Merkel cell carcinoma of the upper eyelid: presentation and management.

Merkel cell carcinoma (MCC) is a rare and potentially aggressive neuroendocrine tumour. The authors describe a unique presentation of a 4.5 cm wide MCC of the upper lid in a 73-year-old female. After total upper lid resection, immediate reconstruction was achieved by a full-thickness lower-lid transposition flap based on the lower lateral palpebral artery. At the 3 year follow-up the patient is free from disease and the reconstructive result is satisfactory both functionally and aesthetically.

Increased signs of acute rejection with ischemic time in a rat musculocutaneous allotransplant model.

BACKGROUND: Composite tissue allotransplantation (CTA) may restore a variety of tissue defects, but carries the potential risks of graft failure and/or immunosuppression-related complications. Ischemia-reperfusion injury has been documented in CTA is known to contribute to acute rejection of solid organ grafts. This study describes the influence of subcritical ischemic time (ie, ischemia sufficient to generate reversible cell damage) on signs of rejection of musculocutaneous allograft components of subcritical ischemic time, namely, ischemia sufficient to generate reversible cell injury. Although skin is considered the most antigenic component of a composite allograft and is currently used for rejection surveillance, muscle and adipose are more susceptible to ischemia-related injury. METHODS: Vascularized epigastric flaps were transplanted from WKY to Fisher 344 rats after 1 or 3 hours of ischemia. Biopsies taken on postoperative day 6 were graded for signs of acute rejection according to criteria modified from previously published grading systems for CTA rejection. RESULTS: Skin and muscle exposed to 3 hours of ischemia showed significantly higher rejection scores than after 1 hour of ischemia, as evidenced by a more aggressive diffuse lymphocytic infiltration with disruption of tissue architecture. The rejection score in skin with 3-hour ischemia was 5.0 +/- 0.1 versus 3.7 +/- 0.2 with 1-hour (Mann-Whitney U test; P < .05). The rejection score in muscle exposed to 3-hour ischemia was 3.6 +/- 0.3 versus 2.5 +/- 0.1 with 1-hour (P < .05). CONCLUSIONS: Muscle and skin demonstrated increased acute rejection of allotransplants with increased subcritical ischemic time. This study supports the use of aggressive methods to reduce subcritical ischemic injury during allotransplantation of composite tissue and inclusion of muscle in postoperative biopsies in this early investigational period of CTA.

[Facial allograft transplantation: fiction or reality? Surgical techniques in a fresh human cadaver model]. / Allogene Gesichtstransplantation: Fiktion oder Realität? : Darstellung chirurgischer Techniken am Leichenmodel.

BACKGROUND: The aim of this study was to describe two methods of face-harvesting techniques -- a skin and soft tissue flap and a combined osteocutaneous flap -- and to demonstrate the compatibility between donor and recipient in a human fresh cadaver model. METHODS: In fresh human cadavers the skin and soft tissue of the face (type 1) and a combined osteocutaneous flap (including a le Fort III segment, type 2) were harvested. The faces were subsequently exchanged among the donor crania, simulating full-face transplantation. RESULTS: Both flaps are based on the external blood supply of the faciotemporal vessels and the external jugular vein. The end branches of the trigeminal nerve could potentially be used for restoration of sensation (type 1 flap). With type 2 flaps the facial expression may be restored with the inclusion of the facial nerve. Four morphological parameters determine the donor/recipient compatibility: skin color and texture, anthropometric head dimensions, specific soft tissue components (nose, lip, cheek, and eyebrow), and gender. CONCLUSION: Apart from ethical considerations, long-term immunosuppression will remain the limiting factor of full facial transplantation in the near future.

A clinically applicable reporting system for the diagnosis of facial fractures.

A clinically applicable, comprehensive reporting system for the diagnosis of facial fractures was developed with three guiding principles: (1) preservation of classical anatomical terminology and nomenclature, (2) facilitation of uniform interpretation of radiographs between radiologists and (3) non-redundant diagnostic descriptions of complex fractures, in a manner that correlates with treatment modality. Twenty-two fracture types (17 simple fracture types and 5 complex fracture types) are included in the system. Each patient's fracture pattern is described by listing the component fractures present. A short narrative (modifying description) is provided after each fracture listed. Simple fractures that help to comprise more complex fractures are not listed separately, but are described within the modifying description of the complex fracture they help to comprise. When components of multiple complex fractures are present, a hierarchy of complex fractures dictates which fracture is described first. Additional complex fractures are only described separately when they do not share common components. In all other cases, the second (lower order) complex fracture is best described by simply listing the component (simple or complex) fractures that are not accounted for in the higher order complex fracture. Adoption of this reporting system should improve communication between emergency medicine physicians, radiologists and surgeons.

Long-term psychometric outcomes of facial lipoatrophy therapy: forty-eight-week observational, nonrandomized study.

The aim of this observational, prospective, nonrandomized study was to assess long-term psychometric outcomes of surgical treatment of HIV-related facial lipoatrophy. Two hundred ninety-nine participants (70.8% male) consecutively attending the Metabolic Clinic of Modena and Reggio Emilia University from November 2005 to July 2006, undergoing surgical interventions for HIV-related facial lipoatrophy were enrolled. Fifty-four (18.1%) underwent facial lipofilling, which consists of the harvesting of a small, intact parcel of fatty tissue with processing that removes the nonviable components and of the transport of fatty parcels through a small cannula to implant the graft in a manner that provides nutrition and anchors the fat to the host tissue. After an initial lipofilling, 24 (8%) needed polylactic acid injections to correct cheek asymmetry, 91 (30.4%) received only polylactic acid infiltrations, and 130 (43.5%) polyacrylamide infiltrations only. Subjective outcome measures were face aesthetic satisfaction, body image perception, depression evaluated by a visual analogue scale (VAS), the Assessment of Body Change and Distress questionnaire (ABCD), and by the Beck Depression Inventory questionnaire, respectively. Objective measure was cheek thickness evaluated by a 7.5-MHz frequency ultrasound probe perpendicular to the skin surface at the nasolabial fold, the corner of the mouth, the zygomatic arch, and centrally between these points in the buccal fat pad area. Both subjective and objective variables were evaluated at baseline and 48 weeks after end of surgical treatment. All 299 participants had significant improvement of the aesthetic satisfaction for the face (VAS from 2.9 +/- 2.1 to 6.2 +/- 2.1, p < 0.0001), of body image satisfaction (ABCD question 7 from 3.8 +/- 1 to 3.1 +/- 1 p < 0.0001 and ABCD question 8 from 70.7 +/- 16.7 to 77.2 +/- 17.2 p < 0.0001), of depression score (Beck score from 11.4 +/- 8.3 to 9.4 +/- 7.8 p = 0.001). Participants experienced a significant augmentation of both cheeks' thickness (right cheek from 4.3 +/- 1.9 mm to 9.5 +/- 3 mm p < 0.0001, left cheek from 4.4 +/- 2 mm to 9.6 +/- 3.1 mm, p < 0.0001). Our data suggest that facial surgery is an important option in the treatment of HIV-related lipoatrophy as an integral part of the management of HIV infection, because of the important and lasting psychological benefits.