A New Approach to Upper Eyelid Reconstruction.

BACKGROUND: Reconstruction of large defects of the upper eyelid is challenging because of its complex anatomy and specialized function. The aim of this work is to develop a single-stage reconstruction procedure based on a new approach. The technique consists of the advancement of an orbicularis oculi myocutaneous flap designed within the blepharoplasty skin excision pattern. METHODS: After the tumor's excision is completed with clear margins, the borders of the flap are incised down to the submuscular plane inside the classical pattern of upper eyelid blepharoplasty. Two myocutaneous triangles are excised on both sides of the flap to allow its advancement to cover the defect. When it is necessary to repair the posterior lamella, we harvest a mucochondral graft. RESULTS: From 2012 to 2015, we performed upper eyelid reconstruction with this technique on six patients. The flap survived in all the patients, without total or partial necrosis. No patient required surgical revision. The results were aesthetically satisfying, and no tumor recurrence was noted. CONCLUSIONS: Our new approach to upper eyelid reconstruction maximizes the cosmetic outcome respecting the principles of radicality. This flap is better suited for lesions involving the median or paramedian eyelid border from the marginal zone up to the palpebral crease. The approach we propose is safe and versatile, and it ensures either a functional or a good aesthetic reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The localization of the distal perforators of posterior tibial artery: a cadaveric study for the correct planning of medial adipofascial flaps.

PURPOSE: The adipofascial flap, introduced by Lin in 1994, has many advantages compared to fasciocutaneous or free flaps. Its dissection is relatively easy and fast with low donor-site morbidity, and it does not alter the shape of the leg. The aim of this dissection study is to evaluate the anatomic localization of the most distal perforator of the posterior tibial vessels to provide an anatomical rationale for the safe harvesting of distally based medial adipofascial flaps of the leg. MATERIALS AND METHODS: 30 Lower limbs from 15 cadavers were used for this study. The most distal perforator from posterior tibial perforator artery, accompanied by at least one vein, was identified and its distance from the medial malleolus was noted. RESULTS: A distal perforator was found in all specimens; the mean caliber was 0.77 mm. In all cases, the perforator artery passed in the septum between flexor hallucis longus m. and flexor digitorum longus m. and was accompanied by two veins. In our series, the distance between the lowest perforator and the medial malleolus ranged from 3.5 to 8.2 cm. The median was 6.75 cm, the 5th percentile 4 cm and the 95th percentile 8.1 cm. The mean distance of the perforator from the medial tibial border was 1.23 cm. The mean ratio between the distance of perforator from the medial malleolus and the total leg length was 21%. CONCLUSION: Compared to all previous researches, our study has found more distal perforators from posterior tibial perforator artery. This fact may have important clinical consequences, because the anteromedial adipofascial flap would cover more distal soft tissue defects. Moreover, our data suggest some safety parameters to make the rising of a medial adipofascial leg flap safer in surgical practice.

A simple and cheap system to speed up and to control the tumescent technique procedure: the Tedde's system.

We have devised a low cost system to quickly infiltrate tumescent solution: we call it the "Tedde's system". This low-cost system offers an improvement in quality and quantity of the infiltration because all the procedure depends on the operators, reducing also the time of the infiltration and consequently of the whole surgical procedure. Moreover, this system can be applied to other surgical procedure that requires large infiltration volumes.

Secondary shaping of the free TRAM: an inferior pedicle reduction mammaplasty.

Secondary shaping of the transverse rectus abdominis myocutaneous (TRAM) flap is a routine treatment, and includes liposuction, skin excision, inframammary fold replacement, dermal fat grafts or lipofilling. Major flap revision may include an augmentation procedure with implants or expanders. We present an inferior pedicle breast reduction in a woman who underwent breast reconstruction using a free TRAM flap. To our knowledge, there are no reports about reduction mammaplasty or mastopexy in Free TRAM flap breast reconstruction. Reduction mammaplasty should be regarded as a valuable option in free TRAM or deep inferior epigastric perforator secondary reshaping.

