Extensive severe intraorbital arteriovenous malformations: report of a rare laser complication and successful management.

Arteriovenous malformations (AVMs) are rare congenital errors of vascular morphogenesis, characterised by abnormal direct communications between arteries and veins, bypassing the normal capillary bed. Apart from the central nervous system, typical locations include the head and neck, and less frequently limbs, trunk or internal organs. AVMs of the head and neck often become clinically evident and symptomatic only in later childhood and are characterised by a history of variable growth, sometimes leading to large, deforming, pulsating masses with a propensity to massive haemorrhage. Therapeutic strategy is based on selective embolisation, surgical excision, or a combination of both. Radical surgical excision of local AVMs is the only effective treatment but it may be mutilating, especially for AVMs of the head and neck. Laser therapy represents a good option to treat the cutaneous aspects of AVMs nevertheless, its efficacy is limited. To the date, pharmacological therapy for AVMs is still on debate due to its controversial outcomes as it seems not as effective as other treatments and usually requires a longer course of application. However, pharmacological therapy could be useful in selected patients and for AVMs nonresponsive to traditional treatment, allowing them to obtain acceptable results without serious complications. This paper reports the case of a serious laser complication of extensive intraorbital AVM successfully treated by local reconstruction and topical pharmacological treatment.

Tear drop-free anterolateral thigh flap, a versatile design for lower limb reconstruction after trauma.

BACKGROUND: In lower limb reconstruction the cosmetic outcome is influenced by the contouring of the flap at the recipient site as well as by the donor site closure. It is also important to minimise compression of the flap pedicle. We discuss the outcomes of a versatile ALT flap design that allows freedom in skin paddle tailoring without elongating the scar, reduction of the tension over the pedicle and improved cosmetic results of both donor and recipient sites. METHODS: Between January 2009 and October 2015, 27 patients underwent reconstruction using tear drop ALTs. The age ranged between 20 and 89 years. Seventeen were elective procedures and 10 were urgent. The locations of the defects were: knee (1 case), achilles tendon (2 cases), os calcis (1 case), lateral malleolus (1 case), fibula (3 cases), tibia (6 cases), tibia/fibula (5 cases), and ankle (8 cases). The sizes of the defects ranged from 4 × 3 cm to 9 × 7 cm. RESULTS: The size of the flap ranged from 6 × 4 cm to 11 × 7 cm. One venous congestion and a wound dehiscence occurred, no flap loss. Two defatting procedures were performed. The mean follow-up was 16.44 months. Final outcomes showed good functional and cosmetic results in both the donor and recipient sites. CONCLUSIONS: The tear drop ALT is a useful tool in lower limb reconstruction allowing to improve skin paddle tailoring without elongating the donor site scar. It allows minimal tension over the pedicle while optimizing the contour of both the donor and recipient sites.

Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral Versus Bilateral Reconstructions.

BACKGROUND: The demand for bilateral breast reconstructions is rising worldwide. In the UK, approximately 30% of breast cancer patients undergoing mastectomy choose autologous tissue breast reconstruction. Although the deep inferior epigastric perforator (DIEP) flap is gaining popularity, bilateral DIEP flap breast reconstruction remains a complex procedure and reliable outcome data are lacking. In the absence of clinical trials, evidence from cohort studies is needed to better inform clinicians and patients. METHODS: Over a 6-year period, all consecutive patients undergoing DIEP flap breast reconstruction were prospectively included and categorized as unilateral or bilateral reconstruction for comparative analyses of outcomes and complications, with the patient as the unit of analysis. RESULTS: Overall, 565 DIEP flaps were performed on 468 women (371 unilateral and 97 bilateral reconstructions [194 flaps]). Postoperative complications requiring reoperation were twice as likely for bilateral reconstructions (risk ratio [RR] 2.1, 95% CI 1.4-3.4, p = 0.002) and were mainly due to venous congestion (RR 3.1, 95% CI 1.2-7.5, p = 0.011). The risk of total flap loss was six times greater in bilateral reconstruction (RR 6.4, 95% CI 1.6-26, p = 0.011). The rates of revision breast and abdominal surgery were similar between groups. CONCLUSIONS: Both unilateral and bilateral DIEP flap breast reconstructions are safe, with a low risk of complications; however, bilateral reconstruction was associated with a higher risk of complications and total flap loss. This information should be highlighted to patients requesting bilateral breast reconstruction, particularly those requesting risk-reducing mastectomy and reconstruction.

Correction to: Reply to ''Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral Versus Bilateral Reconstructions".

In the original article Justin C. R. Wormald's middle initials were incorrect. They are correct as reflected in this erratum. The original article has also been corrected.

The Selective Centrifugation Ensures a Better In Vitro Isolation of ASCs and Restores a Soft Tissue Regeneration In Vivo.

