Correction of cicatricial ectropion using non-ablative fractional laser resurfacing.

Lower eyelid malposition is the most frequent and severe complication after blepharoplasty and ectropion is observed in 1% of patients after surgery. This article describes a non-surgical method to treat lower eyelid cicatricial ectropion using a non-ablative laser as an alternative to surgery. Twelve patients with unilateral or bilateral lower lid cicatricial ectropion, following surgery or trauma, underwent laser therapy from 2012 to 2016. Laser therapy was performed with a fractional non-ablative laser emitting at a wavelength of 1540 nm. Ten patients had a full correction of their ectropion and two patients had a partial recovery after laser therapy at 6-month follow-up visit. No serious adverse events were reported. Non-ablative fractional laser resurfacing can successfully treat cicatricial ectropion by remodeling the periocular scar tissue and improving the scar texture, and as such may be considered as a valuable alternative to surgery in selected patients.

Alternative vascular constructs of lymph node flap transfer.

Vascularized lymph node transfer is a quite innovative physiological surgical procedure for the lymphedema treatment. Although is gaining more popularity due to its promising results, there are some concerns regarding difficult to harvest it and the potential risk of iatrogenic lymphedema. Here, we present alternative vascular constructs of lymph node flap for the treatment of lymphedema, which provide the benefits of a technically easier dissection and physiological reconstruction of the damaged lymphatics. Furthermore, we introduce a classification based on the flap vascular supply including six types of flaps and we provide the details of the surgical technique.

Application of extended bi-pedicle anterolateral thigh free flaps for reconstruction of large defects: A case series.

BACKGROUND: The anterolateral thigh flap is a workforce flap in reconstructive surgery, however, variations in it is vascular anatomy are not uncommon. These variations may affect flap design and survival, especially when large flaps are required. In some anatomical variants the anterolateral thigh flap is supplied by two separate dominant pedicles, and in these cases a bi-pedicle modification may be necessary to ensure complete flap viability. The aim of this report is to evaluate the outcomes, and present our approach in using bi-pedicle anterolateral thigh flaps as a method to reduce the risk of partial flap necrosis when reconstructing sizeable soft tissue defects. PATIENTS AND METHODS: From October of 2013 to November of 2015, seventeen patients were treated with extended bi-pedicled ALT flaps for reconstruction of large defects (16 to 25 × 8 to 13 cm). Following doppler mapping of the lateral thigh perforators, an anterior incision was made. When a distinct oblique branch (OB) was present and the perforators of the descending branch of the lateral circumflex femoral artery (d-LCFA) were small, the large bi-pedicle ALT flaps were harvested based on both the oblique branch and the d-LCFA pedicle. We evaluated the perfusion of the flap using only one pedicle by clamping alternately the OB and the d-LCFA. After flap harvest, we performed two end-to-end venous anastomosis between the lateral circumflex femoral vein and a recipient vein, and the oblique branch vein with a second recipient vein. End to end arterial anastomosis were performed between the two pedicles and two recipient arteries. Y-shaped interposition vein graft (YVG) was applied when single recipient artery was available for revascularization. The flaps were used for scar contracture, chest wall, lower and upper extremity soft tissue defects, breast, scalp, oral cancer, and esophageal reconstruction. RESULTS: The flaps size were 18 to 26 × 10 to 14 cm. For all seventeen patients the reconstructive goals were achieved with complete survival of the large ALT flaps with no events of partial necrosis or failure. We reported one case of re-exploration of a congested flap due to venous thrombosis, which was successfully salvaged. CONCLUSION: Bi-pedicled ALT flaps could be a considered as a valuable option when a second pedicle is encountered and large flaps are required.

The retrograde transverse cervical artery as a recipient vessel for free tissue transfer in complex head and neck reconstruction with a vessel-depleted neck.

