Effects of Cutting Planes on Costal Cartilage Warping.

BACKGROUND: Autogenous costal cartilage becomes a favorable choice for nasal reconstruction and complicated aesthetic rhinoplasty, due to its ample supply, sufficient for most patients. However, a notable drawback is the potential for warping. Our study aims to identify cutting planes that minimize warping. MATERIALS AND METHODS: Two hundred and seven costal cartilage grafts were obtained by slicing the extracted costal cartilages from 10 fresh cadavers, along three main planes: cephalocaudal, anteroposterior, and parallel to the synchondrosis plane. Each of these major planes was further divided into grafts taken from both the central and peripheral portions. Furthermore, both subgroups were categorized into three thicknesses: 1mm, 2mm, and 3mm. The warping angles of all grafts were then compared at various time intervals after the initial cutting. RESULTS: Cephalocaudal cuts exhibited significantly greater warping than other planes. Anteroposterior cuts displayed the least warping, although this difference lacked statistical significance. Peak warping occurred at 30 minutes. Certain grafts continued to warp even at 1 month. Central grafts had less warping than peripheral ones, though not statistically significant. CONCLUSIONS: Cephalocaudal cuts yielded the highest warping angle. Surgeons seeking thin (< 3 mm) straight grafts should opt for anteroposterior or parallel to synchondrosis planes. Thicker grafts (> 3 mm) can be cut in the cephalocaudal plane with an acceptable warping angle, close to parallel with the synchondrosis plane. For curved cartilage, thin cephalocaudal cut is recommended. Additionally, we suggest placing the cartilage in normal saline for at least 30 minutes, allowing for maximum warping to occur.

Unusual manifestation of gastric adenocarcinoma presenting with lymphedema, chylothorax, and chylous ascites.

A 62-year-old Thai man with a 2-year history of bilateral lymphedema and an unprovoked left axillary vein thrombosis presented with progressive leg, scrotal, and abdominal swelling, and shortness of breath. He denied any gastrointestinal symptoms. His lymphedema had initially been diagnosed as chronic filariasis due to positive blood tests for anti-filarial antibodies; however, treatment with anti-filarial drugs failed to improve his symptoms. Subsequently, he underwent surgical lymphaticovenular anastomosis with scrotal reduction, which proved to be of limited symptomatic relief. Later investigations revealed bilateral chylothorax and chylous ascites, with the presence of metastatic adenocarcinoma. Histopathological examination of the patient's skin and scrotum biopsy from his previous surgery revealed invasion of the lymphatics by neoplastic cells with signet ring cell formation. Gastroscopy uncovered a gastric mass, and biopsy confirmed the diagnosis of stage IV gastric adenocarcinoma with signet ring cell. He later received palliative chemotherapy. For the management of chyle leakage, he was prescribed a very low-fat diet and supplemented with parenteral nutrition. Despite treatment, he developed cutaneous metastasis and was transitioned to best supportive care. The patient passed away 14 months after diagnosis.

Carotid artery and soft tissue reconstruction with superficial femoral artery-sartorius muscle-anteromedial thigh chimeric free flap: A case report and review of the literature.

Tumoral involvement of the carotid artery may require en-bloc resection in order to achieve a better regional control. Among the carotid reconstruction methods at disposal, autologous tissues appear to be more reliable in cases with high risk of infection and poor tissue healing like in radiated necks. We describe a case of a 55 year old man, who suffered from recurrent squamous cell carcinoma in the neck region, invading the common carotid artery. After en-bloc resection of the tumor together with skin, internal jugular vein, vagus nerve and common carotid artery, carotid reconstruction was performed with a flow-through chimeric flap based on superficial femoral vessels (15 cm). After resection of the tumor, the flap was used to replace the soft tissue defect (23 × 12 cm). Anteromedial thigh skin paddle (8 × 5 cm) and sartorius muscle (12 × 3 cm) were included in the flap. The superficial femoral vessels were reconstructed with 8-mm ringed polytetrafluoroethylene graft interposition. Thanks to an accurate surgical planning and a 2-team approach, the ischemia time of the leg was 42 min and there were no limb ischemia nor pathologic neurological signs after surgery. During the 12-month follow up, no other complication was registered. In our experience, microsurgical carotid reconstruction represents a reliable option with important advantages such as resistance to infection, optimal size matching, and good tissue healing between the irradiated carotid stump and the vascular graft.

