Francesco Segreto

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.

Oestrogen receptor-alpha and -beta expression in breast implant capsules: Experimental findings and clinical correlates

Myofibroblasts provide a force to decrease the surface area of breast implant capsules as the collagen matrix matures. 17-β-Oestradiol promotes myofibroblast differentiation and contraction. The aim of the study was to investigate the expression of oestrogen receptors α and β in capsular tissue. The study enrolled 70 women (80 capsules) who underwent expander or implant removal, following breast reconstruction. Specimens were stained with haematoxylin/eosin, Masson trichrome and immunohistochemistry and immunofluorescence stainings for alpha-smooth muscle actin (α-SMA), oestrogen receptor-alpha (ER-α) and oestrogen receptor-beta (ER-β). The relationship between anti-oestrogenic therapy and capsular severity was evaluated. A retrospective analysis of 233 cases of breast reconstruction was conducted. Myofibroblasts expressed ER-α, ER-β or both. In the whole sample, α-SMA score positively correlated with ER-α (p = 0.022) and ER-β expression (p < 0.004). ER-β expression negatively correlated with capsular thickness (p < 0.019). In capsules surrounding expanders α-SMA and ER-α, expressions negatively correlated with time from implantation (p = 0.002 and p = 0.016, respectively). The incidence of grade III-IV contracture was higher in patients who did not have anti-oestrogenic therapy (p < 0.036); retrospective analysis of 233 cases confirmed this finding (p < 0.0001). This study demonstrates the expression of oestrogen receptors in myofibroblasts of capsular tissue. A lower contracture severity was found in patients who underwent anti-oestrogenic therapy.

Recurrent Scrotal Hemangiomas During Treatment With Sunitinib

Cutaneous hemangioma is a benign, self-involuting tumor of endothelial cells. In most cases, it is already present at birth or develops as a rapid capillary growth during the first years of life, and in 75% to 100% of cases, it progressively disappears during the first 7 years, thus defining a proliferative phase followed by an involutive phase; among the different histologic types, capillary is the most common. Sunitinib (SUTENT, Pfizer, New York, New York) is an orally administered tyrosine kinase inhibitor approved for the treatment of gastrointestinal stromal tumor and advanced or metastatic renal cell carcinoma. It

Toll-Like Receptor 4 Expression in Human Breast Implant Capsules: Localization and Correlation with Estrogen Receptors.

Background: Capsular contracture is the most common complication following breast augmentation and reconstruction. Myofibroblasts, which are specialized fibroblasts with contractile activity, are involved in its pathogenesis. Toll-like receptor 4 stimulation in fibroblasts induces transcription of genes involved in extracellular matrix remodeling and tissue repair; furthermore, it enhances sensitivity to transforming growth factor-&bgr;1 and promotes transition to myofibroblasts. 17&bgr;-Estradiol, by binding to its main receptors, &agr; and/or &bgr;, increases the expression of toll-like receptor 4 and the production of proinflammatory mediators by macrophages; moreover, it promotes extracellular matrix production and myofibroblasts contraction and differentiation. The aim of the study was to investigate the expression of toll-like receptor 4 in breast implant capsules and its relationship with estrogen receptors. Methods: The study enrolled 30 women who underwent expander removal following breast reconstruction. Specimens were stained with hematoxylin and eosin, Masson trichrome, immunohistochemistry, and immunofluorescence for toll-like receptor 4, &agr;-smooth muscle actin (a marker of myofibroblasts), estrogen receptor-&agr;, and estrogen receptor-&bgr;. Results: Toll-like receptor 4 was expressed by fibroblasts and myofibroblasts of capsular tissue. Its expression positively correlated with estrogen receptor-&bgr; expression (p = 0.012). A positive correlation was found between estrogen receptor-&bgr; and &agr;-smooth muscle actin expression (p = 0.037). Conclusions: This study demonstrates the expression of toll-like receptor 4 in myofibroblasts of capsular tissue and its correlation with estrogen receptor-&bgr; positivity. Activation of toll-like receptor 4 and estrogen receptor-&bgr;, and their interplay, may be involved in myofibroblast differentiation and in the profibrotic pathogenic process underlying capsular contracture.

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.

Modified Extracorporeal Septoplasty: Functional Results at 6-Year Follow-up.

Background Septal deviations represent a major cause of aesthetic disorders and respiratory obstruction. The traditional septoplasty techniques may often be inadequate to treat severe deviations. Recently, we described a modified extracorporeal septoplasty approach based on partial resection of the cartilaginous septum, with preservation of a superocaudal L-strut measuring approximately 0.5 cm in height. At 6-month follow-up, we demonstrated this technique to be functionally and aesthetically effective in addressing mild to severe septal deviation. The aim of the present study was to evaluate the long-term outcomes of this technique in the patients included in the initial prospective study, followed up during a period of 4 to 6 years. Methods One hundred fifty-three patients underwent modified extracorporeal septoplasty from January 2006 to June 2009. One hundred twenty of these patients were included in the present study. Patients were grouped according to the preoperative septal deviation as follows: mild (one-third reduction of the nasal cavity), moderate (half reduction), and severe (two-thirds reduction). Follow-up ranged from 4 to 6 years. Respiratory flow improvement was assessed with active anterior rhinomanometry; subjective evaluation of the respiratory function was obtained by mean of Nasal Obstruction Symptom Evaluation (NOSE) scale. Active anterior rhinomanometry values and NOSE scores were compared with the results obtained preoperatively and at 6-month postintervention. Results In the whole cohort, rhinomanometric analyses and NOSE scores at long-term follow-up demonstrated a statistically significant improvement in inspiratory flow and obstructive symptoms (P = 0.0122 and P < 0.0001, respectively) compared to preoperative values. In group analysis, a significant improvement in NOSE scores was found in patients with severe (P < 0.0001) and moderate (P < 0.0001) deviations. A significant improvement in inspiratory flow was reported in the severe (P < 0.0001) and moderate (P = 0.0212) deviation groups. Conclusions The modified extracorporeal septoplasty technique proved to be functionally effective at long-term follow-up in cases of moderate or severe septal deviation: the improvements in respiratory function and obstructive symptoms found 6 months postoperatively were maintained at 4 to 6 years postintervention. With this technique, structural support is achieved without destabilizing the keystone area; moreover, conservative remodeling of the quadrangular cartilage allows the use of septal cartilage grafts in secondary or revision rhinoplasty.

Lateral arm reconstruction with posterior radial collateral artery perforator based flap

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