The profunda artery perforators: Anatomical study and radiological findings using computed tomography angiography in patients undergoing PAP flap breast reconstruction.

BACKGROUND: The popularity of the profunda femoris artery perforator (PAP) flap is increasing; however, knowledge concerning the standardization of radiological findings and their clinical implications is limited. We evaluated the radiological architecture of posterior thigh perforators using Computed Tomography Angiography (CTA) to identify landmarks to facilitate flap dissection. METHODS: A retrospective study was conducted on 35 patients who underwent unilateral breast reconstruction with a PAP flap. The preoperative CTA scans were analyzed, and the perforator characteristics were evaluated. The perforators were mapped using a Cartesian coordinate system. Data were normalized by anatomical landmarks and overlapped. Perioperative and postoperative results were analyzed. Radiological and intraoperative were compared. RESULTS: Two CTA scans were excluded; 66 thighs were examined. The mean perforator number was 3.2. The mean diameter of chosen perforators was 2.7 mm (DS ± 0.6 mm) at the origin, 2.2 mm (DS ± 0.4 mm) at the adductor space midpoint, and 1.7 mm (DS ± 0.3 mm) at the deep fascia. The mean adipose tissue thickness was 3.35 cm (DS ± 0.94) at the deep fascia and 3.59 cm (DS ± 1.19) at the adductor space midpoint. Intraoperatively, the perforator was located 3.22 cm (DS ± 0.87) from the posterior border of the gracilis muscle and 8.98 cm (DS ± 1.44) from the inferior gluteal crease. A radiological area located 9.33 cm (DS ± 4.81) from the y-axis and 7.48 cm (DS ± 1.88) from the x-axis was identified. CONCLUSIONS: CTA using the volume-rendering technique is a valuable method to study in vivo the radiological anatomy of the posterior thigh perforators.

Deep inferior epigastric perforator flap preoperative planning: A comparative analysis between dynamic infrared thermography, computerized tomography angiography, and hand-held Doppler.

INTRODUCTION: Hand-held Doppler (HHD) sonography and computerized tomography angiography (CTA) are the common assessment tools for deep inferior epigastric perforator (DIEP) flap preoperative planning. CTA is considered the gold standard method for preoperative perforator mapping but necessitates contrast medium and X-ray exposure. Dynamic infrared thermography (DIRT) does not have these drawbacks and allows the detection of hot and cold spots on a given body area. Our study aimed to compare DIRT, HHD, and CTA in perforator mapping for breast reconstruction using DIEP flap. PATIENTS AND METHODS: From March to September 2020, 12 consecutive patients scheduled for DIEP flap breast reconstruction were preoperatively investigated with HHD, CTA, and DIRT. The patients' mean age was 53 and the mean BMI was 29.23 kg/m2 . All the reconstructions were due to breast cancer. The results of preoperative perforator mapping on the lower abdomen were compared among the three techniques. All the evidence was compared to the intraoperative findings, during flap harvesting, to establish if the techniques were able to correctly locate the perforator. RESULTS: We detected 178 perforators intraoperatively, 178 with CTA, 178 with DIRT, and 125 with HHD. The latter revealed a lower number of perforator vessels for each patient (10.42 ± 3.58), compared with CTA (14.83 ± 3.04) and DIRT (14.83 ± 4.76). DIRT resulted superior to HHD (p < .05), while no statistically significant difference (p > .05) was found between DIRT and CTA. We calculated a mean sensitivity of 93.87% for CTA, 69.02% for HHD, and 92.06% for DIRT. CONCLUSION: DIRT is a useful tool in the preoperative planning of DIEP flaps, as it provides information about the location of perforators and the hemodynamic properties of angiosomes. It is easy to use, and it does not involve ionizing radiation. DIRT could represent an innovative and promising implementation of CTA and HHD techniques for preoperative perforator mapping in DIEP breast reconstruction.

Lumbrical Muscles Neural Branching Patterns: A Cadaveric Study With Potential Clinical Implications.

BACKGROUND: Lumbrical muscles originate in the palm from the 4 tendons of the flexor digitorum profundus and course distally along the radial side of the corresponding metacarpophalangeal joints, in front of the deep transverse metacarpal ligament. The first and second lumbrical muscles are typically innervated by the median nerve, and third and fourth by the ulnar nerve. A plethora of lumbrical muscle variants has been described, ranging from muscles' absence to reduction in their number or presence of accessory slips. The current cadaveric study highlights typical and variable neural supply of lumbrical muscles. MATERIALS: Eight (3 right and 5 left) fresh frozen cadaveric hands of 3 males and 5 females of unknown age were dissected. From the palmar wrist crease, the median and ulnar nerve followed distally to their terminal branches. The ulnar nerve deep branch was dissected and lumbrical muscle innervation patterns were noted. RESULTS: The frequency of typical innervations of lumbrical muscles is confirmed. The second lumbrical nerve had a double composition from both the median and ulnar nerves, in 12.5% of the hands. The thickest branch (1.38 mm) originated from the ulnar nerve and supplied the third lumbrical muscle, and the thinnest one (0.67 mm) from the ulnar nerve and supplied the fourth lumbrical muscle. In 54.5%, lumbrical nerve bifurcation was identified. CONCLUSION: The complex innervation pattern and the peculiar anatomy of branching to different thirds of the muscle bellies are pointed out. These findings are important in dealing with complex and deep injuries in the palmar region, including transmetacarpal amputations.

