Carlo Melloni

Segmental anatomy of the vastus lateralis: Guidelines for muscle-sparing flap harvest

Background: The vastus lateralis muscle is a versatile donor site for pedicled and free flaps that, despite great potential, remains unpopular. Although the muscle is classically described as a single belly, evidence exists for a more complex morphology. The aim of this study was to investigate the segmental anatomy of the vastus lateralis muscle and the feasibility of selective flap harvest. Methods: Ten cadaveric lower limbs were investigated. Muscular partitions were identified according to morphologic architecture, vascular supply, and nerve supply; guidelines for selective flap harvest were described. Twenty-three segmental vastus lateralis (n = 14) or chimeric anterolateral thigh–vastus lateralis flaps (n = 9) were raised based on neurovascular segmental supply, and used as noninnervated free flaps for reconstruction of moderate and large defects of the head and neck, trunk, or lower limbs. Intraoperative electrostimulation was used to confirm segmental innervation. Lower limb function was evaluated through the Lower Extremity Functional Scale. Results: The authors clearly identified three anatomical partitions, which receive a constant segmental neurovascular supply, and two aponeuroses. The authors successfully applied the proposed guidelines for flap harvesting to all 23 patients. Intraoperative electrostimulation confirmed functional integrity of both the flap and the spared partitions. All muscle flaps survived. Donor-site morbidity was negligible, with comparable mean preoperative and postoperative Lower Extremity Functional Scale values (67.7 versus 67.4; p > 0.05). Conclusions: This study provides detailed knowledge on the morphologic and neurovascular anatomy of the vastus lateralis muscle, which supports the authors’ guidelines for selective flap harvesting. The technique described is safe and minimizes surgical damage.

Safety and tolerability of local treatment with Iloprost in patients with Peyronie’s Disease. A phase 1 pilot study and proposal of a new symptom questionnaire

PURPOSE Intralesional therapy is a less invasive method for the treatment of Peyronies disease. The objective of this study was to evaluate safety and tolerability of intralesional injections of Iloprost (I2 Prostacyclin analogue) for its property to suppress in fibroblasts CTFG (Connective tissue growth factor) production, which acts in concert with TGF-ß to stimulate the fibrotic process. METHODS Nineteen patients with Peyronies disease were preliminarily evaluated by considering the degree of penile curvature, plaque size and local and systemic symptoms. Each patient then received weekly intralesional injections of 200 ng of Iloprost in 1 ml of normal saline for 4-5 weeks. If tolerated, the single dose increased weekly to the maximum of 400 ng (2 mL). RESULTS The treatment has shown that all patients seem to well tolerate a 200 ng Iloprost dose; 7 of them reached a 300 ng dose and 6 tolerate a 400 ng dose without showing side effects. There was no placebo control group in this study. To evaluate the efficacy of the treatment, the absence of objective parameters (except for the auto-photograph of penis in erection) led us to develop a subjective questionnaire that was given to all patients to assess sexual function, pain reduction, ecc. CONCLUSIONS Due to the relatively small size of the sample, the efficacy evaluation has been restricted to check the questionnaire reliability. Iloprost is well tolerated to a dose of 400 ng in the local treatment of Peyronies disease.

Lower Urinary Tract Symptoms in Male-to-Female Transsexuals: Short Terms Results and Proposal of a New Questionnaire

Presented at the 64th Annual Meeting of the SICPRE, September 17–19, 2015, Milan, Italy. SICPRE: La SICPRE, Societa Italiana di Chirurgia Plastica Ricostruttiva ed Estetica, national meeting, in Milano, Italy on September 17–19, 2015. Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was supported by a grant of family Dioguardi, in memory of Professor Domenico Dioguardi, MD.

Sunitinib related osteonecrosis of the jaw (SURONJ): a rare occurrence?

