Modified transmanubrial approach for complicated type 1 cervical rib resection requiring subclavian artery reconstruction.

The transmanubrial musculoskeletal sparing approach (TMA) is commonly used for resecting apical lung tumours with vascular involvement. Non-neoplastic conditions which might require surgical exploration of the thoracic outlet include the 'cervical rib', a clinical condition consisting of an additional rib forming above the first rib and growing from the base of the neck just above the clavicle. Type 1 cervical rib-when a complete cervical rib articulates with the first rib or manubrium of the sternum-is the most challenging scenario where the subclavian artery can be damaged by continuous compression due to the narrow space between clavicle, first rib and supernumerary cervical rib, requiring prosthetic reconstruction of the involved tract. Here, we describe a modified TMA in which the incision in the neck is conducted posteriorly to the sternocleidomastoid muscle, thus allowing safe dissection of the superior and middle trunk of the brachial plexus.

Free-style propeller ulnar artery perforator flaps for radial forearm flap donor site repair.

INTRODUCTION: The radial forearm free flap (RFFF) is still one of the most used free flaps to repair soft tissue defects of the head and neck. Among its main drawbacks, it presents severe donor site complications. We report our experience about the use of free-style propeller ulnar artery perforator flaps (UAP) to repair RFFF donor site. PATIENTS AND METHODS: From February 2010 to June 2020, six patients who underwent immediate tongue reconstruction with RFFF after cancer excision, had the donor site at the forearm reconstructed with a free-style propeller UAP flap. The indication for a UAP flap was based on defect size and the presence of tendons or radial nerve exposure. Ulnar artery perforators were identified intra-operatively with a handheld Doppler. The UAP flaps were harvested and rotated to cover donor site defects. The patients' mean age was 59, ranging from 49 to 65 years old. The defects size ranged from 8-12 cm × 5-7 cm with a mean size of 10.5 × 6.7 cm. RESULTS: The UAP flap harvested ranged from 8-11 cm × 5-7 cm with a mean size of 10.5 × 5.5 cm. The perforators, identified with a power Doppler, were located at the middle third of the forearm. Flaps' rotation varied from 90 to 160° with a mean rotation of 122°. Mean operating time was 60 min ranging from 40 to 75 min for UAP flap elevation. No flap necrosis or tendon exposure occurred. One case of wound dehiscence was reported. Two out of six patients suffered from tendon adhesions to the flap. UAP flap donor site was primarily closed in four out of six patients, whereas two cases required a split-thickness skin grafts. Mean donor site healing time was about 20 days (19.8 days) ranging from 14 to 30 days. Follow-up ranged from 12 to 31 months with a mean follow up time of 19 months (18.6 months). At 6 months follow-up only one patient experienced a functional limitation of wrist and finger joints extension of 20° which required tenolysis. At the end of the patient's follow up that is 22 months, the range of movement was within normal limits. In our casuistry neuropathic pain was absent. CONCLUSIONS: RFF is still a paramount tool in reconstructive surgery but its donor site is still burdened by a high complication rate. Free-style UAP flaps can provide a local and safe solution.

Reversed distal laterodigital adipofascial flap for nail-bed reconstruction.

BACKGROUND: Lesions of the distal phalanges of the fingers frequently involve the nail bed. There are few therapeutic options for nail-bed reconstruction and they often lead to painful scars and onychodystrophy. We present our experience with the distal adipofascial laterodigital reverse flap. METHODS: Fifteen patients (average age 46.33 years, range 28-73) with tumors or traumatic injuries (crush injuries, nail avulsion, and partial fingertip amputations) of the nail bed, underwent digital reconstruction through the distal adipofascial laterodigital reverse flap from June 2018 to August 2019. The size of the fingertip defect covered with the flap was ranged between 1.1 × 1.1 and 1.6 × 1.2 cm (average size 1.4 × 1.2 cm). The flap was harvested enrolling subcutaneous tissue from the lateral aspect of the middle and distal phalanx from the less damaged side. RESULTS: The average size of the harvested flaps was 1.3 × 1.2 cm (range 1.1 × 1.0 to 1.4 × 1.1 cm). All adipofascial flaps survived entirely and the nail bed healed in all patients, with an average healing time of 21 days and a subsequent regrowth of the nail. The follow up ranged from 6 to 12 months, with a mean of 7 months. CONCLUSIONS: The distal reverse adipofascial flap provides a very versatile and reliable coverage of the distal finger and its nail bed. It is a rapid and reproducible surgical procedure with poor morbidity for the donor site. LEVEL OF EVIDENCE: IV.

