Animal models of vascularized nerve grafts: a systematic review.

The aim of this review is to present and compare the various animal models of vascularized nerve grafts described in the literature as well as to summarize preclinical evidence for superior functional results compared to non-vascularized free nerve grafts. We also will present the state of the art on prefabricated vascularized nerve grafts. A systematic literature review on vascularized nerve graft models was conducted via the retrieval with the PubMed database on March 30, 2019. Data on the animal, nerve, and vascularization model, the recipient bed, the evaluation time points and methods, and the results of the study results were extracted and analyzed from selected articles. The rat sciatic nerve was the most popular model for vascularized nerve grafts, followed by the rabbit; however, rabbit models allow for longer nerve grafts, which are suitable for translational evaluation, and produced more cautious results on the superiority of vascularized nerve grafts. Compared to free nerve grafts, vascularized nerve grafts have better early but similar long-term results, especially in an avascular bed. There are few studies on avascular receiving beds and prefabricated nerve grafts. The clinical translation potential of available animal models is limited, and current experimental knowledge cannot fully support that the differences between vascularized nerve grafts and free nerve grafts yield a clinical advantage that justifies the complexity of the procedure.

Intestinal malrotation in a female newborn affected by Osteopathia Striata with Cranial Sclerosis due to a de novo heterozygous nonsense mutation of the AMER1 gene.

BACKGROUND: Osteopathia Striata with Cranial Sclerosis (OS-CS), also known as Horan-Beighton Syndrome, is a rare genetic disease; about 90 cases have been reported to date. It is associated with mutations (heterozygous for female subjects and hemizygous for males) of the AMER1 gene, located at Xq11.2, and shows an X-linked pattern of transmission. Typical clinical manifestations include macrocephaly, characteristic facial features (frontal bossing, epicanthal folds, hypertelorism, depressed nasal bridge, orofacial cleft, prominent jaw), hearing loss and developmental delay. Males usually present a more severe phenotype than females and rarely survive. Diagnostic suspicion is based on clinical signs, radiographic findings of cranial and long bones sclerosis and metaphyseal striations, subsequent genetic testing may confirm it. CASE PRESENTATION: Hereby, we report on a female newborn with frontal and parietal bossing, narrow bitemporal diameter, dysplastic, low-set and posteriorly rotated ears, microretrognathia, cleft palate, and rhizomelic shortening of lower limbs. Postnatally, she manifested feeding intolerance with biliary vomiting and abdominal distension. Therefore, in the suspicion of bowel obstruction, she underwent surgery, which evidenced and corrected an intestinal malrotation. Limbs X-ray and skull computed tomography investigations did not show cranial sclerosis and/or metaphyseal striations. Array-CGH analysis revealed normal findings. Then, a target next generation sequencing (NGS) analysis, including the genes involved in skeletal dysplasias, was performed and revealed a de novo heterozygous nonsense mutation of the AMER1 gene. The patient was discharged at 2 months of age and included in a multidisciplinary follow-up. Aged 9 months, she now shows developmental and growth (except for relative macrocephaly) delay. The surgical correction of cleft palate has been planned. CONCLUSIONS: Our report shows the uncommon association of intestinal malrotation in a female newborn with OS-CS. It highlights that neonatologists have to consider such a diagnosis, even in absence of cranial sclerosis and long bones striations, as these usually appear over time. Other syndromes with cranial malformations and skeletal dysplasia must be included in the differential diagnosis. The phenotypic spectrum is wide and variable in both genders. Due to variable X-inactivation, females may also show a severe and early-onset clinical picture. Multidisciplinary management and careful, early and long-term follow-up should be offered to these patients, in order to promptly identify any associated morbidities and prevent possible complications or adverse outcomes.

Hyaluronic acid and platelet-rich plasma, a new therapeutic alternative for scleroderma patients: a prospective open-label study.

