Programmed cell death ligand-1 (PD-L1) expression in desmoid tumors: a retrospective study.

OBJECTIVE: Desmoid tumor is a rare benign but locally aggressive monoclonal and fibroblastic proliferation. It lacks metastatic potential but is associated with a high local recurrence after surgery. It is either characterized by the Beta-catenin gene (CTNNB1) or the adenomatous polyposis coli gene (APC) mutation. The most appropriate treatment approach is watchful waiting with periodic follow-ups for asymptomatic patients. However, symptomatic patients who are not good candidates for surgery due to high morbidity risk may benefit from medical therapy. The new drugs targeting programmed cell death protein 1 (PD-1) and programmed death-ligand 1 (PD-L1) display promising results in many cancer types. This study assessed the PD-L1 status of desmoid tumors in 18 patients. PATIENTS AND METHODS: Biopsy and resection materials of 18 patients diagnosed with desmoid tumors between April 2016 and April 2021 were retrieved and assessed for PD-L1 expression. The prepared slides were immunohistochemically stained with PD-L1 antibody using Leica Bond® automated immunohistochemistry stainer. RESULTS: No positive PD-L1 staining of the desmoid tumor cells was detected in any specimens. Intratumoral lymphocytes were present in all specimens. However, five of them were positively stained for PD-L1. CONCLUSIONS: Based on the results of our study, anti-PD-1/PD-L1 therapy may not be a valuable option in desmoid tumor treatment due to the lack of expression of PD-L1 by desmoid tumor cells. Nevertheless, the presence of positively stained intratumoral lymphocytes may warrant further studies.

Primary one-stage reconstruction of cheek defect after a shotgun blast to the face: use of the latissimus dorsi musculocutaneous free flap for soft-tissue repair and facial reanimation.

The authors describe a case of a shotgun blast injury to the face in which early definitive repair of both facial soft tissues and facial reanimation was accomplished in one stage using a free flap. The trauma occurred 2 days before presentation via a hunting rifle fired at a short range. On examination, a 8 x 5-cm cheek defect was evident, involving the full thickness of the perioral facial mimetic muscles as well. A free latissimus dorsi musculocutaneous flap was transferred to the defect, with the thoracodorsal nerve coapted to an ipsilateral, severed buccal branch of the facial nerve. Postoperatively, the flap survived completely, with its skin paddle excised subsequently in two stages. Good muscle movement was obtained, providing resting symmetry and a pleasant smile. Other than soft-tissue and bony defects resulting from shotgun injuries, ablation of the facial nerve or facial mimetic muscles may be an important component of the defect that needs further consideration. The authors conclude that the current technique of one-stage, early definitive repair of soft tissues and facial reanimation in such cases of facial shotgun blast injury offers the advantages of achieving both goals with one flap and accomplishing the procedure primarily in one stage.

Cephalic vein-pedicled arterialized anteromedial arm venous flap for head and neck reconstruction.

The authors describe a case of transfer of an arterialized cephalic venous flap from the anteromedial arm region to the neck with the cranial limb of the cephalic vein serving as the drainage vein and a pedicle. The burn scar contracture of a 45-year-old man was released and repaired with a venous flap based on the cephalic vein in the anteromedial arm. After dissection of the cranial end of the cephalic vein as a drainage vein in the deltopectoral groove, until the flap could be transposed easily to the neck defect pedicled on the dissected cranial limb of the cephalic vein, the flap was arterialized by anastomosing the caudal end of the cephalic vein to a recipient artery in the neck The donor defect was skin grafted and the flap survived completely. The neck contracture improved substantially.

Coverage of a thumb wound and correction of a first web space contracture using a longitudinally split reverse radial forearm flap.

The authors describe a new design for a reverse-flow radial forearm flap. A total thumb amputation by severe avulsion was salvaged by microsurgical replantation and a reverse-flow radial forearm flap with a modified design to allow repair of two separate hand defects concomitantly. This newly described flap design for the reverse radial forearm flap offers a refined technique for simultaneous reconstruction of multiple defects in the hand.

Creating two independent fasciocutaneous free flaps from a single radial forearm donor site.

