The Propeller Myocutaneous Flap of the Upper Eyelid: Anatomical Study and its Clinical Implication.

BACKGROUND: The reconstruction of the upper eyelid and the periorbital region is a challenge for the surgeon. The aims of this reconstruction are to guarantee protection to the eyeball, maintain the visual field, and restore the function of the eyelid without damaging other anatomical structures. In this study, the authors describe the use of a propeller myocutaneous flap based on the small vertical branches of marginal, peripheral ed superficial arcade, for the reconstruction of the upper eyelid or periorbital region. MATERIALS AND METHODS: The authors enrolled 3 patients (Caucasian), between 2018 and 2019, and subjected to reconstructive surgery with the propeller myocutaneous flap of the periorbital region at the Plastic Surgery Unit of the University of Messina. The vascularization of the flap was demonstrated through an anatomical study conducted on cadavers at the dissection laboratories of the University of Bordeaux 2. RESULTS: The authors have shown that the myocutaneous flap represents a valid alternative for loss of substance coverage and reconstruction of the upper eyelid or periorbital region, allowing the achievement of a good aesthetic and functional result. FOLLOW UP: Patients were followed up at 3-6-12 months. No complications were reported (flap retraction, periocular region deformity, donor site morbidity). Furthermore, at the last visit, the scars were almost invisible. CONCLUSIONS: The use of the propeller myocutaneous flap of the upper eyelid is a valid reconstructive alternative to the standard techniques described so far for the reconstruction of the periorbital region.

Use of Lacrimal Symptoms Questionnaire After Punctoplasty Surgery: Retrospective Data of Technical Strategy.

ABSTRACT: The goal of this study is to evaluate postpunctoplasty symptoms with lacrimal symptoms questionnaire (Lac-Q). A retrospective study was conducted on 31 patients (14 men and 17 woman) with a diagnosis of canalicular stenosis: 26 patients with unilateral occlusion and 5 patients with bilateral occlusion. The Lac-Q was administered preoperative and at 1, at 3, and at 6 months following the surgery. Moreover, the Lac-Q questionnaire was administered by an independent observer (SI). The mono-lateral and bilateral postoperative Lac-Q score showed a significant improvement of symptoms at 1, 3, and 6 months than the preoperative results. The Lac-Q questionnaire is a way to evaluate the quality of outcomes after punctoplasty surgery. In this study, all patients showed a significant improvement of symptoms after surgery.

Energy-Based Devices Affect the Aesthetic Outcome of Cervical Thyroidectomy and Parathyroidectomy. A Retrospective Study.

INTRODUCTION: Thyroid and parathyroid diseases are very common. Most of these cases are in women and may be amenable to surgery. The patient's perception that these are not life-threatening diseases leads them to expect an excellent aesthetic result, since the surgical incision area is clearly visible. OBJECTIVE: To evaluate different scarring outcomes using three different energy-based devices (Harmonic Focus®, Johnson & Johnson, New Brunswick, NJ; Thunderbeat Open Fine Jaw®, Olympus Medical, Tokyo, Japan; LigaSure Small Jaw®, Medtronic, Dublin, Ireland) and to determine the impact of post-thyroidectomy/parathyroidectomy scars on the patient's quality of life. METHODS: One hundred female patients who underwent thyroidectomy or parathyroidectomy between September 2017 and September 2019 at the Endocrine and Minimally Invasive Surgery Department of Messina University Hospital were recruited. A retrospective analysis assessed the thickness of the cervical scar via ultrasound imaging, and the patient's degree of satisfaction through the Patient and Observer Scar Assessment Scale (POSAS) and the Body Dysmorphic Disorder Questionnaire (BDDQ). RESULTS: The patients were divided into three groups according to the energy-device used: group A (LigaSure SJ (n=38), group B (Harmonic F, n=32) and group C (Thunderbeat OFJ, n=30). The three groups were homogeneous with respect to number of patients, age and surgical procedures. The best aesthetic result, which correlated with the lowest scar thickness, was observed in group A; these patients were more satisfied than those in the other two groups. Moreover, correlations between scar thickness and quantitative variables (such as age or BMI) were not found in any of the groups. CONCLUSIONS: Based on the data collected and our experience, the LigaSure Small Jaw® (Medtronic) seems to offer the best aesthetic outcome in patients who undergo transverse cervicotomy for thyroid and parathyroid diseases. However, further prospective studies involving a greater number of cases are needed.

The Application of a Venous Catheter for the Surgical Treatment of Punctal Occlusion.

