Regenerative potential of the sural neuroadipofascial flap in the treatment of chronic ulcers of the lower third of the leg.

OBJECTIVE: Surgical reconstruction of soft tissue defects in the distal third of the lower limbs has always been challenging for surgeons. The adipofascial flaps are made up of vascularized adipose tissue, which plastically conforms to the site to be reconstructed with its rich presence of stem cells. In this study, we resumed our case history of reverse neuroadipofascial sural flap, and we evaluated the stability of the scar to verify if this type of reconstruction can ensure long-term results and its regenerative power. PATIENTS AND METHODS: In this retrospective cohort study, we analyzed 32 patients who had undergone lower limb reconstruction with the sural neuroadipovenous flap. RESULTS: A total of 32 patients were included in the study. The average age was 62.2 years. Chronic skin ulcer was the cause of the defects in 13 (40.6%) patients, chronic wound after trauma in 7 (21.9%) patients, wheel bedsores in 4 (12.5%) patients, osteomyelitis in 5 (15.6%) patients, exposed internal hardware in 2 (6.3%) patients, dog bite in 1 (3.1%). The site defect comprised 11 heels (34.4%), 4 external malleoli (12.5%), three medial malleoli (9.4%), 12 lower third of the leg (37.5%), and two dorsa of the foot (6.3%). In all cases, defects were covered with reverse sural island flap. The dimension of the flap ranged from 5 to 9 cm in length and from 3 to 7 in width. Six patients showed early or later postoperative complications. CONCLUSIONS: The neuroadipofascial sural flap is versatile, fast, and easy-to-perform to cover a chronic defect in the distal part of the lower limb, including both the malleoli and the heel, due to its long vascular pedicle. Consistent with the studies carried out in other districts, the present study confirms the remarkable regenerative power of the vascularized adipose tissue at the level of complex wounds of the lower third of the leg.

Wide-awake anesthesia in Dupuytren's contracture treated with collagenase.

The injection of collagenase followed by cord manipulation is one of the most popular treatments for Dupuytren's contracture. This is traditionally performed under local anesthesia or regional nerve block potentially with sedation. Neither the treatment with collagenase, nor the wide-awake anesthesia are novel techniques for hand surgeons. Nevertheless, we report the first experience of cord manipulation using the wide-awake approach. In this prospective study, we compared the pain perception of patients who underwent wide-awake anesthesia versus traditional local anesthesia. We recorded the pain sensation on a visual analog scale (VAS) (0 to 10) during anesthetic injection, during cord manipulation and before discharge. Wide-awake anesthesia significantly reduced pain levels during anesthetic injection (p=0.003) and cord manipulation (p=0.0009). Pain levels did not differ significantly right before discharge in the two groups (p=0.54). Wide-awake anesthesia can be successfully applied to cord manipulation after collagenase injection in Dupuytren's contracture. This way, it is possible to improve the patient's subjective perspective of the procedure.

Multi-dorsal metacarpal artery perforator adipofascial turnover flap for index to little finger reconstruction: Anatomical study and clinical application.

Reconstruction of the dorsum of the hand and fingers is one of the main challenges in hand surgery. Regional flaps from the forearm, free flaps, or pocket procedures are options when multiple digits are injured with tendon damage and bone exposure. These procedures can be technically demanding and are often plagued by a texture mismatch. We conducted an anatomical study of 20 fresh frozen hands. The second, third and fourth intermetacarpal spaces were analyzed with the aim of defining the vascular foundation of dorsal hand adipofascial-turnover flaps based on dorsal metacarpal artery (DMA) perforators, analyzing their potential for reconstruction procedures on the dorsum of the hand. In three cases, the 4th intermetacarpal space lacked the DMA. A mean of 3.5 arterial communications were found between the DMA and palmar arterial system. Each hand had 11 ± 2 dorsal skin perforators, which were equally distributed among different intermetacarpal spaces. At least one perforator was present in each one-third of the space. The most distal perforators were the largest in all spaces but missing in two hands. A clinical case of multiple index finger to little finger reconstruction with this new multi-dorsal metacarpal artery perforator (mDMAP) adipofascial turnover flap is presented. Our anatomical study confirmed previous descriptions of the anatomy of the dorsum of the hand. It supports the safety of the mDMAP adipofascial turnover flap based on all distal arterial perforator for the simultaneous reconstruction of index to little finger injuries. Similarly, adipofascial turnover flaps can be raised from more proximal perforators arising from DMAs if more than one intermetacarpal space is included.