The authors describe the creation of two independent fasciocutaneous free flap units from a single radial forearm donor site. After the radial forearm flap is elevated in the standard manner, based on the entire length of the radial artery, the individual flap units are developed as island flaps based on the proximal and the distal radial artery respectively by transecting the radial artery, its accompanying veins, and the cephalic vein. Thus, two independent radial forearm free flaps are created from a single donor site: The proximal one has antegrade flow and the distal one has retrograde flow. The individual free flap units were transferred, and microvascular anastomoses were performed simultaneously by two surgical teams. This technique was used in 2 patients presenting with bilateral foot defects that required reconstruction with a thin, reliable flap such as the radial forearm flap.

A new flap model in rats: iliac osteomusculocutaneous flap.

Although osteomusculocutaneous flaps are used frequently in clinical practice to repair defects involving soft tissue and bone, there are still many questions that remain to be answered regarding their basic physiology. To accomplish such basic science studies, simple and reliable animal osteomusculocutaneous flap models are needed. The purpose of this study was to describe a new flap model in rats--namely, the iliac osteomusculocutaneous flap. Thirty adult Wistar rats weighing 200 to 250 g were used in this experiment. In 15 rats, the vascular anatomy of the iliolumbar vessels and their relation with adjacent soft tissues and the iliac bone was determined by anatomic dissection. Based on this anatomic study, the iliac osteomusculocutaneous flap model was created in rats. The flap is comprised of a skin island (3 x 3 cm) in the flank region, a 1 x 1-cm segment of iliac bone, and an abdominal wall muscle cuff. In 10 rats, the flap was raised as an island flap based on its vascular pedicle of iliolumbar vessels, and was replaced in situ. In the remaining 5 rats, the flap was transferred to the groin region as a free flap. Direct observation on postoperative day 7 revealed that the skin island of all the flaps was completely viable. Bone scintigraphy performed on postoperative day 3 in free flaps demonstrated radionuclide uptake, indicating viability of the bony segment. The dye injection study revealed ink staining within blood vessels of the bone, confirming its viability. Microangiography of the flap demonstrated vascularity of each component of the flap by the iliolumbar vessels, including a distinct branch to the iliac bone. The authors conclude that the iliac osteomusculocutaneous flap of the rat is a simple and reliable flap model that offers the following advantages: (1) It is a true osteomusculocutaneous flap, (2) it can be used as a free flap without the need for an isogeneic rat, (3) the vascular pedicle is consistent, and (4) it is harvested from a small-animal species.

Fingertip replantation at or distal to the nail base: use of the technique of artery-only anastomosis.

The authors describe the functional and aesthetic results of microsurgical replantation of 21 fingertip amputations at or distal to the nail base-namely, zone I amputations. There were 15 male and 6 female patients, with an average age of 26 years (age range, 1-41 years). Replantations were performed using the anastomosis of the artery-only technique, with neither vein nor nerve repair. Venous drainage was provided by an external bleeding method with a fish-mouth incision in "distal" zone I amputations for approximately 7 days, and by the use of leeches in more "proximal" zone I amputations for 10 to 12 days. Results indicated that the overall survival rate was 76%, with 16 of 21 digits surviving. Sensory evaluation at an average follow-up of 12 months (range, 6-18 months) revealed an average static two-point discrimination of 6.1 mm (range, 2.0-8.0 mm). Considering the unfavorable results and the donor site morbidity of various fingertip reconstructions, a microsurgical fingertip replantation should always be considered except in extremely distal, clean-cut, pediatric cases, in which case a composite graft is a possibility. The results of this series indicate that an amputated fingertip in zone I can be salvaged successfully by microvascular anastomosis of the artery only, with a nonmicrosurgical method of venous drainage. Furthermore, acceptable sensory recovery can be expected without any nerve coaptation.

Microsurgical ear replantation without venous repair: failure of development of venous channels despite patency of arterial anastomosis for 14 days.