Infective complications of cosmetic tourism: A systematic literature review.

BACKGROUND: Cosmetic tourism has increased dramatically over the years. We performed a systematic review of the literature to find reports of infective complications following cosmetic surgery, focusing on epidemiology, clinical, and surgical management. In addition, we identified cosmetic tourism trends in terms of mobilization from the country of origin and travel destinations. METHODS: A search on PubMed, Embase, and Web of Science was performed between March and August 2022. The search was not restricted based on study date. Only English manuscripts were assessed. Reviews, short communications, letters, and correspondences were excluded after reviewing their references for potentially relevant studies. Articles related to non-cosmetic surgeries were also excluded from the study. RESULTS: We identified 152 articles, of which 31 were duplicates and 47 were excluded based on title/abstract assessment. Three non-English manuscripts, 13 reviews, 12 letters to the editor, and 10 articles that did not feature clinical cases were also rejected. Thirty-six articles were included for analysis. We found 370 patients with infective complications following cosmetic surgery. The severity of complications was stratified according to the Clavien-Dindo classification. Most reports were from the United States (56.5%), followed by Switzerland and the United Kingdom. Travel destinations included the Dominican Republic (34.3%), Turkey, and Colombia. CONCLUSION: Infective complications commonly occurred after abdominoplasties in patients who underwent cosmetic surgeries in Latin America or Asia. Most infective complications required management with surgical procedures that involved the administration of local, regional, or general anesthesia. Gluteal augmentations were the fourth most common cosmetic procedures; however, they were associated with the highest number of severe cases, which required intensive care treatment.

Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017.

BACKGROUND: In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries. METHODS: The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held. RESULTS: The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb. CONCLUSION: Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. LEVEL OF EVIDENCE: Systematic review of predominantly level II studies, level II.

Comparison of V-Y Advancement Flap Versus Lotus Petal Flap for Plastic Reconstruction After Surgery in Case of Vulvar Malignancies: A Retrospective Single Center Experience.

Vulvoperineal defects after demolitive surgery for preneoplastic or malignant vulvar lesions require a reconstruction to restore good sexual functions and to offer a satisfactory cosmetic result. Several techniques of reconstruction have been described in the past, leading to a more conservative and localized treatment. This study retrospectively reviewed patients with primary or recurrent vulvar malignancies that had undergone vulvoperineal reconstruction between 2010 and 2016 using the V-Y advancement flap and the 2 variant of the lotus petal flap (LPF) in terms of surgical outcome and postoperative complications. Two hundred eighty-four (284) women were reviewed, 234 of them having undergone V-Y flap and 128, the LPF. Overall, postoperative complications occurred in 21.5% of patients including 21% (27/128) of the V-Y group and in 13% (14/106) of the LPF group. The 2 techniques are valid and feasible for vulvar reconstruction in case of moderate defects. No statistically significant differences in terms of complications were observed between the 2 groups overall (P = 0.588), or by comparing the primary (P = 0.202) or the recurrent setting (P = 0.281). Lotus petal flap, particularly the tunneled variant, was superior to V-Y advancement flap in terms of functional and cosmetic results in patients undergoing resection for primary vulvar malignancies.

Changes in subcutaneous adipose tissue microRNA expression in HIV-infected patients.

