Efficacy of double mirrored omega pattern for skin sparing mastectomy to reduce ischemic complications.

BACKGROUND: Excellent cosmetic results from skin-sparing mastectomy (SSM) are often impaired by skin flaps' necrosis (SFN), from 8%-25% or worse in smokers. This study prospectively investigated the efficacy of Double-Mirrored Omega Pattern (DMOP-SSM) compared to Wise Pattern SSM (WP-SSM) for immediate reconstruction in moderate/large-breasted smokers. METHODS: From 2008-2010, DMOP-SSM was performed in 51 consecutive immediate breast reconstructions on 41 smokers (mean age = 49.8 years) with moderate/large and ptotic breasts. This active group (AG) was compared to a similar historical control group (CG) of 37 smokers (mean age = 51.1 years) who underwent WP-SSM and immediate breast reconstruction, with a mean follow-up of 37.6 months. Skin ischaemic complications, number of surgical revisions, time to wound healing, and patient satisfaction were analysed. Descriptive statistics were reported and comparison of performance endpoints was performed using Fisher's exact test and Mann-Whitney U-test. A p-value <.05 was considered significant. RESULTS: Patients' mean age (p = .316) and BMI (p = .215) were not statistically different between groups. Ischaemic complications occurred in 11.7% of DMOP-SSMs and in 32.4% of WP-SSMs (p = .017), and revision rates were, respectively, 5.8% and 24.3% (p = .012), both statistically significant. Mean time to wound healing was, respectively, 16.8 days and 18.4 days (p = .205). Mean patients' satisfaction scores were, respectively, 18.9 and 21.1, statistically significant (p = .022). CONCLUSION: Although tobacco use in moderate/large breasted patients can severely impair outcomes of breast reconstruction, the DMOP-SSM approach, compared to WP-SSM, allows smokers to benefit from SSM, but with statistically significant reduced skin flaps ischaemic complications, revision surgery, and better cosmetic outcomes.

Tear Trough Deformity: Study of Filling Procedures for Its Correction.

The aim of this work is to discuss the anatomy of the tear trough region with relative danger areas, and to describe 2 different options to correct this deformity.The tear trough is a concave deformity of the orbital fat that is noticeable as a result of inherited anatomic differences and aging. However, the periorbital region is a complex area with its own septa and ligaments, fat compartments, muscles, vascularization, and lymphatic drainage and presents anatomic characteristics that must be taken into account in order to achieve good results and avoid complications.The use of hyaluronic acid gel or autologous fat for soft tissue correction is a good option.A total of 96 patients with periorbital hollowing were divided into 2 groups; each group received a different treatment, from December of 2013 to December of 2015, with hyaluronic- or lipo-filling.

Safety and immunogenicity of inactivated varicella-zoster virus vaccine in adults with hematologic malignancies receiving treatment with anti-CD20 monoclonal antibodies.

BACKGROUND: Immunocompromised patients can experience significant morbidity and occasional mortality from complications associated with herpes zoster (HZ), but live attenuated HZ vaccine is contraindicated for these patients. Inactivated zoster vaccine (ZVIN) is in development for prevention of HZ in immunocompromised patients. However, there are limited data in the literature regarding the effect of anti-CD20 monoclonal antibodies on vaccine-related cell-mediated immune response. This study evaluated safety and immunogenicity of ZVIN in patients with hematologic malignancies (HM) receiving anti-CD20 monoclonal antibodies (alone or in combination chemotherapy regimens) and not likely to undergo hematopoietic cell transplant (HCT) (n=80). METHODS: This was an open-label, single-arm, multicenter Phase I study (NCT01460719) of a 4-dose ZVIN regimen (∼30days between doses) in patients ⩾18years old. Blood samples were collected prior to dose 1 and 28days Postdose 4 to measure varicella zoster virus (VZV)-specific T-cell responses using interferon-γ enzyme-linked immunospot (IFN-γ ELISPOT). The primary hypothesis was that ZVIN would elicit significant VZV-specific immune responses at ∼28days Postdose 4, with a geometric fold rise (GMFR) >1.0. All vaccinated patients were evaluated for adverse events (AE) through 28days Postdose 4. RESULTS: ZVIN elicited a statistically significant VZV-specific immune response measured by IFN-γ ELISPOT at 28days Postdose 4 (GMFR=4.34 [90% CI:3.01, 6.24], p-value<0.001), meeting the pre-specified success criterion. Overall, 85% (68/80) of patients reported ⩾1 AE, 44% (35/80) reported ⩾1 injection-site AE, and 74% (59/80) reported ⩾1 systemic AE. The majority of systemic AEs were non-serious and considered unrelated to vaccination by the investigator. Frequencies of AEs did not increase with subsequent doses of vaccine. No recipient of ZVIN had rash polymerase chain reaction (PCR) positive for VZV vaccine strain. CONCLUSIONS: In adults with HM receiving anti-CD20 monoclonal antibodies, ZVIN was well-tolerated and elicited statistically significant VZV-specific T-cell responses ∼28days Postdose 4. CLINICALTRIALS.GOV identifier: NCT01460719.