The authors describe a case of microvascular ear replantation with repair of the artery only and medicinal leech therapy that survived for 14 days but ultimately failed as a result of the absence of development of venous channels between the replant and the recipient bed. A 35-year-old man presented with complete avulsion of 80% of the right external ear. The auricle was revascularized successfully via transposition of the superficial temporal artery (STA) and end-to-end anastomosis between the STA and an identified arterial branch on the posterior surface of the ear, using the technique of longitudinal wedge resection. No suitable veins could be found, therefore medicinal leech therapy was used for venous drainage as well as for systemic heparinization. Although the replant remained viable, frequency of leeching did not decrease over 2 weeks. On postoperative day 14, despite obvious viability of the replanted ear, leeching was stopped, considering the ongoing blood loss. Unfortunately, the auricle was found to be necrosed totally the following day. In retrospect, the authors think that inadequate debridement of nonvital tissues may have led to the failure of development of venous channels between the replant and the recipient bed, as manifested by the frequent requirement of leeching to relieve venous congestion long after revascularization. They conclude that the importance of thorough debridement cannot be overemphasized in microsurgical ear replantation with no vein anastomosis, as demonstrated in their patient. From the point of view of creation of venous drainage channels, deepithelialization of the posterior ear skin may be beneficial.

A rat musculocutaneous flap model: the biceps femoris musculocutaneous flap.

The purpose of this study was to describe a new musculocutaneous flap model in the rat. A total of 25 Wistar rats weighing 200 to 280 g were used in this experiment. In 15 rats, the vascular anatomy of the biceps femoris muscle and the cutaneous blood supply of its overlying posterior thigh skin were studied by anatomic dissection, dye injection, and microangiography using 5 rats in each group. The anatomic studies revealed that the main axial vessel supplying the biceps femoris muscle was the caudal femoral branch of the popliteal vessels. The posterior thigh skin overlying the biceps femoris muscle received a consistent musculocutaneous perforator at the center of the mid-posterior line of the posterior thigh. Based on the caudal femoral-popliteal vascular pedicle, the biceps femoris musculocutaneous flap was created in the rat, comprised of the whole muscle and its overlying posterior thigh skin. The skin paddle was designed as an ellipse with its longitudinal axis paralleling that of the extremity, generally measuring 4 x 2 cm. Island flaps were raised as described and replaced either in situ (N = 5) or transposed to a sacral defect (N = 5). Results showed that the cutaneous islands of all the flaps survived completely. Tetrazolium blue stain used to indicate muscle survival revealed that the average muscle viability was 86.7+/-3.4%. The authors conclude that the biceps femoris musculocutaneous flap is a reliable and true musculocutaneous flap model for future biological and pharmacological studies. It offers the following advantages: It has a consistent vascular pedicle and a musculocutaneous perforator, it supports a relatively large skin island, and there is no risk of autocannibalization of the flap because the flap is located dorsally.

Congenital isolated absence of the nasal columella: reconstruction with an internal nasal vestibular skin flap and bilateral labial mucosa flaps.

Congenital aplasia of the nasal columella is a very rare anomaly. The deformity is characterized by the isolated absence of the columella from the nasal tip to the root of the philtrum, including the medial crura of the alar cartilages; surrounding structures such as the septum, nose, and upper lip are normal. To the best of our knowledge, only four such cases have been described to date. The embryopathogenesis for this uncommon disease is presently unknown. Our report describes a 14-year-old girl with congenital agenesis of the columella as an isolated anomaly. Her family history was positive for the presence of the same congenital deformity, which also affected her older brother; there was, however, no consanguinity between the parents. The columella defect was reconstructed with an internal nasal vestibular skin flap and bilateral upper labial mucosa flaps. There are many techniques available to repair columella defects, including free grafts from the ear, local flaps from the forehead, face, upper lip, and nose, distant flaps such as tube pedicle flaps, and free flaps from the ear. Each of these techniques has advantages and disadvantages. Because of this, the treatment of columella defects should be individualized.

Clinical and scientific considerations in leech therapy for the management of acute venous congestion: an updated review.

Any surgical intervention that involves the manipulation of veins, large or small, carries the risk of acute venous congestion. Venous congestion is the product of an imbalance between arterial inflow and venous outflow, and results in the stasis of blood in the tissues that are normally drained by the affected veins. The resultant lack of tissue perfusion causes hypoxia, acidosis, and arterial thrombi formation, which can potentially progress to tissue necrosis and wet gangrene. In the past several decades, the use of leeches (Hirudo medicinalis) has been rediscovered as an effective method of relieving acute venous congestion. This updated review of leech therapy focuses on the use of medicinal leeches in a variety of clinical conditions characterized by acute venous congestion, and points out the experimental use of leeches in other pathological entities. A discussion of the recent scientific findings that explain the possible mechanisms of action of leech therapy is also provided.

