Breast Reconstruction with Non-Abdominal Autologous Tissue.

The progresses in surgical field are amazing regarding the possibilities of soft tissue reconstruction. Techniques of breast reconstruction have been evolved since the last 40 years. There was a trend from pedicled flaps toward microsurgical free flaps. In the English literature have been reported several types of free flaps for BR. Although DIEP is the workhorse for the reconstruction, there are patients that do not have enough abdominal tissue to use. In those cases, other donor area such as buttock, thigh, lumbar area has been reported. The present article describes the choices for BR with non-abdominal autologous tissue.

Three Simultaneous Free Flaps to Reconstruct a Complex Frozen Neck and a Large Hypopharyngeal Fistula.

Frozen neck and hypopharyngeal fistula are sometimes present after tumor ablation of the larynx, multiple local surgeries with scar tissue, and radiotherapy and chemotherapy. This multiorgan involvement requires 1 or even 2 flaps. We present a 63-year-old heavy smoker with frozen neck tissue and simultaneous large hypopharyngeal fistula and neck defect. After careful preoperative planning, he was successfully treated with 3 simultaneous free flaps: 2 anterolateral thigh flap (ALT) and 1 lateral arm flap (LAF). One ALT was used as a patch to restore the hypopharynx continuity. A second ALT was used to cover the anterior neck defect and the LAF flap was used to reconstruct the submandibular area. The flaps survived and the patient had a 5 mm proximal fistula which was sutured, and he was able to eat per mouth. By combining multiple free flaps, we were able to restore the function of the hypopharynx and to cover the esthetic units of the neck by avoiding the "turkey neck" appearance.

Strategies for Complex Scalp Reconstruction in Patients With Poor Recipient Vessels.

Complex scalp defects with poor recipient vessels represent a challenge for plastic surgeons. In these cases, free flaps are the last resort for solving the problem. The authors present 5 difficult cases with complex large scalp and calvarium defects with unsuitable small recipient vessels for anastomoses. For these cases, the lesser saphenous vein was harvested and used as an interposition graft between the external carotid artery, the jugular vein, and the flap. Latissimus Dorsi, Anterolateral Thigh, and serratus anterior were the flaps used for reconstruction. Cranioplasty was simultaneously performed in 4 cases. The scalp defects varied from 83 to 288 cm. All flaps survived. In 1 case (extended Latissimus Dorsi) there was local infection and wound dehiscence with marginal flap necrosis that required flap readvancement. In conclusion, end-to-end anastomosis to the external carotid artery offers strong outflow through the vein graft and flap. A large vein graft allows good outflow and is more resistant to the pressure of the skin envelope. Anastomosis to large neck vessels (internal or external jugular) facilitates drainage since there is also an aspiration effect due to the venous flow circulation through it.

Chimeric Lateral Arm Free Flap to Treat Pharyngocutaneous Fistula After Total Laryngectomy.

Pharyngocutaneous fistula is a major complication after total laryngectomy, leading to a severe adverse impact for the patient and social activity. The reported incidence ranges from 9% to 25% in the last decade. In this paper, the authors present our experience using chimeric lateral arm free flap for reconstruction of the pharyngo-esophageal segment. Eight patients with pharyngocutaneous fistula were treated with this technique. The flap has 2 skin islands, each one supplied by a perforator coming from the main pedicle. One skin island is used as a patch for pharynx closure and the other is used for anterior soft tissue coverage. The follow-up period ranged from 8 months to 3 years. All flaps survived. There was 1 small fistula that was sutured. External skin wound dehiscence was present in 1 case and it was secondary closed by itself. All patients were able to eat by mouth and there were no signs of stricture. The authors preferred this type of flap because both defects are simultaneously closed and each skin paddle is supplied by a perforator coming from the main pedicle. It has a better color match than other free flaps. The skin island is thin and remains thin even after the patients gain weight.

Simultaneous Total Esophagectomy and Anterior Mediastinal Tracheostomy for Recurrent Laryngeal Cancer Extended to the Superior Mediastinum.

Recurrent laryngeal cancer has an incidence of 25-50% and a 23-35% fiveyear survival rate. Surgery is the best treatment in order to control local recurrence. Herein, we present our surgical strategy for a patient with a history of modified radical laryngectomy for laryngeal cancer and with recurrent tumor at the cervical tracheostomy site extended to the thoracic trachea and esophagus. The wide resection included the sternal manubrium, the upper thoracic trachea, the entire esophagus and the upper mediastinal lymph nodes. The reconstruction included anterior mediastinal tracheostomy and esophagoplasty with pedicled colonic graft simultaneously with pectoralis major flap for covering the sternal defect.

