Achille Aveta

Free-style local perforator flaps: versatility of the v-y design to reconstruct soft-tissue defects in the skin cancer population.

Background: Free-style local perforator flaps can be harvested from any region of the body where an appropriate and detectable perforator vessel is present. Their use allows the surgeon to perform a “like with like” reconstruction by mobilizing surrounding tissues on a consistent vascular source. The authors report their experience with V-Y free-style perforator flaps in reconstruction of soft-tissue defects subsequent to skin cancer excision. Methods: Forty elective defects in different regions of the body were reconstructed with V-Y advancement local perforator flaps raised in a free-style fashion. There were 23 male patients and 17 female patients. Mean age at surgery was 63 years. All defects resulted from skin cancer ablation. Mean defect size was 5 × 3.7 cm. Mean flap dimensions were 8.8 × 4.2 cm. The flaps were based on one (n = 10), two (n = 18), or three (n = 12) perforators. Results: Mean operative time was 93 minutes. Thirty-seven flaps (92.5 percent) healed uneventfully. In three flaps (7.5 percent), moderate venous insufficiency occurred, leading to partial flap necrosis that required surgical revision. In three cases (7.5 percent), the flap was converted to a rotation/hatchet perforator-based peninsular flap. Slight venous stasis was the most common postoperative finding registered (eight flaps; 20 percent). All flaps achieved adequate and durable reconstruction with excellent contour, with a follow-up ranging between 6 months and 2 years. Conclusion: Free-style local perforator flaps advanced in V-Y fashion proved to be a valid and reliable solution to restore function and aesthetics of the operated site after skin cancer excision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Anterior intercostal artery perforator flap autologous augmentation in bariatric mastopexy.

Background: Breast reshaping after massive weight loss represents a challenging procedure because of severe hypoplasia and tissue ptosis. Standard mastopexy techniques are often inadequate to restore a pleasant profile and volume. The authors present their experience with the anterior intercostal artery perforator flap in breast autologous augmentation and remodeling. Methods: Fifteen bariatric patients (30 breasts) affected by severe breast ptosis and tissue laxity in the upper abdominal wall underwent superior pedicle mastopexy with anterior intercostal artery perforator flap autologous augmentation. The flap was harvested including soft tissues above and below the inframammary fold, extending cranially 5 to 6 cm above the fold and inferiorly over the costal cage and hypochondrium. The flap was completely islanded on intercostal perforators originating from the fifth to seventh intercostal spaces. It was cranially advanced and sutured to the pectoralis major fascia. The medial and lateral borders were sutured together to shape an autologous implant. Results: All of the flaps were transferred successfully. The donor site was always closed primarily and upper abdominal laxity corrected. All of the breasts presented soft at palpation, with no clinical signs of flap necrosis early or late postoperatively. At 1-year follow-up, the breasts maintained good shape and projection. Conclusions: The anterior intercostal artery perforator flap proved to be a reliable option in bariatric mastopexy. The technique can be performed easily and allows the harvesting of a large amount of tissue with a wide range of motion, providing adequate breast volume and projection without the need for implant placement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Scalp reconstruction with superficial temporal artery island flap: Clinical experience on 30 consecutive cases.

BACKGROUND Different techniques are available to reconstruct scalp defects; however, when the cranium is exposed or the hairline compromised, the procedure may become quite challenging. The use of superficial temporal artery fascio-cutaneous flaps has been described mainly to restore the hair-bearing surface of the upper lip or the eyebrow but only few applications in the scalp have been reported. The authors present their experience with the use of superficial temporal artery island flaps to obtain durable coverage and excellent contour in anterior scalp reconstruction. METHODS Thirty consecutive defects in the anterior scalp subunits (temporal = 14; parietal = 12; forehead = 4) were reconstructed with ipsilateral V-Y island flaps nourished by frontal and parietal branches of the superficial temporal artery. All defects resulted from skin cancer excision. Twenty-six flaps were based on the parietal branch. The frontal branch pedicle was used in only four cases to resurface defects in the forehead subunit. Glabrous skin flaps were harvested in six patients. Including a venous branch in the pedicle was not mandatory because the venous drainage of the flaps was provided by the perivascular fascial network. For this reason, a fascial pedicle around the artery, 2-3 cm in width, was maintained to minimise flap venous insufficiency. RESULTS Twenty-nine flaps healed uneventfully (96.7% flap survival rate), providing stable coverage with a mean follow-up of 12 months. In the early postoperative time (up to 48 h), slight venous stasis was observed in 14 flaps (46.6%), but it resolved spontaneously within 1 week. Two flaps showed severe venous stasis, but in only one case (3.3%) it progressed to distal necrosis requiring surgical revision. No cases of alopecia or hairline distortion were postoperatively registered. CONCLUSIONS The use of superficial temporal artery island flaps, mobilised in a V-Y fashion, proved to be an elegant and reliable solution to resurface defects in the anterior scalp subunits in both hairy and bald patients.

