Marked Scarring Research Articles

Role of Ayurveda treatment protocol in the management of Yuvanpidika w.s.r. to Acne Conglobata – A Single Case Study

Acne Conglobata refers to the severe form of acne characterized by large polyporous comedon, severe inflammatory lesions including abscesses and cysts, marked scarring and sinus formation. The etiology of acne involves the interplay of multiple factors, including hormonally-induced sebum production, and inflammation. The gram-positive microaerophilic/anaerobic rod called Cutibacterium acnes (formerly Propionibacterium acnes) is a commensal organism of the skin found deep within the sebaceous follicle and mediates a portion of the inflammatory component. In Ayurveda, AC can be correlated with Mukhadushika which was explained under Kshudra Rogas. Due to vitiation of Kapha, Vata and Rakta, small or medium sized eruptions appeared on the face of adolescents. Classical text explains treatment plan for Mukhadushika is of two types Shodhana Chikitsa and Shamana Chikitsa including Vamana, Nasya, Siravedha, Lepa and Pralepa. A 27 year old male patient came with complaints of Pidaka (glandular and papular swelling) all over the face, Todavat Pida (pricking pain) with oiliness of face, Malabadhata (constipation), improper sleep pattern since last 2 months. After detailed examination and history taking Hetu of the disease were evaluated and patient treated with Shodhan and Shaman for 2 months along with Jalukaavcharan 2 times in treatment duration & was also advised to follow Pathya-Apathy. After completion of treatment patient was got relief of all the complaints and get rid of disease.

Enzyme-immobilized nanoclay hydrogel simultaneously reduces inflammation and scar deposition to treat spinal cord injury

Spinal cord injury (SCI) is a severely disabling pathological condition and always results in sensory and motor functions loss. After SCI, inflammation-mediated secondary tissue damage and subsequent formation of neuroglial scar suppress neuron survival and regeneration, therefore resulting in severe neurofunctional dysfunction. Although nanoclay biomaterials demonstrated useful immunomodulation feature in non-neuronal tissue, it is unclear if they can inhibit inflammation in SCI lesions and promote neurofunctional recovery. In this study, we immobilized chondroitinase ABC enzyme (ChABC), which can degrade chondroitin sulfate proteoglycans (CSPGs) of neuroglial scar, inside nanoclay (Laponite®, Lap) hydrogel through electrostatic interaction. The presented ChABC-immobilized Lap hydrogel (ChABC@Lap) exhibited shear-thinning properties and excellent injectability, allowing to locally deliver it into injured area through a non-invasive manner. Cell biological experiments and SCI rat model research revealed that both pure Lap (without ChABC) and ChABC@Lap hydrogels significantly reduced pro-inflammatory macrophage marker (iNOS) intensity. Importantly, compared with Lap hydrogel, ChABC@Lap hydrogel significantly decreased GFAP and CS-56 marked scar deposition, increased Tuj-1+ neurons regeneration, and promoted NF200+ neurons survival, thereby improving SCI rat of electrophysiological characteristics and motor function. In summary, the designed enzyme-immobilized nanoclay hydrogel offers a promising strategy for SCI therapy through modulating simultaneously inflammation and glial scar deposition.

Intradermal suture post-surgical scar in external dacryocystorhinostomy: technique and patient satisfaction survey

Purpose: Dacryocystorhinostomy surgery may result in significant postoperative scarring. Although other surgical techniques have been developed that achieve a better aesthetic result, the ab externo technique remains the gold standard for this procedure. We developed a telephone survey to evaluate the visual impact of postoperative skin scars associated with ab externo dacryocystorhinostomy. Methods: 470 patients underwent uncomplicated external dacryocystorhinostomy surgery by two consultant surgeons from January 2014 to December 2021. Skin incisions were closed using intradermic continuous suture with prolene 6.0. The exclusion criteria were cases of dacryo-phlegmon and lacrimal sac fistulae with skin maceration. The visual effect of the postoperative scar was evaluated, and the degree of patient satisfaction was measured by a questionnaire with four subjective perceptions of the scar (very good, good, bad, very bad) given by a physician in the first postoperative month. The survey responses were used as the basis for a literature review. Results: The survey received 470 responses (100%) Very good perception of the scar was achieved in 75,8% of patients. There were no other post-operative complications noted from medical records review. Conclusions: Given the small percentage of patients who complained of marked scarring, it should not be the main reason for deciding on the procedure for dacryocystorhinostomy, especially in elderly patients. Therefore, the surgical technique should be considered as a surgically acceptable choice if cosmetic results were selection criteria in the case of total stenosis of the nasolacrimal duct.