The "Crater" Arteriotomy: A Technique Aiding Precise Intimal Apposition in End-to-side Microvascular Anastomosis.

End-to-side arterial anastomoses require a high level of technical competency. The main challenge to a successfully patent anastomosis is intimal interposition during the standardized microvascular suturing. Technical errors during arteriotomy pose a significant challenge for the microsurgical technique, making the end-to-side anastomosis prone to failure. We describe a basic yet fundamental method of performing an arteriotomy, the "crater" technique, which facilitates good visualization of all vessel layers before placement of microsurgical sutures. Using curved microsurgical scissors, the adventitia layer is dissected off the outer surface of the side vessel, a V-shaped cut is then made obliquely at a 30-45 degrees angle to the longitudinal axis of the vessel, and a full thickness oblique cut is made along an elliptical circumference, as the curved scissors enable the creation of a slope-like crater. This concept ensures the intimal layer is adequately exposed through the complete circumference of the arteriotomy rim, while enabling a variable increase in the arterial wall hypotenuse-width circumference. When performed in a standardized manner, the crater arteriotomy can minimize the risk of endothelial misalignment and further technical errors during suturing, thus minimizing the risk of anastomotic failure.

Clear Sinus Sign on Head CT Scan: Reliable Criterion to Exclude Paranasal Sinus Fracture.

PURPOSE: The clear sinus sign has been described in facial computed tomography (CT) as an indication of the absence of fluid in the paranasal sinuses. It is a highly reliable criterion to exclude fracture involving the paranasal sinus wall. Very scarce data on this sign on head CT scan is currently available. We conducted the present study to assess the usefulness of the clear sinus sign on head CT scan to exclude paranasal sinus fracture. MATERIALS AND METHODS: A retrospective cross-sectional review of the medical records and head and facial CT images was performed for 80 trauma patients with a total of 640 paranasal sinuses. The presence and absence of paranasal sinus fracture was recorded and analyzed. RESULTS: The clear sinus sign was found in 207 paranasal sinuses (32.3%) on head CT, and none of these had a paranasal sinus fracture (P < .001). CONCLUSIONS: The presence of the clear sinus sign on head CT scans is an excellent indication for exclusion of a paranasal sinus fracture in trauma patients.

Surgical Treatment of Advanced Lymphatic Filariasis of Lower Extremity Combining Vascularized Lymph Node Transfer and Excisional Procedures.

Background: Lymphatic filariasis (LF) in advanced stage is a clinically challenging disability resulting in poor quality of life. In advanced stage of filariasis, medical management is seldom effective and few surgical procedures are beneficial. In this study, we assessed clinical efficacy of a surgical technique combining vascularized lymph node transfer (VLNT) and serial excision for patients affected by advanced LF. Patients and Methods: A total of 17 patients with grades 2 and 3 lower limb lymphedema after three consecutive humanitarian missions in India between 2014 and 2018 underwent excision of excessive soft tissue of leg and supraclavicular lymph node flap transferred to dorsum of foot. Recipient vessels were prepared and microanastomosis was performed. Lymphedema was assessed by measuring leg circumferences at different levels, episodes of infectious lymphangitis, and lymphoscintigraphy. Results: A significant decrease of lower limb circumference measurements at all levels was noted postoperatively. Postoperative lymphoscintigraphy revealed reduced lymph stasis. One patient suffered of a seroma on donor site. Six patients had partial loss of skin graft over the flap at recipient site and it was managed by regrafting. Data analysis observed statistically significant reduction in feeling of heaviness (p < 0.005) and episodes of acute lymphangitis after surgery. Conclusion: Advanced LF of leg is difficult to manage using traditional medical treatment. The combination of VLNT and surgical excision provided a safe and reliable approach to treat this debilitating disease.