PURPOSE: Presentation about advantages of a new surgical technique in 20 patients with punctal occlusion with a venous catheter during punctoplasty. METHODS: The arrangement of a 30-mm venous catheter used during puncoplasty surgery was performed in 10 patients with punctal occlusion. The venous catheter was removed after 15 to 45 days after surgery. RESULTS: The use of the venous catheter supports the recanalization of the lacrimal drainage system 15 days after surgery. The venous catheter is easy to find, not expensive, and easy to use. CONCLUSION: The technique is performed under regional anesthesia. Furthermore, after surgery, the recanalization of the lacrimal drainage system was observed with a significant reduction of the epiphora in 6 months after surgery.

Anterolateral Thigh Flap in a Chicken Model: A Novel Perforator Training Model.

BACKGROUND: Preclinical training in perforator flap harvesting is typically conducted on living animal models; however, repeated training is not possible with these models because of ethical and/or economical constraints. We describe an anterolateral thigh flap (ALT flap) training model using chicken thigh that seems to be an appropriate training model prior, for example, to raise a perforator flap in a living rat or swine model. METHODS: A total of 10 chicken legs were used in this study. Six chicken legs were anatomically dissected to confirm the presence of the perforator and to identify the main vascular tree. In four chicken legs, a skin flap was planned based on the perforator and intramuscular dissection was performed under magnification. RESULTS: The perforator was identified in all dissections and was consistently found 3 cm above the line extending from the patella to the head of the femur in its third proximal. Proximally, the mean diameter of the artery and vein was 0.56 (σ = 0.04) and 0.84 (σ = 0.06) mm, respectively. The mean dissection time to raise the flap was 88 (σ = 7) min. CONCLUSION: This is the first description of a nonliving biological simulation model for training in perforator flap dissection that mimics an ALT flap. As an ex vivo chicken model, it is a cost effective and readily accessible model suitable for repeated practice.

Elevator Muscle Anterior Resection: A New Technique for Blepharoptosis.

Blepharoptosis is a condition of inadequate upper eyelid position, with a downward displacement of the upper eyelid margin resulting in obstruction of the superior visual field. Levator resection is an effective technique that is routinely used to correct aponeurotic ptosis. The anterior levator resection is the procedure of choice in moderate blepharoptosis when there is moderate to good levator muscle function, furthermore, with an anterior approach, a greater resection can be achieved than by a conjunctival approach. The authors describe a modification in the Putterman technique with a resection done over a plicated elevator, plication that was suggested by Mustardè. The technique has been named as elevator muscle anterior resection. The elevator muscle anterior resection inspires from the Fasanella-Servat operation by the use of a clamp, making the operation simple and predictable.

Long-term patient-reported functional and cosmetic outcomes following severe traumatic foot and ankle wound reconstruction with acellular dermal matrix.

BACKGROUND: The prevalence of acellular dermal matrices in reconstructive surgery has increased through the last decade with satisfying outcomes. Long-term follow-up and effectiveness studies could enable appropriate use of these devices and challenge the current gold-standard treatments. This paper presents functional and cosmetic long-term outcomes on the Integra(®) Dermal Regeneration Template (IDRT) for treating traumatic soft-tissue defects of the foot and ankle. METHODS: All adult patients who underwent severe traumatic foot and ankle reconstruction with Integra(®) since 2004 were retrospectively included. Results were evaluated using standardized outcome instruments. RESULTS: Twenty-one reconstructions were evaluated 4.5 ± 2.5 years after foot and ankle injury. Major complications inducing a second application included 1 hematoma and 1 infection. Seven patients (35%) had good or excellent Foot and Ankle Ability Measures. Subjectively, when asked to compare current function with pre-injury status, the mean response was 66 ± 23%. The Observer Scar Assessment Scale scored 17 ± 5 points (possible range, 5-50), while the Patient Scar Assessment Scale scored 30 ± 11 points (possible range, 6-60). CONCLUSIONS: Long-term functional and cosmetic outcomes 4.5 years after severe traumatic foot and ankle wounds treated with IDRTs were rated fair in the great majority of patients. Nevertheless, because complications and surgical revisions were few, potential benefits might be underestimated because of the initial combined injuries and their sequelae. In this way, for appropriately selected patients with severe traumatic foot and ankle soft-tissue defects, including subacute coverage, it appears that this treatment may be a viable first option.

Anatomical and aesthetical reconstruction of complex hair-bearing areas: a three-step procedure including implant of dermal regeneration templates, skin grafting, and hair micrografting.

