"Lid Switch Flap" for Subtotal Upper Eyelid Reconstruction: Where the Flap Pedicle and the Point of Rotation Should be Located.

We report our experience using the "lid switch flap" for the reconstruction of large upper eyelid defects, emphasizing on the design, the point of flap rotation, and the detailed description of the surgical technique. From 2018 to 2021, three patients with squamous cell carcinoma (SCC) invading 50 to 70% of the upper eyelid underwent tumor excision. The defects were reconstructed using the two-stage "lid switch flap" method. At the first stage, the "switch flap" from the lower eyelid was designed medially based preferably, elevated and "switched" to the defect, whereas the pedicle was divided at the second stage in 2 to 3 weeks. The mean of defect widths after tumor excision (D) was 23.6 mm (range: 18-29 mm) and the mean of widths of lid switch flaps (F) was 15.3 mm (range: 10-20 mm), and thus, the mean of F/D ratio was 0.63 (range: 0.55-0.69). The histopathology report confirmed the complete excision of the SCCs. The patients were followed up for 2 years. The functional and aesthetic results were excellent. Level of Evidence Level II, therapeutic study.

The Inverted V-Shaped Fasciocutaneous Advancement Flap Effectively Solves the Complication of Tracheostomal Stenosis.

ABSTRACT: Tracheostomal stenosis after laryngectomy is a distressing complication. We present a retrospective study on sequential 9 patients who underwent stomaplasty with inverted V-shaped fasciocutaneous advancement flap. This procedure effectively solves tracheostomal stenosis, providing large stoma for breathing with no need for further stenting and low revision rates.

Giant Cell Tumor of Tendon Sheath Developed over Chimeric-Free Latissimus Dorsi and Serratus Anterior Muscle Flaps.

This article describes a rare case of giant cell tumor of the tendon sheath (GCTTS) that was developed over the substance of chimeric-free latissimus dorsi and -serratus -anterior muscle flaps performed for lower limb reconstruction. To our knowledge, development of GCTTS over a free flap is first described in the literature. A 71-year-old -woman was presented with a large protuberant ulcerated tumor mass that was developed over the substance of chimeric free muscle flaps at the foot and ankle. We performed an extensive tumor resection, and the pathology report confirmed the presence of a primary giant cell tumor. The patient was advised to have a below-knee amputation. However, the patient refused the amputation, and 4 months later, she was presented with a metastatic mass proximally at the upper thigh. We believe that the GCTTS was associated with the chronic inflammation of the soft tissue and bones along with the recurrent episodes of infection, mainly due to proteus mirabilis and proteus syndrome (PS). PS may lead to the development of malformations and overgrowth of different tissues in unusual locations. In cases resistant to antibiotics, the radical surgical debridement should be considered as the most effective treatment.

Epidemiological trends in the diagnosis of melanoma in a Southern European population: analysis of a large database from a tertiary referral center.

The aim of this study was to present the epidemiological, clinicopathological, and treatment characteristics of patients diagnosed and treated in a tertiary referral center and to analyze independent factors associated with these characteristics. In this cohort study, epidemiological, clinicopathological, and treatment characteristics of 1461 consecutive melanoma patients diagnosed and treated in a tertiary referral center in 1987-2015 were prospectively collected in a registry. All patients underwent resection of their melanoma lesion. Multiple logistic regression analysis was used to examine independent correlations between characteristics. Internal validation of these correlations was performed by the bootstrap method. The median age of the patients was 53 years. Female sex had a slight predominance, whereas the majority were of Southern European origin. Superficial spreading melanoma was associated with younger age (P<0.001), whereas the nodular melanoma histological subtype was associated independently with indoor occupation (P=0.021) and diagnosis in the years 2004-2015 (P=0.002). Melanomas with Breslow thickness above 1.0 mm were associated with skin type III-IV (P=0.021) and diagnosis in the years 1987-2003 (P=0.046). In addition, histological ulceration was associated with older age (P=0.004) and diagnosis in the years 1987-2003 (P<0.001), whereas histological regression was associated independently with older age (P=0.001). This study presented independent associations between epidemiological, histopathological, and treatment characteristics, which might help to better understand melanoma disease and treatment practices in Southern Europe.

Serum S100B levels correlate with stage, N status, mitotic rate and disease outcome in melanoma patients independent to LDH.

