Enrico Robotti

The distally based superficial sural flap: our experience in reconstructing the lower leg and foot.

&NA; The treatment of soft‐tissue defects of the lower third of the leg and foot is often an awkward problem to tackle because of the frequent involvement of muscle, tendon, and bone, which is caused by the thinness and poor circulation of the skin covering them and by the small quantity of local tissue available for reconstruction. The authors present their experience with the use of sural flaps for the treatment of small‐ and medium‐size defects of the distal region of the lower limb. The flap used was a distally based fasciocutaneous flap raised in the posterior region of the lower two thirds of the leg. Vascularization was ensured by the superficial sural artery, which accompanies the sural nerve together with the short saphenous vein. The authors treated 18 patients (12 men and 6 women) from May 1997 to August 1999 at the Division of Plastic Surgery, University of Turin, Italy. Superficial necrosis without involvement of the deep fascia (which was grafted 1 month later) occurred in 1 patient of the 18 treated. In another 2 patients, defects were found in the flap margins, but no additional surgical revision was necessary, and recovery occurred by secondary intention. In every patient the sural flaps provided good coverage of the defects, both from a functional and an aesthetic point of view. The major advantages of this flap are its easy and quick dissection. Because the major arterial axis is not sacrificed, this flap can be used in a traumatic leg with damaged major arteries. Fraccalvieri M, Verna G, Dolcet M, Fava R, Rivarossa A, Robotti E, Bruschi S. The distally based superficial sural flap: our experience in reconstructing the lower leg and foot. Ann Plast Surg 2000;45:132‐139

Distally Based Fasciocutaneous Flaps: A Versatile Option for Coverage of Difficult War Wounds of the Foot and Ankle

&NA; Early reconstructive treatment of war‐related lower extremity injuries can be feasible even when evacuation to ideal tertiary facilities is impossible. However, in such instances, lengthy procedures considered “state of the art” in the everyday civilian practice of plastic surgery are often impractical, and alternative options need to be sought. Undelayed distally based fasciocutaneous flaps of the leg have recently been used in 12 cases of extensive defects of the foot due to antipersonnel mine injuries. All patients, treated during the conflict in Bosnia‐Herzegovina, were smokers and were between 17 and 45 years of age. No preoperative arteriography or Doppler was available. One flap was totally lost, and two others suffered tip necrosis. All other cases healed uneventfully. We were impressed at the reliability of distally based fasciocutaneous flaps, even with length‐to‐width ratios of up to 5:1, and even after distal deepithelialization or tubing of the pedicle. The whole foot can be reached when the appropriate lateral or medial based flap is selected. Obvious disadvantages are the grafted secondary defect of the leg and the lack of sensation, although the latter is a common feature shared by most other flaps to the foot. Also, free‐muscle transfer is preferable for very deep defects with extensive bone loss. However, for the ease of dissection, versatility, and short operating time, distally based fasciocutaneous flaps find a definite place in reconstructive trauma surgery.

“on Demand” Posterior Tibial Artery Perforator Flaps: A Versatile Surgical Procedure for Reconstruction of Soft Tissue Defects of the Leg After Tumor Excision

Relatively small soft-tissue defects of the lower leg following tumor excision are usually treated, especially in older patients, by split-thickness skin grafting. On specific sites where periosteum or paratenon is exposed, as well as when a skin graft is best avoided for cosmetic reasons, an excellent alternative option is the use of posterior tibial artery perforator flaps.Such flaps are designed and elevated “on demand,” ie, according to the defect location and on whichever perforator is best found suited to supply the flap and allow adequate transposition.However, operative time is longer, and the surgeon needs to be judicious in dissection, as well as versatile in choosing the best flap design after identifying a suitable perforator.Between 2003 and 2008, 24 patients underwent this procedure, with uniformly successful result except for 2 partial flap necrosis.The advantages of posterior tibial artery perforator flaps are a quick and usually safe procedure, which provides good contour with excellent color, texture, and thickness match, with long-term stability of the reconstruction at the expense of minimal donor-site morbidity.