Reconstructive surgery of complex hair-bearing skin defects often represents a challenge for the plastic surgeon; indeed, a multistage procedure is to be planned, including a first reconstructive step including local flaps, even if pre-expanded, or for larger defects, microsurgical flaps. To date, the implant of dermal regeneration templates has been proven an effective alternative. The authors relate their results of a complex hair-bearing reconstruction of a scalp and brow defect after a friction road burn with those reported in literature, concluding that a 3-staged reconstruction (dermal template implantation, skin grafting, and finally hair micrografting) can achieve good results in this complex kind of reconstruction. Histological specimens taken 2 years later confirmed a full anatomical reconstruction of the hair-bearing areas. Finally, this paper reports the first case of brow reconstruction performed with these techniques.

Marking the nipple-areola complex in mastopexy and reduction mammoplasty: a geometrical method.

Mastopexy and reduction mammoplasty are well-established procedures used to address ptotic and hypertrophic breasts. A variety of methods have been described in the literature for managing the three main aspects of these procedures: skin excess, parenchyma, and the nipple-areola complex (NAC). Among these techniques, several have specifically addressed the markings of the NAC in procedures involving a preoperatively established NAC position. While many of these have proven effective over time, the literature lacks standardized and reproducible methods. In this paper, we introduce, step-by-step, a novel approach based on geometrical principles to address this limitation. This method involves the simple process of drawing two hemi circumferences on the vertical limbs of the skin resection pattern, which are commonly marked using the Bisemberg maneuver or similar techniques. The method we introduce is adaptable to virtually all NAC pedicles. Furthermore, as exemplified in the accompanying video, it can be incorporated to most skin resection patterns with a preoperatively defined NAC position. The clinical application, as evidenced in the case reported, appears to be promising. Although it has some limitations, this procedure shows the potential to reduce inaccuracy by minimizing variability factors. As a result, even inexperienced surgeons can achieve precise markings.

Treatment of Chiari III Malformation in Infant with 4K 3D ORBEYE Exoscope.

Chiari malformation (CM)-III is the rarest anomaly among CMs.1 Treatment of choice is surgical repair,2 although poor outcome and postoperative mortality has been reported.3 Surgical timing is still debated.4,5 We present the case of a male infant with a prenatal diagnosis of encephalocele. Presentation was characterized by hemodynamic instability, horizontal nystagmus, and left shoulder dystocia due to caesarean section, with a 64 mm × 49 mm × 76 mm soft, fluctuant, and translucent suboccipital-cervical sac. Magnetic resonance imaging revealed a median occipital bone defect with the meningoencephalic sac communicating with the vermian cistern and the fourth ventricle, moderate hydrocephalus, reduction of the posterior cranial fossa volume, hypoplasia of cerebellar hemispheric, vermian structures, and corpus callosum hypoplasia. The patient underwent surgery on day 4 with the use of a 4K 3D ORBEYE exoscope (Video 1). Surgery consisted of disengagement of nervous structures and repair of the neurocutaneous defect, followed on day 12 by a ventriculoperitoneal shunt with a programmable valve. The procedures were well tolerated. At the 14-month follow-up visit he was in range with growth charts (weight, height, and cranic circumference) and gained the physiologic stages of growth. He had no motor impairment but still present were convergent strabismus and mild left C5-C6 radiculopathy, secondary to shoulder dystocia. This is the first case reported in the literature of CM-III treated with the 4K 3D ORBEYE exoscope. Advantages of the exoscope were ergonomic positions for operative staff, possibility for the team to assist in the 4K 3D view, especially in cases with a narrow operative field, with a clear and detailed vision, although a learning curve is required6 to become a valid alternative in pediatric neurosurgery.

Medial fascia lata perforator flap: Anatomical basis and clinical application as a pedicled or free flap.

Adipofascial flaps have proven to be an excellent tool for multipurpose reconstruction as free or pedicled flaps. The anatomical studies in this field are now focused on improving esthetics in reconstruction while maintaining a minimal donor site morbidity. An anatomical cadaver study has been carried out to investigate the medial thigh region as a potential donor site for adipofascial flaps. Eighteen thighs from fresh cadavers were dissected and a new territory with autonomous vascular supply was defined through vascular injection, anatomical dissection, transillumination, and angiography. Cutaneous access was made in a "T" shape. The fascia harvests had to be centered on the adductor longus and gracilis muscles bearing in mind the position of the flap pedicle. The fascial flap was isolated from adductor longus and gracilis muscles and isolated on his pedicle (medial circumflex femoral artery). After our anatomical study, we used the flap in 2 clinical cases. The results of our anatomical study and clinical cases confirmed the suitability and reliability of a new flap: the "Medial Fascia Lata Flap." Flap size ranged from 20 to 25 cm and has the advantage of preserving the functionality of the thigh muscles. The study showed that the "Medial Fascia Lata Flap" is easy to harvest, and the resulting scar is concealed. In consideration of its suitability, reliability and aesthetical advantages, it could be proposed as a good option in selected cases.