A new carbon dioxide laser combined with cyanoacrylate glue to treat earlobe keloids.

phylaxis against lid malposition during the healing/ edema phase and is not meant to be permanent. All eyelids undergo slight to minimal lower lid fat removal, sometimes purely for contour and “smoothing,” not just for debulking purposes. We have not witnessed any posterior and/or middle lamellae contracture with the five-step method. All patients in our study required at least slight skin pinch excision, and no patients demonstrated exophthalmos, which is a contraindication to this technique. The conservative degree of skin removal and avoidance of injury to the septum/orbicularis muscle anteriorly all help to eliminate tension and resultant anterior lamella shortening. Concern regarding exacerbation of tear trough as a result of adjacent augmentation of the deep malar fat pad is valid and is a common source of trepidation. Selective orbicularis retaining ligament release allows migration of native lower lid fat to coalesce with the superficial and deep malar fat compartments. Molding is performed intraoperatively to further blend this region. Reducing skin laxity with pinch removal also helps reduce tear trough appearance. Deep malar fat augmentation also acts to elevate the superficial fat compartments cephalically to meet the now released lower lid fat. We thank Dr. Gradinger for his clear and directed comments on the numerous challenges inherent in lower eyelid rejuvenation. We hope that our five-step technique helps to shed more light on the key principles and techniques in safe and effective lower eyelidcheek rejuvenation.2–5 DOI: 10.1097/PRS.0b013e31824a61d1

Posterior trunk reconstruction with the dorsal intercostal artery perforator based flap: Clinical experience on 20 consecutive oncological cases.

Few studies in the recent literature have investigated the reliability of dorsal intercostal artery perforator (DICAP) flap in posterior trunk reconstruction. The purpose of this report is to describe our clinical experience with the use of DICAP flaps in a cohort of oncological patients.

Reverse-flow medial sural artery perforator flap: pedicle extension for distal lower limb defects.

We read with great interest the article by Xie and Chai about the clinical applications of medial sural artery perforator (MSAP) flap. As described by the authors, it is mainly used as a free flap in head and neck and extremities reconstruction. According to the main cadaveric and clinical studies, 2 main perforators, respectively approximately 8 and 15 cm from the popliteal crease, are eligible to base the flap on. As a local island flap, it represents the evolution of traditional muscular or myocutaneous gastrocnemius flap, and its use is widely accepted in case of defects around the ipsilateral knee and proximal pretibial and popliteal regions. Nevertheless, in the literature, there are few reports about its use as an island local flap to resurface distal lower limb defects, probably because the length of the vascular pedicle is not always sufficient to achieve adequate range of motion in the caudal direction. We introduce a previously undescribed technical modification, the application of Y-V pedicle lengthening principle, that allowed us to increase the caudal reach of an MSAP flap to resurface a distal lower limb defect. A 39-year-old female patient was referred to our department for treatment of malignant melanoma in the anteromedial surface of the left leg. A 6 6-cm defect was planned. Two main perforators were identified by handheld Doppler examination on the surface of the medial gastrocnemius muscle (Fig. 1, left). A 12 7-cm MSAP flap was islanded on the 2 perforators, both arising from the medial branch of the medial sural artery (MSA), with careful intramuscular dissection. The distal perforator was found to be too small to use, and the proximal one was too much cranial to allow distal movement of the flap. So, the MSA medial branch was cut proximally to the origin of the biggest perforator allowing the flap to be raised in a reverse-flow fashion and sutured without tension. The MSA arises from the popliteal artery and divides into medial and lateral branches in the proximal part of the medial gastrocnemius muscle. More frequently, musculocutaneous perforators arise from the lateral branch. The Y-V pedicle extension was first described by Martin et al in 1994. According to this technique, a flap is raised on a branch of a Y-shaped vascular structure. When the vascular trunk is sectioned at the bifurcation, the structure turns from a Y-shaped to a V-shaped one, thus allowing an increased mobility of the flap on the remaining branch of the V. In our case, by interrupting the medial branch of the MSA, we obtained a V-shaped vascular structure constituted by the perforator and the distal part of the medial branch we sectioned (Fig. 2). As a consequence, the flap was nourished by reverse flow from the distal intramuscular anastomoses with the lateral branch of the MSA, the lateral sural artery, and the distal branches from posterior tibial artery. Clinical findings have shown that a distally based gastrocnemius muscle flap can be safely harvested on the same distal vascular network, interrupting the main pedicle. The successful outcome of our procedure (Fig. 1, right), which is to our knowledge the first report of MSAP flap Y-V pedicle extension, confirms that the same concept can be applied in the planning of reverse-flow perforator flaps in the calf region. With the case shown, we propose FIGURE 1. Left, Preoperative project: a 12 7-cm MSAP flap, based on 2 major audible perforators, has been planned to cover a 6 6-cm defect on the anteromedial surface of the left leg. Right, Six months postoperative result; the flap healed without complications.