Positive compared with negative margins in a single-centre retrospective study on 3957 consecutive excisions of basal cell carcinomas. Associated risk factors and preferred surgical management

Abstract The rate of margins involvement and the associated recurrence risk in basal cell carcinomas (BCCs) varies widely in published works (7%–25% and 26%–67%, respectively). This study investigated the risk factors associated with incomplete excision and their relevance in surgical management when positive margins occur in 3957 BCCs excised in 2358 patients. This study performed a multivariate analysis on the database collected from all patients operated for BCCs in the Plastic Surgery Department between 1 January 1992 and 1 September 2007. All data collected (3957 excisions; 2358 individuals) were divided into complete and incomplete excisions groups and analyzed according to 14 variables. The overall rate of incomplete excisions was 14%. Mean age (68), size of the lesion (< 0.5 cm), BCC subtype (nodular with sclerosant aspects, sclerosant and basosquamous), location (face), infiltration depth (hypodermis and deep tissues), recurrent BCC and re-excised BCC were significantly associated with a higher rate of incomplete excision. The recurrence rate for incompletely excised tumours was 26.8%, while only 5.9% for completely excised tumours. Most of the risk factors associated to incomplete excision can be identified before surgery (by simple anamnesis and clinical examination) and successfully overcome by appropriate surgical margins. The high recurrence rate after incomplete excision and the low patient compliance towards follow-up should lead the surgeon to early re-excise residual cancer.

A single-center retrospective study on 3,957 consecutive excisions of basal cell carcinomas. BCC behavior patterns: retrospective statistical analysis

Basal cell carcinoma (BCC) is the most common skin malignancy. BCC generally has a clinical course characterized by slow growth, minimal local invasiveness, and a high cure rate. Occasionally, however, BCC behaves aggressively with deep tissue invasion, clinical recurrence, and regional/distant metastases. Surgical excision is uniformly indicated as a primary treatment. We carried out a retrospective study by selecting all patients operated for BCC in our Plastic Surgery Department between 1 January 1992 and 1 September 2007. The data collected were about 3,957 excisions performed on 2,358 individuals which is, to our knowledge, the largest population sample ever studied internationally. For this reason, we analyzed the most common BCC features generally reported in published papers so as to identify any difference compared to the data that we gathered in our series. From all of the collected data of the 2,358 patients and 3,957 excisions, 16 variables were drawn, which provided detailed information about patients’ status, biopsy when performed, surgery, and follow-up. All results concerning such variables are discussed. The results of our retrospective statistical analysis on a very large, single-center patient population sample are fully in line with what were previously published in the international literature.

Bergamo 3D Rhinoplasty Software: Select, Store, and Share Surgical Maneuvers in a Three-Dimensional Nasal Model

Background: Rhinoplasty is considered the most challenging chapter of plastic surgery due to its variability and the continuing evolution of surgical maneuvers. Worksheets became essential to unequivocally record surgical steps and to demonstrate their reciprocal effects/interactions during the follow-up period. After 1989, no other software was created to upgrade the Gunter Rhinoplasty Diagrams, the forefather and benchmark of the rhinoplasty “virtual” worksheet maker. Methods: The authors built a new standard three-dimensional nasal framework model in STL format. All the basic components were modified to simulate the interaction among sutures, grafts, and the most common maneuvers performed during rhinoplasty. The authors created a total of 669 (99 built-in units and 285 unilateral units) three-dimensional figures which can be selected by the surgeon from among 230 options. The interface for the surgeon is Bergamo 3D Rhinoplasty Software. Results: Bergamo 3D Rhinoplasty Software is made up of the database section, which gathers all the patient’s personal information and documents, and the surgery section, which groups multiple selection lists in 10 surgical areas. Eighty percent of the options modify the original shape of the three-dimensional model. Several options help the surgeon to tailor the final result and to export it both in desktop software and in a real three-dimensional printed model. Conclusions: Bergamo Rhinoplasty Software revolutionizes the concept of patient and surgical data storage. Furthermore, the immediacy of three dimensions facilitates communication with patients, allows case sharing with colleagues, simplifies teaching, and encourages the surgeon’s self-analysis and professional growth. Customization of the original model and of the maneuvers is the main limitation of the software, because of the currently existing technology in 2014.

