Emilio Trignano

Innervated island pedicled anterolateral thigh flap for neo-phallic reconstruction in female-to-male transsexuals

Many techniques have been described to create an aesthetic and functional neo-phallus after penile amputation or in female-to-male transsexuals. Microsurgical free-flap phalloplasty seems to be the preferred method of penile reconstruction. For many years the radial forearm free flap has been considered the best procedure, but other flaps have been attempted to minimize donor site morbidity and optimize outcome. Pedicled flaps are considered to be reliable and to decrease the risk of total failure. Recently, a one-stage non-microsurgical technique was described for phallic reconstruction in a young male patient. We report successful total phallic reconstruction in a female-to-male transsexual patient using an island pedicled anterolateral thigh (ALT) flap. Urethral reconstruction was left as a possible further procedure due to patients preference. A malleable soft silicone penile prosthesis was inserted within the flap and the lateral cutaneous femoral nerve stump was sutured to the dorsal clitoris branch from the pudendal nerve for flap sensation. After 6 months, the patient demonstrated successful aesthetic and functional reconstruction referring to satisfactory sexual activity. To our knowledge, this is the first report of an innervated island pedicled ALT flap used for female-to-male penile reconstruction in a transsexual patient. The pedicled ALT flap may be a reliable option to avoid visible scarring at the donor site on exposed parts of the body, and reduce the risk of total flap failure from microsurgical procedures for reconstruction of a neo-phallus in this increasing population of patients.

The treatment of composite defect of bone and soft tissues with a combined latissimus dorsi and serratus anterior and RIB free flap

Composite defects of bone and soft tissues represent a reconstructive challenge. Several techniques have been described in the medical literature; however, extensive composite defects should be reconstructed with microvascular free tissue transfer. The purpose of this report is to present the use of a composite latissimus dorsi and serratus anterior and rib free flap (LD‐SA/rib) as an alternative procedure in patients who cannot undergo more commonly used vascularized bone‐containing free flap reconstruction.

Free fibular flap with periosteal excess for mandibular reconstruction

In microvascular transfer of fibular osteocutaneous flap for mandible reconstruction after cancer ablation, good bone union is necessary to allow timely radiation therapy after surgery. As the area of bone contact between fibula and the original mandible at the edge of the mandibular defect is small, a periosteal excess at both ends of the fibula covering the bone junction can be used to increase the chance of bone union. The purpose of this study is to investigate whether a periosteal excess surrounding both ends of the fibula flap can provide better blood supply and, therefore, ensure bone union and wound healing at 6 weeks after surgery and before radiation therapy initiation.

Transverse Upper Gracilis Flap with Implant In Postmastectomy Breast Reconstruction: a Case Report

Autologous flaps can be used in combination with prosthesis in postmastectomy breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the preferred choice among autologous tissue transfer techniques. However, in patients with a peculiar figure (moderately large breasts and large thighs with flat stomach), who cannot use their abdominal tissue, the transverse upper gracilis (TUG) flap with implant is investigated as a further option for breast reconstruction. This report presents a patient who underwent the TUG flap plus implant reconstruction. A bilateral skin‐sparing mastectomy was performed removing 340 g for each breast. The volume of the TUG flaps was 225 g (left) and 250 g (right). Preoperative volumes were restored by placing under the TUG muscle a round textured implant. No complications occurred during the postoperative period both in the recipient and donor site and the outcomes of the procedure were good. In cases where the use of the DIEP flap is not possible because of past laparotomies or inadequate abdominal volume, the TUG flap plus implant may be considered as a valid alternative.

Microsurgical teaching: Our experience

Today, microsurgery plays a fundamental role in plastic surgery, expanding surgical possibilities for cancer, trauma and aesthetic-related surgery. However, throughout the years, teaching and training systems for microsurgery have not evolved in the same manner as its operative techniques. The use of rats has been, and still is, the standard model for microsurgery training. However, stringent laws for animals used in experiments, combined with the rising costs of this model, have instigated the need to find alternative methods. To overcome this dilemma, we have developed a three-step approach to optimise microsurgery training, particularly when there is no access to animal laboratories.

Simultaneous restoration of voice function and digestive tract continuity in patients with synchronous primaries of hypopharynx and thoracic esophagus with pedicled ileocolon flap.

BACKGROUND Defects involving hypopharynx, cervical, and thoracic esophagus are challenging to reconstruct, and the available procedures usually leave patients voiceless. We describe our experience with a modified pedicled ileocolon flap for the reconstruction of alimentary conduit and voice in patients undergoing hypopharyngo-laryngectomy and total esophagectomy. METHODS Between January 1995 and December 2008, 7 patients underwent reconstruction of the digestive tract and voice function with a pedicled ileocolon flap because of extensive defects involving larynx, hyphopharynx, cervical, and thoracic esophagus. Patients charts were reviewed and appropriate clinical data were evaluated. RESULTS All patients were male with a mean age of 58 years. The continuity of the digestive tract was restored with ileum-colon (n = 1) or colon (n = 6). The voice tube was reconstructed with appendix (n = 1) or with terminal ileum (n = 6). The middle colic artery (n = 1) and left ascending colic artery (n = 6) were used as a pedicle. Five flaps were supercharged using ileocolic vessels. All the flaps survived completely. No intraoperative or in-hospital mortalities occurred. The mean hospital stay was 40 days. The mean follow-up was 22.4 months. Two patients died of local recurrence (1 patient) and distant metastasis (1 patient). One patient died of the complications of pre-existing disease. At the last follow-up, the median deglutition score was 5/7. The median speech score for intelligibility and fluency was 3, and 4 for loudness. The maximum phonation time was 7.57 s. The average sound pressure loudness and fundamental frequency were, respectively, 59 ± 3 dB and 133 ± 33 Hz. CONCLUSION The pedicled ileocolon flap as used in this series proved to be a safe and reliable technique for simultaneous reconstruction of voice and digestive tract.

