The Inverted V-Shaped Fasciocutaneous Advancement Flap Effectively Solves the Complication of Tracheostomal Stenosis.

ABSTRACT: Tracheostomal stenosis after laryngectomy is a distressing complication. We present a retrospective study on sequential 9 patients who underwent stomaplasty with inverted V-shaped fasciocutaneous advancement flap. This procedure effectively solves tracheostomal stenosis, providing large stoma for breathing with no need for further stenting and low revision rates.

Sentinel lymph node metastasis in primary cutaneous basosquamous carcinoma. A cross-sectional study.

BACKGROUND AND OBJECTIVES: Basosquamous carcinoma (BSC) is a rare, biologically aggressive tumor. This cross-sectional study aims to define risk factors for subclinical nodal metastasis in primary BSC, and identify the patients who would benefit from routine sentinel node biopsy (SLNB) as part of the initial management. METHODS: A total of 142 patients, with histologically proven BSC without palpable lymph nodes, underwent SLNB after the initial excision. Clinicopathological features and demographics were analyzed between the patients with detected micrometastasis (SLNM) and those with negative SLN. RESULTS: In 7.7% patients, subcapsular and <0.1 mm SLNM were found. The frequency of SLNM was 0.9%, 11.8%, and 80.0% in patients with maximum lesion diameter ≤ 2 cm, 2.1-3.0 cm and >3.0 cm, respectively (P < 0.001) and was strongly associated with perineural (P < 0.001; OR = 26.46, 95% CI = 5.62-124.52) and lymphatic invasion (P < 0.001; OR = 17.35, 95% CI = 4.44-67.91). Within 18-84 months, no recurrence or metastasis were observed in SLNM positive patients. False negative SLNB rate of 15.4% was recorded. CONCLUSION: Cutaneous BSC is associated with early nodal metastatic potential. Tumor size >2 cm, lymphatic and perineural invasion are significant determinants for SLN micrometastasis. In the absence of palpable lymphadenopathy, wide resection and SLNB with long-term follow-up are highly recommended in these patients.

Single stage aesthetic and functional reconstruction of composite facial gunshot wound with a chimeric functioning muscle and fibular osseous flap. Case report and review of the literature.

The current concepts in the aesthetic and functional reconstruction of complex oromandibular defects are presented with a case of a patient with self-inflicted gunshot wound to the face. The patient presented with a 6 cm composite mandibular defect; the buccomandibular and suborbital aesthetic zones of the cheek along with the mucosa lining, and the ipsilateral facial musculature were missing. A rapid prototyping model of the facial skeleton was used to assist in preoperative planning. A single stage reconstruction with two free flaps was planned; a free fibula osseous flap to reconstruct the mandibular defect, and a free chimeric ALT/functioning vastus lateralis muscle. The one skin paddle of the chimeric flap reconstructed the buccomandibular/suborbital zones of the cheek, and the other the lining of the mouth. The functional muscle provided reanimation of the corner of the mouth by coapting the muscle's motor nerve to the ipsilateral marginal mandibular nerve. A good facial contour and reanimation of the mouth with oral continence was achieved, and the patient presented with good social and emotional smile. This first report of combined use of a fibula osseous flap with a chimeric functional ALT/Vastus Lateralis flap suggests that the chimeric flap principle may be used in complex aesthetic and functional challenges of severe facial trauma.

Serum S100B levels correlate with stage, N status, mitotic rate and disease outcome in melanoma patients independent to LDH.