Fluorescent Light Energy and Chronic Lesions: A Winning Association.

BACKGROUND: Chronic ulcers represent a challenge for healthcare professionals and a large expense for national health care systems for their difficulty in achieving complete healing and for their high incidence of recurrence. With the progressive aging of the general population, the incidence of these injuries will only increase, further affecting the public health budget, hence the need to find new strategies for their management. The purpose of this study was to share the experience of the Complex Operational Unit of Plastic Surgery of the University Hospital of Padua with fluorescent light energy therapy, outlining its role in the treatment of chronic ulcers in the daily use outside the previous EUREKA study. METHODS: In this case series study, we enrolled 15 patients with chronic ulcers of any etiology between January 2018 and July 2019 and we treated them using fluorescence light energy. We evaluated efficacy and safety endpoints reporting data in excel files completed by medical staff during the study. RESULTS: The study confirms the effectiveness of fluorescent light energy inducing chronic ulcer healing, regardless of etiology, or at least preparing the lesions for a skin graft closure surgery. The system showed a low rate of complications established by patient adherence to treatment. Patients also reported a reduction in pain both at home and during outpatient dressings. CONCLUSION: Based on our experience, fluorescent light energy shows an excellent safety and efficacy profile in chronic ulcers no more responsive to traditional dressings and/or surgery.

A Misdiagnosed Desmoplastic Neurotropic Melanoma of the Scalp: A Challenging Case for the Pathologist and Surgeon.

Desmoplastic neurotropic melanoma (DNM) is a rare melanoma subtype that shows tropism for the nerves, perineural invasion correlates to higher rate of local recurrence, poorer prognosis and worse morbidity. Given the paucity of typical melanoma features, both clinical and pathological, this confusing skin cancer may act as a pretender, thus leading clinician to misdiagnosis and subsequent inappropriate conservative treatment. Sarcomatoid-like cells rearrangement and absence of pigmentation can lead towards sarcoma diagnosis, so specific skills are required to pathologist to properly recognize this melanoma subtype. In this case report, we present an example of how challenging can be the diagnosis, and how it can affect clinical outcome.

The Role of Hyperbaric Oxygen Treatment for COVID-19: A Review.

The recent coronavirus disease 2019 (COVID-19) pandemic produced high and excessive demands for hospitalizations and equipment with depletion of critical care resources. The results of these extreme therapeutic efforts have been sobering. Further, we are months away from a robust vaccination effort, and current therapies provide limited clinical relief. Therefore, several empirical oxygenation support initiatives have been initiated with intermittent hyperbaric oxygen (HBO) therapy to overcome the unrelenting and progressive hypoxemia during maximum ventilator support in intubated patients, despite high FiO2. Overall, few patients have been successfully treated in different locations across the globe. More recently, less severe patients at the edge of impending hypoxemia were exposed to HBO preventing intubation and obtaining the rapid resolution of symptoms. The few case descriptions indicate large variability in protocols and exposure frequency. This summary illustrates the biological mechanisms of action of increased O2 pressure, hoping to clarify more appropriate protocols and more useful application of HBO in COVID-19 treatment.

Achilles Tendon Region Defects: Delayed Composite Anterolateral Thigh Flap With Stripping of Fascia Lata: A Case Series.

Defects of the Achilles tendon that include the surrounding soft tissue represent a challenge due to complex functionality and biomechanics. PURPOSE: The purpose of this study was to evaluate the functional and physical functioning score out-comes of patients following microsurgical reconstruction of the yarrow region, using a combination of objective, subjective, and semi-subjective measurements. METHODS: Between 2007 and 2018, 15 patients underwent delayed Achilles tendon region reconstruction with different anterolateral thigh flap types. Seven (7) patients underwent tendon and soft tissue re-construction with a chimeric anterolateral thigh flap (ALT) and rolled-up fascia lata, and 8 patients underwent soft tissue reconstruction and only tendon coverage with fascia lata. Follow-up assessments included maximal range of motion (MROM) (plantarflexion and dorsiflexion), the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale score, and the Med-ical Outcomes Study 36-item Short-Form Health Survey physical functioning subscore. RESULTS: A total of 15 patients (11 males and 4 females with a mean age of 39.86 years) were evaluated during a mean follow-up time of 23 months (SD = 7.12). The MROM for plantarflexion and dorsiflexion was 42.71 degrees (SD = 2.9) and 24.8 degrees (SD = 4.29), respectively, in patients who underwent composite ALT with a rolled-up fascia lata. The MROM for plantarflexion and dorsiflexion was 43 degrees (SD = 5.37) and 27.37 degrees (SD = 3.2), respectively, in patients who underwent fasciocutaneous ALT. The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score was 82 for the first group and 86.87 for the second, whereas the mean Medical Outcomes Study 36-item Short-Form Health Survey scores were 82.57 and 81.5, respectively, for the 2 groups. Statistical analysis showed no significant difference between the 2 groups. CONCLUSIONS: The results of this case series suggest that the single-stage composite reconstruction with a fasciocutaneous flap with or without a strip of fascia lata is a safe and reliable strategy for composite reconstruction of the Achilles tendon region. Additional studies to evaluate these outcomes and instruments to evaluate functioning are necessary.

