Davide Lazzeri

Distally based peroneus brevis muscle flap in reconstructive surgery of the lower leg: Postoperative ankle function and stability evaluation

BACKGROUNDnDefects of the distal third of the lower leg with exposed tendons or bone require either local or free flap coverage. Several flaps have been developed, and the distally pedicled peroneus brevis muscle flap has been proven to be a valid local flap alternative.nnnPATIENTS AND METHODSnPeroneus brevis muscle is dissected from the lateral surface of the fibula from proximal to distal, but no further than approximately 3-6 cm proximally to the lateral malleolus, where the most distal vascular pedicle from the peroneal artery enters the muscle consistently. This allows the muscle to be transposed to more distal lesions. The muscle is then covered with meshed split-skin graft. Between 2002 and 2008, 10 patients with defects of the lower leg in the distal lower third have been treated using this muscle flap. The defects were located over the Achilles tendon, the medial and lateral malleolar, the anterior region of the ankle and the heel area. Each patient was examined through assigning clinical demerit points according to a modified Weber scale, and through Olerud-Molander ankle score to analyse postoperative ankle stability and functionality after reverse peroneus brevis flap reconstruction of the defect.nnnRESULTSnAll flaps survived completely, and no secondary local flap was required. In our experience, no complication or patient discomfort was noted. Donor-site morbidity was acceptable and restricted to the scar in the lateral lower leg. As demonstrated by the two score evaluations, the functions of foot eversion and plantar flexion as well as ankle functionality and stability were maintained due to preservation of peroneus longus muscle.nnnCONCLUSIONnThe reverse peroneus muscle flap is ideally suited for small-to-moderate defects of the distal third of the lower leg. This flap offers a convincing alternative for covering defects in the distal leg region. Its arc of rotation allows coverage of more anterior defects of the ankle, of defects of the Achilles tendon and of the heel area as well as of lateral and medial malleolus areas. It is simple to raise and is often transposed easily within the wound without further dissection. As long as the peroneus longus is preserved, ankle instability is not expected.

Skin-reducing mastectomy: New refinements

Abstract Skin-reducing mastectomy is a single-stage technique that helps us to overcome the cosmetic inadequacy of a Type IV Wise pattern skin-sparing mastectomy (final T-inverted scar) in heavy and pendulous breasts by filling the lower-medial quadrant with adequate volume. It also conceals scars as an aesthetic operation and at the same time provides satisfactory and safe coverage of the implant. We report our experience with 22 skin-reducing mastectomies done for 18 women. We modified part of the original description of raising the dermal flap to refine the anatomical results. This flap was mobilised better by detachment of the lateral part of its insertion along the inframammary fold, and this allowed us to close the dermomuscular pouch inferiorly and laterally without raising the serratus anterior or limiting its rise. The total or partial preservation of the serratus muscle together with the creation of a force directed medially, as indicated by the dermal flap, reduced the risks of lateral dislocation of the implant and improved the lateral breast contour to give a more natural shape. Skin-reducing mastectomy is an oncologically safe skin-sparing mastectomy that solves all cosmetic problems and reduces complications of the original Type IV Wise pattern in medium to large breasts. Doing the mastectomy and reconstruction in a single stage aids the favourable psychological approach of the patient. We emphasise the use of our small modification to refine the contour of the breast and improve the aesthetic outcomes by giving a natural curvilinear profile.

Effect of lip adhesion on maxillary arch alignment and reduction of a cleft's width before definitive cheilognathoplasty in unilateral and bilateral complete cleft lip

Abstract High tension and tissue dislocation caused by wide maxillary clefts could prevent an optimal aesthetic and functional outcome in primary cheilognathoplasty. Many surgical techniques or conservative (orthodontic and orthopaedic) devices have been proposed for the initial management of infants with complete cleft lip and palate to achieve a tension-free repair of the lip. Adhesion converts a wide unilateral complete cleft into a lesser deformity anatomically similar to an incomplete cleft lip. This study aimed to measure the effect of lip adhesion on the width of maxillary clefts. Between 2000 and 2007 lip adhesion was used on 49 consecutive infants affected by complete unilateral (nu2009=u200935) and bilateral (nu2009=u200914) cleft lip and palate. The indication for lip adhesion was the presence of a wide alveolar cleft (gap > 7 mm) with severely malpositioned maxillary segments. Lip adhesion was done at about 48 days, followed by definitive cheilognathoplasty at 98 days. Photographs and impressions were obtained before any operation. The width of the maxillary clefts was reduced by 60% in unilateral clefts and 61% in bilateral clefts. By converting a complete wide cleft lip to an incomplete cleft in both unilateral and bilateral clefts, adhesion of the lip achieved a better position and stabilised the arch in a symmetrical platform that eased both definitive closure of the defect in the lip and the restoration of the maxillary gap by periosteoplasty during definitive cheilognathoplasty.