PURPOSE: S100B protein is currently used as an immunohistochemistry marker to confirm melanoma diagnosis in biopsy specimens. Moreover, accumulating evidence supports its potential use as a tumor biomarker in blood. This study aimed to explore the potential uses of serum S100B protein as a biomarker in melanoma patients. METHODS: From 2012 to 2015, 107 sequential patients were diagnosed and treated for melanoma. All patients were tested for serum S100B and lactate dehydrogenase (LDH) at diagnosis and during their regular follow-up. Potential correlations between S100B serum levels and baseline characteristics and its impact on survival were assessed. RESULTS: S100B serum levels were within normal limits in patients with stages I and II, elevated in stage III, and very high in stage IV. In bivariate analysis, serum S100B levels >0.11µg/l and stage IV were the only independent prognostic factors associated with poor survival. Furthermore, S100B >0.5µg/l was associated with stage IV and poor survival. However, there was no significant association with LDH. S100B serum levels were positively correlated with mitotic rate (p=0.003), but only in stage IV patients (p=0.015). In stage III, a statistically significant difference in S100B serum levels were observed between N3, N2 and N1 stages, with higher levels for N2 (p=0.012) and N3 (p=0.009) compared to N1, and no difference between stages N2 and N3 (p=1.000). Also, no correlation was found between the number of primary melanoma lesions and S100B. CONCLUSIONS: S100B serum levels reflect tumor load, correlate with response to treatment, might identify patients who are at increased risk of disease relapse, may predict prognosis independent to LDH, and could be used as early biomarkers of tumor recurrence.

Dermal Matrix for Intraoral Lining Following Composite Mandibular Defect Reconstruction With Chimeric Fibular Osseocutaneous Flap.

BACKGROUND: This report aims to first present Integra as an adjunct to complex mandibular reconstruction for intraoral lining resurfacing, and to review the literature on the use of dermal matrices for mucosal resurfacing of the floor of the mouth. CLINICAL REPORT: A 62-year-old female patient with previous ablation surgery for squamous cell carcinoma of the floor of the mouth, presented with extrusion of the mandibular plate through the chin skin and serious tongue tethering. The patient was managed with a chimeric osseocutaneous free fibula flap to restore the mandibular bone and chin skin defect, followed by a second-stage reconstruction of the intraoral defect with bilayer Integra. Complete release of tongue tethering was achieved enabling normal speech and deglutition and allowing for dental rehabilitation. CONCLUSIONS: Integra was safely used as an alternative for intraoral lining, in composite mandibular reconstruction, downgrading reconstructive demands and offering optimal functional results.

Tips and Outcomes of a New DIEP Flap Inset in Delayed Breast Reconstruction: The Dual-Plane Technique.

Purpose The dual-plane deep inferior epigastric perforator (DIEP) flap inset technique is herein presented with tips for optimizing the aesthetic outcome in delayed autologous breast reconstruction after radiation therapy. Patients and Methods A total of 42 women who underwent microsurgical reconstruction with a free DIEP flap participated in this prospective study. The flap was inset in a dual plane lying behind the pectoralis major at the upper pole and in front of the muscle at the lower pole of the reconstructed breast. Results The dual-plane flap inset resulted in natural transition from native and reconstructed tissues, excellent scar quality, optimal outline of the breast, and overall breast appearance. Moreover, dual-plane reconstruction was associated with constantly high patient satisfaction without wearing brassiere due to fullness of the upper pole and minimal ptosis with time. Conclusion The dual-plane DIEP flap inset results in optimal scar quality, breast shape, and fullness of the upper pole, resulting in high patient satisfaction.

Dual plane diep flap inset: Optimizing esthetic outcome in delayed autologous breast reconstruction.