Anomalies of thoracic outlet in human fetuses: anatomical study.

BACKGROUND: Thoracic outlet syndrome (TOS) identifies the clinical condition determined by the mechanical compression and entrapment of the subclavian vessels and the brachial plexus cords within the space delineated by the scalene muscles, the clavicle, and the first rib. To date, there are no concluding explanations concerning the real causes of the appearance of TOS in children. This is the first study to investigate the existence, frequency, and type of thoracic outlet anomalies in the prenatal stage (human fetuses). METHODS: Eighty cervical dissections (40 consecutive spontaneously aborted human fetuses) were performed, and the musculoskeletal, vascular, and nervous elements that pass through the thoraco-cervico-axillary region were investigated. RESULTS: Overall, anatomical anomalies of the thoraco-cervico-axillary region were found in 60% of the 80 cervical dissections. Nine (22.5%) of the 40 fetuses had normal bilateral anatomy. In 6.3%, the scalene hiatus had an oval shape due to the common costal insertion of the anterior and middle scalene muscles. Fibromuscular bands were found in 15% of the fetuses. Hypertrophy of the anterior scalene muscle was seen in 12.5% of the dissections. In 28.7% of the cervical dissections, hypertrophy of the C7 transversal process was noted, bilateral in seven cases. There was one case of a "C-shaped" clavicle anomaly. The absence of the internal mammary artery was noted in one case. CONCLUSION: This study shows that the presence of TOS anomalies in fetuses is not a rare occurrence, emphasizing a pathological cervical background which can be harmful in situations of cervical trauma or inflammatory processes. Having knowledge of the types of anomalies which can lead to TOS is important for performing a complete surgical correction and avoiding the high failure rate of recurrent TOS.

Simultaneous femoro-popliteal artery bypass and foot free flap for lower limb salvage: a 13-year follow-up.

Critical limb ischemia (CLI) associated with lower extremity complex wounds is challenging for vascular and plastic surgeons. Despite a high risk of perioperative morbidity, complex reconstructive surgery in these patients is an alternative to primary major limb amputation. We present a patient with CLI and a complex foot wound treated with simultaneous femoro-popliteal arterial bypass and free flap for lower limb salvage. The 13-year follow-up showed good functional results.

The role of the pedicle omental flap in ruptured abdominal aortic aneurysm: a case report and literature review.

A ruptured infrarenal abdominal aortic aneurysm (rAAA) is associated with an in-hospital mortality rate of 40% and an overall mortality rate of 60-80%. Open surgical repair for rAAA remains the principal method of treatment when endovascular repair is not available. Graft infection occurs in 1-4% of patients at 5 years, with a high incidence following emergency treatment. Other graft-related complications include pseudoaneurysm, graft occlusion and aorto-enteric fistula. This case report describes a 66-year-old male patient that was admitted to hospital complaining of intense abdominal pain, low blood pressure and tachycardia. He was diagnosed with a rAAA and treated using segmental resection of the abdominal aorta followed by reconstruction with a synthetic Dacron prosthesis. A pedicle omental flap was wrapped around the prosthetic graft and it was also used to fill the retroperitoneal cavity in order to reduce the risk of graft-related complications. Computed tomography angiography after 6 months showed good integration of the aortic prosthetic graft and the viability of the omental flap. In our opinion, vascular surgeons should consider the pedicle omental flap when they perform open surgical repair for rAAA in order to reduce the incidence of graft-related complications.

Polyarteritis Nodosa in Pregnancy.

BACKGROUND: Polyarteritis nodosa (PAN) is a rare disease that occurs predominantly in middle-aged males; its onset during pregnancy is exceptional. CASE REPORT: We present a case of PAN with peripartum onset in a patient with a twin pregnancy after ovarian stimulation for primary infertility. The pregnancy outcome was good in terms of the children's health. In the case of the mother, however, the presence of nonspecific signs and symptoms, a noncontributory ovarian biopsy, and mimics of a puerperal infection delayed the diagnosis of PAN. The emergence of a tender subcutaneous nodule on the forearm and its histopathologic findings were diagnostic. Treatment with pulse methylprednisolone and intravenous cyclophosphamide resulted in the patient's prompt recovery. CONCLUSION: We present the case to stress the value of careful physical examination in unveiling the presence of a rare disease.

How to deal with penile carcinoma inguinal metastases invading femoral vessels.

