Reverse sural flap for ankle and heel soft tissues reconstruction.

Introduction: The potential of the medial calf integument, as donor site for a free flap based on musculocutaneous branches of the medial sural artery, was first identified by Taylor and Daniel, following cadaver investigation. In 1981, Pontén described the fasciocutaneous sural flap as a reconstructive option for soft tissue loss of the lower extremity, particularly around the knee. Two years later, Donski and Fogdestram presented the distally based fasciocutaneous flap from the sural region followed by Montegut and Allen who considered the sural artery perforator flap as a viable alternative for the gastrocnemius myocutaneous flap. The sural flap proved a considerable versatility at the level of the lower leg (from the knee to the ankle and heel) as well as for other anatomical regions. The most common usage of the flap is for the distal-third defects of the leg. Materials and method: A group of 10 patients with soft tissue losses at the ankle or heal due to a various etiopathogeny represented by cancer excision, trauma, unstable scars, chronic osteomyelitis, in which a microsurgical free transfer had no indication or was not wanted, was presented. Our group reported a 30% complication rate in a high-risk patient population, including patients with diabetes mellitus, peripheral vascular disease, and venous insufficiency. Results: All the defects were covered successfully, without major complications. Usually, only a minor margin of the tip of the flap was lost, which was easily solved with a guided secondary healing. Most flaps showed a slight venous congestion, which cleared in a few days. The functional result was very good in all the patients, while the aesthetic appearance was acceptable even in female patients. Discussion: An ideal indication of a reverse sural flap may be a defect over an intact but partially exposed Achilles tendon. Conclusions: The sural reverse flap is useful in the ankle and foot soft tissues reconstruction whenever we have reasons not to use a microsurgical free transfer. Venous congestion with consecutive partial or complete flap loss is a common complication, so this would not be recommended in patients with obvious acute or chronic venous stasis. The reverse sural island flap should no longer be regarded as a flap of secondary choice to free tissue transfer, but as an equally valuable alternative for small and midsized defects around the ankle and heel.

Limb-sparing surgery as an alternative for limb amputation in an invasive myxoid liposarcoma--case report.

In medical practice, plastic surgeons confront with patients with sarcomas of the extremities that require a radical surgical approach. Knowing when to attempt limb-sparing surgery and when to give in to limb amputation is one of the most difficult decisions a surgeon can take. The correct approach and management of such cases ensure surgical success and the patient survival. In this paper, the case of a 56-year-old man, admitted in our clinic with a crush injury of the right calf and subsequent haematoma is presented. During haematoma drainage, the surgeon noticed abnormal tissue and performed an incisional biopsy. The patient was diagnosed with myxoid liposarcoma of the external compartment of the right calf. Limb amputation was proposed, but the patient refused. After the clinical examination, blood tests and diagnostic imaging, which allowed the correct evaluation of the case-tumor sizes and neighboring tissue reports, and preoperatory radiotherapy, limb sparing surgery, respectively primary tumor excision was decided to be performed. Negative margins could not be obtained by 3 successive resections or by adjuvant chemotherapy. The presented case supports the idea that limb-sparing surgery is only applicable to carefully selected patients with soft tissue sarcoma. In some cases, radical excision involving even mutilating amputations may provide a better oncologic and functional result.

Ablation of advanced tongue cancer and mobile tongue reconstruction by using a sensitive anterolateral thigh and vastus lateralis muscle free flap.

BACKGROUND: Successful tongue reconstruction after total glossectomy for advanced tongue or base of tongue cancer should restore swallowing, speech function, and cosmesis. METHODS: The anterior lateral thigh flap sensitive myocutaneous (ALTF) with vastus lateralis muscle was used to reconstruct the oral defect in a patient undergoing total glossectomy with laryngeal preservation for T4 tongue cancer. RESULTS: Good functional outcomes, measured by independent feeding, speech and swallowing, were achieved. CONCLUSIONS: The anterolateral thigh myocutaneous flap for total tongue reconstruction creates a free neotongue tip with an adequate volume, producing acceptable swallowing function and cosmesis. The reconstruction with free flaps is a feasible method of restoring the functional outcomes in speech and deglutition among patients who undergo total glossectomy with laryngeal preservation.

Surgical management in a rare case of basaloid squamous cell carcinoma of the maxilla.

Basaloid squamous cell carcinoma (BSCC) is a rare and aggressive version of squamous cell carcinoma (SCC) that preferentially occurs in the upper aerodigestive tract. Since the first description by Wain SL et al., in 1986, only 21 cases with BSCC in the nasal cavity or in the paranasal cavity have been reported in the English literature. We present a case of BSCC arising in a paranasal sinus, a 51-year-old male patient with four months history of right cheek swelling and unilateral nasal obstruction, who underwent an operation and postoperative radiotherapy. Clinical, pathological and surgical findings in this case are presented along with a brief discussion of literature.