Latissimus dorsi-rib pedicle flap for mandibular reconstruction as a salvage procedure for failed free fibula flap.

BackgroundMandibular reconstruction is usually performed by using free vascular flaps. However, there are instances in which it must be carried out with pedicle flaps. Insofar, the main option recommended is the pectoralis major (PM) + rib pedicle flap. MethodsA 45-year-old patient affected by a primitive mandibular tumor presented after an unsuccessful reconstruction with free fibula flaps. He refused a PM + rib pedicle reconstruction, while he accepted to undergo a latissimus dorsi (LD) + rib flap reconstruction. ResultsThe postoperative course was uneventful. Also, the range of movements of the upper limb involved in the operation showed no significant changes after surgery. ConclusionsThe LD + rib flap proved to be a useful alternative procedure for mandibular reconstruction after cancer ablation in patients who are not candidates for vascularized bone-containing free flaps and refuse the PM + rib flap reconstruction.

Axillary lymph node dissection in patients with breast cancer and sentinel lymph node micrometastasis or isolated tumor cells: is it necessary?

AIMS AND BACKGROUND Sentinel lymph node biopsy is the standard method for axillary lymph node staging in patients with early stage breast cancer. The aim of the study was to evaluate the necessity of axillary lymph node dissection in patients with breast cancer and sentinel lymph node micrometastasis or isolated tumor cells. METHODS Sentinel lymph node biopsy was performed in 136 patients for breast cancer staging: 16 of them (11.7%) were found to have micrometastasis or isolated tumor cells and underwent axillary lymph node dissection. Micrometastases were considered when tumor invasion was ≤ 2 mm and >0.2 mm in diameter and isolated tumor cells when detected alone or in clusters of <0.2 mm in diameter. The dissection of the three axillary lymph node levels of Berg was performed in all cases. RESULTS Two patients (12.5%) presented isolated tumor cells and 14 (87.5%) micrometastasis in the sentinel lymph node. Among them, 25% presented nonsentinel axillary lymph node tumor invasion, whereas 75% had no further nodal involvement. CONCLUSIONS Results suggest that micrometastasis or isolated tumor cells of the sentinel lymph node represent the only site of cancer involvement of the axilla, especially in patients with early breast tumors, and that axillary lymph node dissection may be unnecessary in these cases and represent an overtreatment.

Nodular Cutaneous Amyloidosis of the Scalp Reconstructed With a Free Anterolateral Thigh Flap: A Case Report

i p r T r s w a c n Amyloidosis is a rare disease of unknown cause that is characterized by the extracellular deposition of an amorphous fibrillar insoluble substance (amyloid) in the extracellular spaces of various organs and tissues, resulting in the loss of normal tissue structure. This can give rise to variable functional and structural impairments, depending on the location and intensity of the amount of protein deposition, eventually leading to organ dysfunction. Depending on the biochemical structure of the precursor protein, the amyloid fibrils can be deposited and can affect every organ of the body. Clinical manifestations are nonspecific and are determined by the organ or system concerned. The definitive diagnosis is made by biopsy using Congo red staining. The authors report a unique case of nodular cutaneous amyloidosis in the temporal region of the scalp that was treated by excision and anterolateral thigh (ALT) free flap reconstruction.

Microsurgical Training with the Three-Step Approach

Background Microsurgery is very challenging, requiring a high degree of dexterity and manual skills that should be fully trained outside of the operating room. Common microsurgery courses usually follow a stepwise training approach beginning practice on nonliving models and proceeding with live rats. However, training on live rats raises certain issues, including ethical concerns as well as the associated costs. As such, there is an increasing drive toward alternative models. The current article describes a three‐step training approach (latex glove‐endovascular prosthesis‐human placenta), which aims to prepare trainees for the clinical direct application. Also, to validate it, this approach was compared with microsurgical training on rats. Methods Overall, 20 residents were randomly assigned to two different microsurgical training courses, each based on one of the aforementioned approaches. Residents were evaluated in terms of correct handling of the instruments, correct use of the microscope, adventectomy, triangulation technique, posterior wall technique, success of the end‐to‐end anastomosis, and ability in assisting the tutor during the arterial anastomosis. Results The three‐step and the live rats groups evidenced similar scores in term of acquired basic skill levels. Conclusions The three‐step model allows to progressively gain skills on microsurgical techniques and to perform a good vascular anastomosis without the need of further steps on rats. The availability of both endovascular prosthesis and human placenta makes this training model definitely accessible from a practical and logistical point of view.