Reconstructive Paradigms: A Problem-Solving Approach in Complex Tissue Defects.

The field of plastic surgery is continuously evolving, with faster-emerging technologies and therapeutic approaches, leading to the necessity of establishing novel protocols and solving models. Surgical decision-making in reconstructive surgery is significantly impacted by various factors, including the etiopathology of the defect, the need to restore form and function, the patient's characteristics, compliance and expectations, and the surgeon's expertise. A broad surgical armamentarium is currently available, comprising well-established surgical procedures, as well as emerging techniques and technologies. Reconstructive surgery paradigms guide therapeutic strategies in order to reduce morbidity, mortality and risks while maximizing safety, patient satisfaction and properly restoring form and function. The paradigms provide researchers with formulation and solving models for each unique problem, assembling complex entities composed of theoretical, practical, methodological and instrumental elements.

Lowered hyoid bone overlapping the thyroid cartilage in CT angiograms.

BACKGROUND: The ventral enclosure of the thyroid cartilage by a collapsed hyoid bone (CHB) is poorly encountered in previous research. It was aimed to observe whether or not these malformations could be found and detailed anatomically in a consistent lot of computed tomography (CT) files. METHODS: Two hundred archived CT angiograms were explicitly observed for the CHB anatomical variant. RESULTS: Different possibilities of CHB were found in 6/200 cases, five males and one female. The symmetrical overlap of the thyroid cartilage by the hyoid body was found in one male case. In three cases, two males and one female, there was asymmetrical overlapping due to tilted hyoid bones. In one male case with such asymmetrical CHD, an ossified anterior longitudinal ligament was noted: the tips of the superior horns of the thyroid cartilage reached lateral to it, thus being retropharyngeal. A different male case had a lowered hyoid with a greater horn fused to the superior horn of the thyroid cartilage, with an interposed ossified triticeal cartilage. In the last male case, the right greater horn collapsed laterally to an ossified triticeal cartilage fused with the thyroid cartilage's superior horn. CONCLUSIONS: The CHB is an undeniable anatomical possibility of an atavism that alters conventional anatomical and surgical landmarks. Different anatomical components of the hyoid bone can descend uni- or bilaterally.

Anatomical Variations of the External Jugular Vein: A Pictorial and Critical Review.

(1) Background: The external jugular vein (EJV) descends on the sternocleidomastoid muscle to drain deep into the subclavian vein. Anatomical variations of the EJV are relevant for identification of the greater auricular nerve, flap design and preparation, or EJV cannulation. (2) Methods: Different publications were comprehensively reviewed. Dissections and three-dimensional volume renderings of peculiar cases were used to sample the review. (3) Results: Different anatomical possibilities of the EJV were critically reviewed and documented: fenestrations and double fenestrations, true or false duplications, triplication, absence, aberrant origin or course, or bifurcation. Tributaries of the EJV, such as the facial and posterior external jugular veins, are discussed. The internal jugular vein termination of the EJV is also presented. (4) Conclusions: Care should be taken when different morphological features of the EJV are encountered or reported.

Launay's External Carotid Vein.

Background and Objectives: Launay's external carotid vein (ECV) is poorly represented in the anatomical literature, although it is an occasional satellite of the external carotid artery (ECA). We aimed to establish the incidence and morphology of the ECV. Materials and Methods: One hundred computed tomography angiograms were investigated, and ECVs were documented anatomically, when found. Results: Launay's vein was found in 3/200 sides (1.5%) in a male and two female cases. In two of these cases, the ECV was a replaced variant of the anterior division of the retromandibular vein (RMV), and the facial vein (FV) ended in the external jugular vein. In the third case with the ECV, the RMV was absent and the common FV that resulted from that ECV and the FV drained into the internal jugular vein. The ECV could also appear as an accessory RMV, not just as a replaced one. Additional variants were found, such as fenestration of the external jugular vein (EJV), the extracondylar vein draining the deep temporal veins and an arterial occipitoauricular trunk. Conclusions: Surgical dissections of the ECA in the retromandibular space should carefully observe an ECV to avoid unwanted haemorrhagic events. Approaches of the neck of the mandible should also carefully distinguish the consistent extracondylar veins.

True terminal pentafurcation of the external carotid artery and terminal trifurcation of the contralateral one, occipitoauricular trunk, retropharyngeal internal carotid artery.