BACKGROUND: Systemic sclerosis is a systemic connective tissue disease characterized by endothelium damage, fibrosis, and subsequent atrophy of the skin. Perioral fibrosis produces a characteristic microstomia together with microcheilia, both of which cause severe difficulties and affects patients' daily life, such as eating and oral hygiene. Since there are no effective and specific therapies, we have aimed at evaluating the response to filler injections of hyaluronic acid together with platelet-rich plasma. METHODS: Ten female patients aged between 18 and 70 were included in this study. Each patient was treated with three filler injections of hyaluronic acid and platelet-rich plasma at an interval of 15 to 20 days. Follow-up check-ups were recorded 1, 3, and 24 months after the end of the treatment. During the therapy and the subsequent follow-up, we evaluated the mouth's opening, freedom of movement of the lips, and skin elasticity. RESULTS: After the treatment, patients had achieved good results already after the first injection and the improvement was maintained in the following months, up to 2 years. In particular, 8 (80%) patients showed a greater mouth's opening and increased upper lip's thickness during 1-month follow-up and maintained these results after 2 years (maximum mouth's opening T0 47.61; T3 49.23; T4 48.60 p <  0.0001. Upper lip's thickness T0 4.20; T3 4.75; T4 4.45 p <  0.0001). Moreover, distance between upper and lower incisors (T0 27.05; T3 29.03; T4 28.14 p < 0.0001), inter-commissural distance (T0 49.12; T3 51.44; T4 50.31: p < 0.0001), and lower lip's thickness (T0 3.80; T3 4.85, 5.10; T4 4.25; p < 0.0001) were increased in all of patients in 1-month follow-up, keeping these benefits after 24 months and having a significant increase of skin elasticity 1 month after the end of therapy. CONCLUSIONS: Our study demonstrates that filler injections of hyaluronic acid and platelet-rich plasma represent an efficient local therapeutic alternative for patients affected by scleroderma. The treatment has significantly improved patients' quality of living.

Microsurgery and external fixation in orthoplastic reconstruction of tibial injuries.

BACKGROUND: "Orthoplastics" is a relatively new approach to lower limb reconstruction, where an integration of both plastic and orthopedic expertise is required, together with the availability of well-equipped facilities. Acute shortening and long-term frames for lengthening are generally considered alternatives to length preservation and soft tissue microsurgical reconstruction, but an integration of external fixation and reconstructive microsurgery is gaining an increasing role with refinements of joint approaches. MATERIAL AND METHODS: Data on sixteen patients who underwent microsurgical lower limb reconstruction and external fixation with an orthoplastic approach, following acute or chronic tibial injury, were retrospectively reviewed. All patients presented a post traumatic soft tissue defect associated with a Gustilo III tibial fracture or a tibial septic pseudarthrosis. Data on type and timing of bone and soft tissue reconstruction, outcomes, complications and need for re-operation were extrapolated and compared to an historic group of patients treated with an orthopedic-based approach. RESULTS: In the orthoplastic group, soft tissues were reconstructed with an ALT flap in most cases; a muscle-sparing VL or ALT-VL chimeric flap was necessary in cases with a very extensive defect. In the orthopedic group, soft tissues were left to heal by second intention or patients were lately referred to plastic surgeons. Statistical comparison between the two groups has showed significant differences on the following data: time for soft tissue healing, time to bone union, number of reinterventions, post-operative deep infection rate, time to return to work. CONCLUSION: The orthoplastic approach to complex leg defects yields shorter treatment time and better functional results compared to the orthopedic-based approach. External fixation and microsurgical reconstruction are not necessarily alternative procedures but can integrate in an orthoplastic path to address at best both soft tissue and bone reconstruction.

A Rare Case of Giant Basal Cell Carcinoma of the Abdominal Wall: Excision and Immediate Reconstruction with a Pedicled Deep Inferior Epigastric Artery Perforator (DIEP) Flap.

BACKGROUND Basal cell carcinoma (BCC) greater than 5 cm in diameter is called giant basal cell carcinoma (GBCC), or super giant basal cell carcinoma if it has a diameter larger than 20 cm. Giant BCC only accounts for 0.5% of BCCs and super giant BCC is exceedingly rare. On account of their rarity, there are no established guidelines for GBCC treatment. CASE REPORT We describe a peculiar case of an 82-year-old woman with a GBCC carcinoma of the lower abdominal wall. The tumor was surgically removed with ipsilateral inguinal lymph nodes and the abdominal wall was reconstructed immediately with a pedicled deep inferior epigastric artery perforator (DIEP) flap. CONCLUSIONS Treatment of giant basal cell carcinoma is often difficult, especially in elderly patients with poor general health and multiple pathologies. The pedicled DIEP flap is rotated to cover the loss of substance without tension, and it is easy to harvest and transfer. This flap allowed a good result without local or systemic complication. We present this report as a reminder of the occasional occurrence of extremely aggressive BCCs. We believe that, especially for rare tumors like these, it is very useful for the entire scientific community to publish these cases and the therapeutic strategies used to treat them.