Late-onset gluteal Escherichia coli abscess formation 7 years after soft tissue augmentation with Bio-Alcamid™ in a HIV-positive patient

In 2002, a 41-year-old woman had been treated for severe buttock lipodystrophy resulting from highly active antiretroviral (HAART) therapy medication. During a single session the loss of subcutaneous fatty tissue had been compensated by injections of an undefined quantity of polyalkylimide 4% (Bio-Alcamid , Polymekon Biotech Industry, Milan, Italy). The post-treatment course had been uneventful and the patient had initially been satisfied with the result of this treatment. Seven years later, the patient presented with a redness and swelling of the area (Figure 1) by our unit. The area was hard and extremely painful on touch. All previous antibiotic therapies led only to temporary relief of these symptoms. A bedside drainage of the abscess was performed through a 20-gauge intravenous cannula that was inserted in the thin collagen capsule

A Dermomuscular Pocket Provides Superior Coverage of the Implant in Skin-Reducing Mastectomies

We comment on the paper by Bayram and colleagues entitled Skin-Reducing Subcutaneous Mastectomy Using a Dermal Barrier Flap and Immediate Breast Reconstruction With an Implant: A New Surgical Design for Reconstruction of Early-Stage Breast Cancer [1]. Type 4 skin-sparing mastectomy (SSM) involves heavy and pendulous breasts that require a conspicuous reduction of the skin envelope and a contralateral reduction or mastopexy [2]. Two main limitations have been observed in performing breast reconstruction using this SSM approach. The first limitation is the risk for ischemic necrosis of the two long, thin superior flaps that close down to the inframammary fold, which may lead to healing complications of the inverted T-scar such as superficial epidermolysis, wound dehiscence, and implant exposure. The second limitation is the resulting excessive upper pole fullness due to the presence of a permanent implant in the lower pole of the reconstructed breast that lacks projection. Several personal approaches to overcome these limitations have been proposed. Among these techniques, skinreducing mastectomy (SRM), described by Nava et al. [3], completely releases the pectoralis muscle inferiorly and spares a lower dermal flap sculpted down to the inframammary fold. This procedure allows the creation of a dermomuscular pouch, achieving total implant coverage and overcoming all the inadequacies of type 4 SSM. By augmenting the pocket and providing a new tissue layer at the lower pole of the breast, complications are reduced, and aesthetic outcomes improved compared with those for the traditional inverted T mastectomies [2–7]. We performed 22 SRMs (19 curative and 3 prophilactic) [5] for 18 women following the preoperative assessment according to Nava et al. [3]. For reconstruction of breasts treated with SRMs, style 410 anatomically shaped, highly cohesive silicone gel implants were used. The mediumsized implant was 423 ml. The largest implant was 515 ml and the smallest was 335 ml. We had a minor complication rate of 9% (n = 2), and no severe complication requiring device explantation was observed. One patient (a smoker) experienced superficial epidermolysis of the superior flaps, which was resolved with conservative treatment by regular dressing. In another patient, a 3 9 3-cm area of cutaneous necrosis developed around the T-scar junction and was treated with an autologous split-thickness grafting to respect the timing of chemotherapy. In their paper describing their experience with skinreducing subcutaneous mastectomies (SRSMs), Bayram et al. [1] criticized the submuscular lodging of large prostheses as suboptimal because pressure on the prosthesis may cause low-level breast projection. In addition, they emphasized that preparation of the submuscular area may increase the mean time for the surgical procedure. Notwithstanding, we think that because the implant is well covered, this should help reduce the main sequelae that could affect the final appearance of the new breast, such as capsular contracture after radiotherapy and rimpling due to the thin soft tissue layer coverage, especially in the upper pole and the lateral and medial aspects of the breast. As noted in our experience, SRM prevents complications of type 4 SSM such as a lack of space in the inferior and medial aspects of the submuscular pouch that L. Colizzi D. Gandini M. Pantaloni D. Lazzeri (&) Plastic and Reconstructive Surgery Unit, Hospital of Pisa, Via Paradisa 2, Cisanello, 56100 Pisa, Italy e-mail: davidelazzeri@gmail.com

Solitary plasmacytoma of the jaw.

