Anatomical basis of retrograde thoracic veins flow and its implications in complex thoracic wall reconstructive surgery.

PURPOSE: Internal thoracic veins are increasingly used as recipient's vessels in chest wall reconstructive surgery due to their predictable anatomy and to the possibility to make a double venous anastomosis, exploiting the retrograde flow within them. Over the years, retrograde flow had been explained by the absence of valves in internal thoracic veins, which have been found recently instead. Therefore, our aim is to analyze the retrograde flow and its relationship with valves in the internal thoracic veins. METHODS: We evaluated 32 internal thoracic veins of 16 fresh-frozen specimens with undamaged thoracic cages by dynamic analysis focused on retrograde flow assessment through a partial external circulation system obtained cannulating the subclavian veins. Gross anatomical and morphological evaluations about the presence of valves and their pattern were then made. RESULTS: Efficient, partial, and absent retrograde flow was, respectively, found in 17/30, 8/30 and ITVs and 5/30 internal thoracic veins. Following Arnez's classification, 20/32 Type I and 12/32 Type II internal thoracic veins were identified. Valves were observed in 10/16 specimens (62.50%) corresponding to 36.67% of examined veins (11/30). Three valves were found between the 2nd intercostal space and 12 valves in the 3rd intercostal space. 13/15 valves were bicuspid, 2/15 tricuspid. A significant correlation (p < 0.001) between the retrograde flow and the presence of valves in internal thoracic veins was observed. CONCLUSION: Our study suggests a possible influence of the presence and the number of valves in the efficient retrograde flow of the internal thoracic veins, suggesting that, especially for more complex cases, a preoperative or intraoperative evaluation of the chest wall drainage should be recommended.

Distally Prophylactic Lymphaticovenular Anastomoses after Axillary or Inguinal Complete Lymph Node Dissection Followed by Radiotherapy: A Case Series.

Background and Objectives: Lymphedema is an important and underestimated condition, and this progressive chronic disease has serious implications on patients' quality of life. The main goal of research would be to prevent lymphedema, instead of curing it. Patients receiving radiotherapy after lymph node dissection have a significantly higher risk of developing lymphedema. Through the prophylactic use of microsurgical lymphaticovenular anastomoses in selected patients, we could prevent the development of lymphedema. Materials and Methods: Six patients who underwent prophylactic lymphaticovenular anastomoses in a distal site to the axillary or groin region after axillary or inguinal complete lymph node dissection followed by radiotherapy were analyzed. Patients characteristics, comorbidities, operative details, postoperative complications and follow-up assessments were recorded. Results: Neither early nor late generic surgical complications were reported. We observed no lymphedema development throughout the post-surgical follow-up. In particular, we observed no increase in limb diameter measured at 1, 3, 6 and 12 months postoperatively. Conclusion: In our experience, performing LVA after axillary or groin lymphadenectomy and after adjuvant radiotherapy, and distally to the irradiated area, allows us to ensure the long-term patency of anastomoses in order to obtain the best results in terms of reducing the risk of iatrogenic lymphedema. This preliminary report is encouraging, and the adoption of our approach should be considered in selected patients.

Reconstruction of medial canthal region with orbicularis oculi myocutaneous flap: Our experience.

Reconstructive surgery of the medial canthus is among one of the most challenging due to its complex anatomy and aesthetic features. In this area even the slightest deformity or asymmetry is noticeable. Reconstructive surgery of this anatomical region aims to restore the tissue defect ensuring an appropriate aesthetic and functional feature, restoring colour, thickness and consistency of the replaced tissue. Orbicularis oculi myocutaneous flap is an option to reconstruct the medial canthal region; in this paper the authors present their experience with orbicularis oculi myocutaneous flap in 10 patients with medial canthal malignant lesions. The patients' postoperative period was uneventful, the flaps usually showed some degree of temporary venous congestion during the first days after surgery, and any donor site morbidity was observed: no lid lag, ectropion, ptosis, or other eyelid deformity. This flap offers a similarity in texture, colour, and thickness to the recipient site and a negligible incidence of donor site morbidity, and it can be easily tailored to fit the shape of the soft tissue defect.

