Vulvo-perineal reconstruction with a reverse sensitive rectus abdominis salvage flap in a multirecurrent anal carcinoma.

Reconstructive options after vulvectomy is preferably performed using fasciocutaneous flaps. If the defect is very large, the use of vertical rectus abdominis myocutaneous (VRAM) flap is recommended. We report a case of a patient affected by multirecurrent anal carcinoma, treated by chemotherapy, radiotherapy and surgery several times, until an extended abdominoperineal resection of Miles was performed. Since other surgical options were no more available, a primary reverse VRAM flap reconstruction was harvested, together with an end-to-end nerve anastomosis between the cutaneous ramus of the 8th intercostal nerve and the superior branch of the pudendal nerve to achieve sensibility. Encouraging results, without actual recurrence of the disease, were obtained.

An explosion in the mouth caused by a firework.

Explosion and gunshot mouth injuries represent a challenging problem with regard to restoring optimal oral function. These wounds exhibit a spectrum of complexity and mostly include extensive soft tissue trauma complicated by burns, foreign bodies, fractures and concomitant traumas. To gain maximal restoration of oral function, the use of reconstructive techniques, together with microsurgical techniques, such as grafting of nerves, vessels and soft tissue, as an acute free flap to cover a large defect, are immediately necessary. We report the case of a young Caucasian patient who destroyed the middle and lower thirds of the face when a firecracker blasted in his mouth. His clinical history is unusual in terms of the modality of injury, i.e. a Russian roulette game, and the lesions suffered, in the reconstruction of which we used both surgical and microsurgical techniques.

Comparative study of breast implant rupture using mammography, sonography, and magnetic resonance imaging: correlation with surgical findings.

Purpose of this study was to evaluate the accuracy of mammography, ultrasonography, and magnetic resonance imaging (MRI), in the detection of breast implant rupture and to make a correlation with findings at explantation. The study population consisted of 63 women with 82 implants, undergoing surgical explantation. Implant rupture status was blindly determined obtaining diagnosis of rupture, possible rupture, or intact implant. Strictly predetermined rupture criteria were applied and compared with findings at surgery, which were considered the gold standard. False-positives and false-negatives were retrospectively evaluated to identify pitfalls in the investigation. All associations between imaging signs and surgical findings were evaluated by using chi-square test. The respective sensitivity and specificity of investigations are reported. Our experience suggests that MRI is the more accurate method for identification of breast implant rupture, even if it should be performed following the diagnostic algorithm proposed.

Comparative efficacy of topical versus systemic teicoplanin in experimental model of wound infections.

INTRODUCTION: Surgical site infections are the second most common cause of nosocomial infections and, typically, gram-positive pathogens are involved. MATERIALS AND METHODS: A mouse model was used to investigate the efficacy of different methods for the treatment of wound infections. A full thickness wound was established on the back subcutaneous tissue of adult male BALB/c mice. A small gauze was placed over each wound and then inoculated with 5 x 10(7) colony-forming units of Staphylococcus aureus. The study included a control group that did not receive any treatment and four contaminated groups treated, respectively, with: (1) drug-free Allevyn (Smith and Nephew Healthcare, Yorkshire, United Kingdom), (2) teicoplanin-soaked Allevyn, (3) drug-free Allevyn and daily intraperitoneal teicoplanin (7 mg/kg) and, finally, (4) teicoplanin-soaked Allevyn and daily intraperitoneal teicoplanin (7 mg/kg). Main outcome measures were quantitative bacterial culture, assessment of vascular endothelial growth factor (VEGF) plasma levels, histological examination with assessment of microvessel density, and of VEGF expression in tissue sections. RESULTS: Data analysis showed that strong inhibition of bacterial growth was achieved in any group treated with intraperitoneal teicoplanin. However, the highest inhibition of bacterial growth was obtained in the group that received teicoplanin-soaked Allevyn and intraperitoneal teicoplanin. Histological examination showed that each treatment modality was able to reduce the delay in wound repair. The most effective treatment appeared to be the local application of teicoplanin-soaked hydro gel foam. The tissue effects were associated with an increase in neovascularization and VEGF expression by endothelial cells and fibroblasts in the granulation tissue. Bacterial colonies also were reduced, especially when teicoplanin was given parenterally. CONCLUSIONS: Soaking a hydro cellular foam with an antistaphylococcal agents, such as teicoplanin, may be useful for the management of infected wounds.

Combined use of WEB2170 and HBO therapy can reduce ischemia and reperfusion injury to the skeletal muscle in a rabbit model.

Ischemia/reperfusion injury is regarded as the main cause of failure in revascularization of limbs and transfer of free flaps in the so called nonreflow phenomenon. This type of damage is caused by the production of free radicals, above all, of neutrophils that release great quantities of extracellular superoxide through the action of a membrane enzyme. In our study we used 40 white rabbits. Rabbit rectus femoris muscle is perfused by a single artery and vein and is therefore a valuable model for study of ischemia-induced reperfusion injury of skeletal muscle. The objective of this study was to individualize a valid method of protection for the muscle from damage by ischemia-induced reperfusion injury. We have tested the effectiveness of WEB2170, a PAF antagonist, of hyperbaric oxygen therapy one (HBO), and of combined employment of WEB2170 and HBO. The results show that both PAF and HBO play important protective roles against damage from ischemia/reperfusion injury, and that the combined employment of both therapies has a synergistic effect. We propose therefore a new therapeutic protocol for the prevention of damage resulting from ischemia/reperfusion injury with the simultaneous employment of this PAF and HBO.

Delayed microsurgical reconstruction of the extremities for complex soft-tissue injuries.