PURPOSE: In the present study, we compare the esthetic outcome in delayed autologous breast reconstruction, in the spectrum of irradiated chest wall, following two different abdominal flap inset. PATIENTS AND METHODS: Fifty women, candidates for microsurgical reconstruction with a free deep inferior epigastric perforator (DIEP) flap, participated in this prospective, randomized control study. In group-A (n = 25) the flap was inset using the traditional single plane in front of the pectoral muscle. In group-B (n = 25) the flap was inset in a dual plane lying simultaneously behind and in front of the pectoralis major at the upper and lower poles of the reconstructed breast, respectively. Photographic images were formulated to a PowerPoint presentation and cosmetic outcomes were assessed by means of a questionnaire and a visual analog scale. RESULTS: The dual plane flap inset presented significant advantages over the traditional single plane because of a better scarring (85.6 ± 1.3 vs.73.6 ± 1.2, P < 0.05), better transition from native and reconstructed tissues (90.2 ± 1.5 vs. 81.5.6 ± 1.6, P < 0.05), better outline of the breast (96.3 ± 1.2 vs. 69.6 ± 2.1, P<0.0001), and better overal breast appearance (86 ± 1.5 vs. 72.2 ± 1.9, P < 0.0001). Moreover, patient self-evaluation showed that dual plane reconstruction was associated with higher patient satisfaction without wearing brassiere (P = 0.0016), and this could be attributed to the significantly greater fullness of the upper pole (P = 0.0015) and significantly less ptosis with time (P = 0.0014). CONCLUSION: The dual plane DIEP flap inset improves scar quality, advances the breast shape and fullness of the upper pole, and results in higher patient satisfaction.

Refining perforator selection for deep inferior epigastric perforator flap: the impact of the dominant venous perforator.

INTRODUCTION: This article aims to investigate the critical role of the venous-perforator in the decision-making process of choosing the best suitable perforator-complex in a deep inferior epigastric perforator (DIEP) flap. METHODS: Forty consecutive DIEP breast reconstructions were pre-operatively evaluated by CT-Angiography to identify the dominant and centrally located abdominal wall perforators. The CTA results were used as a guide to conduct a Color-Duplex-Ultrasound examination that was mainly focused on investigating the accompanying venous-perforator. In group-A (n = 20) perforator-complex selection was based on the size of the arterial-perforator, whilst in group-B (n = 20) it was based on the size of the venous-perforator. RESULTS: All single perforator-complex DIEP flaps survived. No significant differences were recorded concerning the size of arterial-perforator between the two groups; however the size of venous-perforator was significantly larger in group-B (P < 0.05). In group-A, four flaps showed vascular compromise intraoperative that was salvaged by flap supercharge with the superficial inferior epigastric system. In contrast, in group-B, all flaps were re-vascularized uneventfully (P < 0.05). Physical examination revealed a palpable mass in one patient and ultrasound investigation added three cases with a firm area of scar tissue in group-A, but no fat necrosis was detected in group-B (P < 0.05). CONCLUSIONS: The CTA-guided duplex ultrasonography could direct the perforator-complex selection according to the size of the venous-perforator, and may reduce the intraoperative problems and the incidence of fat necrosis.

Angiosarcoma of the nasal septum mimicking reticulohistiocytoma.

Angiosarcomas are rare, aggressive tumors of endothelial cells with a high degree of invasiveness and poor survival. Although they arise in the face and scalp of elderly people, the nose represents a rare location with few reports in the literature. Nasal angiosarcoma resembling benign lesion morphologically has been described, but there is no report of angiosarcoma mimicking benign lesion histologically.Here, we report a case of nasal septum angiosarcoma in which the initial misdiagnosis submitted by the referring pathologist was reticulohistiocytoma. Nevertheless, the nasal septum and anterior nasal spine invasion by the tumor led us to suggest extensive surgical treatment: resection of the caudal septum, the anterior nasal spine, the columella, and the philtrum. Thereafter, an L-strut rib cartilage graft reconstructed the septum defect and was lined with a free radial forearm flap, resulting in a satisfactory functional and aesthetic outcome. Histology showed complete resection of a malignant neoplasm of mesenchymal origin, and immunohistochemistry established the diagnosis of epithelial angiosarcoma. The literature regarding this rare presentation of angiosarcoma was reviewed.

Pathologic findings in breast reduction specimens: detection of occult premalignant and cancerous lesions.