Autologous fat grafting procedures in plastic surgery have been extensively used to reinforce soft tissue in congenital or acquired tissue impairments. With this background, the aim of this study is firstly to examine the impact of a selective centrifugation on existing adipose stem cells (ASCs) in terms of stemness profile maintenance and, secondly, to investigate the effect of restoring volume in reconstruction on patients affected by soft tissue damage. After centrifugation, the fat graft products were separated into two layers and subsequently examined in vitro for the expression of CD34, CD90, CD117, CD105, CD29, CD31, CD44, CD73, CD133, CD14 and CD45 markers by flow cytometry and gene expression analyses were performed for Sox2, WNT3A, END, CD44, FUT4, COLL1, CTNNB1, hbEGF, KRTLG, MMP2 and VIM genes. The results showed that in the middle-high density (MHD) layer there was a peak concentration of ASCs, compared to another layer obtained after centrifugation. Research carried out on patients under treatment for soft tissue regeneration using cells obtained from MHD layer selection will be fundamental in comparative analysis. These studies will lead to an adequate standardization of outcomes, provided that treatment is performed through cell selection. Therefore, a unique procedure in tissue reconstruction and regeneration through fat grafting is presented here.

The venae comitantes clipping test for the evaluation of the venous drainage of the radial forearm free flap.

Risks of failure of the radial forearm free flap (FRFF) are mainly related to venous congestion. Two different venous drainage system have been described for the FRFF, but the choice of the best one is still controversial. The superficial systems have a larger diameter and a thicker wall veins which makes them easier to anastomose. The deep system provides most part of the venous outflow if the caliber of the venae comitantes (VCs) is adequate. We propose an intra-operative method to evaluate the FRFF venous drainage: the VCs clipping test. The test has been used in the choice of the vein to anastomose in 12 consecutive patients with oral cavity post oncological defects reconstructed with the FRFF. The cephalic vein was included in the flap; the VCs were individually clipped with small liga-clips and divided with the radial artery still patent. The flap was kept with arterial inflow and superficial venous outflow till the recipient site was ready. If there were no signs of venous stasis, the VCs were kept clipped and the cephalic vein anastomosis was made. If clinical signs of venous stasis were revealed, the largest of the VCs was anastomosed to a vein of adequate caliber in the neck. No signs of flap venous congestion were observed in the postoperative period. No flap necrosis occurred. In this small series of patients the venae comitantes clipping test showed to be an easy, reliable and reproducible method to assess intra-operatively which vein to anastomose. © 2015 Wiley Periodicals, Inc. Microsurgery 36:647-650, 2016.

Modified fish-incision technique in brachioplasty: a surgical approach to correct excess skin and fat of the upper arm (restoring the armpit contour).

UNLABELLED: Brachial ptosis is one of the consequences of massive weight loss. At an early stage, brachial ptosis can be corrected by liposuction, dermolipectomy and liposuction, or minibrachioplasty while the most advanced stage requires extended brachioplasty. Since brachioplasty was first described, various techniques have been proposed in the management of upper extremity contour deformities. Modifications to the original technique were mainly made to shape arm contour, to obtain good morphological reconstruction with attention directed toward improving and refining the resulting scar. We describe a modified approach to the "fish incision" technique defining a preoperative marking procedure that permits the reduction of overcorrection problems to reshape and improve the contour of the armpit with camouflage of scar sequelae. Our modifications to the original technique focus on incision placement along the medial bicipital groove and armpit, based on the the drawings of the tails following dynamic lines of the armpit contour established by the underlying muscles. We drew the tails slightly with a 60° angle between the tails and the width depending on patient's arm contour and on the excess of the skin in the armpit to be removed. The modified technique has obtained satisfactory results for patients and may be considered as a new surgical approach in the management of brachial ptosis. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Microvascular free-flap transfer for head and neck reconstruction in elderly patients.

BACKGROUND: With the increase in life expectancy, the incidence of head and neck cancer has grown in the elderly population. Free tissue transfer has become the first choice, among all the reconstructive techniques, in these cases. The safety and success of micro vascular transfer have been well documented in the general population, but its positive results achieved in elderly patients have received less attention. METHODS: We retrospectively studied 28 patients over the age of 60 years. The aim of this paper was to study the success rate of free tissue transfer and investigate the complication incidence in this patient population. RESULTS: Twenty-eight free flaps were performed to reconstruct medium to large cervico-facial surgical defects in six years. No difference was noted between success and complication rates observed between general and elderly population. CONCLUSION: This study indicates that free-flap technique for head and neck reconstruction could be considered a safe option in elderly patients when a good pre-operative general status is present.