BACKGROUND: Reconstruction in a vessel-depleted neck is challenging. The success rates can be markedly decreased because of unavailability of suitable recipient vessels. In order to obtain a reliable flow, recipient vessels away from the zone of fibrosis, radiation, or infection need to be explored. The aim of this report is to present our experience and clinical outcomes using the retrograde flow coming from the distal transverse cervical artery (TCA) as a source for arterial inflow for complex head and neck reconstruction in patients with a vessel-depleted neck. METHODS: Between July 2010 and June 2016, nine patients with a vessel-depleted neck underwent secondary head and neck reconstruction using the retrograde TCA as recipient vessel for microanastomosis. The mean age was 49.6 years (range, 36 to 68 years). All patients had previous bilateral neck dissections and all, except one, had also received radiotherapy. Indications included neck contracture release (n = 3), oral (n = 1), mandibular (n = 3) and pharyngoesophageal (n = 2) reconstruction necessitating free anterolateral thigh (n = 3) and medial sural artery (n = 1) perforator flaps, fibula (n = 3) and ileocolon (n = 2) flaps respectively. RESULTS: There was 100% flap survival rate with no re-exploration or any partial flap loss. One case of intra-operative arterial vasospasm at the anastomotic suture line was managed intra-operatively with vein graft interposition. There were no other complications or donor site morbidity during the follow-up period. CONCLUSIONS: In a vessel-depleted neck, the reverse flow of the TCA may be a reliable option for complex secondary head and neck reconstruction in selected patients.

Delayed grafting for banked skin graft in lymph node flap transfer.

Over the last decade, lymph node flap (LNF) transfer has turned out to be an effective method in the management of lymphoedema of extremities. Most of the time, the pockets created for LNF cannot be closed primarily and need to be resurfaced with split thickness skin grafts. Partial graft loss was frequently noted in these cases. The need to prevent graft loss on these iatrogenic wounds made us explore the possibility of attempting delayed skin grafting. We have herein reported our experience with delayed grafting with autologous banked split skin grafts in cases of LNF transfer for lymphoedema of the extremities. Ten patients with International Society of Lymphology stage II-III lymphoedema of upper or lower extremity were included in this study over an 8-month period. All patients were thoroughly evaluated and subjected to lymph node flap transfer. The split skin graft was harvested and banked at the donor site, avoiding immediate resurfacing over the flap. The same was carried out in an aseptic manner as a bedside procedure after confirming flap viability and allowing flap swelling to subside. Patients were followed up to evaluate long-term outcomes. Flap survival was 100%. Successful delayed skin grafting was done between the 4th and 6th post-operative day as a bedside procedure under local anaesthesia. The split thickness skin grafts (STSG) takes more than 97%. One patient needed additional medications during the bedside procedure. All patients had minimal post-operative pain and skin graft requirement. The patients were also reported to be satisfied with the final aesthetic results. There were no complications related to either the skin grafts or donor sites during the entire period of follow-up. Delayed split skin grafting is a reliable method of resurfacing lymph node flaps and has been shown to reduce the possibility of flap complications as well as the operative time and costs.

Back-up procedures following complicated gastric pull-up procedure for esophageal reconstruction: Salvage with intestinal flaps.

BACKGROUND: Gastric pull-up (GPU) is the most common procedure for restoring the continuity of the alimentary tract. Yet, complications because of anastomotic problems are reported to be as high as 25% after this procedure. Managing the neck with anastomotic leakage or stricture following failed GPU and/or radiotherapy is formidable. We report our method, basic algorithm and results with the complicated GPU procedure management with intestinal transfers . PATIENTS AND METHODS: Nineteen cases referred to our department with complicated esophageal reconstruction following GPU procedure were included in this report. Of the19 patients, 18 had undergone GPU procedure for reconstruction after cancer resection (mean age 55 years) and one for idiopathic esophagitis (mean age 45years). Fifteen patients presented with severe stricture formation and 4 patients with leakage from the anastomotic site. Average time between the GPU and salvage procedures was 7.3 months for patients with stricture formation and 15.5 days for patients with leakage. Pedicled colon interposition (n = 8) was used when the upper end of the gastric tube was located below the sternoclavicular junction. A free jejunal flap (n = 11) was utilized when defects were located at the neck (above the sternoclavicular junction). RESULTS: In all patients salvage procedures with intestinal flap transfer were successful with complete flap survival. Post-operative period was uneventful except of two patients with pedicled colon interposition who presented minor leakage post-operatively (10.5%). This was treated with conservative means, leading to spontaneous healing. The average follow-up for the patients with tumor resection was 11.8 months (range: 6 to 30) after the salvage procedure. All patients resumed smooth oral intake eventually. There were 16 patients who could feed with solid diet, whereas three patients were able to tolerate only soft diet. CONCLUSION: Intestinal tissues can be safely and successfully transferred as salvage procedures, with meticulous technique, careful patient selection and individual flap design. While gastric pull-up remains a good procedure for esophageal reconstruction, the methods described in this report are useful as back-up armaments in complicated cases. © 2015 Wiley Periodicals, Inc. Microsurgery 36:567-572, 2016.