Epidermal keratin 5 expression and distribution is under dermal influence.

Human skin melanin pigmentation is regulated by systemic and local factors. According to the type of melanin produced by melanocytes, the transfer and degradation of melanosomes differ, thus accounting for most variations between ethnicities. We made the surprising observation that in a drastically changed environment, white and black phenotypes are reversible since Caucasian skin grafted onto nude mice can become black with all black phenotypic characteristics. Black xenografts differed essentially from other grafts by the levels of epidermal FGF-2 and keratin 5. In vitro analysis confirmed that FGF-2 directly regulates keratin 5. Interestingly, this phenomenon may be involved in human pathology. Keratin 5 mutations in Dowling-Degos Disease (DDD) have already been associated with the pheomelanosome-eumelanosome transition. In a DDD patient, keratin 5 was expressed in the basal and spinous layers, as observed in black xenografts. Furthermore, in a common age-related hyperpigmentation disorder like senile lentigo (SL), keratin 5 distribution is also altered. In conclusion, modulation of keratin 5 expression and distribution either due to mutations or factors may account for the development of pigmentary disorders.

An anterior-lateral thigh perforator flap on a recipient brachial-radial vein graft for complex wound reconstruction: a case report.

A case of challenging microsurgical reconstruction of a difficult defect in a radiated upper limb is reported. A difficult wound, with tendon and bone exposition, developed on the dorsum of the forearm in a 76-year-old patient; she had been radiated since almost 50 years and her left hand had also been revascularized twice with venous grafts between the humeral artery and the superficial palmar arch. After failure of a local flap, an anterior-lateral thigh perforator flap was successfully transferred with end-to-side anastomoses on the arterialized venous graft. Up to date follow-up shows a good outcome. The Authors discuss the case and review the indications for microsurgical reconstruction in difficult wounds after radiation and ischemic limb conditions.

A free vein graft cap influences neuroma formation after nerve transection.

INTRODUCTION: : Neuroma formation is a major problem in nerve surgery and consensus about its prevention has not been reached. It has been suggested that vein covering can reduce neuroma formation in transected nerves. In this article, the Authors propose an easy and novel method of covering by nerve stump capping with a free vein graft. METHODS: : Neuroma-like lesions were created on the rat thigh sectioning the femoral nerve above its division in 16 animals. The proximal nerve stump was invaginated into the lumen of a 1.5 cm long femoral free vein graft on the right side, and the vein was closed on itself by microsurgical sutures to form a cap for the nerve stump. On the left side acting as the control neuroma, the nerve was cut and left uncovered. Histological and immunohistochemical assessment was used to quantify the degree of neuroma formation. RESULTS: : Significant differences were found in both neuroma size and axon-glia organization between the treated and control sides indicating that free vein graft capping reduced neuroma formation in comparison to uncovered nerve stumps. CONCLUSIONS: : Our results confirm that vein-covering of a transected nerve stump can be effective in reducing neuroma formation. Moreover, unlike previous works that buried the nerve into an adjacent vein left in place, our experiments showed that also the use of a free vein graft cap can hinder neuroma formation. Although translation of rat experiments to the clinics should be dealt with caution, our data suggest a careful clinical use of the technique. (c) 2009 Wiley-Liss, Inc. Microsurgery, 2009.

Is the adipofascial flap the key to regenerative surgery?

OBJECTIVES: "Form and function restoration" is the ultimate goal of reconstructive surgery, which is oriented toward regeneration rather than reparation. Recently, research in reconstructive surgery has focused on the regenerative potential of the adipose tissue. The aim of the study is to illustrate the surgical methods and show the functional and aesthetic results achieved by the reconstruction of finger soft-tissue defects using homodigital dorsal adipofascial reverse flap (HDARF). MATERIALS AND METHODS: A total of 63 cases (45 acute and 18 elective) were included between September 2010 and August 2016. In each case, we preliminarily performed surgical debridement and then harvested an adipofascial flap from the back of the finger. Nine injured thumbs that were repaired with the flap as emergency cases were also included. The average age of the patients was 46 (range: 4-69) years. RESULTS: All flaps survived without any complications during the 24-month follow-up. Good nail regrowth through the flap and full regeneration were observed in approximately all cases. Sensitivity tests and histological analysis of biopsy samples of the regenerated fingers confirmed full regeneration of the epidermis, dermis, cutaneous adnexa, and nerves. All the patients were satisfied with the hand functionality and aesthetic appearance. CONCLUSION: The HDARF represents a very useful alternative for the reconstruction of nailbed crushes, achieving regeneration of injured segments in deformities caused by trauma or infection.