A Phase III Randomized, Double-blind, Clinical Trial of an Investigational Hexavalent Vaccine Given at Two, Three, Four and Twelve Months.

BACKGROUND: Combination vaccines simplify vaccination visits and improve coverage and timeliness. Diphtheria-tetanus toxoids-acellular pertussis 5, hepatitis B, inactivated poliovirus vaccine and Haemophilus influenzae type b (DTaP5-HB-IPV-Hib) is a new investigational, fully liquid, combination vaccine containing a 5-antigen pertussis component and is designed to protect against 6 infectious diseases. METHODS: In this multicenter, double-blind, comparator-controlled, phase III study (NCT01341639) conducted in Finland, Germany and Belgium, healthy infants were randomized 1:1 to receive 1 of 2 immunization regimens. The DTaP5-HB-IPV-Hib group received the investigational hexavalent vaccine (DTaP-HB-IPV-Hib) and the Control group received Infanrix-hexa (DTPa3-HBV-IPV/Hib) at 2, 3, 4 and 12 months of age. Both groups received concomitantly Prevnar 13 (PCV13) and Rotateq (RV5) at 2, 3 and 4 months of age and ProqQad (MMRV) at 12 months of age. MMRV was also administered to all study subjects at 13 months of age. RESULTS: A total of 628 subjects in the DTaP5-HB-IPV-Hib group and 622 subjects in the Control group were randomized. In a per-protocol analysis, immune responses to vaccine antigens 1 month after dose 3 and after the toddler dose were noninferior in the DTaP5-HB-IPV-Hib group as compared with the Control group. The DTaP5-HB-IPV-Hib group responses to MMRV given concomitantly at 12 months were all noninferior compared with the Control group. Solicited adverse event rates after any dose, including fever, were similar in both groups. Most adverse events were mild-to-moderate and did not lead to subject withdrawal. Vaccine-related serious adverse events occurred infrequently in the DTaP5-HB-IPV-Hib group (0.3%) and the Control group (0.2%). CONCLUSIONS: The safety and immunogenicity of DTaP5-HB-IPV-Hib is comparable to Control when administered in the 2-month, 3-month, 4-month and 12-month schedule. DTaP5-HB-IPV-Hib has the potential to provide a new hexavalent option for pediatric combination vaccines, aligned with recommended immunizations in Europe.

A Phase III randomized, double-blind, clinical trial of an investigational hexavalent vaccine given at 2, 4, and 11-12 months.