Optimizing survival of large fibula osteocutaneous flaps for extensive full-thickness oromandibular defects: A two-stage approach with temporary orocutaneous fistula.

INTRODUCTION: Composite and large head and neck defects requiring extensive skin-mucosa coverage are often reconstructed by combining flaps. Herein, we present a simple and reliable two-stage fibula osteocutaneous (FOC) flap technique to improve the survival of a large skin paddle for oromandibular reconstructions. METHODS: From October 2011 to September 2016, 47 patients with through-and-through oromandibular defects were reconstructed using FOC flaps with large skin paddles. To ensure optimum survival of skin paddles, temporary orocutaneous fistula were left in place and closed during the second stage operation via de-epithelialization of the skin paddle and suturing of mucosa. Demographic data, operative details, and postoperative complications were recorded. RESULTS: The skin paddle dimensions ranged from 20 to 31.5 cm in length and 12 to 17 cm in width with an average area of 430.4 cm2 (range 300-504). The average time between the two stages and hospital stay were 10 days and 14 days, respectively. Complications at the donor site included wound dehiscence (n = 3, 6.4%), partial skin graft loss (n = 3, 6.4%) and hematoma (n = 2, 4.3%). Recipient site complications included two (4.3%) early postoperative venous congestions that resolved after elevation and three (6.4%) partial skin flap necrosis (less than 5% surface area). All complications resolved with bedside conservative management. There was only one take-back for evacuation of recipient site hematoma (2.1%) but no flap loss. CONCLUSION: Two-staged large skin paddle FOC flaps can simplify reconstruction of extensive oromandibular defects by improving the reliability of the sizable skin paddle and negating the need for a second flap.

Normative Data of the Interorbital Distance in Thai Population.

The incidence of the patients with craniofacial anomalies was high in southeast-Asian countries, for example, fronto-ethmoidal encephalo-menigocele or craniosynostosis. These craniofacial anomalies usually involve orbits, so a surgical orbital reconstruction is always required.Various methods have been used in the past to indirectly analyze the craniofacial region. Plain skull radiography, anthropometry, and cephalometry provided the limited information of interorbital distance in terms of accuracy whereas the interorbital distance is crucial to be reconstructed, increasing or decreasing. The accurate normal interorbital distance which grows by age as other craniofacial structures is the important data in the part of interorbital and orbital reconstruction. To date, the normative data of the bony interorbital distance among Thai population have not been established.The purpose of this study is to provide normal values and the growth patterns of the bony interorbital distances and other dimensions of the orbit according to age among Thai population through the axial computed tomography. Comparisons can then be made between normal values and those for an individual patient or those for a group of patients, for example, those with front-ethmoidal meningoencephalocele, Crouzon, or Treacher-Collins syndrome, or among values for individual patients at different time intervals.A retrospective study of computed tomography (CT) scan series of 698 normal orbits from 349 skeletally normal subjects (202 men and 147 women) was enrolled. The age range of the patients was 0 to 21 years (mean, 10.2 years; SD, 5.8 years). A series of 12 measurements were obtained from the CT scans of each subject. All CT images were obtained from patients who underwent CT of the facial bone, brain, and orbits at the Department of Radiology of 3 big hospital in Bangkok-Ramathibodi, Samitivej Srinakarin, and Bangkok hospital-since 2010 to 2015.The normal measurement values in the orbital region through the CT images, as the normal periorbital growth curve, will help improving diagnostic accuracy, staging of reconstruction, precision of corrective surgery, and follow-up of the Thai patients with craniofacial abnormalities such as front-ethmoidal meningoencephalocele, hypertelorism. These data may also apply to the related population in the southeast-Asian countries.