Combined platelet-rich plasma and lipofilling treatment provides great improvement in facial skin-induced lesion regeneration for scleroderma patients.

BACKGROUND: The use of stem cells, including mesenchymal stem cells (MSCs), for regenerative medicine is gaining interest for the clinical benefits so far obtained in patients. This study investigates the use of adipose autologous tissue in combination with platelet-rich plasma (PRP) to improve the clinical outcome of patients affected by systemic sclerosis (SSc). METHODS: Adipose-derived mesenchymal stem cells (AD-MSCs) and PRPs were purified from healthy donors and SSc patients. The multilineage differentiation potential of AD-MSCs and their genotypic-phenotypic features were investigated. A cytokine production profile was evaluated on AD-MSCs and PRPs from both healthy subjects and SSc patients. The adipose tissue-derived cell fraction, the so-called stromal vascular fraction (SVF), was coinjected with PRP in the perioral area of SSc patients. RESULTS: Histopathological and phenotypical analysis of adipose tissue from SSc patients revealed a disorganization of its distinct architecture coupled with an altered cell composition. Although AD-MSCs derived from SSc patients showed high multipotency, they failed to sustain a terminally differentiated progeny. Furthermore, SVFs derived from SSc patients differed from healthy donors in their MSC-like traits coupled with an aberrant cytokine production profile. Finally, the administration of PRP in combination with autologous SVF improved buccal's rhyme, skin elasticity and vascularization for all of the SSc patients enrolled in this study. CONCLUSIONS: This innovative regenerative therapy could be exploited for the treatment of chronic connective tissue diseases, including SSc.

Multimodal surgical and medical treatment for extensive rhinocerebral mucormycosis in an elderly diabetic patient: a case report and literature review.

Diabetes is a well-known risk factor for invasive mucormycosis with rhinocerebral involvement. Acute necrosis of the maxilla is seldom seen and extensive facial bone involvement is rare in patients with rhino-orbital-cerebral mucormycosis. An aggressive surgical approach combined with antifungal therapy is usually necessary. In this report, we describe the successful, personalized medical and surgical management of extensive periorbital mucormycosis in an elderly diabetic, HIV-negative woman. Mono- or combination therapy with liposomal amphotericin B (L-AmB) and posaconazole (PSO) and withheld debridement is discussed. The role of aesthetic plastic surgery to preserve the patient's physical appearance is also reported. Any diabetic patient with sinonasal disease, regardless of their degree of metabolic control, is a candidate for prompt evaluation to rule out mucormycosis. Therapeutic and surgical strategies and adjunctive treatments are essential for successful disease management. These interventions may include combination therapy. Finally, a judicious multimodal treatment approach can improve appearance and optimize outcome in elderly patients.

Reconstruction of nasal alar defects with freestyle facial artery perforator flaps.

In 2009, we have described the use of freestyle facial artery perforator flaps for one-stage nose reconstruction. Since then, several articles have reported the use of facial artery perforator flaps for nose reconstruction. The purpose of this article is to provide an update of the published technique after 10 years of experience. Since 2004, 21 patients have been treated with a freestyle facial artery perforator flap for one-stage reconstruction of the nasal ala. The flaps were 16 propellers, 4 V-Y, and 1 island transposition. A single venous congestion leading to a minor flap tip necrosis and a wound dehiscence was observed. All other flaps healed uneventfully. The V-Y design and multiple subunit reconstruction gave suboptimal results. It was concluded that indications for freestyle facial artery perforator flaps are total nasal alar subunit reconstruction or reconstruction of lateral alar defects when perforator anatomy allows. In these cases, freestyle facial artery perforator flaps are the first choice technique at our institution because they allow excellent results in one-stage operation. One-stage nasal ala reconstruction with freestyle facial artery perforator flaps.

Propeller flaps: a review of indications, technique, and results.

In the last years, propeller flaps have become an appealing option for coverage of a large range of defects. Besides having a more reliable vascular pedicle than traditional flap, propeller flaps allow for great freedom in design and for wide mobilization that extend the possibility of reconstructing difficult wounds with local tissues and minimal donor-site morbidity. They also allow one-stage reconstruction of defects that usually require multiple procedures. Harvesting of a propeller flap requires accurate patient selection, preoperative planning, and dissection technique. Complication rate can be kept low, provided that potential problems are prevented, promptly recognized, and adequately treated. This paper reviews current knowledge on propeller flaps. Definition, classification, and indications in the different body regions are discussed based on a review of the literature and on the authors' experience. Details about surgical technique are provided, together with tips to avoid and manage complications.