Hyperbaric oxygen therapy in Plastic Surgery practice: case series and literature overview.

Hyperbaric oxygen therapy (HBOT) is the use of 100% oxygen at pressures more than atmospheric. Several approved applications and indications exist for HBOT in the literature. Non-healing wounds, such as diabetic and vascular insufficiency ulcers, have 1 Clinic of Plastic and Reconstructive Surgery, Department of Neurosciences, University Hospital of Padova, Padova, Italy 2 Department of Physiology, University of Padova, Padova, Italy Corresponding author: Ilaria Tocco-Tussardi, e-mail: ilaria.toccotussardi@gmail.com © Copyright 2019, CIC Edizioni Internazionali, Romabeen a major area of application, and the use of HBOT as an adjunct has been approved by several studies and trials. HBOT is also indicated for acute soft tissue infections like clostridial myonecrosis, necrotising soft tissue infections, as also for traumatic wounds, crush injury, compartment syndrome, and compromised skin grafts and flaps. Another major area of application of HBOT is radiation-induced wounds. With increasing availability of chambers and studies proving the benefits of use, HBOT should be considered as an essential part of the overall management strategy for plastic surgeons.

Management of complex pediatric burn scars in a humanitarian collaboration.

Burn scars still represent a challenge to the reconstructive surgeon. Their management requires a specific expertise and set up involving the possibility of long term rehabilitation and follow up. Cases encountered in humanitarian missions present additional issues. Often the local environment is not suitable for an appropriate treatment plan, requiring the case to be transferred to a foreign country for surgical care as part of an integrated international and multidisciplinary management. We present the case of a three year-old patient injured in a bomb explosion during the Arab Spring and suffering from severe scar contracture limiting thoracic and upper limb movement. After initial consultation at distance, transfer to our country was organized and an intensive surgical and rehabilitative program was carried out over three months. After five months, the patient returned to his home country where a supportive network had been set up for continued rehabilitation, ensuring follow up for over a year and ultimate success.

Les cicatrices de brûlures représentent toujours un défi pour le chirurgien de reconstruction. Leur gestion nécessite une expertise spécifique et la possibilité de réhabilitation à long terme, y compris le suivi. Les cas rencontrés dans les missions humanitaires présentent des problèmes supplémentaires. Souvent l'environnement local n'est pas adapté pour un plan de traitement approprié, et donc il faut transféré le patient dans un pays étranger pour des soins chirurgicaux dans le cadre d'une gestion internationale et multidisciplinaire intégrée. Nous présentons le cas d'un patient de trois ans blessé à cause de l'explosion d'une bombe pendant le printemps arabe. Ce patient souffrait de contractures graves qui limitaient le mouvement du membre thoracique et supérieure. Après une consultation initiale à distance, il a été transferé à notre pays où il a subi un programme de chirurgie et de réadaptation intensive qui a duré trois mois. Après cinq mois, le patient est retourné à son pays d'origine où un réseau de soutien a été mis en place pour continuer la réhabilitation, assurer un suivi de plus d'un an et le succès final.

Multidisciplinary care in severe pediatric electrical oral burn.

Oral burns in pediatric patient are commonly due to electrical injuries, representing an important reconstructive issue even for functional than esthetic reason. Different classification, surgical management and even oral device were described to allow the best long-term result. In most case a multidisciplinary approach is necessary to achieve a satisfactory outcome. A severe case of pediatric oral burn with germinative teeth damage is presented, describing a multispecialist team approach that guarantee a satisfactory outcome by reconstructive surgery, careful progressive evaluation of dental and soft tissue healing and speech recovery. The use of acellular dermal substitute template within traditional reconstructive surgery had provided a good functional and esthetic result joint to valid preservation of germinative dental element as shown at long-term X-ray evaluation. Intensive rehabilitation speech program has also avoided phonetic impairment in an important speech develop period. It was so evident that the necessity of a multispecialist care in such difficult injury to achieve the best long-term result.

