Anterolateral adipofascial turnover flap of the leg: Anatomical study.

AIM: The aim of this study is to clearly define the vascularisation of the lateral paratibial septum of the leg, defining the basis for a vertical pedicled adipofascial flap harvested from the anterolateral aspect of the leg to cover pretibial soft tissue defects. MATERIALS AND METHODS: Twelve cadaver legs (eight fixed with formalin and four fresh) were dissected. The vessels running into the lateral paratibial septum were identified. The number of vessels were noted and evaluated at the lateral border of the proximal, middle and distal thirds of the leg. In addition, an angiographic study was performed on two limbs to confirm the connection between tibialis anterior artery and the overlaying fascia through these septal vessels. RESULTS: All the specimens had periosteo-septal vessels running in the lateral aspect of the tibia. The average number was 6.6. The distribution was constant in all the thirds of the leg. CONCLUSION: These data are useful to propose the harvesting technique for adipofascial flap with vertical pedicle as a suitable reconstructive option to cover pretibial soft tissue defects.

Invasive macrodystrophia lipomatosa of the hand.

OBJECTIVE: The Authors point out the interest of differential diagnosis and conservative surgical treatment of a rare case of digital and ulnar side of the hand gigantism, with massive fatty infiltration of soft tissues and a neurovascular bundle, to be included into Macrodystrophia Lipomatosa with fibrolipomatous hamartomata. PATIENTS AND METHODS: Excision of the mass included 4th ray disarticulation (the fifth had been amputated several years ago) as well as microsurgical external and internal neurolysis of the ulnar nerve, the ulnar neurovascular bundle being exposed and covered with dermal substitute INTEGRATM, with a good result both from a cosmetic and functional point of view at three year follow up. RESULTS: This is the first report of INTEGRATM covering of a neurovascular bundle. Samples taken from the dermal substitute matrix interface at day 6 and day 25 were examined with transmission Electron Microscopy: a newly formed tissue, rich in precursor cells, was detected. CONCLUSIONS: Conservative surgery, requiring particular microsurgical skills and use of dermal templates, plays an outstanding role in treatment of these rare but aggressive soft tissues masses of the upper limb.

Should fat graft be recommended in tendon scar treatment? Considerations on three cases (two feet and a severe burned hand).

OBJECTIVES: Lipostructure has been reported as a successful ancillary tool for surgery in tenolysis procedures, but to date no reports of its capability to resolve tendon adherence without further surgery have been reported. The aim of this study is to highlight the role of lipografting in the treatment of tendon and joint adherences. PATIENTS AND METHODS: In our experience, we started treating important tendon adherences together with nerve entrapment on the dorsal aspect of the foot in two cases and in a severe burned hand. RESULTS: We achieved good results both in terms of function and sensory recovery. A twenty four month follow up showed good maintenance of the ROM. We also reported gaining of almost 30-40 degrees of a flexion contracure in the second finger of a burned hand, minimizing further surgery for scar contracture and tenoarthrolysis, with a stable follow up. CONCLUSIONS: We suggest that prior to refer to surgery scars involving tendons as well as joints should be considered for lipografting.

Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: anatomical study and clinical applications.

Defects of the dorsum of the foot can be challenging to reconstruct, none more so than the dorsum of the toe. The reverse Dorsalis Pedis Adipofascial Perforator (DPAP) flap is one possible reconstructive option for defects in this region. The aim of this study was to first demonstrate the anatomy of this flap, particularly the consistency of the perforators arising from the dorsalis pedis artery. Second, we present a clinical series based on this flap to demonstrate how it can be used. For the anatomical studies, 22 fresh cadaveric lower extremities were dissected, and injection studies were used to delineate the vascular territories. The presence of the distal perforator, distance to the first metatarso-phalangeal joint and diameter of each perforator were recorded. The cadaveric studies confirmed the presence of distal perforators to the first metatarso-phalangeal joint in 100% of limbs examined. The clinical study demonstrated the feasibility of the use of the adipofascial turn-over perforator flap for dorsal foot reconstruction. These anatomic findings provide an alternative method of reconstruction of great toe defects using the reverse DPAP flap.

Isolated fracture of the capitate with rotation of the proximal fragment. Case report.