Optimization of the Soft Tissue Envelope of the Nose in Rhinoplasty Utilizing Fat Transfer Combined with Platelet-Rich Fibrin.

A thin or damaged skin soft tissue envelope may cause concerns in primary and secondary rhinoplasty. During postoperative healing, unpredictable scarring and contraction may occur and lead to significant aesthetic and trophic sequelae. Besides a meticulous surgical technique, there are no reliable techniques to prevent long-term skin damage and shrinkage. Fat transfer with addition of platelet-rich fibrin (PRF) harbors the possibility of local soft tissue regeneration and skin rejuvenation through growth factors and mesenchymal stem cells. It may also facilitate the creation of a thin fat layer on the dorsum to prevent shrink-wrap forces and conceal small irregularities. The goal is to provide evidence for the feasibility, durability, and beneficial effect of diced macrofat transfer bonded with PRF on the nasal dorsum. We present the technique of fat transfer conjugated with PRF as a nasal dorsal graft. Clinical endpoints were the prevention of trophic disturbances and atrophy at a 1-year postoperative follow-up. We present the skin mobility test as a clinical indicator of a healthy soft tissue envelope. The presented case series consists of 107 rhinoplasties. Fat was harvested in the umbilical or costal region. PRF was created by centrifugation of autologous whole blood samples. Macrofat was diced, cleaned, and bonded with PRF. The compound transplants were transferred to the nasal dorsum. There were no perioperative complications or wound-healing issues. Mean follow-up was 14 months. Clinical inspection showed good skin quality and no signs of shrinkage, marked scarring, or color changes with positive skin mobility test in all patients. Survival of fat was confirmed by ultrasonography and magnetic resonance imaging. Diced macrofat transfer in conjunction with PRF to the nasal dorsum is a feasible and safe method. A beneficial effect on the soft tissue envelope is demonstrated as well as the prevention of shrink-wrap forces.

Fire and Power on the River Basin: Irregular Warfare and Socio-Environmental Consequences of the Guerrilla in Araguaia, Brazil

Abstract The aim of this article is to retrace a guerrilla episode that occurred in the Amazon region of Araguaia during the military dictatorship in Brazil (1972-1975), opposing a group of militants from the Communist Party of Brazil (PCdoB) and the National Brazilian Army. Taking advantage of the geographical characteristics of the region, a small group of guerrilla fighters was able to confront a large military contingent for almost three years. As this article demonstrates, appealing to the powerful symbolic potential of the Amazon jungle, the guerrilla created a solid environmental narrative of force and shrewdness supported by the local population. However, as military forces began to better explore the region and to resort to irregular warfare strategies, they managed to curb the guerrilla, exterminating almost every member involved in the fight. Finally, this article looks at the marked socio-environmental scars that the conflict left in the region, and how these influenced social, political and ecological equilibriums during the following decades.

Orofacial motricity and use of mixed techniques in a cranio-facial trauma: a case report

ABSTRACT No reports about treatments applied by orofacial motricity experts, in craniofacial trauma, were found in the specialized literature. However, their knowledge, added to that of the aesthetic area, would be useful in the rehabilitation of scars. The aim of this work is to describe the mixed use of orofacial motor skills, muscle balance massage and scar management in a patient with soft tissues facial trauma. During the initial evaluation, a decrease in the vertical and horizontal oral opening and in the mimic movements, facial asymmetry and marked scars that affected the oral phase of swallowing, chewing (bolus formation), lip mobility, compromising speech intelligibility and, significantly, aesthetics, were observed. Myofunctional therapy lasted 12 months, during which the patient underwent three surgeries. The process was divided into an intensive phase (six months, two weekly sessions) and a follow-up phase (six months, one weekly session), which ended when the indicators evaluated at the beginning were stable, showing improvements in scars condition and appearance, as well as in orofacial functions, including pre-post therapy self-perception and greater muscular mobility, reflecting a management with an integrative approach.