Digital photography in plastic surgery: the importance of standardization in the era of medicolegal issues.

accurate positioning of subjects, no post–image acquisition changes using computer software, and use of identical views and patient preparation will significantly increase standardization.4 On this topic, in 2007, our group published an article in the journal Aesthetic Plastic Surgery entitled “Digital Photography in Plastic Surgery: How to Achieve Reasonable Standardization Outside a Photographic Studio.”5 In this article, on the basis of the medical literature and our own experience, we reported general criteria concerning patient preparation and camera setting and specific criteria for accurate image capture within different anatomical areas. The aim of our letter is to emphasize the importance of digital photography for plastic surgeons during medicolegal litigation; emphasize that plastic surgeons should use standardized photographic criteria; and raise awareness about some criteria, published in 2007 by our group, that we currently use in clinical practice. Use of strict digital photography guidelines that control all image characteristics will significantly enhance the potential of these images to objectively illustrate the plastic surgeon’s work. DOI: 10.1097/PRS.0b013e31825dc515

A locally aggressive solitary fibrous tumor of the leg: Case report and literature review

INTRODUCTION The solitary fibrous tumor (SFT) is a rare soft tissue tumor with a substantially benign clinical behavior. However, malignant neoplasms with local recurrence or distant metastases have been reported. PRESENTATION OF THE CASE The authors present a case of an aggressive SFT of the leg, in a 55 years old Caucasian man. Radiological, histological and molecular findings are reported. The differential diagnosis, therapy and outcome of this rare tumor are also discussed. DISCUSSION An extensive review of literature showed SFTs clinical behavior as substantially benign, anyway aggressive or malignant neoplasms have been described. The potential risk of local recurrence and distant metastasis thus suggests wide surgical resection and careful long-term follow-up. Differential diagnosis may be quite laborious as SFT can mimic a variety of benign and malignant mesenchymal tumors; immunohistochemical analysis for CD34, CD99, vimentin and bcl-2 is then mandatory. CONCLUSION Our clinical experience confirmed that SFT may have an aggressive behavior, however, conservative surgical treatment may be successful in the long term.

V-Loc suture: a simple wound closure device for areola diameter and shape control in breast reduction and mastopexy.

tion, brachioplasty, body lift, abdominoplasty, and breast reduction. Like the authors, we registered just a few complications, such as suture spitting and wound breakdown at our initial experience. These complications more often occurred in specific sites and procedures, such as the middle part of inguinal scars in patients who underwent thigh lifting. Unlike the authors, we always came out at the end of the incision lines, and our complication rate drastically decreased by suturing more deeply in the dermis. In our experience with body contouring, we found the V-Loc to be extremely useful for the prevention of areolar diameter and shape modifications following breast reduction or mastopexy. Stretching and distortion of the nipple-areola complex, and hypertrophic scars, often complicate these surgical procedures. Thus, they should be prevented by minimizing tension on the closure; nevertheless, round-block and cinching periareolar sutures are often associated with unsatisfying results. From August to December of 2010, we used this suturing device on 19 patients (aged 35 to 58 years) undergoing breast reduction with modified Ribeiro2 inverted-T technique or mastopexy. A 3-0 V-Loc TM180 round-block was performed to minimize areolar tension (Fig. 1, left). Finally, the areola was sutured with 4-0 nylon U Gillies stitches (Fig. 1, right). No postoperative complication occurred. At 6to 11-month follow-up, no significant areola widening (diameter enlargement, 6 to 10 mm) or shape distortion was appreciated (Fig. 2). Furthermore, the scars were normotrophic and aesthetically satisfactory for both the surgeon and the patient. In our hands, the V-Loc, by distributing areola tension, proved to be helpful in preventing areola deformation associated with breast reduction or mastopexy. DOI: 10.1097/PRS.0b013e31824efeee

Superficial temporal artery perforator flap: Anatomic study of number and reliability of distal branches of the superficial temporal artery and clinical applications in three cases

Limited information is available about the anatomical feasibility and clinical applications of flaps based on distal divisions of the superficial temporal artery (STA). The aim of this study was to investigate the anatomy of the STA, focusing on the number and reliability of distal branches and to show representative cases for the use of such flaps for zygomatic, parieto‐frontal and occipital reconstructions.