The contribution of a dermal substitute in the three-layers reconstruction of a nose tip avulsion.

Through and through defects of the nasal ala still remains debated challenge in plastic reconstructive surgery. We present a 36 y.o. woman who suffered by a through and through nose tip avulsion subsequently a dog bite. She refused the use of traditional auricular composite graft or the multiple stages midline forehead flap due to the secondary visible scars. We treated her with the combined use of mucoperichondrial septal flap, cartilage graft and dermal substitute Integra graft, followed by a secondary, full-thickness skin graft. We consider the Integra(®) as a useful option for the treatment of a complex trauma of the nose with through and through tip and alar avulsion when, due to scar or consent problem, it's not possible the use of other techniques.

Knee Region Coverage with Reversed Gracilis Pedicle Flap (GReSP Flap).

INTRODUCTION: To treat severe soft-tissue complications of total knee arthroplasty, we used an extended reversed gracilis flap based on secondary pedicles (the GReSP flap). STEP 1 PREPARE WOUND BED: Locate the gracilis and pedicles, then debride the wound bed. STEP 2 EXPOSE GRACILIS MUSCLE: Expose the superficial aspect of the muscle, while protecting the saphenous vein and nerve. STEP 3 CHECK MUSCLE PERFUSION: Temporarily clamp the main vascular pedicle to ensure blood supply when perfused only by the secondary pedicles. STEP 4 MOBILIZE MUSCLE FLAP: Transect the proximal tendon of the gracilis muscle to provide maximal length for the muscle flap and ligate the main vascular and nerve pedicles. STEP 5 COVER WITH SKIN GRAFT: Suture the flap in place and cover with skin graft. STEP 6 POSTOPERATIVE CARE: Immobilize the knee for two weeks; follow with rehabilitation to restore range of motion. RESULTS & PREOP/POSTOP IMAGES: We treated three patients who had an infection at the site of a total knee arthroplasty and exposure of the implant. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Use of acellular dermal regeneration template in a complete finger degloving injury: case report.

Finger degloving injury remains one of the most difficult challenges in hand reconstructive surgery. We report the use of an acellular dermal regeneration template to create a neodermis, followed by a secondary, full-thickness skin graft on a complete finger degloving injury, achieving a satisfactory recovery of range of motion and a cosmetically acceptable result.

Reversed gracilis pedicle flap for coverage of a total knee prosthesis.

BACKGROUND: Poor wound-healing and skin necrosis are potentially devastating complications after total knee arthroplasty. Primary soft-tissue coverage with a medial or lateral gastrocnemius transposition flap is typically the first choice for reconstruction. The aim of this study was to evaluate the use of a distally based secondary-pedicle flap of the gracilis muscle for reconstruction of a soft-tissue defect. METHODS: The characteristics of the distally based (secondary) pedicles of the gracilis muscle were studied with use of dissection (ten cadavers) and computed tomographic angiograms (fifty patients). On the basis of the anatomical features, an extended reversed gracilis flap based on the secondary pedicles was used in three patients with severe soft-tissue complications of total knee arthroplasty. RESULTS: The mean number of secondary pedicles was 1.8 (range, one to four). The pedicles originated from the superficial femoral or popliteal artery. The most proximal pedicle was often the largest (mean caliber, 2.0 mm), and its point of entry into the gracilis muscle was an average (and standard deviation) of 21 +/- 3.6 cm (range, 16 to 28 cm) from the ischiopubic branch. A significant positive association (p = 0.001; r(2) = 0.49) was found between the caliber of the proximal secondary pedicle and the number of other secondary pedicles. In all three patients, the adequate caliber of the secondary pedicles (as shown on preoperative computed tomographic angiograms) and good muscle vascularization confirmed the utility of the gracilis as a distally based pedicle flap. CONCLUSIONS: For the treatment of large soft-tissue defects of the patella or the proximal part of the knee, or for soft-tissue reconstruction over an exposed total knee prosthesis, the reversed gracilis pedicle flap may be an alternative to, or may be integrated with, a lateral or medial gastrocnemius flap.