Complications and Patient-Reported Outcomes in Male-to-Female Vaginoplasty-Where We Are Today: A Systematic Review and Meta-Analysis.

INTRODUCTION: There is an increased need for evidence-based practices in male-to-female (MtF) transgender vaginoplasty. Although there are a multitude of surgical techniques, there is a paucity of data comparing these procedures. A systematic review of retrospective studies on the outcomes of MtF vaginoplasty was conducted to minimize surgical complications and improve patient outcomes for transgender patients. METHODS: Applying the Preferred Reporting Items for Systematic Review and Meta-Analysis, a comprehensive search of several databases from 1985 to November 7, 2017, was conducted. The databases included PubMed, Ovid MEDLINE Epub Ahead of Print, Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Web of Science. The resulting publications were screened, and those that met our specified inclusion/exclusion criteria were analyzed. The DerSimonian and Laird random-effects model was used to pool complications and patient-reported outcomes. RESULTS: A total of 471 articles were initially identified, of which 46 met our eligibility criteria. A total of 3716 cases were analyzed. Overall incidence of complications included the following: 2% (1%-6%) fistula, 14% (10%-18%) stenosis and strictures, and 1% (0%-6%) tissue necrosis, and 4% (2%-10%) prolapse (upper and lower limits of the 95% confidence interval). Patient-reported outcomes included a satisfaction rate of 93% (79%-100%) with overall results, 87% (75%-96%) with functional outcomes, and 90% (79%-98%) with esthetic outcomes. Ability to have orgasm was reported in 70% (54%-84%) of patients. The regret rate was 1% (0%-3%). The length of the vaginal cavity was 12.5 cm (6.3-4.4 cm). CONCLUSIONS: Multiple surgical techniques have demonstrated safe and reliable means of MtF vaginoplasty with low overall complication rates and with a significant improvement in the patient's quality of life. Studies using different techniques in a similar population and standardized patient-reported outcomes are required to further analyze outcomes among the different procedures and to establish best-practice guidelines.

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.

Gender-Confirmation Surgery Using the Pedicle Transverse Colon Flap for Vaginal Reconstruction: A Clinical Outcome and Sexual Function Evaluation Study.

Vaginal reconstruction and vaginoplasty are indicated in vaginal agenesis, following pelvic tumor resection, trauma, and for gender-confirmation surgery. In this article, the authors present the clinical outcomes and sexual function evaluation when using the pedicle transverse colon flap for gender-confirmation surgery in transgender women. This is a retrospective chart review of all transgender women who underwent gender-confirmation surgery using the pedicle transverse colon flap. Demographics, procedure specifics, and surgical outcomes were recorded and analyzed. Sexual function was measured using the Female Sexual Function Index and the Female Genital Self-Image Scale 1 year after surgery. Fifteen patients underwent gender-confirmation surgery using the aforementioned technique. The average age of the patients was 20 years (range, 18 to 32 years), and the average operating room time was 10.1 hours (range, 8 to 12.5 hours). The average length and width of the flaps were 15 and 2.8 cm, respectively. During a 12-year follow-up, two complications were reported: one patient had pain caused by narrowing at the introitus, which required intervention, and one patient had an excessive amount of secretions in the first month, which subsided 3 months after surgery. The mean Female Sexual Function Index score was 28.6 (range, 24 to 31). All patients achieved normal sexual function as indicated by a Female Sexual Function Index score of 25 or more. For the Female Genital Self-Image Scale, the mean total score was 20.0 ± 4.5 (range, 7 to 28). The pedicle transverse colon flap is another valuable alternative method for vaginoplasty with promising results and minor complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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.

A head-to-head comparison among donor site morbidity after vascularized lymph node transfer: Pearls and pitfalls of a 6-year single center experience.