The distally based sural flap for lower leg reconstruction: versatility in patients with associated morbidity.

INTRODUCTION: Coverage of soft tissue defects in the lower leg is often made by use of free flap, also because of the improving of anaesthesiology techniques in the last decades. However, there are disadvantages in the use of free flaps like the need for a remote donor site, increased operative time, use of a major vessel to the leg, and microsurgical skills. Besides these, trauma in the lower limb are often cause of damage for a major vessels of the leg, so the use of free flaps in these patients may be related to an higher incidence of complications; also associated pathologies, like diabetes and vascular pathology, can increase the incidence of complications when a free flap is utilized. In all these cases local fascio-cutaneous flaps, like the sural reverse flap, because of their easy and short time harvesting, can be a very good alternative to free flaps. Superficial sural artery flap is a adipofasciocutaneous flap based on the vascular axis of the sural nerve, which gets reverse blood flow through communication with the perforating branch of the peroneal artery, situated in the region of lateral malleolar gutter. PATIENTS AND METHODS: Between 2000 and 2005, 11 patients, mean age 68 (range 58-78 years), were treated at the Plastic and Reconstructive Surgery Unit of Messina University, for soft tissue defects of lower limb and foot, using the distally based sural artery flap. The defects were related to post-traumatic damage of soft tissue, diabetic and vascular ulcers, osteomyelitis and oncological resection. Mean follow-up time was 20 months (range 6-55 months). All patients were pre-operatively assessed for vascular patency of peroneal axis and associated morbidity that could increase risk offlap necrosis. This included diabetes mellitus type II, osteomyelitis and peripheral arterial diseases. RESULTS: All flaps survived with the exception of one that sustained partial skin necrosis, in the ratio of 25% of the skin island. All defects were covered with no major complications and none of the patients required a blood transfusion. Moreover aesthetic results were good with satisfaction of all the patients. CONCLUSION: In our cases we found the sural reverse flap to have a good reliability with low incidence of complication and surgical outcomes. This flap is an excellent option for covering defects of minor deficiency of skin in the third distally of lower limb, ankle and heel. It allows rapid, reliable coverage of defects extending as far distally as the forefoot. Because of the sparing of major vessels, the short surgery time in harvesting the flap, and the good vascular pattern of the flap, we retain the flap a first choose technique for reconstruction in lower leg, especially in politrauma and in patients with associated pathology as vascular diseases or diabetes.

Lipograft in cicatricial ectropion.

AIM: Cicatricial ectropion is secondary to an excessive scar contraction after trauma, burns, skin conditions, scarring skin tumours, medication, allergies, blepharoplasty complications 1,2. The estimates for ectropion incidence following removal of eyelid lesions have been reported as varying from 2.5% to 7% 3. A variety of surgical techniques can be applied to achieve the correct shape and position of lower lid 4-7. Fat grafts in association with other technique are commonly used in orbital reconstruction in a variety of procedures 8 including of the correction of cicatricial ectropion 9,10. MATERIAL OF STUDY: The Authors propose the use of fat graft as only procedure for the correction of cicatricial lower eyelid ectropion. Two male patients with cicatricial ectropion were treated with this technique in two time and followed for 12 months. RESULTS: Lipofilling for cicatricial eyelid ectropion give excellent outcomes, with release of the scar without recurrence, 11. DISCUSSION: Autologous fat grafting has many clinical applications, and its use in Plastic Surgery is increasing: The key point is the presence into fat of Adipose stem cells (ASCs), that have been identified as an ideal source of cells for regenerative medicine, with potential and rapid improvement of healing process and complete recovery of tissue integrity after surgery to confirm the regenerative effect of fat graft. CONCLUSION: Lipografting can be considered a safe and effective alternative procedure 12,13. KEY WORDS: Defect of lower lid, Ectropion, Lipograft.

A 14-year-old girl with a sudden arm swelling after axillary depilatory wax.

Takayasu's arteritis is a systemic vasculitis predominantly affecting the aorta and its major branches. We report a 14-year-old girl in whom incidentally a deep upper limb vein thrombosis was found. She was referred to the emergency unit due to swelling and intermittent cyanosis of the right arm following an axillary depilatory wax. High-resolution echo colour Doppler ultrasonography showed a deep vein thrombosis with thickening of the proximal common carotids. A diagnosis of type IIb Takayasu's arteritis was made. The patient's history revealed fatigue, myalgia and headache. Immunosuppressive treatment and anticoagulation were introduced with a rapid and sustained improvement.