Treatment of Advanced Male Genital Lymphedema With a Complete Functional Lymphatic System Pedicled Transfer.

OBJECTIVE: To evaluate the functional efficacy of the superficial circumflex iliac artery perforator (SCIP) -lymphatic pedicled flap in the treatment of advanced male genital lymphedema. METHODS: From February 2018 to January 2022, we treated 26 male patients with scrotal and penoscrotal advanced lymphedema using reconstructive lymphatic surgery. Isolated scrotal involvement was seen in 15 patients, and 11 patients had penoscrotal involvement. Excision of genital lymphedematous fibrotic tissue was followed by reconstruction utilizing the SCIP-lymphatic flap. Patient characteristics, intraoperative data, and postoperative results were evaluated. RESULTS: The mean patient age was 39 ± 4.6, and the mean follow-up time was 44.9 months. the SCIP-lymphatic flap was used to reconstruct partial (n = 11) or total (n = 15) scrotum and used to reconstruct total penile skin in 9 cases and partial in 2 cases. The flap survival rate was 100%. Cellulitis rates were dramatically reduced after reconstruction (P value <.001). The mean genital lymphedema score (GLS) after surgery was 0.05, which was significantly lower than the preoperative 1, 6.2 (P < .001). The median Glasgow Benefit Inventory (GBI) total score was +41, all 26 patients (100%) showed a degree of quality of life improvement. CONCLUSION: The pedicled SCIP lymphatic transfer approach in advanced male genital lymphedema can provide a durable complete functional lymphatic system that improves the appearance and genital lymphatic drainage. This leads to an improvement in quality of life as well as in sexual functions.

The durability of thin superficial circumflex iliac artery perforator flap in sole reconstruction: Clinical experience with 18 cases.

BACKGROUND: The superficial circumflex iliac artery perforator flap's overall success in the reconstruction of the lower limb has been acceptable, but the sole of the foot remains more challenging. The purpose of this article is to report our experience employing the SCIP flap and evaluate its durability in reconstructing different units of the foot's sole, heel, middle, and forefoot. PATIENTS AND METHODS: This retrospective study reviewed 18 patients with sole defect reconstructed with free SCIP flap from 2017 to 2019. 18 free SCIP flaps were harvested depending on the superficial branch of SCIA (n = 16) or deep branch (n = 2). All flaps were thin and elevated above the scrapa's fascia. The heel (n = 10), middle foot sole (n = 5), forefoot sole (n = 2), and combined heel and midfoot in one patient were among the defect locations. Sole defects were caused by trauma in 10 patients (55.5%), while the rest of the causes were melanoma (three patients, 16.7%), diabetic ulcer (three patients, 16.7%), and unstable scar (one patient), and calcaneal osteomyelitis (one patient). The defect size ranged from 24 to 230 cm2 . RESULTS: The flap dimensions ranged from 6 × 4 to 18 × 11 cm. Mean follow-up observations were 42.5 months. 72.2% of our patients developed protective sensation between 12-18 months. No ulcerations were observed, and all of the patients had successful functional recoveries with satisfying cosmetic outcomes. CONCLUSION: The SCIP flap can be an optimal durable skin flap for weight-bearing sole reconstruction. SCIP flap has the advantage of being thin minimizing the problem of shearing, the need for secondary procedures, and the faster recovery of protective sensation that could prevent ulceration.

Facial Reanimation With Free Latissumus Dorsi Muscle Transfer, a Comparative Study Between Lateral and Supine Approach.

ABSTRACT: In this article, the authors present the versatility of the Latissmus dorsi muscle as a donor option in facial reanimation and compare between different approaches in harvesting this muscle.The study included 24 Latissimus Dorsi (LD) functional muscles were transferred for smile reanimation of complete facial palsy. The patients were classified into 2 groups in which the muscle either harvested with supine or lateral (trans-axillary) approach. Muscle harvesting time, total operating times, blood loss, and bulkiness of the flap were analyzed and compared. The hypoglossal nerve was used in 14 cases, the masseteric nerve in 4 cases, and the lower trunk of the facial nerve was used in 6 cases as adonor nerve. No microvascular complications were observed, hematoma occurred in 2 cases only. No donor site complications in any of the cases.The trans-axillary approach provides less operative time, blood loss, and donor site morbidity, while the classic approach is easier and has the advantage of skin paddle in complex cases.

