion or entropion of both lids was reported (Figures 4A & 4B).

Figure 3: Immediate post-operative wound aspect.

Figure 4: Functional and aesthetic outcome after one-year follow-up,

A. Eye open and

B. Eye closed.

Discussion

In the present case, the complete excision of the basal cell carcinoma led to a very important full-thickness defect, which involved the upper and lower lids, the lateral and medial canthi, and the entire orbital skin. The method chosen to restore the integrity of the area depends on numerous factors and has to be customized according to the size of the tissue defect, clinical severity, lesion location, and the surgeon’s experience. Reconstructive procedures should provide good eyeball protection, prevent drying, and meet the aesthetic criteria. Therefore, the two-fold layered structure of the eyelid should be considered in the planning of reconstructive surgery because of anatomical and functional reasons [7]. In the case of a full-thickness defect of both superior and inferior eyelids, a single-stage surgical approach should be avoided because of the risk of a greater skin retraction. In the present case, we chose a hard palate mucosal graft as the posterior lamella for both lids, [8,9] given that it could better match the normal tissue. The Mustardé flap was the best option to cover the oral mucosal graft to ensure minimal donor tissue scarring, good reconstruction of the lower lid, and prevention of ectropion or lagophthalmos. For the upper lid, [10] the galeal flap is strong enough to reconstruct the tarsus, and the frontal muscle can still preserve lid elevation. Even if the skin graft healed well, significant depression and retraction with a poor cosmetic outcome were expected; therefore, for the first time we chose a DRT to cover the external surface of the galeal flap [11]. The DRT is perfectly integrated where it is placed, regenerating a tridimensional structure known as “neo-dermis”, in which fibroblasts, lymphocytes, macrophages and neovascularization are clearly detectable. This type of DRT offers multiple advantages. It allows for immediate wound closure, thus preventing fluid loss and restoring the functional barrier of the skin. It also prepares the wound before the positioning of a thin skin graft, improving the final outcome, reducing the risk of necrosis, and improving the scar’s appearance. The engrafted DRT adds softness to the tissues. The main drawback of the DRT is linked to its high cost, followed by the second intervention required for engrafting a skin flap. Notably, the main advantages of the DRT outweigh its disadvantages as it has the potential of filling larger surgical defects without sacrificing aesthetic results and the proper functionality of the lids.

Conclusion

Our experience indicates that, compared to traditional techniques, the DRT can be effective as an adequate reconstruction alternative for challenging cases and can provide good aesthetic and functional results, thereby guaranteeing a normal daily routine and a good quality of life to the patient.

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