Geomorphological and geophysical surveys with InSAR analysis applied to the Picerno earth flow (southern Apennines, Italy)

Landslides represent a major geomorphological feature influencing the evolution of the southern Apennine slopes with earth flows being one of the most representative types of landslide. The development of earth flows in the southern Apennines is facilitated by the widespread occurrence of clayey lithologies. Earth flows can either produce marked scars along the slopes, when their activity is high, or give rise to bumpy areas that are frequently covered by vegetation, when their activity is low. In this latter case, although the risk is significantly reduced, the earth flow can still represent a problem for buildings and infrastructure. The Picerno earth flow in the Basilicata region is an example of a low-activity earth flow. This NW-SE–oriented landslide extends for a length of ~ 5.5 km, has an average width of ~ 680 m, and affects the village of Picerno. Our investigations mainly focused on the terminal portion of the landslide and revealed that some significant linear infrastructures (e.g., the Potenza–Naples railway) and important provincial and municipal roads are affected by the earth flow. In order to better define the amount of displacement characterizing the Picerno earth flow and gain insights into the lateral extension and the depth of the main detachment surface, we undertook a detailed geological and geomorphological survey. Interferometry synthetic aperture radar data provided by the processing of SAR images, with the aim of highlighting the regions of the landslide that are currently active, together with electrical resistivity tomography data which have been utilized to define the geometry of the landslide body. Our results provide useful suggestions for planning appropriate actions aimed at stabilizing the landslide body.

A comparative study of surgical accesses to breast fibroadenoma

Introduction: A Breast lump is a major health concern amongst women.Increased awareness has resulted in patients seeking early surgical consultation. Surgical resection is traditionally done by Fibroadenoma excision through an overlying incision (FETOI). This technique results in marked scarring. Another approach to Fibroadenoma excision through a periareolar incision (FETPI), which pays special attention to incision location to preserve cosmesis. In this study we assessed the cosmetic superiority and early complications of employing these two incisions in patients with fibroadenoma. Materials and Methods: A prospective non-randomised study of 70 patients who were divided into two groups as per the criteria described in materials and methods section, was carried out in our hospital between April 2015 to September 2017. Examination carried out in detail and diagnosis was established by clinical examination and USG of breasts followed by FNAC of lump. Patients were subjected to FETPIand FETOI Procedures and results were compared. Results: The incidence of early complications such as pain, hematoma and skin flap bruising at post-op day 1, day 2 and day 3 follow-ups did not differ significantly between two groups (P-value>0.05 for all). The distribution of total cosmetic score is significantly better in Group A compared than Group B (P-value<0.001 for all). The distribution of self-assessment score at post-op 1-month, 3-months and 6-months follow-ups is significantly better in Group A compared to Group B. Conclusion: The FETPI technique yields superior cosmetic and self-assessment results with minor incidence of early postoperative complications.

Z Lengthening of Achilles Tendon through Three Longitudinal Mini Incisions

Category: Ankle Introduction/Purpose: Achilles tendon lengthening is considered an integral step in management of major foot and ankle deformities. Many procedures were described. Selective gastrocnemius recession is sometimes useful but is insufficient in severe equinus deformities in which the Achilles tendon itself needs to be lengthened. Z lengthening is sufficient to correct severe equinus deformities but is associated with marked scarring and tension on the wound after correction of the deformity. Percutaneous triple hemisection is an alternative but has the disadvantages of uncontrolled lengthening and risk of rupture in correcting severe deformities. In this study, a new technique of Z lengthening through three small longitudinal incisions to avoid the disadvantages of open Z lengthening and percutaneous triple hemisection was evaluated. Methods: Three longitudinal incisions of 1 to 1.5 cm were done, one over the most distal portion of the Achilles tendon and the second and third incisions over the midportion and the upper end of the tendon. Through the distal incision, the distal part of the tendon was split into two equal halves and the medial half was detached from the calcaneus and sutured. The suture was then passed using an artery forceps to the middle and then the superior incision with gentle pulling to complete the splitting of the two halves. Then, the lateral half was detached from the tendon proximally. Then, the equinus was corrected and the two halves were sutured together through the middle incision with removal of excess tendon. Longitudinal incisions were preferred to avoid fish mouth opening with deformity correction and to leave a chance to convert to open lengthening should posterior capsular release found necessary. Results: Ten patients with severe fixed equinus deformity alone or as an element of more complex foot deformities with clinically and radiologically reasonable ankle joints that can be preserved were included in the study. Three patients had poliomyelitis, two had Charcot-Marie Tooth syndrome, two had cerebral palsy, two had idiopathic equinocavus deformity and one had posttraumatic deformity. The average age was 24 years (range: 14-36). The follow up was at least six months. Equinus deformity was successfully corrected in all patients and the Achilles lengthening procedure was successful in all cases without need to convert to the classic open technique. No wound healing problems were encountered and the extensive scarring associated with open Z lengthening of the Achilles tendon was not encountered. Conclusion: Z lengthening of the Achilles tendon using three mini incisions can be a good option to treat severe equinus deformities with avoiding the complications of open Z lengthening and the percutaneous triple hemisection. It has however a limitation when posterior ankle capsular release is needed, but in such cases, the incisions can be connected converting the procedure to an open Z lengthening. Further studies are needed with larger number of cases and with comparison to other methods of Achilles lengthening.