Lower limb perforator propeller flaps - clinical applications.

BACKGROUND: A great variety of flaps have been used in lower limb reconstructive surgery: random pattern flaps, axial flaps and free microsurgical transfers with many variants. After further research on the cutaneous blood supply and improvement of microsurgical techniques, perforator propeller flaps began to be studied and used. MATERIAL AND METHOD: A propeller flap is defined as an insular flap mobilized through an axial rotation on a perforator pedicle in order to cover a defect that has to be reconstructed.According to the specialized literature data and to the studies we made on cadavers, this paper establishes a classification based on several criteria: 1) the position of the supplying perforator; 2) the reconstructive necessities and the skin island;3) the flap blood supply; 4) the aesthetic and functional demands of the reconstructed areas. Based on this study we established the specific reconstructive indications for these propeller flaps. CONCLUSIONS: The reconstructive lower limb strategy allows the use of the perforator propeller flaps as first therapeutic option for small and medium defects in certain areas considered as "critical". Knowledge of the pedicle length and the surface of the flaps facilitates the optimum flap choice in the reconstruction of a certain area.

Learning curve in hemifacial transplantation in rats.

INTRODUCTION: The aim of this study was to emphasize the learning curve of hemifacial transplantation in rats by comparison between 2 operators: medical student trained in basic microsurgery and an experienced microsurgeon. MATERIALS AND METHODS: A total number of 15 hemifacial transplants between Brown Norway as donors and Wistar as receiver rats were performed by two operators: experienced microsurgeon (group II, n=5) and the medical student (group III, n=10). Warm ischemia time and operative time were used as instrument for comparison. All the rats received immunosuppressive treatment with cyclosporine A in monotherapy for 30 days. Results were processed statistically using Microsoft Excel. RESULTS: Transplantation procedure duration time performed by experienced microsurgeon began from 420 min and decreased to 330 min after 5 transplantations, with confidence interval (95% probability)382 ± 37.9 min and the warm ischemia time decreased from 140 min to 50 min, confidence interval of the warm ischemia time being 90 ± 33.52 min. After transplantation the rats were treated with cyclosporine A and monitored for 30 days. Medical student tended to equalize the operative time and warm ischemia time, approximately, after 9 transplantations, from 660 min to 330 min and warm ischemia time from 190 min to 60 min. The confidence interval (95%) of the procedure by duration of the surgery was 467 ± 80.66 min and 133.5 ± 31.44 min for the warm ischemia time. Most of the rats (n=11) survived in both transplanted groups (group II and group III) performed by microsurgeon and student. By analyzing learning curves using two parameters (operative time and warm ischemia time) and survival rates no statistically significant difference was found (p 0.05). CONCLUSION: Hemifacial transplantation model in rats is a useful tool for preparing experimental and clinical application of the facial transplantation. It is a good model for training young specialists for future transplantation surgery. It is important to notice that the medical student had previous experience in microsurgery and the learning curve was applied only for this specific procedure. Even young specialists in microsurgery could perform such a complex procedure after an appropriate training period (in our study after 9 consecutive transplantations) in the same fashion and with the same results as an experienced microsurgeon. Usage of cyclosporine A as monotherapy gave good immunosuppression results in rats' transplantations for the studied duration of time (30 days).

Orbital exenteration - a salvage procedure?

Orbital exenteration is a procedure performed usually for malignancies. The subsequent reconstructive efforts are directed towards rapid and stable healing but allowing detection of recurrent disease, obliteration of any communication between the orbit and surrounding cavities and above all a good quality of life. The surgical options must be tailored to each patient; we have to achieve first disease control and to compensate a 3D defect as best as we can. In the following, we present a series of three patients with aggressive tumors of the midface, admitted in our clinic in the last four years. For each case, orbital exenteration was performed in order to achieve tumor clearance. The results were good excepting one case (a relapse at three years interval) with a squamous cell carcinoma and perineural invasion.

A Romanian therapeutic approach to peripheral nerve injury.

The study of nerve regeneration and functional recovery of the injured peripheral nerves represents a worldwide subject of clinical and scientific research. Our team aimed to obtain the first guide for nerve regeneration, bioartificial and biodegradable, using exclusively Romanian resources and having the advantages of price and quality, over the imported nerve conduits already used in clinical practice. First steps of this project consisted in obtaining the prototype of nerve guide conduit and its' testing in vitro and in vivo. Tests of physicochemical characterization, FTIR (Fourier Transform Infrared) spectrometry, thermal analysis (differential calorimetry, thermo-gravimetry), electron microscopy, water absorption and enzymatic degradation of the obtained prototype were followed by in vivo testing. The first results, obtained on a group of Brown Norway rats who suffered experimental lesions of 1 cm at the level of left sciatic nerve, which have then been repaired using the Romanian conduit prototype, are favorable in terms of biocompatibility, biodegradable capacity and support of nerve regeneration.