BACKGROUND: Combination vaccines simplify vaccination visits and improve coverage and timeliness. DTaP5-HB-IPV-Hib is a new investigational, fully-liquid, combination vaccine designed to protect against 6 infectious diseases, including 5 pertussis antigens and OMPC instead of PT as conjugated protein for Hib component. METHODS: In this multicenter, double-blind, comparator-controlled, Phase III study (NCT01480258) conducted in Sweden, Italy, and Finland, healthy infants were randomized 1:1 to receive one two immunization regimens. The DTaP5-HB-IPV-Hib Group received the investigational hexavalent vaccine (DTaP5-HB-IPV-Hib) and the Control Group received Infanrix-hexa (DTPa3-HBV-IPV/Hib) at 2, 4 and 11-12months of age. Both groups received concomitantly Prevnar 13 (PCV13) and Rotateq (RV5) or Rotarix (RV1) at 2, 4months of age and PCV13 at 11-12months. Subjects administered RV5 received a 3rd dose at 5months of age. RESULTS: A total of 656 subjects were randomized to the DTaP5-HB-IPV-Hib Group and 659 subjects to Control Group. Immune responses to all vaccine antigens post-toddler dose were non-inferior in the DTaP5-HB-IPV-Hib Group as compared to the Control Group. Additionally, the post-dose 2 and pre-toddler DTaP5-HB-IPV-Hib anti-PRP responses were superior. The DTaP5-HB-IPV-Hib Group responses to concomitant RV1 were non-inferior compared to the Control Group. Solicited adverse event rates after any dose were similar in both groups, except for higher rates of pyrexia (6.4% difference; 95% CI: 1.5,11.3) and somnolence (5.8% difference; 95% CI: 1.7,9.8) in the DTaP5-HB-IPV-Hib Group. Vaccine-related serious adverse events occurred infrequently in the DTaP5-HB-IPV-Hib Group (0.3%) and the Control Group (0.5%). CONCLUSIONS: The safety and immunogenicity of DTaP5-HB-IPV-Hib is generally comparable to Control when administered in the 2, 4, 11-12month schedule. Early Hib responses were superior versus Control. DTaP5-HB-IPV-Hib could provide a new hexavalent option for pediatric combination vaccines, aligned with recommended immunizations in Europe. STUDY IDENTIFICATION: V419-008 CLINICALTRIALS.GOV identifier: NCT01480258.

Prospective control study using fibrin sealants and Harmonic® scalpel in Latissimus Dorsi flap transfer.

BACKGROUND: Latissimus dorsi flap (LD) is used in breast reconstruction procedures, although prolonged donor site drainage is a frequent complication. To decrease this problem, quilting sutures and/or fibrin sealants were proposed, with alternate results. The primary objective of this study was to assess the effectiveness of Tisseel® in association with the Harmonic Synergy® blade system to reduce this complication. MATERIALS AND METHODS: Between 2010-2012, 20 consecutive patients undergoing immediate unilateral breast reconstruction with LD were enrolled in the study (Group A) and matched with 20 patients in which LD was raised with electrocautery (Group B), and 20 patients in which LD was harvested with Harmonic® (Group C). After informed consent acquisition, Harmonic® was used in Group A for LD harvesting, but differed from other groups as fibrin glue was applied to the donor site prior to closure. In all groups donor site drainage measurements at 24 and 48 hours, total drain volume, days to drain removal, operation time, and complication rate were recorded. Pearson's Chi-squared, ANOVA, and Bonferroni post-hoc tests were used to analyze the data. RESULTS: Data analysis did not show any statistical difference. Prolonged drains output ≥ 15 days occurred in one patient of Group A and C, and in three Group B patients. CONCLUSION: Although the combined use of Harmonic® and Tisseel® presents a low donor site fluid collection rate, the fibrin glue seems not to have further beneficial effects in reducing the post-operative serous drainage or to lead to an early drain removal when compared to Harmonic® only.

One-stage DIEP flap breast reconstruction: Algorithm for immediate contralateral symmetrization.

The aim of this study was to investigate clinical and aesthetic results of simultaneous contralateral balancing procedures in unilateral DIEP flap reconstructions by means of a symmetrization algorithm. Between 2004 and 2013, 335 patients underwent DIEP flap breast reconstruction with 48 patients (mean age 51.8 years, range 32-69 years) undergoing contralateral procedure. Patients were divided in Group-A including 31 cases who underwent one-stage procedure and Group-B including 17 cases who underwent staged procedure. A symmetrization algorithm was proposed to plan immediate breast reduction/mastopexy. The groups were homogeneous regarding patient's age, BMI, mastectomy and flap weight (P > 0.05). All flaps survived. No complications were observed to the mastectomy skin flaps and to the reduction mammaplasty/mastopexy procedures in both groups. The mean operation time was 5 h in Group-A while 5 h and 37 min in Group-B (P = 0.0682). Contralateral procedures included 23 breast reductions and 8 mastopexies in Group-A, while 10 breast reductions and 7 mastopexies were performed in Group-B. Two and 6 patients required revision of the balancing procedure in Group-A and Group-B, respectively. The follow-up time was 47.3 months (range 14-120 months) in Group-A and 91.3 months (range 41-110 months) in Group-B. Volume, upper/lower pole shape, projection, breast mound placement, IMF, symmetry, overall appearance, and general satisfaction sub-items obtained high-score evaluation without significant difference between the two groups (P > 0.05). One-stage DIEP flap reconstruction by means of the symmetrization algorithm resulted in comparable aesthetic outcomes and patient satisfaction to a staged procedure.

