Keystone Flap Type IV in Breast Reconstruction: A Case Report.

OBJECTIVE: The objective of this paper is to present and document a specific case of breast reconstruction using an adapted Type IV Keystone Flap technique, with a droplet-shaped design with a reduced flap ratio, and to identify the qualities of this method. CASE REPORT: A 41-year-old woman, with a history of myocardial infarction and low ejection fraction, underwent a lumpectomy, resulting in a lower medial quadrant deficit in her left breast. After she developed skin and tissue necrosis and infection, implementing the Type IV Keystone Flap effectively addressed the deficit, ensuring sufficient coverage. The flap extended dropwise beneath the deficit, progressing anteriorly towards the upper rectus abdominis, with a ratio of 2.5:1. The flap's novel droplet shape allowed for the utilization of fewer perforators, while ensuring adequate blood supply and tissue coverage, leading to improved perfusion and aesthetic outcome. CONCLUSION: The application of the adapted Type IV Keystone Flap highlights its capacity as a versatile and effective method for breast reconstruction post-lumpectomy. With the advantages of a short learning curve, easy execution, and acceptable risk profile, it offers a valuable alternative for patients who may not be suitable for more complex surgeries. Further research is recommended to confirm its broader applicability and to conduct a comparative analysis with other techniques.

Surgical Treatment and Recurrence of Cutaneous Nasal Malignancies: A 26-Year Retrospective Review of 1795 Patients.

Frequent localization of facial malignancies in the nasal area and their required complete surgical extirpation pose a significant challenge to the plastic surgeon, who is called to perform a suitable delicate reconstruction of produced nasal skin defects. The present study was aimed to examine the role of tumor characteristics in the prognosis of patients with nasal skin cancer undergoing surgical management.A retrospective review of 1795 patients operated on for nasal cutaneous neoplasms during a 26-year period is presented in our study. Descriptive statistics were appropriately calculated; multivariate Cox regression analysis was performed regarding the possible risk factors for recurrence. Only those with a complete follow-up were included in the study. The mean age of our study population was 66.7 years with a male majority (52.4%). Basal cell carcinoma appeared as the most common histological type (87.7%), followed by squamous cell carcinoma (7.9%); the latter correlated with poor prognosis.The nasal sidewalls were the most frequent lesion location (29.8%), followed by the alae (27.8%), dorsum (21.7%), and tip (19.3%). The columella was very rarely affected (0.5%) but was associated with increased recurrence [hazard ratio, 4.74; 95% confidence interval (CI), 1.12-20.00; P = 0.034]. Most patients were treated with elliptical excision and direct closure (58.7%). Local flaps (31.0%) and skin grafting (9.0%) proved very reliable surgical options, especially for larger, high-risk lesions. Recurrence transpired in 46 patients (2.6%) and 4 skin cancer-related deaths occurred.Surgical modality of choice should be individualized and carefully adjusted to patients' needs. Moreover, more elective techniques, such as Mohs micrographic surgery or cumulative therapeutic approaches, like irradiation, should be examined as a beneficial aid to confront high-risk malignancies.

Sentinel lymph node biopsy for cutaneous melanoma: a propos of 144 cases.

PURPOSE: The aim of this study was to identify the predictive factors of a positive sentinel lymph node (SLN) in patients with cutaneous malignant melanomas and tumor progression. METHODS: From October of 2000 to January of 2006, 144 patients with cutaneous malignant melanoma underwent SLN biopsy. Patients were divided into two groups according to the SLN status (positive vs negative) which were compared with regards to patient demographics and primary tumor characteristics. RESULTS: In 37 (25.69%) patients SLN biopsy was positive . Nodular melanomas (p=0.047), blood (p=0.010) and lymph (p<0.001) vessel infiltration, mitotic rate (p=0.019) and Breslow thickness (p=0.012) were predictive of a positive SLN biopsy. The overall recurrence, mortality and the overall disease free survival (DFS) rates were 6.25, 1.4 and 93.75, respectively. CONCLUSION: SLN biopsy is the most important predictor of early disease recurrence and survival in patients with cutaneous malignant melanoma. Considering all the examined factors, a positive SLN biopsy is related with Breslow thickness and lymph vessel infiltration.