Cosmetic evaluation of surgical scars after external dacryocystorhinostomy.

To evaluate the surgical scars of external dacryocystorhinostomy (DCR) cosmetically. Totally 50 consecutive cases of primary acquired nasolacrimal duct obstruction (PANDO) were included in the study. Surgical scars were assessed by the patients and two independent observers at 2, 6 and 12wk postoperatively on the basis of visibility of the scars and still photographs respectively and were graded from 0-3. Kappa test was utilised to check the agreement of scar grading between the two observers. Wilcoxan signed ranks test was used to analyse the improvement of scar grading. Thirty-four (68%) patients graded their incision site as very visible (grade 3) at 2wk. At 6 and 12wk, incision site was observed as grade 3 by 7 (14%) and 1 (2%) patients respectively. Photographic evaluation of patients by 2 observers showed an average score of 2.75, 1.94 and 0.94 at 2, 6 and 12wk respectively. Change in scar grading from grade 3 to grade 0 in consecutive follow-up (2, 6 and 12wk) was found to be highly significant both for the patient as well for the observers (P<0.0001). The external DCR is a highly effective and safe procedure and in view of low percentage of cases who complained of marked scarring in the present study, thus scarring should not be the main ground for deciding the approach to DCR surgery, even in young cosmetically conscious patients.

Abundant immunoglobulin (Ig)G4-positive plasma cells in interstitial pneumonia without extrathoracic lesions of IgG4-related disease: is this finding specific to IgG4-related lung disease?

There have been few reports on immunoglobulin-G4 (IgG4)-related interstitial pneumonia (IP), and its clinical features remain unclear. The objective of this study was to assess whether IP with marked IgG4-positive plasma cell infiltration without extrathoracic lesions of IgG4-related disease (RD) should be diagnosed as a subtype of IgG4-RD or a separate entity. All consecutive patients with surgical lung biopsy-proven idiopathic IP with an IgG4/IgG-positive cell ratio of >40% and >50 IgG4+ plasma cells in a high-power field without extrathoracic lesions of IgG4-RD were reviewed retrospectively. Five patients were enrolled into this study. All patients were male with a history of smoking. Four patients met the comprehensive diagnostic criteria for IgG4-RD. The remaining patient lacked data related to the serum IgG4 level. Histologically, a non-specific IP pattern was observed in all patients. The key morphological features of IgG4-RD, such as storiform fibrosis and obliterative phlebitis with lymphoplasmacytic infiltration in a loose background texture, were absent in every patient. In contrast, venule obstruction by densely packed lymphoplasmacytic infiltration was observed in two patients. Marked scarring and remodelling of the lung were also noted, which is not seen typically in IgG4-RD. A favourable response to corticosteroid monotherapy was observed in all patients; however, two patients developed lung cancer during the course of observation. IP with marked IgG4-positive plasma cell infiltration without extrathoracic lesions of IgG4-RD had different pathological features from those of IgG4-RD, and it is appropriate to regard this as a separate entity.

Surgical management of vulvovaginal agglutination due to lichen planus

Lichen planus is a rare dermatological disorder that is often associated with painful and disfiguring vulvovaginal effects. At the University of Michigan Center for Vulvar Diseases, we see many women with vulvovaginal lichen planus each year, with marked scarring and vulvovaginal agglutination that precludes vaginal intercourse and causes difficulty with urination. Through our experience, we developed a protocol for the operative management and postoperative care for severe vulvovaginal agglutination. Our objective is to share this protocol with a wider audience so that providers who see patients with these devastating effects of lichen planus can benefit from our experience to better serve this patient population. The figure represents a case of erosive lichen planus with early vaginal agglutination. The video reviews the pathophysiology and presentation of lichen planus. We then present a case of scarring and agglutination in a young woman, including our surgical management and postoperative care recommendations.