BackgroundThere is a lack of consensus on the appropriate management of solitary plasmacytoma (SP) of the jaw. The aim of the present investigation was to provide scientific evidence for the optimal management of this disease through a systematic literature review. MethodsThe included articles are published in English from 1948 to March 2011 and describe the population affected by SP of the jaw with site, clinical and radiographic features, special findings, initial diagnosis, treatment, and follow-up. ResultsFifty cases of SP of the jaw were identified. It typically presents as a single osteolytic lesion with no plasmocytosis involvement of bone marrow. Long bones and vertebrae are the most common sites of SP. Rarely, it involves the jaw occurring in only 4% of cases, mainly in the bone marrow–rich areas, angulus and ramus. Solitary plasmacytoma of the jaw has a worse prognosis than multiple myeloma (MM), and in half of the cases, it evolves in MM. ConclusionsBecause SP of bones is an uncommon tumor that rarely involves the jaws, through this article we emphasize early diagnosis and appropriate management to avoid progression to MM.

Bone Regeneration and Periosteoplasty: A 250-Year-Long History

Background: Since antiquity, many attempts have been carried out and a number of theories proposed to explain the process that leads to bone regeneration. Through manifold experiments, several authors tried to understand and subsequently to control the physiological events that enable bone healing. Between the 18th and 19th centuries something changed. Although the scientific world was initially skeptical, a new idea emerged in the field of bone surgery. It principally concerned the necessity to perform amputations and resections leaving intact the periosteum to obtain new bone formation. Materials and Methods: With this article we emphasize the contribution of many authors in the development of knowledge about the osteogenic properties of the periosteum. In particular we focus on the experiences of unknown Italian authors Michele Troja and Bernardino Larghi, consider well-recognized scientific personalities such as Leopold Ollier and Bernhard von Langenbeck, and reach a milestone of plastic surgery with Tord Skoog and his description of periosteoplasty. Conclusion: Various surgical approaches have been proposed to provide optimal care for patients with cleft lip and palate disorders. Among several treatment options, periosteoplasty is one of the choices to correct maxillary clefts. Highlighting difficulties and successes of many authors in demonstrating osteogenic properties of periosteum, this paper describes how periosteoplasty performed in maxillary cleft restoration capitalizes on what has been discovered during a 250-year-long history.

Plastic surgery and Munchausen's syndrome: ‘surgeon, beware!’

A 24-year-old woman was admitted to our department with a loss of substance of the volar aspect of her right forearm. Surgical debridement and subsequent coverage with skin graft were required. Her symptoms had started 10 months earlier when she had broken her right wrist. Right forearm cellulitis had been diagnosed 2 weeks after the gypsum was removed and treated in several hospitals under different specialties. Because her condition had gradually worsened, she was referred to our unit. The medical history of the patient was considerable despite her young age. She had diagnosis of chronic hyposideremic anaemia, moderate depression, hiatal hernia and haemorrhoids. Moreover, she had already undergone adenoidectomy, appendectomy and reductive mammaplasty. Within the next 5 months four consecutive surgical debridements were performed because of recurrences (painful swelling, skin necrosis, hot and indurated subcutaneous areas and ulcers of different sizes) on her right forearm (Figure 1). Two months later, two abdominal wounds appeared (Figure 2), having the same features of the lesions on the forearm. She was afebrile; all baseline investigations including blood count and serum electrolytes were normal. Necrotic tissue was debrided again thrice in a month. Although further evaluations were carried out, haematologic, rheumatologic, infective, allergic and toxic causes were all excluded. Another area of inflammation developed in much the same way on the patient’s left forearm. Again, histopathological and bacteriological examinations were not helpful, as no organisms had been cultured from any of the wound swabs, blood cultures or tissue specimens. At this stage, suspicion was raised regarding the possible factitious nature of her problem because of an inability to explain the cause of her wounds. Finally, a suspicious amount of toothpaste and after shave cream packaging was found during the inspection of patient’s bathroom while she was out for a consult. Chemical analysis confirmed that subcutaneous toothpaste and cream injections were the organic cause of the multiple inflammatory reactions present in the lesions. We confronted with the patient. She became a little

Anterolateral thigh flap as the ideal flap to full-thickness cheek reconstruction.

Reconstruction of the cheek presents a number of challenges when seeking to recreate form and function. The use of the anterolateral thigh flap in various and novel configurations is argued as being the ideal reconstruction, illustrated by case reports.

Eyelid and periorbital necrotizing fasciitis as an early devastating complication of blepharoplasty.

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