A rare case of basaloid squamous cell carcinoma of the maxilla.

Basaloid squamous cell carcinoma (BSCC) is a rare and aggressive variant of squamous cell carcinoma (SCC) that occurs preferentially in the upper aerodigestive tract. Since the first description by Wain SL et al., in 1986, only 21 cases with BSCC in the nasal cavity or in the paranasal cavity have been reported in the English literature. We present here a case of BSCC arising in a paranasal sinus. The case was a 51-year-old male patient with four months history of right cheek swelling and unilateral nasal obstruction, who received operation and postoperative radiotherapy. Clinical, surgical and pathological findings in this case, including immunohistochemistry is presented along with brief discussion of literature.

Vascularized bone marrow transplantation model in rats as an alternative to conventional cellular bone marrow transplantation: preliminary results.

The aim of the study was to follow the development of microchimerism after allogeneic vascularized bone marrow transplantation (VBMT) versus conventional bone marrow transplantation (BMT). In one group, a VBMT model consisted of donor Brown Norway rat hind limb heterotopic transplanted on recipient Lewis rats. An intravenous infusion of donor bone marrow cells in suspension equivalent to that grafted in the vascularized femur limb was administered intravenously to recipient rats in the second group. Cellular microchimerism was investigated in recipients of VBMT versus BMT. Donor-derived cells could be detected in VBMT recipients at 30 and 60 days but not in recipients of intravenous suspension of BMC. VBMT provides a theoretical alternative to conventional cellular bone marrow transplantation by addressing crucial clinical problems such as failure of engraftment or graft-versus-host disease.

Hand transplant--a challenge in immunological management of patients.

The concept of composite tissue allotransplantation (CTA) for restoration of congenital or acquired deformities is not new and the recent success of clinical composite tissue allotransplantation (CTA) attests to the fact that composite tissue allografts have tremendous potential in these life-enhancing reconstructions. A hand transplant, unlike a solid organ transplant, involves multiple tissues (skin, muscle, tendon, bone, cartilage, fat, nerves and blood vessels) and can be considered the 'gold standard' in CTA. In this regard, no other organ or tissue transplant matches the hand transplant in its immunogenicity as well as complexity. Development of assays that allow us to monitor the current state of an immune response (rejection/tolerance) is of great interest and requires an in-depth understanding of the complex and rare phenomenon of tolerance.

Sentinel skin allograft-a reliable marker for monitoring of composite tissue transplant rejection.

Previous studies have demonstrated that composite tissue transplants such as limbs reject more slowly than skin transplants. This has led to the hypothesis that a simultaneous skin graft may act as an effective marker of limb rejection. The aim of this study was to test the predictive value of a sentinel skin graft as a marker of rejection, using a hind limb transplantation model in rats. Lewis rat recipients received hind limb transplants alone from a Brown Norway donor (control; n = 15) or combined with a full-thickness 15 cm(2) sentinel skin graft (n = 45). All animals received drug therapy (tacrolimus, mycophenolate mofetil, and prednisone) for 6 weeks; then, treatment was ceased entirely. Rejection of the skin graft and limb skin was assessed both by visual and histologic grading systems. Detectable visual rejection (grade 1) was observed earlier in the sentinel skin graft than in the limb skin (P < .0005); the clearest visual rejection (grade 2) appeared earlier in the sentinel skin graft (P < .005). The average histologic grade for early rejection of the skin graft was 1.46 and 1.08 for the limb skin (P < .05). These findings confirmed a visual and histologic delay in the rejection of limb skin compared with a distant sentinel skin graft. Skin grafts transplanted simultaneously with hind limbs may be a useful marker of early rejection.

Occurrence and attenuation of specific organic compounds in the groundwater plume at a former gasworks site.

The changing contaminant pattern with travelled distance was investigated in the anaerobic groundwater plume downstream from an extended zone containing residual NAPL at a former gas manufacturing plant. With increasing distance, O- and N-heterocyclic aromatic compounds are enriched in the plume relative to the usually assessed coal tar constituents (poly- and monocyclic aromatic compounds). In a first approximation, the overall concentration decrease of the investigated compounds follows a first order overall decay. The half life distance in the plume downgradient from the source varied between 20 m for benzene and up to 167-303 m for alkyl-naphthalenes. Acenaphthene is degraded only within about 50 m downstream from the source area, then its concentration remains constant (ca. 180 microg/l) and far above the legal limit. Dimethyl-benzofurans were the most recalcitrant among all compounds which could be quantified with the analytical method available. The overall groundwater contamination in the plume is seriously underestimated if only BTEX and 16-EPA-PAHs are monitored.