Squamous Carcinoma of the Oral Cavity in Patient with Fanconi Anemia: A Challenging Reconstruction with Double-barrel Free Fibula Flap Case Report.

Fanconi anemia (FA) is a very rare form of aplastic anemia. Patients with FA have a higher risk of developing solid tumors such as head and neck squamous cell carcinoma, higher risk of local recurrence, and impaired resistance to chemotherapy and radiotherapy treatments than the normal population. In this article, we describe the challenging clinical case of a patient with FA who underwent surgery for the removal of a large squamous cell carcinoma in the oral cavity. Mandibular reconstruction was performed using a biaxial double-barrel fibular flap, with excellent functional aesthetic outcomes.

Inferior gluteal artery perforator (IGAP) flap versus profunda artery perforator (PAP) flap as an alternative option for free autologous breast reconstruction.

BACKGROUND: When patients are unsuitable for deep inferior epigastric perforator (DIEP) flap breast reconstruction, the inferior gluteal artery perforator (IGAP) flap has been used as an alternative option. However, the profunda artery perforator (PAP) flap is also gaining popularity as an alternative to the DIEP flap for several reasons. This retrospective cohort study compares baseline characteristics, peri- and post-operative outcomes following IGAP flap and PAP flap breast reconstructions after mastectomy for cancer. METHODS: In a single center in the UK, from September 2008 through December 2016, 43 women underwent IGAP Flap(s) breast reconstruction and 51 received PAP flap(s) breast reconstructions. Statistical analysis was performed to compare baseline, peri-operative and post-operative variables between the two reconstruction methods. RESULTS: Perioperative complications requiring reoperation were experienced in women undergoing IGAP flap breast reconstructions only (21% versus 0%, p = 0.001), principally due to the risk of total flap failure (12% versus 0%, p = 0.01). Women undergoing IGAP flap breast reconstructions were at significantly higher odds of revision surgery (OR 17 [95% CI: 5.5-53], p < 0.001), which was unchanged after adjusting for bilateral reconstructions (adjusted OR 18 [95% CI: 5.3-58], p < 0.001). CONCLUSIONS: PAP flaps appear to be associated with significantly fewer complications and revision surgeries than IGAP flaps for breast reconstruction in women undergoing mastectomy for cancer and who are unsuitable for a DIEP flap breast reconstruction.

Superficial peroneal nerve accessory artery (SPNAA) flap for head and neck reconstruction: A cadaveric anatomical study and retrospective case series review.

BACKGROUND: Several different flaps can reconstruct intraoral defects or lower limb deficits after free fibula osteo-cutaneous flap harvesting for jaw reconstructions. However, commonly used options may not be available for various reasons and can be associated with significant morbidity. We hypothesized that flaps supplied by the superficial peroneal nerve accessory artery (SPNAA) could be a viable alternative reconstructive option. METHODS: We describe the SPNAA's anatomy using 20 human cadaveric leg dissections and report eight cases involving SPNAA-based perforator flap reconstructions (six propeller flaps and two free flaps) in a retrospective case series. Patient-specific baseline variables and intraoperative and postoperative outcomes are described. RESULTS: Cadaveric dissection suggests that the location of the SPNAA is reliable but its origin varies, with 40% (N = 8) of SPNAAs being of type I origin, 20% type II (N = 4), and 40% (N = 8) type III in our series. All reconstructions were successful. No intraoperative complications occurred during propeller or free-flap reconstructions. No flap failures occurred. One propeller reconstruction showed distal superficial skin necrosis and one donor site wound dehisced; both were successfully managed conservatively. No other short-term or long-term complications occurred. CONCLUSIONS: Flaps based on SPNAA perforators appear effective, reliable, and safe reconstructive methods for covering fibula osteocutaneous donor site defects and for intraoral reconstructions. Controlled trials are required to compare its effectiveness and safety with other reconstructive methods.

A New Human-Derived Acellular Dermal Matrix for 1-Stage Coverage of Exposed Tendons in the Foot.

The closure of wounds associated with soft tissue defects is surgically challenging, frequently requiring extensive plastic surgery and free flaps. The combination of ADM and STSG is an innovative method used to cover such wounds. The human-derived ADMs (H-ADMs) are the most described in the literature but according to European legislations, Companies H-ADMs outside the EC are not allowed to commercialize them in Europe, H-ADMs being "human products" and not "medical devices", so being ruled by European legislations on transplants. The Skin Bank of the Bufalini Hospital (Cesena, Italy) obtained in 2009 the approval for the production and distribution of the first human cadaver-donor derived ADM from the Italian National Transplant Center and National Health Institute, we called with the Italian acronym M.O.D.A. (Matrice Omologa Dermica Acellulata). We present here the first use of a new H-ADM for treatment of distal lower extremity wounds with exposed tendons managed in one-stage pocedure with STSG. The excellent performance suggests that in cases where autologous tissue is unavailable or undesirable, the use of M.O.D.A. in one-stage procedure represents a promising alternative for covering wounds associated with tendons exposition.