Free transfer of the radial forearm flap with preservation of the radial artery.

One of the main disadvantages of the radial forearm flap is the sacrifice of a major artery. To overcome this drawback the authors describe a technique of free transfer of the flap with preservation of the radial artery. The flap is elevated as a distal row perforator-based fasciocutaneous flap with a very short segment of the radial artery included in the inverted-T-shaped arterial pedicle. The venous outflow of the flap is provided by the cephalic vein, with accompanying veins of the radial artery left behind. Although the donor radial artery is repaired primarily, the flap is transferred to reconstruct a soft-tissue defect resulting from the release of a neck contracture after radiotherapy in a 42-year-old patient who had previous excision of a mandibular osteosarcoma. The arterial anastomosis was performed end to end between the superior thyroid artery and one limb of the arterial pedicle, with the other limb ligated. The venous anastomosis was performed end to end between the cephalic vein and the external jugular vein. The flap survived completely and a satisfactory result was obtained. The radial artery is demonstrated to be patent long after surgery, both with Allen's test and with a Doppler examination. Considering the possible sequelae of the sacrifice of the radial artery, this technique is obviously advantageous to such patients, even with a nonsatisfactory preoperative Allen's test. This perforator-based radial forearm flap is very easy to raise and to transfer, with anastomoses of large-diameter vessels.

Osteocutaneous flap prefabrication based on the principle of vascular induction: an experimental and clinical study.

Conventional osteomyocutaneous flaps do not always meet the requirements of a composite defect. A prefabricated composite flap may then be indicated to custom create the flap as dictated by the complex geometry of the defect. The usual method to prefabricate an osteocutaneous flap is to harvest a nonvascularized bone graft and place it into a vascular territory of a soft tissue, such as skin, muscle, or omentum, before its transfer. The basic problem with this method is that the bone graft repair is dependent on the vascular carrier; the bone needs to be revascularized and regenerate. The bone graft may not be adequately perfused at all, even long after the transfer of the prefabricated flap. This study was designed to prefabricate an osteocutaneous flap where simply the bone nourishes the soft tissues, in contrast to the conventional technique in which the soft tissue supplies a bone graft. This technique is based on the principle of vascular induction, where a pedicled bone flap acts as the vascular carrier to neovascularize a skin segment before its transfer. Using a total of 40 New Zealand White rabbits, two groups were constructed as the experimental and control groups. In the experimental group, a pedicled scapular bone flap was induced to neovascularize the dorsal trunk skin by anchoring the bone flap to the partially elevated skin flap with sutures in the first stage. After a period of 4 weeks, the prefabricated composite flaps (n = 25) were harvested as island flaps pedicled on the axillary vessels. In the control group, nonvascularized scapular bone graft was implanted under the dorsal trunk skin with sutures; after 4 weeks, island composite flaps (n = 15) were harvested pedicled on the cutaneous branch of the thoracodorsal vessels. In both groups, viability of the bony and cutaneous components was evaluated by means of direct observation, bone scintigraphy, measurement of bone metabolic activity, microangiography, dye injection study, and histology. Results demonstrated that by direct observation on day 7, the skin island of all of the flaps in the experimental group was totally viable, like the standard axial-pattern flap in the control group. Bone scintigraphy revealed a normal to increased pattern of radionuclide uptake in the experimental group, whereas the bone graft in the control group showed a decreased to normal pattern of radioactivity uptake. The biodistribution studies revealed that the mean radionuclide uptake (percent injected dose of 99mTc methylene diphosphonate/gram tissue) was greater for the experimental group (0.49+/-0.17) than for the control group (0.29+/-0.15). The difference was statistically significant (p<0.01). By microangiography, the cutaneous component of the prefabricated flap of the experimental group was observed to be diffusely neovascularized. Histology demonstrated that although the bone was highly vascular and cellular in the experimental group, examination of the bone grafts in the control group revealed necrotic marrow, empty lacunae, and necrotic cellular debris. Circulation to the bone in the experimental group was also demonstrated by India ink injection studies, which revealed staining within the blood vessels in the bone marrow. Based on this experimental study, a clinical technique was developed in which a pedicled split-inner cortex iliac crest bone flap is elevated and implanted under the medial groin skin in the first stage. After a neovascularization period of 4 weeks, prefabricated composite flap is harvested based on the deep circumflex iliac vessels and transferred to the defect. Using this clinical technique, two cases are presented in which the composite bone and soft-tissue defects were reconstructed with the prefabricated iliac osteomyocutaneous flap. This technique offers the following advantages over the traditional method of osteocutaneous flap prefabrication. Rich vascularity of the bony component of the flap is preserved following transfer (i.e. (ABSTRACT

A new flap model in the rat: the pectoral skin flap.