When staged surgical treatment can solve bilateral axillary and inguinal severe hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic and debilitating disease that primarily affects the axillary, inguinal and anogenital areas. The treatment requires wide surgical excision of the affected tissue with adequate free margins in order to avoid recurrence. However, axillary and inguinal regions reconstruction after HS excision still represents a big challenge; the large defect can be closed using flaps, which allows more rapid rehabilitation and minimizes the risk of later scar contracture. In this report is discussed our experience with reconstruction of severe bilateral hidradenitis lesions of the axillary and inguinal areas in a young woman. Bilateral thoracodorsal artery perforator flaps were used for the axillary reconstruction while profunda artery perforator flap and direct suture were used respectively for left and right inguinal region.

Safety of Reconstructive Microsurgery in the Elderly Population: a Multicentric Prospective Study.

BACKGROUND: Safety of reconstructive microsurgery in elderly patients is still a topic of debate, because no conclusive evidence exists that provides indications and risk evaluation in elderly patients. The purpose of this study, which the Italian Society for Plastic, Reconstructive, and Aesthetic Surgery (SICPRE) has promoted, is to evaluate the safety and the complication risk of elective reconstructive microsurgery in elderly patients as well as to identify patient- or procedure-related risk factors. The secondary aim is to evaluate the predictive role for complications of the Geriatric 8 score (G8). METHODS: A total of 194 consecutive patients from 18 centers, aged 65 or older, who received an elective microsurgical flap between April 2018 and April 2019 were prospectively evaluated. Patient-related, treatment-related, and outcomes data were recorded and statistically analyzed through multiple-adjusted logistic regression models. RESULTS: Our study showed an increased risk of complications and a longer hospitalization in patients aged ≥75 years with the American Society of Anesthesiologists (ASA) score ≥3 (or G8 score ≤11) as compared to patients >65 years of age and <75 years of age who undergo reconstruction with a microsurgical flap. Instead, flap survival did not significantly vary with age, but was associated only with ASA score ≥3 (or G8 score ≤11) and surgeries that last longer than 480 min; however, flap survival (92.3%) was slightly lower than that commonly reported for in the general population. CONCLUSIONS: Reconstructive microsurgery in the elderly is generally safe. The ASA score is easier and quicker than the G8 score and equally useful for risk stratification.

Full-thickness lower eyelid reconstruction with a conchal chondro-perichondral graft and local coverage with Mio-cutaneous flaps--our divisional experience.

BACKGROUND: Eyelid reconstruction represents a challenge because of the complexity of this structure. Full-thickness eyelid defects demand the reconstruction of 2 fundamental elements: anterior and posterior lamellae. The available reconstructive techniques are all associated with the attention to restore the support and responsibility of eyelid stability, represented physiologically by the tarsus. In 1987, Matsuo proposed a reconstructive technique that involved the use of a chondro-perichondral graft harvested from the auricular concha to reconstruct the posterior lamella, and an adjacent skin flap to restore the anterior lamella. MATERIALS AND METHODS: We report our divisional experience of a series of 28 patients operated on from 2000 to 2004, whose eyelid restoration was achieved with the use of Matsuo's technique modified with the purpose to avoid complications such as ectropion or lagophtalmus. RESULTS: All the grafts survived, and no major complication such as ectropion or lagophthalmos has been detected. Our specialistic judgment has ranged from good to excellent regarding symmetry, eyelid closure, and donor site morbidity. Patients were entirely satisfied with the functional result obtained, and generally with the esthetic outcome also, judged as ranging from good to extremely satisfactory. CONCLUSIONS: The success of eyelid reconstruction using modified Matsuo's technique depends, in our minds, on an adequate knowledge of traditional eyelid reconstruction methods, and on a few technical fine points that help to reduce postoperative complications and to optimize the quality of the end result; hence, this technique has become the gold standard in lower eyelid reconstruction in our division.