The external carotid artery (ECA) commonly ascends in the retromandibular fossa and bifurcates posteromedial to the neck of the mandible into the maxillary (MA) and superficial temporal (STA) arteries. In its course in the neck, the ECA gives off the superior thyroid, lingual (LA), facial (FA), ascending pharyngeal (APA), occipital (OA) and posterior auricular (PAA) arteries. When the computed tomography angiograms of a 65-year-old male were evaluated, extremely rare anatomical variations of both ECAs were found. The right ECA trifurcated terminally at the neck of the mandible into the MA, STA and middle meningeal artery (MMA). A right occipitoauricular trunk was found coursing posterior to the ECA to further divide in the parotid region into the OA and PAA. The left ECA had a terminal pentafurcation, with the FA/APA/OA/MA/STA pattern, and the PAA branched from the STA. This pentafurcation occurred deep to the angle of the mandible and the medial pterygoid muscle, in front of the internal jugular vein. The MA ascended behind the medial pterygoid muscle, deep to the posterior border of the ramus of the mandible and reached the lateral pterygoid muscle to continue normally. The right internal carotid artery (ICA) had a lower medial curvature intercalated between the third cervical vertebra and the pharynx. To the authors' knowledge, a terminally pentafurcated ECA has not been previously recorded, and a terminal trifurcation with an added MMA has only been observed once. Such drastically modified arterial patterns expose the branches emerging from the pentafurcation and pose a risk during surgical approaches within the parotid region. Additionally, a retropharyngeal curvature of the ICA could be subject to compression during deglutition.

Clinical, histological and therapeutic modern approach of Ledderhose disease.

Ledderhose disease or plantar fibromatosis is a rare hyperproliferative disorder of the plantar aponeurosis, clinically characterized by nodules situated especially on the medial border of the foot. It is histopathologically associated with Dupuytren's disease. This disease has some risk factors, like old age, alcohol or nicotine abuse, liver dysfunction, trauma or exposure to vibrations and autoimmune disorders, but the exact etiology is still unknown. Even though it is benign, the local manifestations can be aggressive, leading to debilitating deformities and contractures of the toes. Ultrasound and magnetic resonance imaging are used to confirm the diagnosis and to eliminate other disorders. Whenever is possible, the conservative therapies are recommended. Having a high recurrence, Ledderhose disease can be hard to treat, needing multiple surgical interventions. This paper aims to cover all the important aspects of this disease for daily medical practice, from history to clinical manifestations, diagnostic methods and histopathological features, to conservative and surgical treatment modalities.

The interdisciplinary approach of an aggressive giant cell tumor of bone complicated with a fracture of the distal femur.

Giant cell tumor of bone (GCTB) represents one of the commonest bone tumors encountered by an orthopedic surgeon. The giant-cell tumor is generally classified as benign but the fast growing rhythm and the aggressive soft-tissue invasion may in some cases demonstrate a malign potential of the tumor. We present the case of an aggressive giant cell tumor in a young patient that was first diagnosed in our emergency department with a fracture of the distal femur after a low energy trauma. With further examinations, we discovered that the tumor was invading the both femoral condyles and was vascularized by three major arterial pedicles. The onset of his problems was the femoral fracture and the changes on the major vessels, muscles and nerves. After an interdisciplinary approach of the patient and a meticulous preoperative planning, we decided to make an extensive total resection of the tumor followed by a complex reconstruction surgery for the bone. A very stable fixation of a vascularized graft allowed the bone to heal even if the surrounded soft-tissue was almost completely invaded by the tumor and removed during the excision. The follow-up of this case demonstrated that using an interdisciplinary approach of the patient with the Plastic Surgery team, we manage to remove the tumor within oncological limits and achieved bone healing with good stability of the distal femur.

Biphasic synovial sarcoma in a 19-year-old pregnant woman: a case report.

Synovial sarcoma is a rare malignant tumor of mesenchymal multipotent cells. We hereby present a case of synovial sarcoma of the upper left thigh. A 19-year-old patient was referred to our clinic by another hospital in Bucharest, Romania, for a soft tissue mass in the left upper thigh. Local examination of the left thigh revealed a 15÷13 cm, ovoid, painful upon touch, soft tissue mass occupying the proximal-medial aspect of the thigh. Bilateral inguinal nodes' enlargement was noticed. Upon suspecting regional node involvement, the surgical team decided to perform left limb amputation due to tumor size and the proximity to major arterial and nervous trunks as well as the femoral shaft, making curative surgery and 'free of disease' resection margins improbable. The patient refused the operation. The surgical team (plastic surgeon, orthopedic surgeon) decided to attempt limb-sparing surgery. After tumor resection, free-of-disease surgical margins were achieved. The pathological examination as well as the immunohistochemistry (IHC) diagnosed a large biphasic synovial sarcoma warranting oncologic treatment. The association between tumor growth and pregnancy poses important therapeutic problems, such as the use of preoperative chemotherapy, potential pregnancy termination, limb amputation versus limb salvage intervention and types of protocols of chemotherapy or radiotherapy indicated.

Therapeutic protocol using growth factors in electrocution wounds--case reports and review of the literature.

Injuries by high voltage electrocution represent rare and very complex accidents. In order to provide support to surgical therapy, to limit the extension of injuries or to support the natural process of tissue repair, we oriented towards the use of two growth factors, insulin and platelet-enriched plasma (PRP) administered locally, on the injury site. The therapeutic protocol was applied on three cases of electrocution with promising results in reducing the duration of surgical and pharmacological treatment and of time of hospitalization. The influence of growth factors on healing wounds, the mechanism of action and recent therapeutic applications are also discussed.