Anatomical Considerations and Plastic Surgery Reconstruction Options of Sacral Chordoma Resection.

Introduction Chordomas are slow-growing malignant bone tumors arising from remnant embryonic notochord cells with predilection for the sacrum. They rarely metastasize, and early surgical resection with clear margins is the treatment of choice followed by plastic surgery reconstruction supplemented with adjuvant radiotherapy based on the local treatment protocol or in cases with a contaminated surgical field. Aim The aim of the present study is to present our experience in surgical management of sacral chordomas and propose a surgical reconstruction algorithm considering anatomical parameters after partial or total sacrectomy. Materials and methods  Twenty-seven patients with sacral chordomas were treated in our Orthopaedic Surgery Department between January 1997 and September 2022, and 10 of them had plastic surgery reconstruction. Patients were divided into groups based on the type of sacrectomy, sacrum anatomical vascular or neural variations, partial or total, and the type of soft tissue reconstruction. The postoperative complications and the functional outcomes in each patient were assessed. Results  Bilateral gluteal advancement flaps or gluteal perforator flaps are the first choice in patients with partial sacrectomy, intact gluteal vessels, and without preoperative radiotherapy followed by transpelvic vertical rectus abdominis myocutaneous flap or free flaps in those patients with near total sacrectomy and preoperative radiation therapy. Conclusion  There are four reliable options for patients after sacral chordoma resection: direct closure, bilateral gluteal advancement flaps, transpelvic vertical rectus abdominis myocutaneous flaps, and free flaps. Each time, tumor-free margins and a good reconstructive plan according to the defect and patient characteristics are mandatory.

Lengthening Phalloplasty with Division of the Suspensory Ligament and Distally Based Fat Flaps in Penis Enlargement Operations.

SUMMARY: Small penile size is worrying for most men and leads to poor self-esteem, anxiety, and depression. A penis can be enlarged in two ways: by increasing the length and by increasing the circumference. The purpose of this article is to present a new procedure of augmentation phalloplasty thst combines these two parts in the same operation with a new technique to fill in the dead space created by the suspensory ligament division. The lengthening of the penis is achieved with an inverted V-Y plasty followed by a division of the suspensory ligament of the penis all the way down the pubic symphysis. Two distally based fat flaps are advanced into this area to fill in the dead space. The widening of the circumference is performed with fat injections. The penile length gain postoperatively is 2 to 4 cm in the flaccid state, and the widening component with the fat grafting technique gives an approximate circumference increase of 1 cm with excellent natural results. Sexual self-esteem and functioning improvement was reported by the patients, 75 in total. Three patients returned after the operation for revision of fat injections 6 to 12 months after the operation. The literature regarding the long-term results after augmentation phalloplasty is poor, and it is difficult to compare results with other techniques. Penile enlargement, when performed for the appropriate reasons, can have a positive effect on the lives of many men. After 15 years of experience, this procedure gives very pleasing results with minimal complications.

The modified horn flap for nasal tip reconstruction.

Numerous flap design techniques have been proposed for soft tissue reconstruction of the nasal tip. The modified horn flap based on the superior alar artery and nasalis muscle is the preferred option for defects ranging in size from 1 to 2 cm vertically and 1.5 to 3 cm horizontally after skin cancer excision. This innovative technique is a reliable and versatile island flap for reconstruction of the nasal tip in a one-stage operation, providing successful functional and aesthetic results, as tissues for the flap are generated from the nose. The contribution of the superior alar artery, which forms the vascular axis of the flap, plays a vital role in flap survival - together with part of the nasalis muscle.

The management of locally advanced head and neck squamous and basal cell carcinomas.

PURPOSE: The management of locally advanced head and neck basal (BCC) and squamous cell (SCC) carcinomas has been controversial and often debated. The purpose of the current study was to present our experience in the treatment of non-melanotic head and neck skin malignancies. METHODS: From 2000 to 2017, 34 patients with locally advanced head and neck skin tumors were treated in our hospital with wide local excision and immediate reconstruction mainly with rotational flaps, free tissue transfers and skin grafting. RESULTS: Histopathological examination revealed 10 BCCs, 22 SCCs and 2 cases of metatypical basal cell carcinomas. All patients were successfully submitted to ablative procedure with minimal morbidity and acceptable cosmetic results. CONCLUSIONS: Locally advanced head and neck SCCs and BCCs are large tumors that may invade adjacent structures or infiltrate into deep tissues. Complex reconstructive methods are needed to close the defect, with free tissue transferring being a reliable option. Finding clear margins is crucial in order to prevent unnecessary morbidity and local recurrence.