The latissimus dorsi-groin-lymph node compound flap: A comprehensive technique with three features including skin coverage, restoration of motor function, and prevention of upper limb lymphedema.

Reconstruction of complex upper extremity defects requires a need for multiple tissue components. The supercharged latissimus dorsi (LD)-groin compound flap is an option that can provide a large skin paddle with simultaneous functional muscle transfer. It is necessary to supercharge the flap with the superficial circumflex iliac pedicle to ensure the viability of its groin extension. In this report, we present a case of a supercharged LD-groin flap in combination with vascularized inguinal lymph nodes, which was used for upper limb reconstruction in a young male patient, following excision of high-grade liposarcoma. Resection resulted in a 28 cm × 15 cm skin defect extending from the upper arm to the proximal forearm, also involving the triceps muscle, a segment of the ulnar nerve and the axillary lymph nodes. Restoration of triceps function was achieved with transfer of the innervated LD muscle. Part of the ulnar nerve was resected and repaired with sural nerve grafts. Post-operatively, the flap survived fully with no partial necrosis, and no complications at both the recipient and donor sites. At 1-year follow up, the patient had a well-healed wound with good elbow extension (against resistance), no tumor recurrence, and no signs of lymphedema. We believe this comprehensive approach may represent a valuable technique, for not only the oncological reconstruction of upper extremity, but also for the prevention of lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:689-694, 2016.

The combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for breast reconstruction.

BACKGROUND: Surgical options for breast reconstruction include alloplastic and autogenous reconstructions. In autologous cases where the abdomen is not a suitable primary donor site, secondary donor sites such as the thigh or buttock are considered. The aim of this report is to describe a novel approach, the combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap, aimed at medium to large volume breast reconstruction, with a single donor site used per breast. METHODS: Between January 2011 and June 2013, 32 consecutive unilateral immediate breast reconstruction cases were performed using free flaps. In nine cases, patients had previously undergone abdominal surgery, therefore abdominal flaps were excluded and TUGPAP flaps were performed. The TUGPAP flap consisted of the combination of two well-described flaps: the transverse upper gracilis (TUG) and the profunda artery perforator (PAP) flap. All TUGPAP flaps were based on two pedicles: the ascending branch of the medial circumflex femoral artery (MCFA) for the TUG component, and the profunda artery perforator itself for the PAP component. RESULTS: The mean size of the harvested skin paddle was 28.6 × 8 cm2 (range, 27 × 7 cm2 to 30 × 9 cm2). The average length of the TUG flap pedicle was 7 cm (range, 6-8 cm) and the PAP flap pedicle was 9 cm (range, 8.5-10 cm). The flap survival rate was 100% with no re-exploration, and no partial flap loss. Post-operatively there was one case of persistent donor site seroma, which was managed conservatively. CONCLUSION: With appropriate patient selection and surgical technique the TUGPAP flap could be a valuable option as an alternative method for autologous breast reconstruction. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

Keyhole anterolateral thigh flap: A special way of partition for reconstruction around a protruding structure or cavity/tunnel.

BACKGROUND: Anterolateral thigh (ALT) flap is now a workhorse flap for reconstruction of skin and soft tissue defects. However, there are some drawbacks in its application, and revisions are often needed after surgery. Here, we present the results of the use of a special type of partition for ALT flap based on the concept of perforator flap vascular anatomy for reconstruction around a protruding structure, a cavity or a canal, in patients. PATIENTS AND METHODS: We used the keyhole design for reconstruction with ALT flaps in five patients. Wounds involved circumferential soft tissue defects around the following structures: thumb (two cases), penis, ear canal, and anus. Defects arose following excision of scar contracture, arterio-venous malformation, Paget's disease, squamous cell carcinoma, and Fournier's gangrene, respectively. The ALT flap was raised based on perforators. The flap was partitioned with a keyhole incision performed in a zone between two perforators or distal to them, avoiding complete split of the flap and minimizing disruption of its vascular crossover. The circulation of the flap was well preserved. The closure of the flap had no tension. RESULTS: All the flaps had 100% viability without partial loss. Mean follow-up was of 7.4 months (range 4 - 11 months). Significant functional improvement was achieved in the two thumb cases. Adequate patency of the ear and anal canals was obtained. No contracture around the penis was observed. CONCLUSION: The keyhole design may be a valuable method of partition of the ALT flap for specific reconstructions around protruding organs, cavities, or canals.