Treatment of secondary scrotal and lower extremity lymphedema using combined pedicled lymph node transfer and lymphaticovenous anastomosis: A case report.

Combined secondary scrotal and lower extremity lymphedema is an infrequent complication of radical excision of urogenital cancers associated with pelvic lymphadenectomy. Scrotal lymphedema is usually psychologically distressing, and difficult to treat. We report a case of a 41-years old male who presented with scrotal and left lower extremity lymphedema after radical prostatectomy and pelvic lymphadenectomy successfully treated with pedicled superficial inguinal lymph node (SILN) transfer and lymphaticovenous anastomosis (LVA) restoring the lymphatic drainage. The flap consisted of subscarpal adipofascial tissue between the level of the inguinal ligament and the groin crease measuring 11 × 7 cm. The flap composed of afferent lymphatics from the lower abdomen, lymph nodes, and fatty tissue without skin, the right-sided flap was transposed to the root of scrotum while the left one to the proximal left thigh, then two-level LVA were performed in the left extremity. The surgery went uneventful with no postoperative complications. At a 9 month follow-up, there was a significant reduction of the scrotal volume with a reduction of excess volume of the lower extremity from 49.6 to 9.4% compared with the healthy side. No cellulitis was reported during the follow-up period with improvement in the patient's clinical symptoms and quality of life. We believe that pedicled superficial inguinal lymph node flap together with LVA is a reliable and safe treatment option for either scrotal or lower extremity lymphedema following pelvic cancer treatment.

3D printing guided surgery in the treatment of unicoronal craniosynostosis orbital dysmorphology.

PURPOSE: The purpose of our study was to improve the minor asymmetries of fronto-orbital advancement (FOA) by introducing a simple model to guide the FOA in unicoronal synostosis which may help saving time and cost. METHODS: A retrospective analysis of 16 consecutive patients with unicoronal synostosis corrected by FOA guided by a guide model. Patients with syndromic craniosynostosis or associated craniofacial anomalies were excluded from the analysis. In all cases, 3D mirror image models were used for guiding unilateral fronto-orbital advancement. Demographic, perioperative, and follow-up data were collected for comparison. Cranial and orbital volumes were documented preoperatively and postoperatively and compared with the non-synostotic side. The postsurgical appearance of the face was documented photographically and then evaluated and scored using the Whitaker scoring system. RESULTS: The study included nine males and seven females. The mean age of the patients at the time of the operation was 20.4 months. The mean follow-up duration was 36 months. Mean operative time was 170 min, mean anesthetic time was 230 min, mean blood loss was 50-80 ml, and the average hospital stay was 4.4 days. No relapse that required surgical correction was reported. There were improvements in the orbital indices and volume to be near equal to the normal side. Excellent to good results were obtained in all patients according to the Whitaker classification system. CONCLUSION: Residual deformity after FOA mandates another tool to optimize the results. Our study introduced a simple, easy, and applicable method to guide the FOA with lesser asymmetries.

Two Abnormal Cell Lines of Trisomy 14 and t(X;14) with Skewed X-Inactivation.