The treatment of severe wounds of the extremities, characterized by large posttraumatic tissue loss, represents a clinical problem difficult to resolve, especially when the lesion is surrounded by large areas of ischemic distrophic tissue which progressively aggravate and extend the initial lesion, with frequent exposure of bone and joint structures making the amputation of the limb an inevitable outcome. The authors present their experience based on combined treatments by medical support methods such as hyperbaric oxygen (HBO) and vacuum-assisted closure therapy (VAC) and microsurgical reconstruction of the limbs, within a precise therapeutic protocol. The use of this protocol in appropriate times and ways allowed us to successfully treat severe posttraumatic sequelae of the limbs, avoiding the delayed healing typical of these pathologies, both on the donor site of the flap and on the repaired area, and avoiding unsuitable microsurgical reconstruction of limbs, allowing satisfactory morpho-functional restoration and a reduction of the hospitalization period.

From the "charretera" to the supraclavicular fascial island flap: revisitation and further evolution of a controversial flap.

Wide tissue defects located on the face and neck area often require distant flaps or free flaps to achieve a tension-free reconstruction together with an acceptable aesthetic result. The supraclavicular island flap surely represents a versatile and useful flap that can be used in case of large tissue losses. Because of its wide arc of rotation, which ensures a 180-degree mobilization anteriorly and posteriorly, the flap can reach distant sites when harvested as a pure island flap. The main vascular supply of the flap, the supraclavicular artery, a branch of the transverse cervical artery or, less frequently, of the suprascapular artery, though reliable, is not a very large vessel. In some particular cases, when too much tension or angles that are too tight are present, the vascular supply of the flap can be difficult and special care must be taken to avoid flap failure. To avoid this problem, the authors started harvesting the flap not as a pure island flap but with a fascial pedicle, thin and resistant, which ensures good reliability; also, when a higher tension rate is present, it avoids the risk of excessive traction or kinking of the vessels. Twenty-five consecutive patients with various defects located on the head, neck, and thorax area were treated in the past 2 years using the modified supraclavicular island flap. There was no flap loss or distant necrosis of the flap, and there was marginal skin deepithelialization in only two cases, which only required minor surgery. Postoperative morbidity was low, similar to the classic supraclavicular island flap, with primarily closed donor sites, except for one case, and tension-free scars. The authors show how the modified supraclavicular island flap is a reliable and safe flap that gives a good aesthetic result with low risk concerning the viability of the transferred skin. The technique, similar to supraclavicular island flap harvesting, is easy to perform and is attractive in patients at risk for poor or delayed healing such as smokers or patients with complex medical histories.

Local rh-VEGF administration enhances skin flap survival more than other types of rh-VEGF administration: a clinical, morphological and immunohistochemical study.

The aim of the present study was to evaluate experimentally whether administration of recombinant (rh) vascular endothelial growth factor (VEGF) can protect skin flaps from necrosis and to study the optimum mode of rh-VEGF administration. We used rats to study the effects of local or systemic administration of rh-VEGF on skin flap during surgery; we also tested preoperative systemic administration of rh-VEGF to assess whether it may prepare the tissue to respond to the hypoxic injury better than previously tested methods. The animals were 30 male Sprague-Dawley rats. Group I rats received multiple systemic injections of rh-VEGF in the tail artery prior to flap dissection. Group II rats were injected with rh-VEGF in the clamped left epigastric artery during flap dissection; in this group, the left flaps thus received rh-VEGF locally (via incubation for 10 min during hypoxia) and the right flaps systemically, after blood flow restoration. Group III received saline solution instead of VEGF in the same way as group II. Skin samples from the distal portion of the flaps were collected on day 7 for morphological and immunohistochemical analysis. The flaps exhibiting the least necrosis were those treated with local rh-VEGF, followed by those treated with systemic rh-VEGF. The flaps that received rh-VEGF locally showed a strong VEGF expression on keratinocytes and endothelial cells, the greatest amount of mature and newly formed vessels and strong survivin expression in endothelial cells. Local rh-VEGF administration should thus be considered as an effective therapeutic option to enhance the survival of a tissue at risk for perfusion.

Which is the best position for the remote injection dome using the adjustable expander/prosthesis in breast reconstruction? A comparative study.

Breast reconstruction using mammary implants is a routinely performed surgical procedure that gives good aesthetic results with a relatively simple operation for the patients. When an adjustable expander/prosthesis with remote dome is used for reconstruction, the device is filled through an injection dome connected to the implant through a filling tube. The injection dome is usually inserted into a subcutaneous pocket, either in the axillary area or, most frequently, in the lower lateral thoracic area. Sometimes, this location is not well tolerated by the patient because of pain or discomfort in the breast-thoracic area and can give problems related to the distance, which causes kinking of the filling tube. To avoid this inconvenience and because of frequent patient complaints, the authors decided 3 years ago to place the injection dome in a parasternal position and compare this location with the previously used lower lateral thoracic location. Two hundred sixty patients were divided into two groups (130 patients in each group) and evaluated. All patients underwent mammary reconstruction in the authors' department using Becker adjustable implants. In all patients, the injection microdome was used. In group A, the injection microdome was positioned in the lower lateral thoracic area; in group B, the injection microdome was positioned in a parasternal area. Both groups were compared, considering different features such as pain, discomfort, ease of injection, pain during puncture, aesthetic appearance, risk of kinking, and risk of upside-down rotation of the dome. Average follow-up was 1.6 years. Statistical analysis was performed using Pearson's chi-square test regarding the differences in frequency of two features-aesthetic appearance and pain during puncture-between the two groups. The comparisons regarding both aesthetic appearance and pain during puncture did show a significant difference between the two groups, with a value of p < 0.05 in both cases. In the present study, the results showed how the patients had less pain during puncture and a better aesthetic appearance when the microdome was located in the parasternal position instead of the lower lateral thoracic area. Advantages and disadvantages of the locations used are discussed in this article.