Supraclavicular osteocutaneous free flap: clinical application and surgical details for the reconstruction of composite defects of the nose.

The supraclavicular fasciocutaneous flap is a well-recognized flap in head and neck reconstruction. In this report, we describe for the first time a variation of this flap, the osteocutaneous supraclavicular (SOC) free flap, which was used to reconstruct a composite nasal defect. The defect arose after resection of a recurrent squamous cell carcinoma and involved dorsal nasal skin, cartilage, and the entire nasal bone. A 6 cm × 4 cm size flap including skin, subcutaneous tissue, and a vascularized cortico-periosteal segment of the clavicle was raised based on the transverse cervical artery. The flap survived with no complications. A satisfactory aesthetic outcome was achieved following two revision procedures. We believe that the incorporation of bone to the supraclavicular flap may expand its applications in reconstruction of composite nasal and facial defects.

Outcomes of head and neck cancer management from two cancer centres in Southern and Northern Europe during the first wave of COVID-19.

OBJECTIVE: To describe the approach and outcomes from two cancer centres in Southern and Northern Europe during the first wave of coronavirus disease 2019 (COVID-19) of patients with head and neck cancer (HNC). METHODS: Data collection was performed on a retrospective cohort of patients surgically treated for primary HNC between March and May 2020, using data from two tertiary hospitals: the European Institute of Oncology (Milan) and Guy's & St Thomas' NHS Foundation Trust (London). RESULTS: We included 77 patients with HNC. More patients with COVID-19 were taking angiotensin-converting enzyme (ACE) inhibitors and had Clavien-Dindo Classification grade I compared to negative patients, respectively (60% vs 22% [p = 0.058] and 40% vs 8% [p = 0.025]). Multivariate logistic regression analyses confirmed our data (p = 0.05 and 0.03, respectively). Sex and age were statistically significantly different (p = 0.05 and <0.001 respectively), showing more male patients (75% vs 53.66%, respectively) and more elderly patients in Italy than in the United Kingdom (patients aged >63 years: 69.44% vs 29.27%). CONCLUSIONS: This study presents a large cohort of patients with HNC with nasopharyngeal swab during the first peak of the COVID-19 pandemic in Europe. Patients with HNC with COVID-19 appeared more likely to develop postsurgical complications and to be taking ACE inhibitors. The preventive measures adopted guaranteed the continuation of therapeutic surgical intervention.

Modified distal anastomosis between colon and thoracic esophagus for hypopharynx reconstruction using free colon flap: A comparison study.

BACKGROUND: Free colon flap is the preferred method of hypopharynx reconstruction when the defect is substantial, or simultaneous voice reconstruction is planned. Most of the complications in free colon flaps are located at the anastomosis between colon and thoracic esophagus due to size mismatch of the lumen. We present our experience comparing a modified anastomosis technique and a conventional anastomosis technique at the distal end of interposed colonic segment. METHODS: In this retrospective review, 94 patients, divided into two groups, underwent hypopharynx reconstruction. Group A (18 patients), conventional anastomoses between colon and thoracic esophagus was performed, while in Group B (76 patients), underwent the modified method of anastomosis. RESULTS: The average follow-up period was 46 months in group A and 54 months in group B. Fistula formation was found in 2 patients from Group A, and 1 patient from Group B. Strictures were observed in 4 patients from Group A, and 1 patient from Group B. Difference between both groups regarding complications of leakage and stricture formation was statistically significant (p < 0.05). CONCLUSION: Modified method for anastomosis between colon and thoracic esophagus was found to be effective in the reduction of complications associated with the use of a free colon flap for hypopharyngeal reconstruction. Further advances of this technique could gain momentum in the future.

Microsurgical dissection of facial nerve in parotidectomy: a discussion of techniques and long-term results.