A case of capitate fracture in a 28-year-old man, with a 180-degree rotation (volar dislocation) of the proximal fragment is reported. Due to a late diagnosis, the patient presented 2 weeks after trauma. Open reduction and internal fixation with Kirschner wires provided good bone alignment, uneventful healing and a good range of wrist motion was achieved. The authors remind the reader the possibility of capitate fracture, a rare but troublesome event among wrist traumas, requiring a prompt diagnosis and treatment to relief important wrist pain and to restore function. Moreover, in consideration of important vascular complications, producing non-union and arthritis, the emerging role of imaging in detecting even minor signs of bone necrosis, leading to correct surgical indications, has to be taken into account.

Reduction mammaplasty and related impact on psychosexual function.

INTRODUCTION: Reduction mammaplasty brings an effective improvement, both from the physical and psychological points of view. However, psychosexual consequences are as yet poorly studied, although scars, impairment of sensibility, change in shape and asymmetry can have a negative effect on sexual life. AIM: These authors retrospectively reviewed 55 patients to verify the existence of a close relationship between this popular surgical procedure and psychosexual function. MATERIAL AND METHODS: All patients were compared to a group (51 healthy women) chosen from the hospital personnel. Both groups answered four psychological questionnaires (Short Form (SF)-36, Hamilton Anxiety Rating Scale (Ham-A), Hamilton Rating Scale for Depression (Ham-D), Female Sexual Function Index (FSFI)) anonymously, in addition to the scar-assessment test as a single physical test. Psychological tests aim to evaluate self-esteem, quality of life (SF-36) and sexual function in women (FSFI, a test based on Erectile Function Index of Male). High levels of anxiety and depression were used as exclusion criteria in our study (Ham-D and Ham-A). Statistical analysis was based on non-parametric correlation test adjusted for small groups and Spearman's rho test to verify the associations among sub-items scales. RESULTS: Almost all patients (98%) fulfilled the inclusion criteria for our study. Sexual function index was equal in both groups, but it still showed a higher quality of life in the control group. Nevertheless, the SF-36 value of the patients' group is still enough to allow for acceptable self-esteem. CONCLUSIONS: We can confirm that reduction mammaplasty does not impair sexual satisfaction or quality of life; moreover, we believe that this procedure can improve such indices. Further investigation will compare patient's values prior to and following surgery to put in evidence a stronger relationship between mammary reduction and sexual function.

Actinic keratosis associated with squamous and basal cell carcinomas: an evaluation of neoplastic progression by a standardized AgNOR analysis.

In an attempt to investigate the neoplastic progression in different stages of actinic keratosis (AK), a standardized AgNOR analysis was performed in 94 cases of AK, 35 of which were associated with squamous cell carcinoma (SCC) or basal cell carcinoma (BCC), and in 31 cases of SCC and 22 cases of BCC. The cases were subdivided into low- and high-AgNOR-expressing (AgNOR status) AK by using the mean area of AgNORs per cell (NORA) value (3.996 micro(2)) as the cut-off. In AK samples, a progressive increase of the mean NORA value from Stage I to Stage IV was encountered. In addition, a significantly higher mean NORA value was found in the AK cases associated with SCC, in comparison to those without SCC; by contrast, no significant differences in the mean NORA value were noted between AK cases with or without BCC. A highly significant association between a high AgNOR quantity and the coexistence of SCC was encountered in AK; no association was appreciable between the AgNOR quantity and the co-occurrence of BCC. Moreover, when the co-existence of SCC in AK was considered as the reference point, the AK cases associated with SCC mostly (95.5%) presented a high AgNOR quantity (high sensitivity), but only 57.6% of cases without SCC displayed a low AgNOR quantity (low specificity). Additionally, our data document that the standardised AgNOR analysis represents a strong negative predictor for the association between SCC and AK. Indeed, a low AgNOR quantity mostly is associated with AK cases without SCC.

[Fibular pedicled proximal vascular island flap for distal femoral bone reconstruction. Anatomical study]. / Le lambeau pédiculé en îlot vasculaire proximal de fibula dans la reconstruction distale du fémur. Etude anatomique.