Trisomy 14 is incompatible with live, but there are several patients reported with mosaic trisomy 14. We aimed to study the pattern of X inactivation and its effect on a translocated autosome and to find out an explanation of the involvement of chromosome 14 in 2 different structural chromosomal abnormalities. We report on a girl with frontal bossing, hypertelorism, low-set ears, micrognathia, cleft palate, congenital heart disease, and abnormal skin pigmentations. The patient displayed iris, choroidal, and retinal coloboma and agenesis of the corpus callosum and cerebellar vermis hypoplasia. Cytogenetic analysis revealed a karyotype 45,X,der(X)t(X;14)(q24;q11)[85]/46,XX,rob(14;14)(q10;q10),+14[35]. Array-CGH for blood and buccal mucosa showed high mosaic trisomy 14 and an Xq deletion. MLPA detected trisomy 14 in blood and buccal mucosa and also showed normal methylation of the imprinting center. FISH analysis confirmed the cell line with trisomy 14 (30%) and demonstrated the mosaic deletion of the Xq subtelomere in both tissues. There was 100% skewed X inactivation for the t(X;14). SNP analysis of the patient showed no region of loss of heterozygosity on chromosome 14. Also, genotype call analysis of the patient and her parents showed heterozygous alleles of chromosome 14 with no evidence of uniparental disomy. Our patient had a severe form of mosaic trisomy 14. We suggest that this cytogenetic unique finding that involved 2 cell lines with structural abnormalities of chromosome 14 occurred in an early postzygotic division. These 2 events may have happened separately or maybe there is a kind of trisomy or monosomy rescue due to dynamic cytogenetic interaction between different cell lines to compensate for gene dosage.

Effect of Simvastatin Use in Free Tissue Transfer: An Experimental Study in a Rat Epigastric Free Flap Model.

BACKGROUND: Statins are traditionally used in lowering cholesterol and low-density lipoprotein biosynthesis, but recent reports show their beneficial effect on microcirculation. The aim of this study was to investigate the effect of simvastatin on the microcirculation and in conjunction with aspirin in a rat free epigastric flap model. METHODS: Thirty-six Sprague-Dawley rats were divided into group A (control, n = 12), group B (simvastatin treated, n = 12), and group C (simvastatin and aspirin, n = 12). Bilateral free epigastric skin flap was used to evaluate the effect. At 48 hours, flaps biopsies were evaluated for inflammatory activity, nitric oxide content, and thrombomodulin regulation in the endothelial lining of microvessels. Flap survival was evaluated on day 7. RESULTS: The diameter of microvessels and nitric oxide activity in groups B and C were significantly higher than in group A (p < 0.005 and 0.015, respectively). The perivascular inflammatory cell infiltrates and intravascular adhesions were predominant in group A compared with groups B and C (p < 0.005). Groups B and C demonstrated significant higher degree of thrombomodulin expression. The flap survival rate on day 7 was 70.8% for group A, and 87.5% and 91.7%, respectively, for groups B and C without significance between the two (p = 0.675). CONCLUSION: Simvastatin significantly improves the free flap survival by effective anti-inflammatory, vasodilator, and anticoagulant activities. Combined therapy did not have an antagonistic effect and further study is needed to see synergistic action through different mechanisms.

Infantile Asymmetrical Diffuse Infiltrative Lipomatosis of the Abdomen and Upper Thighs: A Case Report with Long-Term Follow-up.

The authors present the case of an 11-year-old male patient with a diffuse infiltrative lipomatosis involving the abdomen, flanks, and upper thighs by applying body contouring principles at this early age. Abdominoplasty can be used in children for various purposes, including harvesting a full-thickness skin graft in burns or to treat congenital anomalies involving the pelviabdominal area.

Bone Transport Distraction Osteogenesis in the Reconstruction of Pediatric Posttraumatic Calvarial Defects.

Reconstruction of posttraumatic calvarial bone defects in pediatric patients is a challenge due to the growing brain and limited autogenous bone supply. Traditional techniques such as split calvarial and particulate bone grafts are associated with prolonged operative time and significant blood loss, which is a major concern in children under the age of 3 years. Bone transport distraction osteogenesis has proven efficacy and safety in the reconstruction of other craniofacial deformities. This procedure is less invasive and requires shorter operative times and hospital stay. We report our experience with 2 cases of bone transport distraction osteogenesis for the reconstruction of large posttraumatic calvarial defects in pediatric patients.

Extended Bifurcated Superficial Temporal Artery Island Flap for the Reconstruction of a Periorbital Burn: A Case Report.

A 47-year-old man with severe thermal burn injury to the face, including bilateral periorbital regions, presented with bilateral upper and lower ectropion with loss of both eyebrows. The periorbital area was reconstructed with the extended bifurcated superficial temporal artery flap with two islands extending out of territory to restore both eyebrows, lower eyelid, and add length to upper eyelid. After 12 months of the operation, the patient showed complete resolution of postburn sequels in addition to a high grade of satisfaction.