Lipoatrophy induced by subcutaneous insulin infusion: ultrastructural analysis and gene expression profiling.

CONTEXT AND OBJECTIVE: Subcutaneous adipose tissue (SAT) lipoatrophy (LA) is a rare complication of insulin therapy. We aimed to analyze the ultrastructural and molecular aspects of LA lesions. SETTING AND PATIENTS: Macroscopic and microscopic morphology of SAT beneath the LA areas from patients with type 1 diabetes treated with Lispro insulin by continuous sc insulin infusion was studied using magnetic resonance imaging, immunohistochemistry, electron microscopy, and quantitative PCR for adipose tissue-specific genes. RESULTS: SAT was present in LA lesions characterized by: 1) smaller, unilocular perilipin-positive adipocytes, with lipofuscin granules; 2) some "slimmed cells" losing lipid droplets as those we observed during starvation; and 3) numerous perivascular preadipocytes. We did not identify inflammatory cells. SAT in LA areas displayed a strong leptin down-regulation and an increase of AEBP1, a preadipocyte marker. CONCLUSIONS: Our results clearly indicate that the remarkable reduction in fat cell lipid droplets and adipocyte size justifies the decrease of SAT without a reduction in adipocyte number because of necrosis or apoptosis. Thus, immune cells and any other toxic damaging fat cells were not involved in the generation of LA. We speculate that adipocytes chronically exposed to high local insulin concentrations could become severely insulin resistant, dramatically increasing lipolysis and giving rise to "slimmed cells." Clinical LA regression could be explained by the active recruitment of preadipocytes, even if they were unable to differentiate and regenerate adipose tissue unless the insulin injection was removed.

Surgical anatomy of the radial nerve at the elbow.

An anatomical study of the brachial portion of the radial nerve with surgical implications is proposed. Thirty specimens of arm from 20 fresh cadavers (11 male, 9 female) were used to examine the topographical relations of the radial nerve with reference to the following anatomical landmarks: acromion angle, medial and lateral epicondyles, point of division between the lateral and long heads of the triceps brachii, lateral intermuscular septum, site of division of the radial nerve into its superficial and posterior interosseous branches and entry and exit point of the posterior interosseous branch into the supinator muscle. The mean distances between the acromion angle and the medial and lateral levels of crossing the posterior aspect of the humerus were 109 (+/-11) and 157 (+/-11) mm, respectively. The mean length and calibre of the nerve in the groove were 59 (+/-4) and 6 (+/-1) mm, respectively. The division of the lateral and long heads of the triceps was found at a mean distance of 126 (+/-13) mm from the acromion angle. The mean distances between the lateral point of crossing the posterior aspect of the humerus and the medial and lateral epicondyles were 125 (+/-13) and 121 (+/-13) mm, respectively. The mean distance between the lateral point of crossing the posterior aspect of the humerus and the entry point in the lateral intermuscular septum (LIS) was 29 (+/-6) mm. The mean distances between the entry point of the nerve in the LIS and the medial and lateral epicondyles were 133 (+/-14) and 110 (+/-23) mm, respectively. Our study provides reliable and objective data of surgical anatomy of the radial nerve which should be always kept in mind by surgeons approaching to the surgery of the arm, in order to avoid iatrogenic injuries.

Pectoral and femoral fasciae: common aspects and regional specializations.