Perineal Reconstruction with a Diamond-shaped Perforator Flap: A Case Report.

Reconstruction of perineal defects is a challenging procedure. Various surgical techniques have been proposed. Compared with traditional myocutaneous flaps, pedicled perforator flaps are believed to be a less invasive option for perineal reconstruction, with better functional and cosmetic results. We present the case of a 47-year-old woman with a perianal Paget's disease who underwent surgical excision of the lesion. The reconstructive technique was a pedicled flap based on an internal pudendal skin perforator artery. The flap was designed in a diamond-shaped pattern. Six months after the operation, the patient is disease-free with successful aesthetic and functional results. A polygonal diamond-shaped flap is an easy and reliable choice for perineal reconstruction, offering better adjustment in the perianal region and avoidance of the curvilinear perianal incision (which often leads to anal stenosis).

Intramuscular granular cell tumor of the gluteal region.

Granular cell tumors are uncommon, usually benign neoplasms, mainly observed in the head and neck region, chest wall and upper extremities. These tumors account for ~0.5% of all soft-tissue tumors. Less than 2% are malignant. These are associated with poor prognosis. Clinical signs suspicious for malignancy are large size, rapid growth, invasion, recurrence and metastasis. Malignancy is confirmed by histological examination. We present the case of a 79-year-old patient with a 6-month history of a rapidly growing mass in the left gluteal region giving the clinical impression of a malignant tumor. The patient underwent surgical excision of the tumor and the pathology report revealed a granular cell tumor. In difficult cases, multidisciplinary approach is necessary for appropriate diagnosis and management.

The Anterolateral Thigh Perforator Flap in an Innovative Microsurgery Training Method.

The road to becoming a good and confident microsurgeon requires love for your work, patience, and good training facilities. Safe and effective training procedures for young microsurgeons during their plastic surgery residency are necessary and should be applied under standardized conditions. We present an innovative microsurgical training method for plastic surgery residents in the operation theater concerning the anterolateral thigh perforator flap (ALT). In a 2-team approach, the ALT flap harvesting begins parallel to tumor resection. Although the tumor excision team still works in the tumor region, and after the reconstructive team has successfully completed the ALT dissection, residents can work distally to the origin of the perforator vessel (which supplies the flap). Their training involves dissection and anastomosis of the continuation of the descending branch, distally to the perforator supplying the flap. Since 2015, eight operations have been performed with this innovative method with the participation of upcoming microsurgeons. A written informed consent is given to all patients. Our study resulted in the improvement of microsurgical skills of the young microsurgeons. There is no impact to the ALT perforator flap or to the operative time. This training procedure can be safely applied as a training method during plastic surgery residency under standardized conditions. We have the joy of seeing our resident's progress through their high success rates in microsurgery. We recommend this innovative procedure as an adequate teaching method during residency to promote the future of our specialty, and we hope that our students will become even better than their teachers.

Dermatofibrosarcoma protuberans coexisting in a patient with a vascular malformation-a rare coincidence.

Dermatofibrosarcoma protuberans with fibrosarcomatous differentiation (DFSP-FS) is a rare soft tissue tumor with more aggressive behavior and it is not clear what causes this type of skin cancer. We describe the case of a 48-year-old woman who was born with a vascular malformation in the sternal region and presented suddenly with a soft tissue sarcoma (DFSP-FS) in the same territory. She was initially treated by embolization as the sarcoma was misdiagnosed but the tumor within 6 months seemed to be growing rapidly and reached a giant dimension with ulceration and required surgical intervention. The patient underwent a surgical removal of the mass but as the pathology report included a DFSP-FS with close margins,a second operation was required. A wide local excision was performed and reconstruction of defect by using bilateral pectoralis major muscle flaps and a full thickness skin graft from the abdominal wall. Post operatively the patient was treated with radiotherapy.