OBJECTIVES: We evaluated the possibility that a pattern of abnormal microRNA (miRNA) expression could be fuelling the mechanisms causing HIV-associated lipodystrophy (HAL). METHODS: In this case-control study, samples of subcutaneous adipose tissue from eight consecutive HIV-infected patients on combination antiretroviral therapy with HAL (cases) were compared with those of eight HIV-negative subjects (controls). Human miRNA microarrays were used to probe the transcriptomes of the samples. Analysis of differentially expressed miRNAs was performed using DataAssist v2.0 software, applying a paired Student's t-test. RESULTS: Data showed that 21 miRNAs out of 754 were overexpressed in the patient group. Ten of these (i.e. miR-186, miR-199a-3p, miR-214, miR-374a, miR-487b, miR-532-5p, miR-628-5p, miR-874, miR-125-b-1* and miR-374b*) were up-regulated to a significant degree (fold change >2.5; P < 0.01). Eleven other miRNAs (i.e. miR-let-7d, miR-24, miR-30c, miR-125a-3p, miR-149, miR-191, miR-196-b, miR-218, miR-342-3p, miR-452 and miR-454*) were 2- to 2.5-fold more expressed in HIV+ samples than in controls. Levels of mRNA for lipin 1, the target of miR-218, were significantly lower in subcutaneous adipose tissue from HIV patients. CONCLUSIONS: In adipocytes of HIV-infected patients, the up-regulation of specific miRNAs could lead to an increased 'activation' that might contribute to the pathogenesis of HAL by increasing cell turnover and/or promotion of apoptosis.

Tunneled modified lotus petal flap for surgical reconstruction of severe introital stenosis after radical vulvectomy.

INTRODUCTION: We presented the anatomical, functional and aesthetic results achieved with lotus petal flap in case of introital stenosis as a results of inadequate primary plastic reconstruction. We discussed the potential advantages of lotus petal flap compared to others vulvar reconstructive techniques. PRESENTATION OF CASE: We report a case of a 44-years old woman presenting a severe introital stenosis following radical surgery for vulvar cancer. She could not have a normal sexual activity life because the narrow scarred introitus resulting after primary closure of a large vulvar defect. The patient comes to our attention after three years from primary surgery. Once the scar was removed we performed a vulvoperineal reconstruction with bilateral tunneled lotus petal flaps. DISCUSSION: Lotus petal flap is a safe, easy and quick technique, has a good functional and cosmetic results in this young woman, and represents an optimal alternative solution for plastic reconstruction in case of severe introital stenosis after primary closure of large vulvoperineal defect. CONCLUSION: Tunneled lotus petal flaps represents a feasible, attractive and versatile surgical reconstructive technique that can be easily performed after surgical treatment of vulvoperineal neoplasms.

Outcomes with respect to disabilities of the upper limb after hand allograft transplantation: a systematic review.

The aim of this work is to compare disabilities of the upper limb before and after hand allograft transplantation (HAT), and to describe the side effects of immunosuppressive (IS) agents given to recipients of hand allografts. Clinical cases of HAT published between 1999 and 2011 in English, French, or German were reviewed systematically, with emphasis on comparing disabilities of the arm, shoulder and hand (DASH) scores before and after transplantation. Duration of ischemia, extent of amputation, and time since amputation were evaluated for their effect on intrinsic musculature function. Infectious, metabolic, and oncological complications because of IS therapy were recorded. Twenty-eight patients were reported in 56 clinical manuscripts. Among these patients, disabilities of the upper limb dropped by a mean of 27.6 (±19.04) points on the DASH score after HAT (P = 0.005). Lower DASH scores (P = 0.036) were recorded after secondary surgery on hand allografts. The presence of intrinsic muscle function was observed in 57% of the recipients. Duration of ischemia, extent of transplantation, and time since amputation were not associated statistically with the return of intrinsic musculature function. Three grafts were lost to follow-up because of noncompliance with immunosuppression, rejection, and arterial thrombosis, respectively. Fifty-two complications caused by IS agents were reported, and they were successfully managed medically or surgically. HAT recipients showed notable functional gains, but most complications resulted from the IS protocols.