A technical refinement to prevent supratip deformity in aesthetic rhinoplasty: "the trapezoid peak".

BACKGROUND: The relationship between appropriate caudal dorsum resection and supratip deformity or inadequate tip projection currently is clear. Correct quadrangular cartilage management seems to have a basic role in the final tip aspect after aesthetic rhinoplasty. METHODS: Primary aesthetic rhinoplasty was performed for 38 Caucasian patients. A septal refinement was used for patients requiring extra tip support and not requiring grafts. RESULTS: The minimum follow-up period was 1 year. No supratip deformity was noted after surgery. The tip and midvault had adequate projection. CONCLUSIONS: The described maneuver sustains the alar cartilage without sutures, preventing supratip deformity, sustaining soft tissues, and avoiding loss of tip projection.

Endometriosis in a trocar tract: is it really a rare condition? A case report.

In literature an elevated number of isolated cases of endometriosis in post-laparoscopic scar or laparoscopic trocar tract are described. Actually no theory can completely account for endometriosis, and it is most likely that a combination of events is responsible for it. The case of a 37-year-old woman with a nodular mass in the right hypochondrium is reported. The nodule appeared after a laparoscopic cholecystectomy. Surgical excision was performed and microscopic analysis showed skeletal muscle and fibrous connective tissues with a typical glandular proliferation as in endometriosis. Endometrioma etiology is far to be cleared; the most practical and popular explanation is direct implantation. Our case may be explained according to this theory but it is difficult to achieve definitive conclusions due to the rarity of endometrioma and to the lack of information.

Treatment of non-melanoma skin cancer in North Sardinia: is there a need for biopsy?

UNLABELLED: Non-melanoma skin cancer (NMSC) is the most common type of skin cancer. Important controversial issues are the need for incisional biopsies, surgical margin, and timing of follow-up. METHODS: A retrospective study was undertaken on 2544 lesions. Accuracy of diagnosis and prevalence of incomplete excision were evaluated, comparing clinical and histological diagnosis using chi2 tests with Yates' correction. Kaplan-Meier recurrence graphs have been obtained. RESULTS: Lesions were correctly diagnosed in 94% of basal cell carcinomas (BCC) and in 69% of squamous cell carcinomas (SCC) (p < 0.001). Positive margins on pathological examination were 6.6% for BCC and 6.8% for SCC. A significant difference for incomplete excision has been found for BCC in the face (p < 0.001). Kaplan-Meier survival curves showed a different pattern for BCC and SCC. CONCLUSIONS: On the basis of our data, if clinical diagnosis is BCC, excision and reconstruction may be undertaken without an incisional biopsy. Alternatively, if clinical diagnosis is SCC, it is advisable to consider an incisional biopsy, before definitive surgical treatment.

Ultrastructural anatomy of contracted capsules around textured implants in augmented breasts.

The development of a capsule around an implant is part of the physiological response to a foreign body. Capsular contracture is the most specific and frustrating complication of augmentation mammaplasty, and a lot of studies have been devoted to it. The aim of the current study is to examine the fine architecture of the contracted capsule around textured implants in humans. Eight capsules from augmented and contracted breasts with gel-filled, textured-surface silicone implants were studied after standard preparation for light and scanning electron microscopy, and after partial digestion in sodium hydroxide. Two capsules from contracted breasts around smooth implants and two noncontracted capsules around textured implants were prepared and studied in the same fashion as controls. A multilayer structure of the contracted capsule was seen, and the architecture of the various layers is described. The inner surface presents irregular craterlike depressions. The arrangement of collagen fibers varies in capsule layers. The effect of a textured-surface implant on the mechanism of capsule contraction based on the observed capsular architecture is that only part of the capsule is effective mechanically in producing a contracting force. A thin vascular layer was identified near the inner surface in contracted capsules around textured implants, and the authors' think that this layer is probably the key structure in the histological development and growth of the capsule.