Penile cancer accounts for 1-10% of men neoplastic diseases and 30-60% of patients have inguinal metastases at the time of diagnosis. Inguinal metastases of penile cancer with femoral vessel involvement could lead to vascular fistula and hemorrhagic shock. We present 3 consecutive patients with inguinal metastases of penile cancer complicated by infection and hemorrhage from femoral vessels invaded by the tumor. Simultaneous extra-anatomical axillo-femoral bypass graft, wide excision of tumor and groin defect reconstruction was used to achieve "tumor-free" oncologic aim and to save the lower limb. We consider the extra-anatomic axillo-femoral bypass associated with wide inguinal tumor excision and defect covering a feasible surgical solution for improving the life quality and extend life expectancy in patients with lymph node metastasis of penile cancer complicated by necrosis, infection and femoral vessel involvement.

Simultaneous Extended ALT Flaps for Foot Salvage After Severe Frostbite.

Plantar area reconstruction represents the most challenging part of the lower limb. The anterolateral thigh (ALT) flap proved to be a versatile flap for this special area. Herein, we present the application of bilateral ALT free flaps for foot salvage after frostbite injury and long-term follow-up. Single perforator bilateral ALT flaps (304 and 320 cm(2)) were harvested and anastomosed to posterior tibial vessels. The lateral femoral cutaneous nerve was anastomosed to the calcaneal branches of the posterior tibial nerve. The two-point discrimination test showed values from 16 to 28 mm in different flap areas 5 years later. The patient is able to walk with crutches. This is the first case report of bilateral ALT for foot salvage.

Mangled lower extremity: can we trust the amputation scores?

BACKGROUND: Limb injuries represent a constant and severe problem. Several lower limb injuries are more frequent than upper limb injuries. Over time, in an attempt to quantify the severity of traumas and to establish guidelines for the decision whether to save or amputate a mangled extremity, several scoring systems have been reported. Most refer to bone fractures, soft tissue damage, vascular, nerves and tendon lesions. MATERIALS AND METHODS: Articles dealing with mangled lower extremities published in the last 15 years were analyzed. Other inclusion criteriaincluded:articles reporting MESS, PSI, LSI, and Gustillo-Anderson scores, studies based on groups of more than 25 patients, and English language articles. We tried to determine if there was good correlation between amputation recommendations and various scores of injury, with regard to combat wounds and civilian injuries, in adult and pediatric groups. RESULTS: Thirty-two papers fulfilled our criteria; in 17 of these, correlation between mangled extremity scores and the decision to amputate or salvage the limb was well-defined. Good correlation between MESS and amputation was found in 25% of the papers. The highest correlation was found for pediatric injuries and combined adult and pediatric combat injuries. CONCLUSIONS: The mangled extremity is a long-lasting, unsolved problem, with much debate and a large number of protocols and scoring systems, but with no unanimously-accepted solution. Many mangled extremities are borderline cases, and the decision to amputate or to salvage a limb must be carefully assessed. With advances in the medical field over the last 15 years, more mangled lower extremities are salvaged, especially in civilian injuries.

Electricity and fishing - a dangerous mix.

BACKGROUND: The advent of fishing rods made of carbon fiber and graphite rods has greatly increased the risks of electrical injuries associated with fishing. The braided fishing lines and metal hooks put the fishermen at risk for electrical injuries. PURPOSE: We review our burn center's experience with electrical injuries related to fishing activities during the last four years. PATIENTS AND METHOD: We retrospectively collected data on patients with electrical burns related to fishing activities between January 2006, when our burns unit was established, and December 2009. Eight patients with electrical burns were admitted during this period of time, five who sustained the injury while fishing, due to contact of the fishing rod with overhead high-voltage cables and three who were injured during illegal fishing, using electricity to stun the fish. RESULTS: The total burn surface area ranged from 0.5% to 70%. Three of the patients sustained fourth degree burns, while the rest had second and third degree burns. One patient underwent scapulohumeral disarticulation and an above-knee amputation. Two patients had fingers and toes amputated. Latissimus dorsi and anterolateral thigh flaps were used to cover the defects in two cases. Local flaps were employed in other two cases to cover the tissue defects. Two patients died. CONCLUSION: Fishing-related burns and illegal fishing can lead to serious injuries and death.

Omental free-tissue transfer: indications and results from personal experience.

Between 1987-2002, omental free-tissue transfer was used in 11 patients, aged 6-65 years (mean age, 37.6). The omentum was used for the treatment of brachial plexus injury pain (3 cases), Romberg's disease (1 case), defects of the extremities occurring with chronic obstructive arterial disease (2 cases), posttraumatic lesions (3 cases), and following oncological resections (2 cases). In 2 cases, omental tissue represented the secondary option, after the failure of muscular tissue transfer. In 2 patients, the omental tissue transfer helped to preserve the knee. There was 1 failure, followed by amputation of the thigh. Two patients died from their underlying disease 10 and 36 months, respectively, after the operation.