BACKGROUND: Parotidectomy has well-documented post-operative complications. Dissection of the facial nerve branches can be challenging even under loupe magnification, and partial, or complete injury of the nerve branches can occur during surgery. To reduce this risk and the associated complications, we propose a number of microsurgical best practices, which can be performed during parotidectomy. METHODS: A retrospective survey was conducted on 109 patients (45 males and 64 females, average age 46.2 years, range of 6 to 74 years) who underwent parotidectomy in two different institutions. RESULTS: Our data showed no permanent injury to the facial nerve, and 17% of neuroapraxia that had resolved with time. Post-operative complications have occurred in 33 cases (30% rate). In the superficial parotidectomy cohort (78 patients), the number of complications was 17 (21%). In the total parotidectomy cohort (31 patients), the number of complications was 16 (51%). CONCLUSIONS: Based on our results, we believe that the use of microsurgical techniques during parotidectomy may represent a useful tool in improving accuracy and minimising local tissue trauma that can affect nerve recovery. This is particularly true in situations such as tumor recurrence, tissue fibrosis or in case of sizeable tumors around the facial nerve branches. We believe that the decreased risk of facial nerve post-operative symptoms outweigh the disadvantage of increased operative time of this procedure.

Efficacy of a Novel Optimized Pulsed Light Source (MaxG) for the Treatment of Facial Vascular Lesions.

BACKGROUND AND OBJECTIVE: Facial vascular malformations can cause a number of functional problems, including difficulties in breathing, eating, speech, and mobility. Psychological problems can also arise due to the possible unpleasant appearance of such lesions. Further, these lesions can lead to a number of complications, including pain, ulceration, infection, and significant bleeding. Many treatments have been proposed in the literature. Laser therapy (and its related treatments by non-coherent light sources) is now considered the gold standard in the treatment of the majority of vascular lesions. METHODS: Here, we present our experience with a novel optimized pulsed light source for the treatment of vascular anomalies. In this prospective study, we evaluate the clinical outcomes of 30 patients treated with this method. RESULTS: Our results confirm the efficacy and safety of this treatment for facial vascular lesions. CONCLUSIONS: Based on our experience and results, we believe this device could be considered as both an alternative monotherapy and a useful adjunctive to the already existing laser instruments.

Surgical management of neonatal limb ischaemia: a technique for open thrombectomy and the novel use of Integra.

Neonatal limb ischaemia (NLI) is a rare but potentially catastrophic condition. Although medical therapy remains as first-line treatment, surgery has an important role when limb-threatening events are present. In this paper we outline the milking technique for open thrombectomy used by the senior author in the treatment of 5 NLI cases. We also present the use of Integra and it's specific benefits in the management of wounds in these challenging situations. Skin grafts over the Integra can be avoided by staged excision of the silicone layer from the margins. We believe this is a novel approach to the use of Integra.

Sentinel lymph node biopsy in thick malignant melanoma: a 10-year single unit experience.

Between the years 2000-2010, 195 patients were diagnosed with ≥4 mm Breslow thickness malignant melanoma in our unit. Median follow-up was 36.8 months. 49% of patients were male and 51% were female. Median age was 74 years. The commonest melanoma type was nodular (55%). The commonest tumour location was on the extremity (45%). 64% of tumours were ulcerated. Median mitotic rate was 9. Median Breslow thickness was 7 mm 66 patients underwent sentinel lymph node biopsy. 44 (67%) patients had negative results and the remaining 22 (33%) patients were positive for metastatic melanoma. There was no statistically significant correlation between any of the patient or tumour variables (age, sex, melanoma type, melanoma site, Clark level, Breslow thickness, mitotic rate, ulceration) and sentinel lymph node status. Patients with Breslow thickness melanoma of <6 mm had a significantly better 5-year disease free and overall survival compared with those patients with >6 mm Breslow thickness melanoma (63.5% vs. 32.9%; P=0.004 and 73.9% vs. 54.7%; P=0.02 respectively). Recurrence rate was 50% in those with positive sentinel lymph node biopsy compared to 23% in those with negative results. Distant recurrence was the commonest in both groups. 5-year disease free survival was 64.1% in the SLNB -ve group and 35.4% in the SLNB +ve group (P=0.01). There was no significant difference in overall survival between the SLNB -ve and SLNB +ve groups (70.3% vs. 63.7% respectively; P=0.66). We conclude that sentinel lymph node biopsy in our unit has provided no survival benefit in those with thick melanoma over the past 10 years but is an important predictor of recurrence free survival. Breslow thickness remains an important predictor of disease free and overall survival in thick melanoma.