Our experience with secondary reconstruction of external rotation in obstetrical brachial plexus palsy.

BACKGROUND: Restoration of shoulder external rotation is very important for upper extremity function. The purpose of this study was to present the authors' experience with secondary restoration of external rotation in patients with obstetrical brachial plexus palsy. METHODS: From 1978 to 2002, 46 children underwent secondary surgery for restoration of external rotation. Outcomes were analyzed in relation to various factors, including the type of procedure, muscle transfer only versus nerve reconstruction and muscle transfer, denervation time, type of injury (Erb versus global palsy), and severity score. In addition, the effect of restoration of external rotation on the final outcome of shoulder abduction was assessed. RESULTS: There was significant improvement in every case (p < 0.01) between preoperatively and postoperatively. The overall mean postoperative Mallet score for the group undergoing muscle transfer only was 3.95, whereas in the nerve reconstruction and muscle transfer group, the score was 3.88 (p >0.05). The resulting gain in external rotation was 99 degrees versus 93.8 degrees. In both populations, a very significant improvement (p <0.0001) was identified in the final outcome of shoulder abduction (109 degrees after muscle transfer versus 48.3 degrees before muscle transfer, and 112 degrees postoperatively after neurotization and muscle transfer versus 43.8 degrees before any surgery). Patients with Erb palsy had a better but not significant result (p >0.05; p = 0.94), compared with those with global palsy in both Mallet score (3.77 versus 3.76) and final active external rotation (81.7 degrees versus 77.6 degrees). CONCLUSION: Secondary surgery for the restoration of external rotation is a rewarding procedure, which also significantly improves the final outcome of shoulder abduction.

Tubulization techniques in brachial plexus surgery in an animal model for long-nerve defects (40 mm): a pilot study.

The critical length of 30 mm beyond which nerve regeneration was not possible limited up to now the use of tubulization. In this pilot study, a novel animal model is introduced using tubulization techniques for long-nerve defects (40 mm) in brachial plexus surgery. Twelve Sprague-Dawley rats were divided into 3 groups. A poly-DL-lactide-epsilon-caprolactone tube (group 1), a collagen tube (group 2), and a nerve graft (group 3) were, respectively, used to bridge a 40-mm gap between the right C7 root and the left musculocutaneous nerve. Animals were euthanized on day 30. Evaluation consisted of behavioral assessment, needle electromyography studies, biceps muscle weight measurements, qualitative, and quantitative morphometry. Only group 3 demonstrated axon regeneration and reinnervation potentials. There was statistical significant difference for biceps weight left/right ratio (P = 0.010) but not for behavioral results (P = 0.10) between group 3 and groups 1 and 2. This study introduced a novel rat model for the studying of nerve regeneration along long-nerve gaps (4 cm). Although using an autologous nerve graft regeneration achieved, the use of synthetic conduits failed to show regeneration. This may be attributed to gap length; duration of follow-up; and to no administration of a neurotrophic factor.

Review of nasal reconstruction.

INTRODUCTION: Nasal reconstruction after tumor extirpation is a necessity. The aim of the current study was to present the Greek experience in this field for a long period. MATERIALS AND METHODS: Charts of patients who underwent nasal reconstruction, from 1985 to 2006, were reviewed retrospectively. They were analyzed in relation to their age, sex, location of the defect, histologic diagnosis of the lesion, type of reconstruction, recurrence of the tumor, and final outcome. RESULTS: A total of 1585 patients underwent nasal reconstruction by the senior author (O.P.) during a period of 21 years in our department. A clear male preponderance was shown (845 or 53.3% vs 740 or 46.7%). Their age ranged from 13 to 97 years with a mean of 65.9 years. One thousand five hundred ninety-three different tumors had been resected during the studied period (some patients had >1 lesion). Basal cell carcinoma was the most common type, affecting 1399 patients (87.8%), followed by squamous cell carcinoma, which was identified in 109 patients (6.8%). Cutaneous melanoma was not a frequent diagnosis. Excision and primary closure represented the most frequent type of reconstruction, followed by flap reconstruction and any type of graft. Sidewalls were the usual location in the whole population. Recurrence rate was 3.4%. CONCLUSIONS: Nasal reconstruction remains a challenge for every plastic surgeon. Efficient diagnosis and appropriate reconstruction are prerequisites for the final desired outcome.