Erosive pustular dermatosis of the scalp in skin grafts: report of three cases.

Three patients developed erosive pustular dermatosis of the scalp (EPDS). Two of them, both males, had previously undergone surgical excision for squamous cell carcinoma and basal cell carcinoma, and a female experienced avulsive trauma of the scalp. The erosive lesions and crusts were located at the site of a skin graft; microbiological cultures were negative for bacterial and fungal growth. Histological examination ruled out pustular bullous disorders. Topical therapy with corticosteroids and antibiotics resulted in clinical remission in only 2 cases. The third case showed a tendency to recur despite numerous therapeutic attempts with oral dapsone and isotretinoin. We conclude that surgical trauma is a possible cause of EPDS. Our patients seem to be the first reported cases of EPDS in skin grafts following plastic surgical procedures.

Extremely high HDL levels in a patient with multiple symmetric lipomatosis.

An extreme form of hyperalphalipoproteinemia was studied in a patient affected by multiple symmetric lipomatosis (MSL); four relatives and three MSL controls were also evaluated. Plasma lipids and apolipoproteins were measured and overall lipoprotein profile was assessed by density gradient ultracentrifugation. The patient showed a plasma HDL-cholesterol of 138 mg/dl and an apo A-I of 218 mg/dl; moreover significantly high HDL levels were found in two unaffected relatives. The hypobetalipoproteinemia trait was also found both in the patient and in one of his daughters. We suggest that some pre-existing conditions may enhance lipoprotein metabolism alterations in this lipid storage disease.

The amplified sliding flap.

During recent years, sliding flaps have had great popularity owing to their advantages in terms of reliability, ease of execution, and good morphofunctional results. The limits of these flaps are related to the capacity of excursion in the advancement. To improve these limits, we describe in this article a personal modification of the flap that extends the possibilities of coverage in the distal areas, reducing the tensile distress. We report our experience with 19 patients, treated with this modified flap in various areas of the body, with good results and without noticeable complications.

Squamous cell carcinoma and lichen sclerosus et atrophicus of the prepuce.

Two cases of squamous cell carcinoma of the prepuce arising on balanitis xerotica obliterans are described. This event is unusual and not well known. The surgical treatment was a wide circumcision in which the prepuce and part of the shaft skin were removed, performing as well a decortication of the glans base. This technique seemed to be satisfactory in removing the carcinoma and obtaining a definite improvement in the clinical picture of balanitis xerotica obliterans as well.

HLA and multiple skin carcinomas.

The presence of HLA-associated genetic factors in patients with multiple skin carcinomas was investigated. 43 patients affected by multiple basal and squamous cell carcinomas and 220 healthy age-matched controls were typed for 72 HLA-A, B, C, DR antigens. A negative association of B-17 (mostly B-58) and a positive association of Cw-3 and DR-1 was observed in patients with multiple basal cell carcinomas; a similar negative association with B-58 and positive association with DR-1 was seen in patients with squamous cell carcinomas. The results of this study suggest the presence of resistance factors to the development of skin cancers associated with B-17 (B-58) antigen.

Surgical treatment of balanitis xerotica obliterans.

Balanitis xerotica obliterans, or kraurosis penis, is a chronic progressive scleroatrophic process of the penis, prepuce, and urethral meatus. This syndrome is due to lichen sclerosus et atrophicus of the genital region. We have observed 32 patients, whose ages ranged from 24 to 78, with different clinical and pathologic findings. Clinical symptomatology consisted of painful erection with secondary impotence, burning, itching, and urinary disorders. The treatment in the early stages is pharmacologic; stenosis of the meatus, phimosis, scar adhesions, fissures, and erosions of glans and prepuce prescribe a surgical treatment. We have performed modified circumcision, meatotomy and meatoplasty, removal of the scleroatrophic tract and subsequent grafting. The functional results were satisfactory.