Perioperative antibiotic prophylaxis in plastic surgery: a prospective study of 1,100 adult patients.

BACKGROUND: Although guidelines for antibiotic prophylaxis to prevent surgical site infections (SSIs) exist, specific guidelines for plastic surgery are missing and there is a tendency towards excessive administration of antibiotics. A total of 1100 patients were prospectively studied according to an evidence-based protocol to investigate if limiting antibiotic prophylaxis to high-risk cases does increase the infection rate. METHODS: Between April 2009 and April 2010, 1100 consecutive patients undergoing elective reconstructive or cosmetic procedures were enrolled. Procedures were classified into four groups, and prophylactic antibiotics were only administered perioperatively in 23.4% of cases, according to patient-related and procedure-related risk factors. RESULTS: The overall SSI incidence was 1.4% (1.1% for clean surgery and 3.8% for clean-contaminated surgery). Oral oncologic surgery showed the highest infection rate (5.3%). CONCLUSIONS: Specific guidelines are provided to encourage judicious use of antibiotics. Antibiotic prophylaxis is administered based on the type of operation and the patient's characteristics. No prophylaxis was carried out in superficial skin surgery and simple mucosal excisions. Antibiotic prophylaxis is always indicated in microsurgery, prosthetic surgery, incisional hernias, clean non-prosthetic osteoarticular surgery and clean-contaminated procedures such as oral cavity or genitourinary system. In clean surgery and rhinoplasty, antibiotic prophylaxis is only indicated when the operation lasts more than 3 h and/or the American Society of Anesthesiologists (ASA) score is 3 or more. With the protocol reported, the risk of infection can be kept very low, avoiding the negative effects of indiscriminate use of antibiotics.

The face lift SMAS plication flap for reconstruction of large temporofrontal defects: reconstructive surgery meets cosmetic surgery.

BACKGROUND: Reconstruction of large defects in the temporal region can be performed with skin grafts or pedicled or free flaps. Results are often not optimal because of the patch of a skin graft, lack of availability of local flaps, and distant skin from free flaps. A technique for reconstruction of these defects with local tissue is presented in this article that uses superficial musculoaponeurotic system (SMAS) plication to allow wide advancement of a cervicofacial flap. METHODS: Once the defect is outlined, a face-lift-like skin incision is used to raise the flap. The SMAS is plicated with two purse-string sutures that relieve tension on the flap and allow maximal advancement. Thirteen face-lift SMAS plication flaps were used in 12 patients (mean age, 70.2 years) after cancer resection, which was bilateral in one case. Defects up to 8 cm in largest diameter can be closed. In one case of an 8 × 6-cm defect, a 1 × 1.5-cm skin graft was necessary. RESULTS: All flaps healed uneventfully, and no reoperation was necessary. Scars are almost completely hidden and the cosmetic result is satisfactory. The asymmetrical face-lift effect fades out within 6 months. CONCLUSIONS: The face-lift SMAS plication (FLISP) flap allows reconstruction of large defects in the temporal region with a local flap providing an excellent cosmetic result and avoiding the need for distant tissue and multiple scarring. This flap provides an example of how reconstructive surgery and cosmetic surgery are complementary and can be mutually beneficial.

Anatomic study on the transverse cervical vessels perforators in the lateral triangle of the neck and harvest of a new flap: the free supraclavicular transverse cervical artery perforator flap.

BACKGROUND: Vessels in the supraclavicular area and their contribution to skin vascularization have always been studied for flaps planning in head and neck reconstruction and many pedicled flaps have been described based on those vessels. Little has been written instead about the vascularization of the supraclavicular skin itself for the use as a free flap. The purpose of this anatomical study was to assess the vascularization of the supraclavicular skin and the possibility of finding an adequate pedicle to harvest it as a free flap in order to close the donor site directly. METHODS: A total of 25 cadavers, 10 formalin fixed and 15 fresh, have been studied in cooperation with the Division for Clinical-Functional Anatomy, Department of Anatomy, Histology and Embryology, Innsbruck Medical University, Innsbruck, Austria and the Laboratoire d'Anatomie, Universiteé R. Descartes, Paris, France. RESULTS: The supraclavicular skin was nourished by perforators coming from the transverse cervical artery and constantly present in an average number of four. Venous drainage was accomplished through the superficial cervical vein, and not through the venae comitantes of the transverse cervical artery. CONCLUSIONS: Based on the results of this investigation, a free supraclavicular transverse cervical artery perforator (STCAP) flap seems to be feasible pedicled on perforators from the transverse cervical artery and drained by the superficial cervical vein. Due to its thickness and skin texture, it can be indicated for facial and intraoral defects, with the limitations of a relatively short pedicle. Primary closure of the donor site can be accomplished concealing the scar in the neck crease.