Diced cartilage combined with warm blood glue for nasal dorsum enhancement.

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of

Successfully exploiting two opposing forces: a rational explanation for the "interlocking suture".

BackgroundIssues of poor circumareolar scars and asymmetry or malposition of the nipple–areola complex (NAC) are frequently associated with those breast reduction or pexy techniques that rely on an ample excision of skin around the areola, either alone or associated with a vertical scar in a circumvertical approach. To prevent such problems, in 2007 Hammond et al. introduced the “interlocking suture.” The objective of this study was to demonstrate the true ability of this suture to reduce the common complications of periareolar surgery simply by managing the existing contrast between NAC centripetal and outer breast tegument centrifugal forces.MethodsBy using finite element method (FEM) software, the NAC traditional interrupted stitches were compared with both round-block and interlocking sutures, and the skin strain in all three procedures was qualified.ResultsThe contribution of circuitous stitches in the interlocking suture leads to a more advantageous distribution of forces. FEM analysis shows that the interlocking suture reduces skin stress on peripheral breast teguments by 14% compared to the round-block suture and by 15% compared to the traditional (radial) suture. When evaluating the areolar edge, the interlocking suture leads to a reduction in skin stress of 9.9% compared with traditional interrupted stitches.ConclusionsThe efficient, long-lasting results of the interlocking suture are directly due to its unique design, which effectively reduces the tension between the NAC and breast tegument edges in periareolar surgery, thus improving the quality of the scar.

Giant basal cell carcinoma: a series of 37 cases without metastasis.

Sir: We sincerely appreciate the comments by Codazzi et al. in reply to our article entitled “Giant Basal Cell Carcinoma: 11-Year Follow-Up and Seven New Cases.”1 Although the main point of our article was to reiterate the idea that size of a basal cell carcinoma is not a risk factor for malignancy, as evidenced by a low metastasis rate of less than 0.5 percent observed in several studies, their reply sheds light on an issue that is certainly important to surgeons managing these tumors: excision and coverage. In our practice, we commonly use split-thickness skin grafts to resurface defects left behind by lesion excision. In our series of 14 giant basal cell carcinomas (Table 1), tumors involved the head and neck in five cases (36 percent), the trunk in four (28 percent), and the extremities in five (36 percent), for the most part areas that are generally inconspicuous. Even in the case of facial tumors, we believe flaps are not always indicated, despite the better tissue match. A defect larger than 5 Table 1. Seven Previously Reported Cases (1 through 7)* and Seven New Cases (8 through 14)

A user's guide to local perforator flap reconstruction in a post-conflict setting

Local perforator flaps are a versatile source of vascularized tissue. A “user’s guide” has been proposed to enhance the outcome of these reliable flaps when performed in a post conflict environment. This is based on the authors’ experience of second wave surgery treating civilians in the Middle East. The post-conflict population has certain characteristics. The injuries presenting are chronic wounds that have received minimal, or no, primary treatment. Injuries of poverty follow those of war: acute domestic injuries are neglected because families cannot pay for treatment or none is available. Neglected wounds progress to ungraftable areas, scar tissue and severe contractures. For the adult patients the primary goal is return to function, work and to support their families. For children, future growth must be considered in their reconstructive plan. Population mobility has to be factored into patient care as refugees displace locally or may be sent to other countries. The ideal reconstruction for this population is therefore a singlestage procedure with minimal donor site morbidity, minimal rehabilitation necessary, maximal functional outcome and minimal complications. Local perforator flaps fit these criteria by importing vascularized tissue to complex defects as well as composite, elastic tissue that can expand with growth and stretch when used as interpositional flaps postcontracture release. The user’s guide (Table 1) describes considerations and lessons learnt when performing local perforator flaps in the above populations. The ten sub-headings chosen may be routine considerations in our regular practice but they carry a different emphasis in the environment of second wave surgery. The complexity, and severity, of the cases presenting will be greater than at home, yet facilities are less available. A reconstruction must maximize function, have