The fibular pedicled proximal vascular island flap for distal femoral bone reconstruction described for the first time by Cariou on 1996, is studied in this article with an anatomical view. This anatomical morphometric study allows to assure the surgeon that this procedure can be done and to precise the surgical technique. The authors showed that, dependent on the length of the lower limb and the level of the fibular artery origin, 10 to 19 cm of femoral bone reconstruction could be done, after 180 degrees flap rotation. The flap can be used, the fibula separated in two parts, for inferior femoral metaphysis reconstruction or for knee joint arthrodesis.

Topical negative therapy and vacuum assisted closure. New strategies and devices in surgical reconstruction.

Topical negative pressure (TNP) has been introduced in complex surgical reconstruction and difficult wound healing, having proven to be effective in both drainage of wound secretions and calling for a new, sterile granulating tissue. In the last 15 years many reports have been focusing on TNP in different surgical specialties (orthopedic surgery in exposed fractures, general surgery in eventration, cardiothoracic surgery in sternal dehiscences, plastic surgery in difficult wounds and pressure sores). The authors report their personal experience being among the first Units to use TNP systematically in Italy.

The orbicularis oculi myocutaneus flap in the repair of the medial canthal region. A new strategy for canthal resurfacing.

The aim of this study was to review the surgical anatomy and the variants of the orbicularis oculi myocutaneus flap (OOMF) for reconstruction of inner canthus defects. Anatomic studies in fresh heads were carried out to demonstrate its blood and nerve supply. Four cases of epitheliomas of the inner canthus were treated with surgical excision and reconstructed with medially based island and nonisland OOMF. A 36-months follow-up showed no deformities of the flap, good colour matching and satisfaction scars. The flap is recommended for small to medium size defects of the inner canthus in patient with skin excess in the eyelid.

[External oblique muscle-cutaneous flap use of the in the reconstruction of large chest wall defects after mastectomy]. / Utilizzazione del lembo muscolo-cutaneo di obliquo esterno nella ricostruzione della parete toracica dopo mastectomia allargata.

The use of an external oblique muscle-cutaneous flap in the reconstruction of large chest wall defects after mastectomy is described. The flap is drown as a V-Y advancement-rotation flap, laterally based, on the ipsilateral abdominal wall. The flap extends from the posterior axillary line to the linea alba, vascular supply is provided by the musculo-cutaneous perforating arteries of the intercostal vessels. Mobilization starts medially including the anterior rectus sheath, décollement continues between the external and the internal oblique muscles as far as the posterior axillary line. The abdominal wall, after flap mobilization, is reinforced by the plication of the internal oblique sheath. The flap was used in 13 patients with major anterior chest-wall defects after mastectomy. In one patient a marginal skin necrosis of about 2 cm was observed. The flap described differs from other external oblique flaps already described in several technical innovations that allow to obtain better functional and esthetic results.

Bowenoid basal cell carcinoma of the thumb: a case report and review of the literature.

Basal cell carcinoma (BCC) is the most common skin malignancy arising from cells of the basal layer of the epithelium or from the external root sheath of the hair follicle. BCC of the digit is a rare entity. The article presents one such case of bowenoid BCC of the thumb which required amputation at the MP joint.

[Subcutaneous peduncle flaps in reconstructive surgery]. / I lembi a peduncolo sottocutaneo in chirurgia ricostruttiva.

Among the varying forms of cutaneous flaps, V-Y flaps are finding an increasingly wide application in reconstructive surgery. Their use has been extended, depending on the cutaneous area in question, to various sizes of loss of substance. According to the type of tissues involved, the peduncle may be adipose, fascial or muscular. Vascularisation is random, but in those cases in which the base consists of muscle fascia an axial type is used since the peduncle generally corresponds to a well-known artery. V-Y flaps can repair defects measuring upto 5 cm in diameter and also guarantee a rotation of upto 90 degrees. The authors report their experience of 134 cases in which V-Y flaps were used in the reconstruction of loss of substance localised on the face, upper limbs, trunk, gluteal region, ear, leg and foot. The underlying pathologies consisted mainly of skin cancers, loss of substance following injury, scar retractions, syndactylia, decubitus ulcers in the gluteal region and a trophic foot ulcer. It was not necessary to re-operate any patient owing to problems linked to retraction or the unsightly appearance of residual scars. In the past V-Y flaps were indicated above all for the reconstruction of loss of face substance, but their use today has been extended to other districts. The authors highlight the advantages offered by V-Y flaps: ease and rapidity of use, the characteristics of the skin graft are identical to that removed, and the preservation of sensitivity.