Vascular anatomy of the supraclavicular area revisited: feasibility of the free supraclavicular perforator flap.

BACKGROUND: The supraclavicular skin has been studied extensively and used as a pedicled flap for face and neck reconstruction. Its use as a free flap has not paralleled its use as a pedicled flap. The authors performed an anatomical investigation to assess the possibility of harvesting a free supraclavicular flap with the donor-site scar lying in the supraclavicular crease. In this article, the authors present the results of their anatomical study together with the preliminary clinical applications. METHODS: Skin vascularization and feasibility of a free supraclavicular perforator flap were studied on 25 cadavers (15 fresh cadavers injected with colored latex at the Universiteé René Descartes in Paris; and 10 formalin-fixed, noninjected cadavers at the Innsbruck Medical University). The flap was used in two patients at the Plastic Surgery Department of the University of Palermo for a cutaneous facial reconstruction and intraoral reconstruction after cancer excision. RESULTS: An average of four perforators were consistently found in the supraclavicular area coming from the transverse cervical artery. Venous perforators drain into the superficial venous plexus rather than into the venae comitantes of the transverse cervical artery. Two flaps were successfully used based on these vessels. CONCLUSIONS: The vascularization of the supraclavicular skin depends on skin perforators coming from the transverse cervical artery and draining into the superficial venous plexus. Based on these vessels, a reliable free supraclavicular flap seems to be safe to harvest, with the scar hidden in the supraclavicular crease. The preliminary clinical applications of such a flap gave promising results, suggesting its potential applications.

Superior pedicle retroauricular island flap for ear and temporal region reconstruction: anatomic investigation and 52 cases series.

BACKGROUND: On the basis of a previously published anatomic study on the superior auricular artery (SAA) and on a series of 52 consecutive cases, the authors propose a new superior pedicle retroauricular island flap (SP-RIF) for defects of the upper half of the ear and for temporal region or superficial helical defects. METHODS: Twenty five auricular regions were dissected after colored latex injection in the carotid artery of 13 fresh cadavers to investigate the SAA. A SP-RIF was used in 52 consecutive cases after tumor excision. In 51 cases, the defect involved the upper half of the ear. In one case, the defect was in the temporal region. RESULTS: The SAA originates either from the superficial temporal artery (44%) or from its parietal branch (56%). Length, caliber, and course have been assessed. Esthetic results of the reconstruction were excellent. There were no major complications in this series. No sequelae at the donor site were recorded. CONCLUSIONS: The SP-RIF can be considered as a first choice option to repair nonmarginal losses of substance of the upper half of the ear. Because of its wide arc of rotation, it can also be used for superficial marginal defects of the helix and in selected cases of temporal region defects.

Static treatment of paralytic lagophthalmos with autogenous tissues.

BACKGROUND: Long-standing facial paralysis is frequently seen in patients who have undergone surgical procedures with sacrifice of the facial nerve and have never been counseled about limiting its consequences. Lagophthalmos must always be treated in these patients to protect vision. The authors describe their techniques of static treatment for lagophthalmos using autologous tissues and their classification system for standardizing patients. METHODS: From July 2001 to September 2005, 12 patients (9 men and 2 women) ranging in age from 37 to 77 years (mean, 58.5 years) were treated. Their paralysis was attributable to acoustic neuroma resection in seven cases, to resection of a cerebral vascular anomaly in two cases, and to total parotidectomy with facial nerve sacrifice in three cases. The patients were treated with elongation of the levator palpebrae superioris muscle using a fascia lata graft, bolstering of the lower eyelid with a conchal cartilage graft, or both, combined with a Kuhnt type resection when needed. RESULTS: Complete closure was achieved for nine patients (75%). For all the patients, resolution of symptoms and keratitis was achieved. No complications were observed. The follow-up period ranged from 14 to 51 months (mean, 39.5 months). The cosmetic outcome also was satisfactory. CONCLUSIONS: For candidates eligible to undergo static treatment of lagphthalmos, the techniques described may be considered valuable options for the correction of lagophthalmos using autologous tissues, thus avoiding the complications related to alloplastic material implantation.