Beniamino Brunetti

Spitz Nevus: Follow-Up Study of 8 Cases of Childhood Starburst Type and Proposal for Management

Spitz nevus is an uncommon, benign melanocytic neoplasm that shares many clinical and histological features with melanoma. It presents clinical ambiguity that makes the diagnosis and management of the patient difficult. We present our experience in the management of Spitz nevus by rigorous dermoscopic long-term follow-up of 8 Spitz nevi in patients younger than 12 years. Dermoscopic images, acquired every 6 months, show evolution and modifications of these lesions. The aim of this paper is to better understand the long-term modifications of nevi with starburst pattern to avoid surgical excision of these lesions in the pediatric age group.

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.

Aesthetic subpectoral placement of implantable cardioverter defibrillators.

AbstractThe implantable cardioverter defibrillator (ICD) is the treatment of choice for life-threatening arrhythmias. Usually, the device is placed, by a subclavian access, on the upper portion of the pectoralis major muscle. As a result, the visibility of the device and the wide subclavian scar create an important aesthetic deformity, especially in young women, evolving in a relevant psychosocial distress. The authors report their experience with subpectoral ICD implantation. Between January 2001 and December 2011, approximately 30 consecutive female patients underwent submuscular ICD implantation or substitution, performed in collaboration with the cardiology team. No significant complications, except 1 case of wound dehiscence and 2 cases of caudal dislocation of the device, were observed. At 6 and 12 months’ follow-up, no significant difference between preoperative and postoperative breast symmetry and volume was noticed. The combined approach aims at reducing the visible signs of the procedure and improving the psychological outcomes.

Postural variations after breast reduction: introduction of a new technique to achieve an objective analysis.

The authors performed a prospective study to evaluate postural variations arising after reduction mammaplasty, objectively recorded by means of static stabilometry. Thirty consecutive patients affected by various degrees of breast hypertrophy were enrolled in the study. Obesity, orthopedic, and otoneurologic diseases were the exclusion criteria. Postural function was evaluated with static stabilometry preoperatively and 1 and 6 months postoperatively. Patients were grouped according to age, sternal notch–nipple distance, and glandular resection and general and subgroup statistical analysis using Student t test for paired samples were performed. Statistically significant differences were found only after 6 months (P = 0.026). In the subgroup analysis, statistically significant differences were found for the age group >35 years (P = 0.0237) and for the sternal notch–nipple distance >30 cm (P = 0.0320). Stabilometry objectively demonstrated postural improvement perceived following breast reduction. Age and ptosis degree appeared to influence posture more than the entity of resection.

Burn after breast reconstruction

AIMS Burns occur rarely after breast reconstruction, and results from loss of sensory and thermoregulatory skin functions. We aimed to investigate the pathophysiological processes leading to these injuries. METHOD Cases described in the literature are reviewed and discussed. Three cases of burn complicating the outcome of two implants and one autologous breast reconstruction are newly reported. DISCUSSION The ineffectiveness of skin thermoregulatory reflexes, caused by different surgical procedures, plays an essential role in the pathogenesis of burns to reconstructed breasts; tissue expansion and radiotherapy are also essential aetiological factors.

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.

The Use of Acellular Dermal Matrix in Reconstruction of Complex Scalp Defects

Multi-focal basal or squamous cell carcinomas of the scalp, as well as recurrent tumors or previously irradiated lesions, always require large full thickness excision to achieve successful and complete healing. Loco-regional or micro-vascular flaps are the gold standard for closure of complex defects of the scalp but in some, especially older, patients, these techniques may be contraindicated. Over the last few years, the introduction of dermal substitutes has improved wound healing and modified surgical strategies in the treatment of complex tissue loss. Matriderm s (Eurosurgical Limited, Guildford, UK) is an acellular dermal substitute constituted by a matrix of type 1 bovine collagen and elastin, with a thickness of 1 to 2mm and pores of about 75mm. Since its introduction in clinical practice, it has been used in the reconstruction of tissue following burns or complex wounds, 1,2 but few studies have focused on its use in the craniofacial region and no studies appear to have evaluated its usefulness in scalp reconstruction. Herewith, we report our personal experience using this acellular dermal matrix in a complex scalp reconstruction, comparing the esthetic outcome to that of a previous full-thickness skin graft in the same region.