[On parosteal lipomas of the limbs]. / Considerazioni sui lipomi parostali degli arti.

Among the benign neoplasias of mesenchymal origin, parosteal lipomas represent a relatively rare occurrence. They are deep seated (subfascial) lipomas which during the course of their slow growth become adherent to the periosteum. The parosteal lipoma is not dissimilar to the so-called common or superficial lipoma both in terms of its macroscopic appearance, since this neoplasia has no capsule which separates it from surrounding tissue and likewise enables an easy enucleation owing to the presence of a cleavage plane, and in terms of its microscopic appearance since it is made up of mature adipose cells. Moreover, comparative cytogenic tests have revealed chromosomic alterations common to both the superficial and parosteal lipoma. The peculiarity of the parosteal lipoma lies in its clinical evolution which depends on the original site; it is in fact most often described in relation to bone segments of the limbs where it may lead to the compression of the vasculonervous axes. In particular, parosteal lipoma of the forearm, especially if localised in the upper third, represents a separate clinical entity given that, during the course of its growth, it may cause the compression of the posterior interosseous nerve and the surface (sensitive) branch of the radial nerve. This occurrence, which is observed in approximately half of all cases, must be taken into consideration and should lead to the decision to operate in order to prevent compressive sequelae involving nervous axes. After reviewing the literature on the subject, the authors report their experience of four recent cases and evaluate the anatomical, clinical, diagnostic and therapeutic aspects of parosteal lipoma.

[Angioma in childhood: current criteria for therapy]. / Angiomi dell'infanzia: attuali criteri di terapia.

After examining the most recent literature on this subject, the authors assess the state of the art of current knowledge regarding cutaneous angioma in the light of their personal experience. The histological, biological and clinical characteristics are analysed and enable a new nosographic evaluation of this frequent pathology which must be differentiated from vascular malformations. In the light of these unique features, the authors examine the current forms of treatment for angioma using local, systemic or physical therapy. Cutaneous angioma may be present at birth or may appear during the first months of life, occasionally regressing spontaneously up until the child is seven years old. They also present a population of proliferating endothelial cells. This explains the possibility that these neoformations will spontaneously regress, an event that must be taken into account before commercing therapy. With regard to their diagnosis valuable information is provided by telethermography, ultrasonography, Doppler scan and CAT. If an angioma is present from the first weeks of life, a wait-and-see policy should be adopted unless the lesion is localised in an orbital, mammary, palpebral, subglottic, nasal or labial region. Local therapy of angioma using sclerosant substances is now controversial; the best results are obtained using periodical administrations of triamcinolone acetonide or betamethasone. Systemic treatment with prednisone is indicated in forms localised on the orbita where interlesional injections are frequently followed by complications such as hematoma and infections. Systemic treatment requires an interdisciplinary approach, especially in pediatrics, due to the repercussions which the use of high dose conrticosteroids provokes on hormone function in children. The use of alpha interferon with discordant results has recently been reported in the literature. In superficial forms physical therapy may be more appropriate. Cryotherapy provoked a lesion caused by cold: an ionic alteration of tissues through freezing leads to necrosis. Plesiotherapy has been now virtually abandoned due to the risks of growing tissue. In terms of therapy and application there has been a widespread increase in the use of argon laser over the past years: the "Tunable Dye Laser" present unique characteristics which allow the wave length to be modulated in relation to the colour and depth of the lesion to be treated, causing selective photothermolysis. Encouraging results can be obtained by subjecting immature angioma to applications every 3-4 weeks using an every of 7-8 J/cm2. The use of the tunable dye laser is, however, preferable in superficial angioma. Compressive therapy using elastic bandages or specially made garments is effective only in those localisation where it is possible to obtain compression, like limbs and the parotid region. From the above comments it can be seen that the treatment of immature angioma is extremely complex due to their clinical and evolutive variability. It is therefore vital to following the rules laid down by experience: waiting for the involution of the angioma, even if it is commonly observed event, is often difficult to achieve due to the scarce collaboration of parents. Moreover, it is important to achieve a close interdisciplinary collaboration between pediatrician, dermatologist and plastic surgeon.