BACKGROUND: As reduction mammaplasty has become one of the most popular reconstructive procedures, there is an increasing number of reports regarding histopathologic findings in breast tissue yielded by the procedure. PATIENTS AND METHODS: This study evaluates histopathologic findings in breast tissue removed during reduction mammaplasty procedures performed during a 40-month period (2008-2011), and includes 300 patients of which 258 underwent bilateral breast reduction (group B) and 42 unilateral reduction for symmetry to the contralateral reconstructed breast (group U). RESULTS: Occult carcinomas were detected in 4 (1.55%) group B patients and 1 (2.38%) group U patient. Atypical hyperplasia and intraductal papillomas were identified in 22 (8.6%) and 5 (11.9%) patients, respectively. Benign pathologic changes including typical mild ductal hyperplasia, fibrocystic disease, adenosis, fibroadenoma, and lobular atrophy were identified in 174 (67.44%) group B and 26 (61.9%) group U patients. CONCLUSION: Breast carcinomas are rarely detected in breast tissue yielded by reduction mammaplasty procedures due to routinely performed preoperative assessment including clinical examination and mammograms. Pathologic examination of specimens provides the clinician with a conclusive diagnosis allowing for possible prompt further management.

Aesthetic and anatomic subunit reconstruction of composite mandibular gunshot wound.

BACKGROUND: Gunshot facial traumas involving the mandible and surrounding soft tissues are represented by the potential for loss of relationships between the functional and the aesthetic subunits of the head. METHODS: A patient presented with an 8-cm composite mandibular defect, resulting from a self-inflicted gunshot injury. Taking into account the anatomic/aesthetic subunits involved, a fibular osseoseptocutaneous flap was transferred to reconstruct the left lateral mandibular segment and the floor of the mouth, whereas a preexpanded temporal scalp flap was transferred to restore the hair-bearing skin of the left buccomandibular subunit. A review of the literature is also presented. RESULTS: A satisfactory functional and aesthetic outcome was achieved. Although current literature supports the value of aesthetic subunit face reconstruction and the use of double flaps for the reconstruction of through-and-through oromandibular defects, there is no previous report of the combined use of temporal scalp flap and fibular osseocutaneous flap. CONCLUSIONS: The combined use of hair-bearing skin and osseocutaneous flap may achieve optimal results in through-and-through oromandibular defects.

Impact of portable duplex ultrasonography in head and neck reconstruction.

We have reviewed the use of portable duplex ultrasonography (PDU) in 12 patients who underwent soft tissue/bone head and neck reconstruction, aiming to determine its role in the design and management of such complex cases. According to our data, there were modifications either of the surgical plan or of patient's management, based on PDU findings, in 9 (75%) of 12 patients. The use of ultrasound directed to subtle modifications in 3 patients (25%) but to significant changes of the surgical plan in the other 3 patients (25%). Also, the use of duplex ultrasound impacted significantly the postoperative management in 4 patients (33.33%). Thus, significant impact of PDU in patient's treatment was recorded in 58.33% of cases. Portable ultrasound represents generally available method for preoperative, intraoperative, and postoperative diagnosis and decision making in free tissue transfer, hence could replace in the future the unidirectional Doppler in the hands of head and neck surgeons.

Foucher first dorsal metacarpal artery flap versus littler heterodigital neurovascular flap in resurfacing thumb pulp loss defects.

Our study aims to illustrate the advantages and disadvantages of Foucher's first dorsal metacarpal artery flap and Littler's heterodigital neurovascular flap in thumb pulp reconstruction, by assessing wound healing of donor and recipient sites, sensibility, and functional outcome of the reconstructed thumb. Fourteen male patients were reconstructed either with Foucher (n = 8) or Littler flap (n = 6). Dissection of Foucher's flap was faster than that of Littler's flap. All Littler flaps survived completely, but we experienced 1 partial Foucher flap necrosis. Thumb motility and stability was optimal in all patients. Wound healing of donor sites was achieved in both groups. Two patients reconstructed with Littler flap developed scar contractures and presented a reduced range of motion of donor finger and first webspace, respectively. Although Littler flap resulted in better sensibility and tactile gnosis of the reconstructed thumb-pulp, Foucher flap ensured negligible donor site morbidity, complete cortical reorientation, and better overall hand function.