The purpose of this study was to describe a new axial-pattern experimental flap model in the rat. Wistar rats weighing 200 to 250 g were used in the experiment. In 15 rats, the superficial anatomy of the ventral thoracic region was studied by anatomic dissection, dye injection, and microangiography, using 5 rats in each group. The anatomic studies revealed that the ventral thoracic skin derives its principal blood supply from the long thoracic artery--a branch of the common thoracic artery. Based on these anatomic studies, the pectoral skin flap model, pedicled on the long thoracic vessels, was created in the rat. The flap is bounded medially by the midsternal line, laterally by the anterior axillary line, and superiorly and inferiorly by transverse lines passing at the level of the suprasternal notch and the xyphoid process respectively. In 5 animals, bilateral flaps (N = 10) were raised and replaced in situ. In 15 animals, oversized flaps were created by extending the flap for both a greater width (N = 10) and length (N = 10). Although all the flaps limited to the cutaneous territory as described were found to survive totally, oversized flaps underwent partial necrosis distally. The authors conclude that the pectoral flap is a simple and reliable skin flap model for future biological and pharmacological study because it is very easy to raise, has a consistent vascular pedicle, and has well-defined borders with consistent landmarks.

Endoscopically assisted removal of unilateral coronoid process hyperplasia.

Coronoid process hyperplasia (CPH) is an uncommon disorder characterized by an enlarged coronoid process impinging against the posterior aspect of the zygomatic arch. Young male adults are usually affected, presenting with limited mouth opening, which is typically painless and progressive in nature. The diagnosis of true CPH is established by the findings of (1) uniform coronoid enlargement on radiographic examination and (2) normal bone structure on histopathological examination (i.e., the specimen should be free of any neoplastic growth, such as the previously reported cases of coronoid osteomas, osteochondromas, or exostoses). The treatment is mainly surgical, by means of a coronoidectomy. An intraoral approach is mostly preferred for this procedure to avoid an external scar. However, to avoid the drawbacks of this approach, such as limited exposure and the risk of hematoma and subsequent fibrosis, an extraoral approach may be indicated. This report describes a case of true unilateral CPH in a 17-year-old boy who presented with progressive limited mouth opening in the absence of any pain. Computed tomography (CT) demonstrated a uniformly enlarged right coronoid process. A coronoidectomy was performed with the aid of endoscopic systems, approaching via two short incisions in the temporal scalp. Histopathological examination of the specimen demonstrated essentially a normal bony structure with no evidence of a neoplasm. The authors present the endoscopically assisted technique of coronoid process excision as an alternative method of surgical treatment of CPH and any mass of the coronoid process in general. With this method, the incision is much shorter than a conventional coronal incision and thus morbidity is diminished considerably.

Arterialized venous dorsal digital island flap for fingertip reconstruction.

Fingertip resurfacing is a challenging reconstructive problem; despite the existence of many different surgical methods, enthusiasm on developing versatile flap techniques has been continuing. In this report, we describe an arterialized venous dorsal digital island flap for fingertip reconstruction. The vascularity of the reverse dorsal digital island flap is augmented by performing an arteriovenous anastomosis between a dorsal vein in the flap and one of the proper digital arteries at the fingertip. Eight flaps were used in eight patients for the reconstruction of their fingertip defects. The ages of the patients ranged from 19 to 41 years, with an average of 28.4 years. In two cases, the flap was used as a neurosensorial flap by coapting the dorsal digital radial nerve to the digital nerve. The mean follow-up was 11 months, and all but one flap totally survived. The operative technique is easy except for the necessity of performing standard microvascular surgery. The flap may be a good alternative for repairing fingertip defects in selected cases.