Sir, Sunitinib is a drug approved in 2006 by the FDA for the treatment of renal cell carcinoma (RCC) and resistant gastrointestinal stromal tumor (GIST). The capillary endothelium is the first target of sunitinib: it blocks several pathways central to proliferation, migration, differentiation, neoangiogenesis, and invasion of cancer cells, including vascular endothelial growth factor receptors (VEGFRs), plateletderived growth factor receptors (PDGFR-α and PGRF-β), the stem cell factor receptor (c-Kit) and the Fms-like tyrosine kinase 3 (FLT3), and glial cell–derived neurotrophic factor receptor (RET), colony-stimulating factor type 1 (CSF-1R) [1, 2, 9]. In literature, several adverse effects of sunitinib have been described (pain, fatigue, hypertension, gastrointestinal toxicity, proteinuria, neurotoxicity, coagulation disorders, mucositis, hypothyroidism, nausea, diarrhea, altered taste, skin abnormalities and, rarely, osteonecrosis) but its long-term side effects are not completely known [2]. We report a case of osteonecrosis of the jaw related to sunitinib hesitated in a multifragmentary fracture. A 62-years-old male patient presented with a painful and infected lesion to the cutaneous side of the left jaw of 1-month duration. Eleven years before, he experienced a radical left nephrectomy for a clear renal cell carcinoma, followed by a 6-month therapy with IFN and IL-2. Five years after nephrectomy, he developed a cutaneous metastasis on the left maxillary region that was removed. During the follow-up, few months later, imaging showed the presence of metastasis on the neck lymph nodes bilaterally. He underwent a 50 mg/day sunitinib therapy (Sutent®) for four consecutive weeks of therapy followed by 2weeks of discontinuation (4/2 scheme). The patient felt limited mouth opening since the beginning of sunitinib treatment and, 18 months later, the lesion appeared at the jaw and sunitinib has been discontinued. Accurate intraoral exam showed exposed bone measuring 7mm in diameter in the left jaw (Fig. 1) with swelling and slight purulent excretion. He had no previous history of bisphosphonate treatment. The patient had undergone dental extraction procedures and presented a complete healing of the mucosa 1 year before starting the therapy with sunitinib. The patient had difficulty in mastication but not in deglutition or phonation. He underwent antimicrobial rinses and broad-spectrum antibiotics (amoxicillin/clavulanic acid) treatment for 6 days as firstline drugs documented in the literature [3]. Dental panograph and CT scan revealed, in IV sextant, a multifragmentary fracture of the left horizontal branchof the jawwith dislocation of the stumps and diffuse trabecular bone hyperdensity due to reactive osteosclerosis with seizures bone (Fig. 2). The patient refused any invasive procedure as fixation of the fracture sowe performed a surgical sequestrectomy, ablation of the necrotic bone and a mucosal flap to cover the loss of substance. Thirty minutes prior to the operation, we administered i.v. antibiotic therapy with amoxicillin+clavulanic acid (1000+200 mg). Pathology revealed the presence of necrotic bone with osteomyelitis, while microbiological culture showed the presence of Streptococcus mitis sensitive to ofloxacine. The patient received oral antibiotics treatment with 400mg ofloxacine twice a day for 2 weeks. The patient returned for a follow-up visit after 1, 6, and 12 month: intraoral lesion was completely healed; he partially recovered mouth opening and normal alimentation. Osteonecrosis of the jaw (ONJ) constitutes a serious complication following radiation treatment of head/neck tumors, trauma, dental surgery procedures, odontogenic infections, chemotherapy for malignant diseases, and treatment with bisphosphonates [4, 5]. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) has been frequently discussed [4] because of its consequences on patient’s quality of life but its etiopathogenesis has not been completely elucidated.Various hypotheses suggest that inhibition * Carlo Melloni carlomelloni.unipa@gmail.com

Variability and reliability of the vastus lateralis muscle anatomy

Abstract Purpose: The aims of this study are to investigate the variability of the morphological and neurovascular anatomy of the vastus lateralis (VL) muscle and to describe the relationships among its intramuscular partitions and with the other muscles of the quadriceps femoris. Clinical implications in its reliability as a flap donor are also discussed. Methods: In 2012, the extra- and intramuscular neurovascular anatomy of the VL was investigated in 10 cadaveric lower limbs. In three specimens, the segmental arterial pedicles were injected with latex of different colors to point out their anastomotic connections. The morphological anatomy was investigated with regard to the mutual relationship of the three muscular partitions and the relation of the VL with the other muscles of the quadriceps femoris. Results: The VL has a segmental morphological anatomy. However, the fibers of its three partitions interconnect individually and with the other bellies of the quadriceps femoris, particularly, in several variable portions with the vastus intermedius and mainly in the posterior part of the VL. The lateral circumflex femoral artery and its branches have variable origin, but demonstrate constant segmental distribution. Intramuscular dissection and colored latex injections show a rich anastomotic vascular network among the three partitions. Conclusions: Moderate variability exists in both the myological and the neurovascular anatomy of the VL. Despite this variability, the anatomy of the VL always has a constant segmental pattern, which makes the VL a reliable flap donor. Detailed knowledge of the VL anatomy could have useful applications in a broad clinical field.