One-Stage Soft Tissue Reconstruction Following Sarcoma Excision: A Personalized Multidisciplinary Approach Called "Orthoplasty".

Background and Objectives. Wide surgical resection is a relevant factor for local control in sarcomas. Plastic surgery is mandatory in demanding reconstructions. We analyzed patients treated by a multidisciplinary team to evaluate indications and surgical approaches, complications and therapeutic/functional outcomes. Methods. We analyzed 161 patients (86 males (53%), mean age 56 years) from 2006 to 2017. Patients were treated for their primary tumor (120, 75.5%) or after unplanned excision/recurrence (41, 25.5%). Sites included lower limbs (36.6%), upper limbs (19.2%), head/neck (21.1%), trunk (14.9%) and pelvis (8.1%). Orthoplasty has been considered for flaps (54), skin grafts (42), wide excisions (40) and other procedures (25). Results. At a mean follow-up of 5.3 years (range 2-10.5), patients continuously showed no evidence of disease (NED) in 130 cases (80.7%), were alive with disease (AWD) in 10 cases (6.2%) and were dead with disease (DWD) in 21 cases (13.0%). Overall, 62 patients (38.5%) developed a complication (56 minor (90.3%) and 6 major (9.7%)). Flap loss occurred in 5/48 patients (10.4%). The mean Musculoskeletal Tumor Society (MSTS) and Toronto Extremity Salvage Score (TESS) was 74.8 ± 14 and 79.1 ± 13, respectively. Conclusions. Orthoplasty is a combined approach effective in management of sarcoma patients, maximizing adequate surgical resection, limb salvaging and functional recovery. One-stage reconstructions are technically feasible and are not associated with increased risk of complications.

Risk of translocated soft-tissue sarcoma recurrence using perforator propeller flap: Case report and literature review.

Tumor seeding after intra-abdominal and head and neck cancer surgery is a well-known entity. The risk of disseminating cancerous cells during surgery is also described for soft-tissue sarcoma of the extremities. Nonetheless, after reconstructive surgery using flaps, the risk of recurrence at the donor site is extremely rare. Up to this date, the literature describes only three cases, but none of them reported a translocated recurrence after a reconstruction with a propeller flap. Here, we report a case of high-grade pleomorphic sarcoma of the knee, which recurred at the proximal edge of a propeller flap 28 months after the first excision surgery. The reasons for such local recurrences are not clear and previous works have advocated different theories: direct contamination by tumor cells, physical manipulation of the tumor and creation of surgical wounds with tumor supportive properties. Although these particular cases of recurrence are exceedingly rare, certain precautionary meticulous surgical techniques and a thorough preoperative planning are pivotal to avoid the contamination of "clean" areas during the first excision surgery.

Gender-specific Anatomical Distribution of Internal Pudendal Artery Perforator: A Radiographic Study for Perineal Reconstruction.

BACKGROUND: Cancer, trauma, infection, or radiation can cause perineal defects. Fasciocutaneous flaps based on perforator vessels (PV) from the internal pudendal artery (IPA) provide an ideal reconstructive option for moderate defects. We hypothesized that, due to gender differences in the pelvic-perineal region, the anatomical distribution of PV differs between genders. METHODS: Computed tomography angiographies from male and female patients without pelvic-perineal pathologies were retrospectively analyzed to study the vascular anatomy of the IPA. The number, size, type, and distribution of PV were recorded and compared between genders. Four anatomical regions were defined to describe the distribution of PV on each perineal side: anterior (A), anterior-central (AC), central-posterior (CP), and posterior (P). RESULTS: A total of 63 computed tomography angiographies were analyzed (men, 31; women, 32). Each IPA provides 2 ± 1 PV and 5 ± 2 terminal (cutaneous) branches: in both genders, 85% of PV are septocutaneous (15% musculocutaneous). In women, 70.5% of PV are located in AC, 28.2% in CP, 1.2% in A, and 0% in P: average diameter of the PV is 2.4 ± 0.3 mm. In men, 53.7% of PV are located in CP, 43.1% in AC, 3.3% in A, and 0% in P: average diameter of the PV is 2.8 ± 0.5 mm. Gender-specific differences in anatomical distribution of PV are significant (P < 0.001). CONCLUSIONS: Number, size, and type of terminal branches of PV of the IPA are consistent between genders, but their distribution is different, with women having an anterior predominance. Knowledge of gender-specific anatomy can guide preoperative planning and intraoperative dissection in flap-based perineal reconstruction.