Breast Reconstruction with Delayed Fat-Graft-Augmented DIEP Flap in Patients with Insufficient Donor-Site Volume.

BACKGROUND: Microvascular reconstruction provides natural, lasting breasts that can be integrated easily into body image but most thin patients are often not ideal candidates because of inadequate donor-site volume. The purpose of this study was to present our experience in delayed augmented DIEP flaps with large fat-volume transfer. METHODS: From 2010 to 2014, 20 consecutive patients were prospectively enrolled for delayed fat-graft-augmented DIEP flaps (active group, AG) and matched with a control group (CG) submitted to the same procedure without fat-injection. Patient's age, mastectomy and flap weight, number of take-backs to the theater for secondary procedures, total treatment period (TTP), and complications were collected and analyzed. Patient and surgeon surveys rated aesthetic outcomes. Continuous and categorical variables were analyzed using student t test and Kruskal-Wallis test, respectively. A value of p ≤ 0.05 was considered statistically significant. RESULTS: The groups did not differ in age and mastectomy weight (p > 0.05). The AG had a smaller BMI and flap weight (p < 0.05). Comparison of the mean number of take-backs (1.5 in AG vs. 1.4 in CG) and mean TTP (8.6 months in AG vs. 8.9 months in CG) did not show a significant difference (p > 0.05) between groups. Volume, upper/lower-pole shapes, projection, breast mound placement, IMF, symmetry, overall appearance, and general satisfaction sub-items obtained high-score evaluation without a significant difference between groups (p > 0.05). CONCLUSION: Delayed fat-graft-augmented DIEP flaps can be offered to patients with insufficient donor-site volume and medium/large breasts. In comparison with the same technique without fat grafting, no additional take-backs and no prolonged TTP were required to achieve pleasing aesthetic results. LEVEL OF EVIDENCE III: 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 .

Skin grafted latissimus dorsi flap for reconstruction of lateral aesthetic units of the face.

Reconstruction of large defects of the lateral region of the face is rather challenging due to the unique color, texture, and thickness of soft tissues in this area. Microsurgical free flaps represent the gold standard, providing superior functional and aesthetic restoration. Purpose of this study was to assess reliability of skin-grafted latissimus dorsi (LD) flap, for a pleasant and symmetric reconstruction of the lateral aesthetic units of the face compared to a control group of patients addressed to perforator flaps. From November 2008 to June 2012, 5 patients underwent skin-grafted LD flap reconstruction of defects involving the lateral aesthetic units of the face, with 8.1 ± 0.5 × 9.7 ± 1.3 cm mean size. A 1-to-4 Likert scale was used to assess skin color, texture, shape, and bulkiness. Using the Pressure-Specified Sensory Device epicritic, proprioceptive, and protopathic sensitivities were tested. Outcomes were compared with those of a control group of 5 patients addressed to reconstruction with perforator flaps (3 anterolateral thigh flap, 2 vertical deep inferior perforator flap). At mean 21-month follow-up all flaps healed uneventfully without need for revisions, all developing more satisfactory results in terms of skin color (P = 0.028) and texture (P = 0.021) match, shape (P = 0.047) and bulkiness (P = 0.012) compared with perforator flaps. No differences in epicritic, proprioceptive, and protopathic sensitivities were observed (P > 0.05) between the two groups. Skin-grafted LD flap may be a suitable option for reconstruction of wide defects of the lateral aesthetic units of the face.

Sensate anterolateral thigh perforator flap for ischiatic sores reconstruction in meningomyelocele patients.