Management of large dorsal diffuse plexiform neurofibroma

Neurofibromas are considered one of the hallmark signs of neurofibromatosis type 1(NF1). Diffuse plexiform neurofibroma is a congenital NF1-associated tumor, characterized by overgrowth and interference with function of the affected area. The rich vascular plexus associated with neurofibromas, together with their infiltrative pattern, makes them difficult to eradicate. Complications of neurofibromas are rare but include malignant transformation and potentially life-threatening hemorrhages. The use of the term “giant” to define a neurofibroma is controversial because there is no clear consensus and descriptions are limited to few case reports. We report a case of a large dorsal diffuse plexiform neurofibroma responsible for significant worsening of a patient’s quality of life. These features make us believe that the mass can be defined as “giant.” Comprehensive perioperative management, including arterial embolization of the feeding vessels and stabilization of the patient’s conditions, is required to perform a safe surgical procedure in such a complicated case.Level of Evidence: Level V, therapeutic study

Metastatic Renal Cell Carcinoma to Submandibular Gland: A Rare Occurrence

Approximately 20-30% of patients affected by renal cell carcinoma (RCC) present with metastatic disease, and 20% to 40% undergoing nephrectomy for clinically localized disease will develop metastases. A 53 years old female patient developed a left submandibular swelling. Four years before she experienced a left radical nephrectomy for a clear cell tumor and two years later right kidney was removed for a cancer having the same histologic subtype. In that circumstance duodenal pancreasectomy was required for infiltration of pancreatic gland. A sialoadenectomy has been performed and pathology demonstrated an intraglandular neoplasm with characteristics of a clear renal cell carcinoma. Although it is extremely rare, submandibular salivary gland may be a site of RCC metastasis. Diagnosis of metastatic disease for patients affected by submandibular swelling with a previous history of RCC should be always considered.

Basal cell carcinoma on rhinophyma: a case series analysis

BackgroundSeveral authors described the presence of malignant tumors that rarely can grow hidden over rhinophymatous skin. Basal cell carcinoma (BCC) is the most commonly reported tumor and it should always be sought and diagnosed in presence of a rhinophyma.MethodsBetween 1998 and 2012, 56 cases of rhinophyma were treated at our department. There were 54 males and 2 females with an age range between 34 to 87 years. In all cases of major or moderate degree, scalpel decortications was executed, while in cases of suspicious lesions, a biopsy and histological examination was also indicated.ResultsIn this series, six cases of BCC were diagnosed and treated showing an incidence rate higher than 10 %.ConclusionsOur results support the need of histological examination of the surgically removed tissue in patients with rhinophyma.Level of Evidence: Level IV, therapeutic study.

PEDICLED PERFORATOR FLAPS IN NASAL RECONSTRUCTION: A REVIEW

Introduction Multiple factors must be considered in the reconstruction of nasal defects. These include size and location of the defect, previous surgical treatments and patient’s general health status. The patient’s and surgeon’s aesthetic aims should also be included in the decision making process. Among the numerous options available, from simple skin grafts to free flaps, local flaps are still the preferred method for reconstruction of nasal defects, because they provide matching color and texture, resulting in a far superior aesthetic outcome. Classical flaps for nasal defect reconstruction, such as forehead or nasolabial flaps, have some disadvantages with regard to limitations in their arc of rotation and the multiple stages of surgery necessary. Perforator flaps have greatly expanded our reconstructive tools in all body regions and often allow us to overcome these limits. Since their first description by Koshima and Soeda (1) in 1989, these flaps have become popular in many areas of reconstructive surgery, because they provide design freedom, reduce donor site morbidity and allow thinner flaps to be tailored for more accurate reconstruction in single stage surgery. Review