Superficial temporal artery flap for reconstruction of complex facial defects: A new algorithm.

BACKGROUND: A variety of island flaps can be based on the superficial temporal artery with variable tissue composition. They can be used for defect reconstruction, cavity resurfacing, facial hair restoration, or contracture release. METHODS: Seventy-two patients underwent facial reconstruction using a superficial temporal artery island flap from October 2010 to October 2014. The defects had various etiologies, including trauma, burns, tumors, exposed hardware, and congenital causes. We classified the patients by indication into 5 groups: cavity resurfacing, contracture release, facial hair restoration, skin coverage, and combined. The demographic data of the patients, defect characteristics, operative procedures, postoperative results, and complications were retrospectively documented. The follow-up period ranged from 24 to 54 months. RESULTS: A total of 24 females and 48 males were included in this study. The mean age of the patients was 33.7±15.6 years. The flaps were used for contracture release in 13 cases, cavity resurfacing in 10 cases, skin coverage in 17 cases, facial hair restoration in 19 cases, and combined defects in 13 cases. No major complications were reported. Conclusion: Based on our experiences with the use of superficial temporal artery island flaps, we have developed a detailed approach for the optimal management of patients with composite facial defects. The aim of this article is to provide the reader with a systematic algorithm to use for such patients.

Craniofacial Distraction in the Management of Anterior Plagiocephaly: A Novel Idea and a Systematic Review of the Literature.

BACKGROUND: The objective of this work is to present a review of all reports involving the management of unicoronal synostosis with distraction osteogenesis (DO). Also, we have innovated a new method in the treatment of cases of anterior plagiocephaly at a young age using DO. METHODS: We present a case in which anterior plagiocephaly was treated by DO of both metopic and hemicoronal sutures in a 4-month-old female patient. A comprehensive systematic literature review was completed using the search terms "distraction osteogenesis," "unicoronal synostosis," "anterior plagiocephaly," and "craniosynostosis." We excluded all experimental articles and reviewed clinical reports detailing the use of DO in the management of unicoronal synostosis. RESULTS: The study sample of this review consisted of 16 reports published over a period of 17 years that were analyzed in detail. The total number of patients treated by DO was 120, and the mean age at operation was 12 months. In the case presented, successful correction of the unicoronal synostosis was achieved. CONCLUSION: Hemicoronal and metopic suture distraction in anterior plagiocephaly achieves considerable improvement in the midline shift of the anterior cranial base and naso-orbital complex.

Bifurcated Superficial Temporal Artery Island Flap for the Reconstruction of a Periorbital Burn: An Innovation.

BACKGROUND: Facial burns represent between one-fourth and one-third of all burns. The long-term sequelae of periorbital burns include significant ectropion and lagophthalmos as a result of secondary burn contractures in the lower and upper eyelids, in addition to complete or incomplete alopecia of the eyebrows. METHODS: A retrospective study of 14 reconstructive procedures for 12 postburn faces was conducted with all procedures performed since 2010 at the Department of Plastic Surgery, Al-Hussein University Hospital, and at the Craniofacial Unit, Nasser Institute Hospital. Four patients experienced chemical burns, and 8 patients experienced thermal burns. All patients underwent periorbital reconstruction using a bifurcated superficial temporal artery island flap to reconstruct the eyebrows, correct the lagophthalmos, and release the ectropion in both the upper and the lower eyelids. Two patients underwent bilateral periorbital flap reconstruction. The mean age of patients was 29 years, and the study was conducted on 8 males and 4 females. Patient satisfaction was assessed using a questionnaire completed by all patients postoperatively. RESULTS: The complete release of both the upper and the lower eyelids was achieved in all cases, together with ideal replacement of brow hair; no complications were noted, apart from one case in which a loss of hair density in the new eyebrow was observed, combined with the partial loss of the flap in the lower eyelid. Patient satisfaction results were collected and assembled in a table. CONCLUSION: A bifurcated superficial temporal artery island flap is an innovative flap for reconstructing both burned eyebrows and eyelids.