Recidivating pressure sores are a frequent complication in meningomyelocele patients because of their limitation in motility and their scarce ability to monitor the pressure applied on insensate areas while seated. We report the utilization of the sensate pedicled anterolateral thigh perforator flap for reconstruction of ischiatic sores in meningomyelocele patients. Between May 2011 and September 2013, five patients underwent transfer of a sensate pedicled anterolateral thigh flap, by an intermuscular passageway through the upper thigh, to reach the ischial defect. Flap was properly harvested from the thigh after assessment of the lateral cutaneous femoral nerve sensitive area with the Pressure-Specified Sensory Device. In all cases the flap reached the ischial defect harmlessly, healing was uneventful with no immediate nor late complications. Each patient showed persistence of sensitivity at the reconstructed area and no recurrent ischiatic sore was observed at mean follow-up of 26.4 months. The sensate pedicled anterolateral thigh flap is a valuable solution for coverage of recurrent ischial sores in meningomyelocele patients, in which pressure consciousness is fundamental. The intermuscular passageway allows to reduce the distance between flap's vascular pedicle origin and the ischial defect, hence to use the more reliable skin from the middle third of the anterolateral thigh.

DIEP flap sentinel skin paddle positioning algorithm.

Although clinical examination alone or in combination with other techniques is the only ubiquitous method for flap monitoring, it becomes problematic with buried free-tissue transfer. We present a DIEP flap sentinel skin paddle (SSP) positioning algorithm and its reliability is also investigated using a standardized monitoring protocol. All DIEP flaps were monitored with hand-held Doppler examination and clinical observation beginning immediately after surgery in recovery room and continued postoperatively at the ward. Skin paddle (SP) position was preoperatively drawn following mastectomy type incisions; in skin-sparing mastectomies types I-III a small SP (sSP) replaces nipple-areola complex; in skin-sparing mastectomy type IV, SSP is positioned between wise-pattern branches while in type V between medial/lateral branches. In case of nipple-sparing mastectomy SSP is positioned at inframammary fold or in lateral/medial branches of omega/inverted omega incision if used. Three hundred forty-seven DIEP flap breast reconstructions were reviewed and stratified according to SP type into group A including 216 flaps with large SP and group B including 131 flaps with SSP and sSP. Sixteen flaps (4.6%) were taken back for pedicle compromise, 13 of which were salvaged (81.25%), 11 among 13 from group A and 2 among 3 from group B. There was no statistical difference between the groups concerning microvascular complication rate (P = 0.108), and time until take-back (P = 0.521) and flap salvage rate (P = 0.473) resulted independent of SP type. Our results suggest that early detection of perfusion impairment and successful flaps salvage could be achieved using SSP for buried DIEP flap monitoring, without adjunctive expensive monitoring tests.

The axillary versus internal mammary recipient vessel sites for breast reconstruction with diep flaps: a retrospective study of 256 consecutive cases.

The aim of this study is to present our experience on the use of various recipient sites for deep inferior epigastric perforator (DIEP) flap breast reconstruction and compare them by means of objective data. Two hundred fifty six DIEP flap breast reconstructions, performed between March 2004 and May 2011, were retrospectively analyzed. Only unilateral reconstructions were included in the study and divided into three groups depending on the recipient site choice: internal mammary vessels (IMV) (n = 52), thoracodorsal vessels (TDV) (n = 109), and circumflex scapular vessels (CSV) (n = 95). Clinical records of each patient were reviewed to acquire relevant data such as operative time, postoperative complications, and use of a second vein anastomosis. CSV group showed a statistically significant lower operative time (4.92 ± 0.54 hours) compared to TDV (5.67 ± 1.01 hours) and IMV groups (6.75 ± 1.09 hours) (P < 0.001). Second vein anastomosis was performed in 84 cases (88.1%) of CSV, in 85 cases (77.9%) of TDV, and in 18 cases (35.1%) of IMV groups (P < 0.001). No significant differences were observed among groups regarding risk factors and complications (P > 0.05). The axillary vessels seem to be the ideal recipient site because of reduced operative time and increased possibility to perform a second vein anastomosis. Among them, CSV can be safely used due to following advantages: easy dissection, larger vessel caliber, and optimal flap insetting. Moreover, their location does not expose them completely to radiotherapy consequences.

Latissimus dorsi flap for total autologous immediate breast reconstruction without implants.