Between 2010 and 2016, 110 patients with extremity lymphedema underwent vascularized lymph node (VLN) transfer: groin (G-VLN = 20), supraclavicular (SC-VLN = 54), and right gastroepiploic (RGE-VLN = 36) open and laparoscopic approach. Herein, we discuss the pearls and pitfalls for VLN harvest and compare donor site morbidity and complications. Lymphatic leakage: G-VLN (n = 1) and SC-VLN (n = 1) and one hematoma: SC-VLN were found. Laparoscopic harvest of the RGE-VLN reduces donor site morbidity. However, surgeons experience is imperative to minimize donor site morbidity and complications. J. Surg. Oncol. 2017;115:37-42. © 2016 Wiley Periodicals, Inc.

The laparoscopic right gastroepiploic lymph node flap transfer for upper and lower limb lymphedema: Technique and outcomes.

BACKGROUND: Lymph node flap transfer popularity for treatment of extremity lymphedema is increasing quickly. Multiple flap donor sites were described in search of the optimal one. We describe the technique and outcomes of a laparoscopically harvested right gastroepiploic lymph node flap for treatment of extremity lymphedema. METHODS: From January 2012 to January 2013, 10 consecutive female patients, average age 54.8 years, with International Society of Lymphology stage II-III extremity lymphedema refractory to conservative management were included. Five patients had upper limb breast cancer-related lymphedema and five patients had lower limb pelvic cancer-related lymphedema. All patients underwent laparoscopic harvest of the right gastroepiploic lymph node flap, transferred to the wrist and ankle as recipient sites. Flaps were covered with a small skin graft taken from the thigh. Perioperative assessment included physical exam, photography, circumference measurements, CT scans, lymphoscintigraphy, and Lymphedema Quality of Life (LYMQOL) questionnaire. Clinical and CT evaluation of donor-site morbidity were performed. RESULTS: The flap survival rate was 100%, with a mean harvest time of 32 minutes and total operating time of 164 minutes. One case required regrafting for skin graft loss. The mean limb reduction rate was 39.5% at a mean follow-up of 14.7 months. Perioperative lymphoscintigraphy demonstrated transferred lymph node viability and lymphatic transport improvement. LYMQOL showed a 2.6-fold quality-of-life improvement (P < 0.01). No donor-site morbidity was encountered. CONCLUSIONS: The use of the laparoscopically harvested right gastroepiploic lymph node flap may be a safe technique that improves limb measurements and quality of life in extremity lymphedema patients. © 2015 Wiley Periodicals, Inc. Microsurgery 37:197-205, 2017.

Clinicopathological features of dermatofibrosarcoma protuberans.

Dermatofibrosarcoma protuberans (DFSP) is a superficial cutaneous tumor of low malignant potential characterized by a high rate of local recurrence. The histopathological appearance shows uniform spindle neoplastic cells arranged in a predominantly storiform pattern, typically with positive staining for cluster of differentiation (CD)34 and vimentin on immunohistochemistry. A minority of cases of DFSP have areas of sarcomatous transformation. Wide surgical excision is the cornerstone of treatment for DFSP. The objective of the present study was to determine the clinicopathological features of DFSP. Pathological records were searched for cases of DFSP in the database of the Department of Pathology, Faculty of Medicine Ramathibodi Hospital (Mahidol University, Bangkok, Thailand) between 1994 and 2013. The results showed 68 cases with DFSP. The mean age at diagnosis was 40 years (range, 3-86 years). Among this group of patients, 26 cases (38.2%) experienced local recurrence and 6 (8.8%) exhibited sarcomatous transformation of DFSP. The factors that predict the recurrence of DFSP are an incorrect first pathological diagnosis and an inadequate surgical margin. The factors that predict the sarcomatous transformation of DFSP are a larger tumor size and an incorrect first pathological diagnosis. In patients who have tumors with spindle cells arranged in a storiform pattern, CD34 immunohistochemical staining provides the definitive diagnosis. Exact histopathological categorization is important to select the appropriate treatment and predict the clinical outcome.