The aim of this study was to analyse the organization of the deep fascia of the pectoral region and of the thigh. Six unembalmed cadavers (four men, two women, age range 48-93 years old) were studied by dissection and by histological (HE, van Gieson and azan-Mallory) and immunohistochemical (anti S-100) stains; morphometric studies were also performed in order to evaluate the thickness of the deep fascia in the different regions. The pectoral fascia is a thin lamina (mean thickness +/- SD: 297 +/- 37 mum), adherent to the pectoralis major muscle via numerous intramuscular fibrous septa that detach from its inner surface. Many muscular fibres are inserted into both sides of the septa and into the fascia. The histological study demonstrates that the pectoral fascia is formed by a single layer of undulated collagen fibres, intermixed with many elastic fibres. In the thigh, the deep fascia (fascia lata) is independent from the underlying muscle, separated by the epimysium and a layer of loose connective tissue. The fascia lata presents a mean thickness of 944 mum (+/-102 mum) and it is formed by bundles of collagen fibres, arranged in two to three layers. In each layer, the fibres are parallel to each other, whereas the orientation of the fibres varies from one layer to the adjacent one. The van Gieson elastic fibres stain highlights the presence of elastic fibres only in the more external layer of the fascia lata. In the thigh the epimysium is easily recognizable under the deep fascia and presents a mean thickness of 48 mum. Both the fascia lata and pectoral fascia result innerved, no specific differences in density or type of innervations is highlighted. The deep fascia of the pectoral region is morphologically and functionally different from that of the thigh: the fascia lata is a relatively autonomous structure with respect to the underlying muscular plane, while the pectoralis fascia acts as an additional insertion for the pectoralis major muscle. Different portions of the pectoralis major muscle are activated according to the glenohumeral joint movements and, consequently, selective portions of the pectoral fascia are stretched, activating specific patterns of proprioceptors. So, the pectoralis muscle has to be considered together with its fascia, and so as a myofascial unit, acting as an integrated control motor system.

The gracilis muscle and its use in clinical reconstruction: an anatomical, embryological, and radiological study.

The gracilis muscle is used widely in reconstructive surgery, as a pedicled or as a free microsurgical flap, for soft tissue coverage or as a functioning muscle transfer. Many studies, based on cadaver dissections, have focused on the vascular anatomy of the gracilis muscle and provided different data about the number, origin, and caliber of its vascular pedicles. Computed tomographic (CT) angiography of both thighs of 40 patients (35 males and 5 females, mean age: 63 years) have been analyzed to provide a detailed anatomical description of the arterial supply of the gracilis muscle. The gracilis muscle had a mean length of 41 +/- 2.1 cm. The principal pedicle enters the gracilis muscle at a mean distance (+/-SD) of 10 +/- 1 cm from the ischiopubic attachment of the muscle. Its caliber shows a mean value of 2.5 +/- 0.5 mm, and it is statistically larger when originating directly from the deep femoral artery (45%) than from its muscular branch supplying the adductors, i.e., the "artery to the adductors" (46%) (P < 0.01). A significant correlation between the caliber of the artery of the main pedicle and the volume of the gracilis muscle was found (P < 0.01). The mean number of distal accessory pedicles is 1.8 (range, 1-4,) and the artery of the first of these pedicles shows a mean caliber of 2.0 mm. There is no correlation between either the number or the caliber of the artery of the accessory pedicles and the volume of the gracilis muscle. CT angiography, providing detailed images of the muscular and vascular structures of the thigh of each patient, could be a useful preoperative study for the reconstructive surgeon. It would allow a personalized planning of a gracilis flap, reducing the risk of iatrogenic damage.

Persistence of embryonic pattern of hepatocaval venous junction and patent ductus venosus in Budd-Chiari syndrome.

We report an autopsy study on a case of Budd-Chiari syndrome (BCS) in a 44-year-old woman. Dissection showed that the outlets of the right hepatic vein (HV) and of the common trunk of the middle and left HVs appeared as two small depressed areas with narrow ostia. Histological examination showed recent thrombosis of the tributaries of the HVs and centrilobular congestion with necrosis of the hepatic parenchyma. The juxtacaval portions of the major HVs showed a cuneiform shape, because of marked dilation, with thread-like ostia, and multiple small outlets of minor hepatic veins were also present. The coexistence of patent ductus venosus may have prevented the development of the hepatocaval venous junction, with persistence of the embryonic pattern, composed of multiple small channels draining into the right hepatocardiac channel. The unusual hepatocaval venous junction may have predisposed to thrombosis of the HVs, causing BCS.