BACKGROUND: The latissimus dorsi flap provides suitable recipient tissue for fat transfer, with a good blood supply and a reasonable volume of host tissue to inject into. The authors present their experience with use of the pedicled latissimus dorsi flap for fat grafting in total autologous immediate breast reconstruction without implants. METHODS: From 2010 to 2013, 23 patients underwent breast reconstruction with primary fat augmented latissimus dorsi flaps (21 unilateral procedures and two bilateral procedures). Mean patient age was 52.3 years (range, 39 to 68 years); mean body mass index was 24.77 kg/m2 (range, 21.5 to 28.7 kg/m2). Fat was harvested using the Coleman technique with 10-ml syringes and injected into the adipose layer and muscle fascia of the latissimus dorsi flap skin paddle with 1-ml syringes. RESULTS: The mean size of the harvested skin paddle was 19.7 × 11.04 cm (range, 18 × 10 cm to 21 × 12 cm). Mean operative time was 2.62 hours (range, 2.10 to 3.20 hours) and 4.12 hours (range, 4.10 to 4.15 hours) for unilateral and bilateral reconstructions, respectively. Mean harvested fat volume was 126 ml (range, 90 to 180 ml), and mean injected fat volume was 101 ml (range, 60 to 150 ml). All flaps healed uneventfully, no seroma occurred at the flap donor-site, and no fat grafting-related complications were observed. CONCLUSION: To the best of the authors' knowledge, this is the first report in which fat transfer was used to achieve immediate latissimus dorsi flap volume augmentation as an alternative for total autologous reconstruction, avoiding implant-related complications.

Total breast reconstruction using autologous fat grafting following nipple-sparing mastectomy in irradiated and non-irradiated patients.

BACKGROUND: Although autologous microvascular reconstruction following nipple-sparing mastectomy (NSM) is considered one of the best reconstructive choices, this procedure cannot be offered to all patients. The aim of this study was to define a fat grafting protocol for successful reconstruction following NSM and to assess its reliability in irradiated and non-irradiated patients. MATERIALS AND METHODS: Twenty-one patients were prospectively enrolled and stratified in Group-A (11 non-irradiated) and Group-B (10 irradiated) NSMs comparing clinical and aesthetic outcomes. A fat grafting protocol was used to standardize the procedure. Continuous and categorical variables were analysed using the Student t test and the Kruskal-Wallis test, respectively. A value of p ≤ 0.05 was considered statistically significant. RESULTS: The groups were homogeneous in terms of demographics (p > 0.05), while number of sessions, mean volume of the first two treatments, and overall injected volume showed significant differences (p < 0.001; p < 0.001; p = 0.002). Volume, shape, position of the breast mound, IMF and scar location subscales obtained high score evaluations without a significant difference between the groups (p > 0.05), whereas the skin texture subscale showed a lower score evaluation in Group-B than in Group-A (p = 0.001). Although a significant difference for total subscales was in favour of Group-A (p = 0.001), the global score had a high rate evaluation in both groups (p = 0.132). Inter-rater reliability showed substantial agreement among all categories, total and global scores. CONCLUSIONS: To the best of our knowledge, this is the first prospective series of fat transfer reconstructions following NSM using a systematic approach. Although further studies are required, it may be considered an effective option whenever flap reconstruction cannot be performed. LEVEL OF EVIDENCE III: 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.

The use of the serratus anterior muscle vascular pedicle as recipient site in DIEP flap transfer for breast reconstruction.

Currently, the choice for recipient vessels in microvascular breast reconstruction is made between axillary and internal mammary regions. The authors report their experience with anastomosis to a new, unconventional, axillary recipient vessel, the serratus anterior muscle vascular pedicle. Among 340 deep inferior epigastric perforator (DIEP) flap breast reconstructions performed between 2004 and 2013, 11 were successfully revascularised to the serratus anterior (SA) pedicle: In three cases, complications led to a salvage procedure, while in eight cases, anastomosis to this recipient site was electively planned. The pedicle was constantly present, with calibre always comparable to that of flap's pedicle. At the mean 24-month follow-up, no recipient site complications were observed. The SA muscle pedicle resulted as a reliable choice in salvage procedures and a suitable option for recipient vessel selection in elective cases.