[Primary peritonitis in the newborn: a recently recognised disease]. / Peritonite primitiva in neonati. Una entità nosologica recentemente riconosciuta.

BACKGROUND DATA: Neonatal primary peritonitis (or autonomic bacterial peritonitis) is a diffuse peritoneal inflammation without any obvious visceral cause. It is a disease rarely described during the neonatal period. OBJECTIVE: The aim of the current study was to make the surgical community aware of it, in an attempt to help a prompt diagnose and to avoid any unnecessary surgery in patients admitted in Neonatal Intensive Care Unit (NICU). MATERIALS AND METHODS: It concerns the description of 7 cases of newborns affected by primary peritonitis during their hospitalization in the NICU, underlining their signs and symptoms along with all additional paraclinical tests and the final outcome. RESULTS: Primary peritonitis was identified in 7 neonates (5 females and 2 males). Despite the severity of their symptoms (e.g., abdominal sensibility, a long standing ileus etc.) none of them had sustained any surgery and the mortality was nil. CONCLUSIONS: Neonatal primary peritonitis should always be taken into account in such circumstances. The final outcome, despite the initial clinical severity, is favorable with the appropriate conservative therapy

Necrotizing fasciitis in childhood. Case report, and review of the literature.

INTRODUCTION: Necrotizing fasciitis (NF) is an aggressive and relatively rare soft tissue infection, involving the fascia and the subcutaneous tissue, with a rapidly fatal evolution. CASE REPORT: GE, an 8 year-old girl presented with edema and redness of the external genitalia. Twelve hours later, she became toxic while her redness extended in the abdominal wall and both upper thighs. CT of the abdomen was consistent with NF. She underwent prompt surgery (debridement and colostomy), followed by plastic reconstruction. CONCLUSION: Early suspicion and prompt aggressive surgery is the key of therapy in case of NF.

Contralateral C7 transfer in adult plexopathies.

In the current study, a retrospective review of 56 patients with posttraumatic root avulsion brachial plexus injuries who underwent contralateral C7 transfer using the selective contralateral C7 technique is presented. The intraoperative findings of the involved brachial plexus, the surgical technique of preparation of the donor C7 nerve root, and the various neurotization procedures are reported. The surgical outcomes as well as the potential adverse effects of the procedure are analyzed. We conclude from this study that the selective contralateral C7 technique is a safe procedure that can be applied successfully for simultaneous reconstruction of several different contralateral muscle targets or for neurotization of cross chest nerve grafts for future free muscle transplantation.

Arterial blood supply of the extensor apparatus of the long fingers.

BACKGROUND: The extensor apparatus vascularization is less studied compared with flexor tendons. The aim of the present anatomical work was to study it in a more systematic way and find clinical applications. METHODS: The study was carried on 40 fingers from 10 fresh cadaver hands. Two catheters (16 gauge) were introduced into the radial and ulnar arteries on the volar side of the wrist. Acetone was used for arterial cleaning and color latex for the arterial system coloration. The authors proceeded with the dissections, always in the same manner: they first made the longitudinal dorsal incisions from the metacarpophalangeal to distal interphalangeal joints. Raising the skin, they identified the thin subcutaneous branches into the hypodermal plane; they followed their course until their origin, which allowed identification of the arterial branches of the extensor apparatus. For measurements, they used as a point of reference the emergence distance of those dorsal branches from the metacarpophalangeal and proximal and distal interphalangeal joints. RESULTS: The extensor apparatus vascularization was segmental, realized through the paratenon from the branches of a vascular cutano-tendino-osseous complex through a common trunk, issued from the propria digital artery. This complex nourished not only the extensor apparatus but also the dorsal digital skin and periosteum. Its location was consistent at the level of both proximal and middle phalanges. CONCLUSIONS: This consistency explains the anatomical basis for the realization of composite-free tissue transfer in cases of banked fingers. The osteotomies could be performed at well-defined distances from the joints.