Changes in arterial blood flow of free flaps after the administration of sildenafil in swine.

We evaluated blood flow changes after experimental free tissue transfer and the potential hemodynamic effect of sildenafil on the free flap. Sixteen swine were used for free transfer of a latissimus dorsi myocutaneous flap to the chest that was anastomosed to the internal mammary vessels, and were randomized into controls and study group. The latter received a single dose of sildenafil, 6 hours following flap revascularization. Doppler ultrasonography revealed that arterial flow was mainly systolic postoperatively. Diastolic flow patterns were gradually restored after the first postoperative day. Pulsatility index (PI) significantly increased and flow volume decreased in all animals postoperatively. In the sildenafil group, PI significantly decreased and flow volume increased, while diastolic flow patterns were restored earlier on compared to controls, postoperatively. In conclusion, the administration of sildenafil after free tissue transfer increases flow volume and facilitates the restoration of diastolic blood flow patterns in the early critical postoperative period.

Can the use of hyaluronidase reduce capsule formation?

BACKGROUND: The purpose of this study was to find whether the use of hyaluronidase reduces capsule formation. METHODS: Ten New Zealand White rabbits were used. Eight pockets were created using an aseptic technique, four on the right side and four on the left side, along the vertebral column of every animal. One piece of silicone from a silicone block was inserted inside every pocket. The dimensions of each piece were 3.5 × 2 × 1.5 cm. In every pocket on the right side of each animal we placed 0.5 ml of hyaluronidase solution. The animals were sacrificed 5 months postoperatively. Capsule formation in the each side of the animals was compared. RESULTS: Two rabbits presented infection in two pockets and were excluded from the study. There was a statistically significant difference between groups concerning the capsule thickness variable using parametric (P = 0.003) and nonparametric (P = 0.001) analysis [capsule thickness on the right side: 256.46 ± 114.88 (mean ± SD) and on the left side: 369.10 ± 147.81 (mean ± SD); capsule thickness on the right side: 235.69 (104.72) [median (IQR)] and on the left side: 332.12 (188.68) median (IQR)]. CONCLUSION: The use of hyaluronidase may reduce capsule formation around implants.

Evaluation of six CTLA-4 polymorphisms in high-risk melanoma patients receiving adjuvant interferon therapy in the He13A/98 multicenter trial.

PURPOSE: Interferon is approved for adjuvant treatment of patients with stage IIb/III melanoma. The toxicity and uncertainty regarding survival benefits of interferon have qualified its acceptance, despite significant durable relapse prevention in a fraction of patients. Predictive biomarkers that would enable selection of patients for therapy would have a large impact upon clinical practice. Specific CTLA-4 polymorphisms have previously shown an association with response to CTLA-4 blockade in patients with metastatic melanoma and the development of autoimmunity. EXPERIMENTAL DESIGN: 286 melanoma patients and 288 healthy controls were genotyped for six CTLA-4 polymorphisms previously suggested to be important (AG 49, CT 318, CT 60, JO 27, JO30 and JO 31). Specific allele frequencies were compared between the healthy and patient populations, as well as presence or absence of these in relation to recurrence. Alleles related to autoimmune disease were also investigated. RESULTS: No significant differences were found between the distributions of CTLA-4 polymorphisms in the melanoma population compared with healthy controls. Relapse free survival (RFS) and overall survival (OS) did not differ significantly between patients with the alleles represented by these polymorphisms. No correlation between autoimmunity and specific alleles was shown. The six polymorphisms evaluated where strongly associated (Fisher's exact p-values < 0.001 for all associations) and significant linkage disequilibrium among these was indicated. CONCLUSION: No polymorphisms of CTLA-4 defined by the SNPs studied were correlated with improved RFS, OS, or autoimmunity in this high-risk group of melanoma patients.

Portable duplex ultrasonography: A diagnostic and decision-making tool in reconstructive microsurgery.