Accidental injury of the latissimus dorsi flap pedicle during axillae dissection: types and reconstruction algorithm.

The intra-operative latissimus dorsi (LD) pedicle damage during axillary lymph-node dissection by the general surgeon is a rare complication leading to flap failure and poor outcomes. The authors present their experience on this topic and develop a classification of the thoracodorsal (TD) pedicle injuries and reconstruction algorithm. Pedicle damage of LD occurred in five cases, three of which were experienced during immediate breast reconstruction and two observed in patients who underwent prior surgery. In two cases the thoracodorsal vein (TDV) was damaged in its proximal segment, thus end-to-end anastomosis was performed between distal stump of TDV and circumflex scapular vein (CSV). In one case the TDV required simple microsurgical repair while in other two cases the severe damage of vein and artery required more complex surgical strategies in attempt to salvage the flap. Four cases completely survived with one case of rippling phenomenon. One case had partial flap necrosis that required subtotal muscle resection. Based on these cases, the authors have developed a reconstruction algorithm in attempt to repair LD pedicle damage while preserving breast reconstruction. Taking into account its anatomical conformation, TD pedicle injuries are classified in four different types and available options are suggested for all of them according to the anatomical site and to the mechanism and timing of injury.

Wide excision and anterolateral thigh perforator flap reconstruction for dermatofibrosarcoma protuberans of the face.

Dermatofibrosarcoma protuberans is a rare cutaneous malignant tumor associated with a high cure rate but with a high incidence of local recurrence. Because of its tentacle-like subcutaneous infiltrating pattern that extends far beyond the clinically visible skin lesion, a wide resection margin is recommended. Hence, its localization to the head-and-neck regions, although rare, represents a real challenge for both the oncologic surgeon and the reconstructive surgeon, who aim to achieve a radical resection of the tumor with the best possible aesthetic outcome.A case of a 21-year-old Mediterranean man who presented with a 7-month history of a slowly growing subcutaneous lesion of the left preauricular region is reported. A diagnosis of dermatofibrosarcoma protuberans CD34+ was confirmed through surgical biopsy, and the patient subsequently underwent a wide en bloc local surgical resection, followed by anterolateral thigh perforator free flap reconstruction. Healing was uneventful. Initially, there was some facial nerve neurapraxia; however, this completely subsided within 3 months after the surgery. At the 13-month follow-up, the patient was completely well and free from the disease.

The mushroom-shaped anterolateral thigh perforator flap for subtotal tongue reconstruction.

BACKGROUND: Reconstruction of a functional tongue with proper motility and sensation after subtotal resection is a demanding procedure. The authors describe the reinnervated mushroom-shaped anterolateral thigh perforator flap for subtotal tongue reconstruction. METHODS: Thirteen patients (mean age, 54.8 years; range, 49 to 71 years) diagnosed with T3 and T4 squamous cell carcinomas were allocated prospectively to anterior total mobile (n = 7) or subtotal tongue resection (n = 6). All patients received the mushroom-shaped anterolateral thigh perforator flap. A Likert scale ranging from 1 to 4 was used to assess speech intelligibility, swallowing function, and cosmetic results. Epicritic and proprioceptive sensitivity testing was performed with the Pressure-Specified Sensory Device on the tip of the tongue preoperatively, on the neotongue at the donor site preoperatively, and at the recipient site 12 months postoperatively; protopathic thermoreceptor and nociceptors were clinically investigated. Outcomes were analyzed, and values of p < 0.05 were considered significant. RESULTS: All flaps healed uneventfully (mean follow-up, 18 months). Six patients (46.2 percent) recovered a nearly natural deglutition, whereas seven (53.8 percent) had mild impairment (p = 0.274). Normal intelligible speech was achieved in seven cases (53.8 percent), and acceptable intelligible speech was achieved in six (46.2 percent) (p = 0.286). Aesthetic results were excellent in eight patients (61.5 percent) and good in five (38.5 percent) (p = 0.592). All patients recovered epicritic, proprioceptive, and protopathic sensitivity; cortical upgrading phenomena of the recipient nerve were observed. CONCLUSION: The reinnervated mushroom-shaped anterolateral thigh perforator flap was found to be an innovative and effective option for subtotal tongue reconstruction.