PURPOSE: S100B protein is currently used as an immunohistochemistry marker to confirm melanoma diagnosis in biopsy specimens. Moreover, accumulating evidence supports its potential use as a tumor biomarker in blood. This study aimed to explore the potential uses of serum S100B protein as a biomarker in melanoma patients. METHODS: From 2012 to 2015, 107 sequential patients were diagnosed and treated for melanoma. All patients were tested for serum S100B and lactate dehydrogenase (LDH) at diagnosis and during their regular follow-up. Potential correlations between S100B serum levels and baseline characteristics and its impact on survival were assessed. RESULTS: S100B serum levels were within normal limits in patients with stages I and II, elevated in stage III, and very high in stage IV. In bivariate analysis, serum S100B levels >0.11µg/l and stage IV were the only independent prognostic factors associated with poor survival. Furthermore, S100B >0.5µg/l was associated with stage IV and poor survival. However, there was no significant association with LDH. S100B serum levels were positively correlated with mitotic rate (p=0.003), but only in stage IV patients (p=0.015). In stage III, a statistically significant difference in S100B serum levels were observed between N3, N2 and N1 stages, with higher levels for N2 (p=0.012) and N3 (p=0.009) compared to N1, and no difference between stages N2 and N3 (p=1.000). Also, no correlation was found between the number of primary melanoma lesions and S100B. CONCLUSIONS: S100B serum levels reflect tumor load, correlate with response to treatment, might identify patients who are at increased risk of disease relapse, may predict prognosis independent to LDH, and could be used as early biomarkers of tumor recurrence.

The use of the ALT Flap and Lateral Femoral Cutaneous Nerve for the Reconstruction of Carpal Soft Tissue and Ulnar Nerve Defects: a Case Report.

The anterolateral thigh (ALT) flap has become one of the workhorse flaps, with indications including diverse reconstructive problems. The lateral thigh area is also a useful donor site for nerve grafts. The lateral femoral cutaneous (LFC) nerve can be dissected along with the ALT flap for a substantial length, depending on the requirements of the recipient site. The LFC nerve can be used as a vascularized or non-vascularized nerve graft. The technique offers advantages and it can find clinical applications, satisfying the functional and aesthetic reconstructive requirements of a complex defect. We report the case of a patient who presented with traumatic soft tissue defect of the volar aspect of the wrist and ulnar nerve defect as a complication of a fracture of distal radius. An ALT flap was used to reconstruct the soft tissue defect. The ulnar nerve was resected due to necrosis and the gap was repaired with non-vascularized grafts of the anterior branch of the LFC nerve. The soft tissues were resurfaced successfully without complications. Functional recovery was good for the superficial branch of the ulnar nerve, whereas it was variable for the deep branch of the ulnar nerve. The anterolateral thigh area offers significant advantages as donor site in the reconstruction of complex soft tissue defects being a large source of vascularized skin, fat, fascia, muscle and nerve. This availability allows for single donor site dissection, minimizing the operating time and the associated morbidity.

Preservation of toes in advanced lymphedema: an important step in the control of infection.

In advanced lymphedema, the most important goal of treatment is the control or eradication of infection. Toes are the major cause of infection mainly due to lack of space at the webs. The fibrosis of the soft tissue with impaired circulation of the toes certainly contribute to infection of the toes, foot, and even proximal to the leg. Between 2004 and 2008, 20 patients with severe lymphedema and fibrosis of lower limbs were treated with Charles' procedure and included in this study. The toes were preserved. Excisional therapy is the only choice to decrease the lymphatic load and control the infection. The toes can be preserved if there is only swelling without previous cellulites or verrucous hyperkeratosis and neither deformity nor osteomyelitis of the toes. The surgical technique to treat the toes includes (1) excision of the soft tissue at the dorsum of the toes with preservation of the extensor tendon and its paratenon, to facilitate the take of skin graft, and (2) preservation of skin flaps at the web spaces. This avoids contracture at the web spaces and crowding of the toes, improves foot hygiene, and hence prevents infection. Proper aesthetic and functional results were obtained in all patients and 18 of 20 patients have been free of recurrent infection at 3-years follow-up. In the treatment of advanced lymphedema of the lower extremity, the toes are the major determinant of future infection after surgery. For preservation of toes, careful selection of patients and correct surgical procedure are essential for success.