Optimizing DIEP Flap Insetting for Immediate Unilateral Breast Reconstruction: A Prospective Cohort Study of Patient-Reported Aesthetic Outcomes.

BACKGROUND: To improve the aesthetic outcome of deep inferior epigastric perforator (DIEP) flap breast reconstruction, flaps should be tailored to the patient's characteristics. A single method of DIEP flap insetting will not suffice for all women seeking breast reconstruction. The authors share the outcomes of a prospective longitudinal study on DIEP flap insetting and present an algorithm for reconstruction. METHODS: Over 4 years, 70 consecutive immediate unilateral DIEP flap breast reconstructions were prospectively evaluated. DIEP insetting was based on the characteristics of the donor site and contralateral breast, according to the authors' algorithm. Baseline and outcome data were collected. Aesthetic outcomes were evaluated by a panel of three independent assessors, and patient-reported outcomes were quantified using the BREAST-Q at 1 year after reconstruction. RESULTS: Seventy women underwent reconstruction. There were no total or partial flap failures, four cases of fat necrosis, and 14 revision operations. Women reported a mean overall BREAST-Q score of 82 of 100, representing excellent satisfaction but poor satisfaction with sexual well-being. BREAST-Q scores were not associated with age or body mass index. Fat necrosis reduced satisfaction with the chest (absolute mean reduction, 13; 95 percent CI, 8 to 18; p = 0.002). Independent assessors scored the outcomes favorably, but there was no agreement between surgeons, nurses, and lay assessors. CONCLUSIONS: The authors' algorithm can support surgeons in selecting individually tailored DIEP flap insetting to achieve excellent aesthetic outcomes. Further research is needed as to the relevance of scores from BREAST-Q in relation to interventions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

How to assess the volume of a DIEP flap using a free online calculator: The DIEP V (volume) method.

INTRODUCTION: Among the few methods available, none is able to determine accurately the volume of a DIEP flap. Specimen weight is commonly used to assess the amount of flap needed to reconstruct a breast, but the density of breast is different from that of abdominal tissues; therefore, the volume should be used as a unique unit of measure. The purpose of this study was to provide a simple method to calculate the predicted volume of a DIEP flap in order to match the volume of the breast being reconstructed. MATERIAL AND METHOD: We hypothesised that the shape best resembling a DIEP flap was a truncated pyramid. Based on this shape, we tailored 30 DIEP flap models using the discarded tissue after unilateral DIEP flap breast reconstructions. The awaited volume (AV) of the models was calculated with a free online calculator measuring the length and height with a ruler, and width (fat thickness) with Ultrasound (US). The real volume (RV) of the models was calculated using water displacement method. AV and RV were compared and statistical analysis was performed. RESULTS: The mean difference between the AV and the RV was not statistically significant with a mean estimation error of 6.75%. When the AVs were plotted against the RVs, the two data sets were highly statistically correlated (correlation coefficient (r = 0.997). CONCLUSIONS: The proposed tool can be a useful, precise, easy and accessible tool to improve the current DIEP flap size assessment improving outcomes for both surgeons and patients.

Augmentation Mastopexy with Implant and Autologous Tissue for Correction of Moderate/Severe Ptosis.

PURPOSE: Breast augmentation combined with mastopexy is associated with a significantly higher complication rate than augmentation alone. The combination of mastopexy and breast implants has revealed a moderate recurrence of breast ptosis in many patients particularly with use of medium to large implants. Ptosis is the "bottoming out" of the breast tissue with loss of the desired roundness, due to the ptosis of the breast implant and the mammary tissue. In this study, we hypothesize the need for careful planning and careful preoperative surgical execution to minimize this complication. PATIENTS AND METHODS: Between January 2007 and July 2011, augmentation mastopexy with implant and autologous tissue ("double implant") was performed for 25 patients with grade III mammary ptosis. All patients underwent inverted-T mastopexy with supramuscular moderately cohesive gel breast implant using an inferior-based flap of de-epitelialized dermoglandular tissue and a superior-based nipple-areola complex pedicle. RESULTS: An inferior-based flap of deepithelialized dermoglandular tissue was used to stabilize the implant and is projection. Breast lifting was performed through a strong anchorage to fascia and to muscle of second intercostal space, improving the profile of the breast. Results were analyzed, no breast ptosis recurrence was noted at 30-month follow-up. CONCLUSIONS: Our technique presents the challenge of determining the amount of excess skin to be removed after implantation to create symmetry and provide for skin tightening without compromising tissue vascularization.