Petaloid-pattern pigmentary retinopathy: a novel case report

We report the case of a 6-year-old girl with an unusual petaloid-pattern pigmentary retinopathy associated with nyctalopia and reduction of vision which had been invariably static over the past 5 years. We performed a comprehensive ophthalmic examination including fundoscopy, autofluorescent imaging, electroretinography and optical coherence tomography. There were diffuse retinal pigment epithelium (RPE) washout areas with blotches of pigment distributed in the pattern of a petal with marked chorioretinal atrophy and scar at the fovea. The arterial caliber was normal. Investigations ruled out intrauterine and neonatal infection. Systemically, she was healthy with normal intellect but with 3-month delayed milestones of development. She had used valproic acid for seizure disorder (without any organic central nervous system lesion) from 2-5 years of age. Electroretinography showed extinguished scotopic responses with slight reduction in cone responses. Optical coherence tomography showed a scar with attenuated RPE-choriocapillary complex at the macula. Her clinical profile did not fully match with any previously described pigmentary retinopathies except rod-cone dystrophy and choroidal dystrophy to a certain extent. The pigmentary retinopathy reported here is a combination of a petaloid pattern of pigmentary disturbance, stationary reduction of vision, nyctalopia, normal intellect and marginal delayed milestones. In the absence of such a description in the literature we named this disorder as petaloid-pattern pigmentary retinopathy.

Alternative nipple suspension technique in the treatment of inverted nipple: reverse s-shaped design.

The primary aim in the treatment of inverted nipple is to achieve a satisfactory and permanent projection of the nipple. The drawbacks of reported techniques include sensory disturbance of the nipple, marked scarring of the nipple and areola, destruction of breast function and incomplete correction. In the present study, the authors introduced a new modification of using two opposite nipple-based areolar dermal flap in the treatment of grades 2 and 3 inverted nipple cases. Nipple-based areolar flaps designed at 3 o’clock and 9 o’clock were raised by two linear incisions and the tip of each flap was sutured on the base of the nipple close to the base itself in a reverse S shape at 6 and 12 o’clock. Successful outcome was obtained due to a strongly suspending effect of the design of the flaps. The mean follow-up period was 6 months. The patients were satisfied with the result and the scars were minimal. The authors recommend the use of the technique that is a simple, reliable and with minimal scars for correcting grades 2 and 3 inverted nipples.

Sensory Recovery with Innervated and Noninnervated Flaps after Total Lower Lip Reconstruction: A Comparative Study

This study compares sensory recovery after total lower lip reconstruction in a wide variety of flaps including bilateral depressor anguli oris flap, submental island flap, bilateral fan flaps, radial forearm flap, and pectoralis major myocutaneous flaps in a large number of patients. Spontaneous return of flap sensation was documented by clinical testing in the majority (3%) of patients who underwent total lower lip reconstruction. Sensory recovery occurred more often in patients with fasciocutaneous free flaps than in those with musculocutaneous flaps. Flap sensation to touch, two-point discrimination, and temperature perception was correlated with age, smoking, and radiation treated patients. We conclude that reasonable sensory recovery may be expected in noninnervated flaps, provided that the major regional sensorial nerve has not been sacrificed, and also provided that the patients age is relatively young and that enough surface contact area of the recipient bed is present without marked scarring. This trial was regestered with Chinese Clinical Trial Registry (Chi CTR) with ChiCTR-ONC-13003656.

Nasal reconstruction by modified bilobed forehead flap

Paramedian forehead flaps, which are supplied by supratrochlear artery and have structural compatibility with nasal skin, have been successfully used for nasal reconstruction for many years. However, removing this flap from midline as perpendicular to natural lines of forehead may lead to marked scar. A flap extending to lateral in parallel to natural lines of forehead results in ipsilateral elevation of eyebrow. In this article, we aimed to demonstrate a flap technique called as "modified bilobed forehead flap technique". In this technique, pedicle of the flap is supplied by supratrochlear artery at one side and the flap is removed at the contralateral side of the lesion using parallel incision to natural lines of forehead. Another flap with a half thickness of the original flap is removed from contralateral frontal region and interpolated to the site where the original flap is removed to prevent the asymmetrical elevation of eyebrow ipsilateral to flap removal. The aim of this technique is to utilize masking effect of natural lines of forehead, while the basic method is bilobed flap technique. Secondary benefits of this technique include forehead lifting and bilateral eyebrow lifting.

