Primary Central Nervous System Posttransplant Lymphoproliferative Disease in a Bilateral Transfemoral Lower Extremity Transplantation Recipient.

Posttransplant lymphoproliferative disorder (PTLD) is a heterogeneous group of clinical and pathological entities characterized by malignant lymphoid cell proliferation occurring after solid organ transplantation, with frequent extranodal involvement. Central nervous system (CNS) involvement occurs in 7-15% of the cases and it is a significant negative prognostic factor. A case of primary CNS (PCNS) PTLD in the first bilateral lower limb transplant recipient is presented.

Single-stage reconstruction of flexor tendons with vascularized tendon transfers.

The reconstruction of finger flexor tendons with vascularized flexor digitorum superficialis (FDS) tendon grafts (flaps) based on the ulnar vessels as a single stage is not a popular technique. We reviewed 40 flexor tendon reconstructions (four flexor pollicis longus and 36 finger flexors) with vascularized FDS tendon grafts in 38 consecutive patients. The donor tendons were transferred based on the ulnar vessels as a single-stage procedure (37 pedicled flaps, three free flaps). Four patients required composite tendon and skin island transfer. Minimum follow-up was 12 months, and functional results were evaluated using a total active range of motion score. Multiple linear regression analysis was performed to evaluate the factors that could be associated with the postoperative total active range of motion. The average postoperative total active range of motion (excluding the thumbs) was 178.05° (SD 50°). The total active range of motion was significantly lower for patients who were reconstructed with free flaps and for those who required composite tendon and skin island flap. Age, right or left hand, donor/motor tendon and pulley reconstruction had no linear effect on total active range of motion. Overall results were comparable with a published series on staged tendon grafting but with a lower complication rate. Vascularized pedicled tendon grafts/flaps are useful in the reconstruction of defects of finger flexor tendons in a single stage, although its role in the reconstructive armamentarium remains to be clearly established.

Bilateral transfemoral lower extremity transplantation: result at 1 year.

Upper limb transplantation has become a treatment option for upper limb amputees with good midterm results. Lower extremity transplantation has never been considered for fear of poor results. The authors present a bilateral transfemoral transplantation of lower extremities performed to a 22-year patient at 12 months of follow-up. The donor was a full HLA-mismatched female multiorgan donor. CMV status was D-/R-. A primary CMV infection coincident with an acute rejection occurred at 3 months and responded to treatment. At 1 year, the Tinel's sign is at malleolar level, there is active knee extension and active plantar flexion of the foot. The patient is walking between parallel bars. Further substantial improvements are expected with longer rehabilitation and follow-up.

Bilateral trans-humeral arm transplantation: result at 2 years.

Unilateral and bilateral hand transplantations have been performed worldwide with good mid-term functional results. An above-elbow bilateral transplantation was performed in a 29-year-old male patient from a fully HLA-mismatched donor. Alemtuzumab induction and steroid-free maintenance immunosuppression with tacrolimus and mycophenolate was used. Due to acute rejection, steroids were introduced at 6 months. Three acute rejection episodes occurred, one treated with alemtuzumab. New-onset diabetes after transplant, dyslipemia and worsening of previous high blood pressure required treatment. At 26 months post-transplantation, the patient has excellent elbow active movement, active flexion and extension of the thumb and fingers, useful sensation and a gainful job. Based on the functional results of the case reported, bilateral trans-humeral transplantation could be a viable treatment for selected bilateral above-elbow amputees.

Effects of heat deproteinate bone and polynucleotides on bone regeneration: an experimental study on rat.

This experimental study evaluated the effects of polynucleotides on bone regeneration on rats. Defects with a diameter of 2mm were prepared in the thickness of cortical bone of 32 rat tibiae and filled with different compounds: polynucleotide gel (PDRN), deproteinated porcine cortical bone (HDB) obtained by high temperature heating in the form of granules and a paste made of HDB granules and PDRN gel. Bone regeneration of the gaps was histologically analysed after a treatment time ranging from 1 to 12 weeks. Both PDRN and HDB stimulated bone growth and repair, but the paste prepared combining HDB granules and PDRN showed the best performance with faster filling, better osteconductive and biocompatible properties and easier handling. This study suggests that the paste prepared combining HDB and PDRN gel induces rapid bone regeneration in different clinical situations.

Neurovenous superficial inferior epigastric flaps in rats.