Unidirectional Doppler is a common diagnostic tool by the Reconstructive Microsurgeons; however, it may generate false signals and surely provides less imaging data as compared to duplex ultrasonography. We have reviewed the use of Portable Duplex Ultrasonography (PDU) in 16 patients who underwent complex soft-tissue/bone reconstruction, aiming to determine its role in the design and management of free tissue transfer. According to our data, there were modifications either of the surgical plan and/or of patient's management, based on PDU findings, in 10 out of 16 patients (62.5%). The use of ultrasound directed to subtle modifications in three patients (19%), but to significant changes of the surgical plan in four patients (25%). Also, the use of ultrasound improved significantly the postoperative management in three patients (19%). Thus, significant impact of PDU in patient's treatment was recorded in 44% of cases. Portable ultrasound represents generally available method for preoperative, intraoperative, and postoperative diagnosis and decision-making in free tissue transfer, hence could replace in the near future the unidirectional Doppler in the hands of Microsurgeons.

Giant Cell Tumor of Tendon Sheath Developed over Chimeric-Free Latissimus Dorsi and Serratus Anterior Muscle Flaps.

This article describes a rare case of giant cell tumor of the tendon sheath (GCTTS) that was developed over the substance of chimeric-free latissimus dorsi and -serratus -anterior muscle flaps performed for lower limb reconstruction. To our knowledge, development of GCTTS over a free flap is first described in the literature. A 71-year-old -woman was presented with a large protuberant ulcerated tumor mass that was developed over the substance of chimeric free muscle flaps at the foot and ankle. We performed an extensive tumor resection, and the pathology report confirmed the presence of a primary giant cell tumor. The patient was advised to have a below-knee amputation. However, the patient refused the amputation, and 4 months later, she was presented with a metastatic mass proximally at the upper thigh. We believe that the GCTTS was associated with the chronic inflammation of the soft tissue and bones along with the recurrent episodes of infection, mainly due to proteus mirabilis and proteus syndrome (PS). PS may lead to the development of malformations and overgrowth of different tissues in unusual locations. In cases resistant to antibiotics, the radical surgical debridement should be considered as the most effective treatment.

First Reported Case of Skin Necrosis Due to Prolonged Mechanical Compression After Transradial Catheterization.

We present a patient under triple-antithrombotic therapy who underwent prolonged mechanical compression after radial intervention; the subsequent necrosis at the access site required surgical repair.

Prognostic significance of autoimmunity during treatment of melanoma with interferon.

BACKGROUND: Immunotherapy for advanced melanoma induces serologic and clinical manifestations of autoimmunity. We assessed the prognostic significance of autoimmunity in patients with stage IIB, IIC, or III melanoma who were treated with high-dose adjuvant interferon alfa-2b. METHODS: We enrolled 200 patients in a substudy of a larger, ongoing randomized trial. Blood was obtained before the initiation of intravenous interferon therapy, after 1 month of therapy, and at 3, 6, 9, and 12 months. Serum was tested for antithyroid, antinuclear, anti-DNA, and anticardiolipin autoantibodies, and patients were examined for vitiligo. RESULTS: The median duration of follow-up was 45.6 months. Relapse occurred in 115 patients, and 82 patients died. The median relapse-free survival was 28.0 months, and the median overall survival was 58.7 months. Autoantibodies and clinical manifestations of autoimmunity were detected in 52 patients (26 percent). The median relapse-free survival was 16.0 months among patients without autoimmunity (108 of 148 had a relapse) and was not reached among patients with autoimmunity (7 of 52 had a relapse). The median survival was 37.6 months among patients without autoimmunity (80 of 148 died) and was not reached among patients with autoimmunity (2 of 52 died). In univariate and multivariate regression analyses, autoimmunity was an independent prognostic marker for improved relapse-free survival and overall survival (P<0.001). CONCLUSIONS: The appearance of autoantibodies or clinical manifestations of autoimmunity during treatment with interferon alfa-2b is associated with statistically significant improvements in relapse-free survival and overall survival in patients with melanoma.