Use of porcine small intestinal submucosa for corneal reconstruction in dogs and cats: 106 cases

To describe the efficacy of porcine small intestinal submucosa in corneal reconstructive surgery in dogs and cats through a large retrospective study. A retrospective evaluation of 106 cases of surgical reconstruction of the cornea with small intestinal submucosa seen between May 2005 and January 2010 was carried out. The corneal defect was filled by microsurgical grafting of porcine small intestinal submucosa. The biomaterial implant was deposited in one or several layers depending on the depth of the defect. The animals were examined 3, 6 and 12 weeks after surgery. Vision was preserved in all eyes at three months post-surgery. In 74 cases (69.8%) the corneal scar was either transparent or discrete, whilst in 32 cases (30.2%) a mild or marked scar was observed. Minor complications occurred in 9 cases (8.5%) with partial integration of the small intestinal submucosa and in 24 cases (22.6%) with faint or mild corneal pigmentation, without impairing vision. In cases followed over a period longer than three months, major complications occurred in five dogs resulting in vision impairment because of pronounced pigmentation. Corneal grafting of porcine small intestinal submucosa is an effective method for corneal reconstruction resulting in corneal transparency in most cases. It is an excellent alternative to conventional conjunctival grafts.

A case of application of bone transport and bone graft using Auto-tooth bone for alveolar cleft repair

Introduction: Secondary autogenous cancellous bone grafting is a widely used method for the treatment of alveolar clefts and oronasal fistulae. However, failure of iliac bone grafting sometimes occurs due to inadequate covering with the surrounding soft tissue and marked scar formation, or large clefts. We report a case of application of the combination for alveolar cleft repair of Maxillary bone transport surgery and Auto-tooth bone graft system using autogenous extracted teeth developed in Korea.

Application of the Lateral Orbital Flap to Reconstruction of the Upper and Lower Eyelids and the Eye Socket After Enucleation

The wide applications of the subcutaneous pedicle flap "lateral orbital flap" named by the author is presented. The flap is designed between the lateral canthus and the sideburn as a spindle or crescent shaped island 2- to 3-cm wide and 5-cm long. To reconstruct the upper or lower eyelids, the flap is elevated as thin as possible, whereas for the eye socket reconstruction, an adequate volume of subcutaneous fat tissue is attached to the flap. The pedicle is designed inferomedially for the reconstruction of the recipient, any shape of the flap can be designed. As the anatomic structure of the donor site is similar to the eyelid, the excellent result can be obtained both functionally and cosmetically. The donor site is primarily closed without a marked scar. The cases of reconstructions using lateral orbital flap for the upper eyelid and the eye socket in the anophtalmic condition are presented.

The Bulgheria canyon-fan: a small-scale proximal system in the eastern Tyrrhenian Sea (Italy)

The Bulgheria canyon-fan system in the eastern Tyrrhenian Sea displays well-developed, small-scale, fluvial-like features and has formed alongside the northern slope of the Sapri peri-Tyrrhenian basin. This study reveals, for the first time, the morphology and course of the present-day system as well as the buried elements based on a Digital Terrain Model and high-resolution seismic profiles interpretation. Two adjacent canyons (Infreschi and Luna) originate in the Cilento outer shelf at a short distance from each other and feed an intraslope basin fan through two main sub-parallel channels that run about 12 and 8 km, respectively. Channel and levee development seems to be controlled primarily by the local slope gradient and by Coriolis forces that induce a faster vertical growth of the right-side features, as is often observed in the Northern Hemisphere. Centrifugal forces, on the other hand, have induced episodic flow-stripping at the meander loops and bends, causing local destruction of the main channel levees rather than new levee growth at the outer bends. Overbank deposits are associated with overspill turbidite deposition in the mid fan where a topographic constraint occurs, whereas large-sediment, low-angle wave fields are mainly developed on the outer fan. Buried features and relict morphologies suggest that the Infreschi channel experienced at least two phases of re-incision since the final stages of the middle Pleistocene. Local re-adjustment of outer lobe growth due to channel avulsion and meander abandonment is possibly a consequence of relative base-level fluctuations. The sedimentary record of the mid and outer fan includes outrun mass wasting deposits from extensive failures of the Sapri slope. Indeed, a marked scar is present on the eastern side of the modern outer lobe that indicates the persistency of mass flow passages up to recent times. In addition to the environmental factors that are currently considered to cause canyon formation on the shelf margin, this study proposes the possibility that the head canyon branch close to the mainland was incised by massive and persistent underground freshwater flow from the adjacent aquifer when the sea-level was lower than at present.