BACKGROUND: We performed an experimental study on 46 male rats to evaluate the vitality of superficial inferior epigastric neurovenous flaps performed following different procedures. METHODS: Rats were divided into 5 groups: A (n=6), B (n=10), C (n=10), D (n=10) and E (n=10). On each rat a hemi-abdominal flap based on the superficial inferior epigastric pedicle was raised. In group A the flap was sutured into its original position, isolating it from underlying tissues by a latex glove patch. In group B an arteriectomy of the superficial inferior epigastric artery was performed. In group C the superficial inferior epigastric artery was sectioned at its origin, without dissecting it out of the pedicle. In group D and E the same procedures performed respectively in group B and C were followed, but the epigastric pedicles were immediately explanted for optic microscope observation. Flap vitality in groups A, B and C was checked after 7 days. RESULTS: Flaps in group A appeared completely vital: the glove did not interfere with flap survival. All flaps in group B looked necrotic. In group C, 9 flaps survived completely and 1 flap underwent complete necrosis. Pedicle specimens of the viable flaps (group C) were explanted for observation under the optic microscope. Each specimen from groups C, D, E revealed a rich vascular plexus in the connective tissue around the pedicle. Seven days after surgery, neo-microangiogenesis was evident. CONCLUSIONS: The results witness the importance of perivenous and perineural arterioles for neurovenous flaps survival, also considering the adaptive increase in capillary development in the days following surgery.

A case of life-threatening sepsis after breast augmentation by fat injection.

A case is presented in which an aesthetic breast augmentation by fat injection led a young woman to a life-threatening sepsis due to bilateral mammary abscesses. Immediate and late complications of this procedure are considered; infection is the frightful complication that can lead to septic shock, affecting survival, aesthetic outcome, and reconstruction possibilities of the patient's breasts.

Successful breast reconstruction with a perforator to deep inferior epigastric perforator flap.

The authors report their experience with deep inferior epigastric perforator (DIEP) flap breast reconstruction in which an unusual recipient site was used. Successful anastomosis between a suitable perforating vessel from the internal mammary axis and the deep inferior epigastric bundle was performed, and the advantages of this alternative recipient site (perforator to the DIEP flap) are examined.

Ultrasound assisted liposuction for the palliative treatment of Madelung's disease: a case report.

Benign Symmetric Lipomatosis (Madelung's disease) is a rare disease, characterized by massive fatty deposits in the neck, the shoulders, and the upper extremities. The deformity is associated with chronic alcohol use, malignant tumors of the upper airways, neuropathy, diabetes mellitus, hyperlipidemia, and other metabolic disorders. Although the deformity is prone to recurrence, surgical removal via lipectomy or liposuction provides the only way of palliation. This paper describes the treatment of a 51-year-old man with a history of alcoholism and liver cirrhosis. He reported masses in his cervical and facial regions that had gradually enlarged over a period of 6 years. He also developed respiratory symptoms due to the fatty compression of his upper airways. Our experience with ultrasound-assisted liposuction for the palliative treatment of this disease is reported.

Do superficial epigastric veins of rats have valves?

The rat is a good model for experimental studies on the haemodynamic patterns of free-flap transfer but models involving the superficial epigastric vein have not been supported by the demonstration of the anatomical presence or absence of valves inside it. We performed a morphological study to assess whether or not valves are present inside the superficial epigastric vein of the rat. Segments of superficial epigastric veins were explanted from fifteen Sprague-Dawley rats. The lumen was studied with scanning electron microscopy after longitudinal or transverse incision of the venous walls. No valves were detected and we saw no evidence of their accidental removal. As most human veins do have valves, the clinical implications of haemodynamic data on reverse-flow island flaps obtained in rats must be considered very carefully.

[Plastic surgery in the setting of a public hospital day care unit]. / La chirurgia plastica nell'ambito di un'unità operativa ospedaliera centralizzata di day surgery.

BACKGROUND: The authors describe the advantages and disadvantages of plastic surgery performed in a day-care public hospital unit. METHODS: A retrospective study was made of the day-surgery activities over 16 months (1998-1999) as part of a centralized system. Data were compared to day-surgery activities undertaken in 1997 using a non-centralized system. The study was based in the Macchi Foundation Hospital in Varese. A total of 179 patients were treated from all age group whose clinical, intellectual and social characteristics enabled them to be treated using a day-hospital regime. The pathologies treated can be classified into six groups: benign skin pathologies, malignant skin pathologies, scar pathologies, hand disorders, burns and others. All operations were performed as planned under general, local or regional anesthesia with the help of an anesthetist. RESULTS: The centralized system has a number of advantages of a social and technical kind; there are few disadvantages, mainly consisting in the impossibility of using this approach for emergency surgery and its overall rigidity. CONCLUSIONS: This form of surgery provides a service that stands out for its quality, organisational efficiency and low cost.