Giuseppe Cuccia

Vacuum-Assisted Closure for the Treatment of Fournier’s Gangrene

Background: Fournier’s gangrene (FG) is a very aggressive necrotizing fasciitis involving subcutaneous fat and skin of scrotal and perineal regions. Vacuum-assisted closure (VAC) is a well-known method used to treat complex wounds. The authors for the first time enhance a multimodal strategy to treat the FG using VAC, reducing the number of surgical debridements, allowing a one-step surgical reconstruction with locoregional fasciocutaneous flap. Methods: Six patients with the diagnosis of FG were reviewed retrospectively at our institution. All patients were affected by very extensive FG. The FG Severity Index (FGSI) was used to evaluate the prognosis of the case at admission. Following the acute phase (24–48 h), VAC was used to achieve wound cleaning and prepare the area to a single-stage reconstruction with superomedial thigh flap. Hyperbaric oxygen therapy was also used before final reconstruction. Results: The average FGSI was 10.5, ranging from 8 to 12. All patients survived and were completely healed at the mean follow-up time of 9 months (range 3–30 months). Conclusions: VAC therapy is effective to clean and prepare the wounds, cutting off the fasciitis process and reducing the hospital stay and patient discomfort. Multidisciplinary treatment is mandatory during this devastating infection.

A comparison of temporalis transfer and free latissimus dorsi transfer in lower facial reanimation following unilateral longstanding facial palsy

The ultimate goal in the treatment of facial palsy is the restoration of voluntary and spontaneous movement to the paralyzed side of the face, symmetrical to the normal side. We report our experience treating 40 patients with established facial palsy over a 4-year period. All patients underwent either temporalis transfer or free latissimus dorsi transfer as a single stage to improve lower facial symmetry. We believe that both techniques reliably achieve an increase of movement in facial reanimation after oncological, traumatic, or congenital facial palsy.

The orbicularis oculi muscle flap: Its use for treatment of lagophthalmos and a review of its use for other applications

BACKGROUND The management of lagophthalmos in patients with long-standing facial palsy is difficult, since the immobility and scleral show have to be corrected to protect the vision. In this article, the authors describe the treatment of paralytic eye with a static technique using a medially based orbicularis oculi muscle flap (OOMF) from the upper eyelid in patients with lagophthalmos. PATIENTS AND METHODS From April 2006 to May 2008, five Caucasian patients with ages ranging from 45 to 71 years (mean, 61 years) were treated at the Plastic Surgery Unit of Messina University. All patients underwent orbicularis oculi muscle (OOM) transposition flap to support the lower orbicularis oculi and create a suspension of the eyelid. To validate the anatomical features of the OOM transposition flap, four fresh cadaver heads (eight eyelids) were dissected to demonstrate flap viability, feasibility and suspension effect. RESULTS We achieved resolution of the lagophthalmos and good cosmetic appearance in all cases. The distance between the upper and lower eyelid points during eye closing (as for sleep) was reduced postoperatively on the paralysed side compared to the contralateral healthy side. Follow-up time ranged from 3 to 25 months (mean, 12 months). All patients healed well with no complications of the flaps. There was no flap contraction, recurrent deformity or significant donor-site morbidity in the follow-up period. The incision scars were almost invisible. CONCLUSIONS The authors believe that the switching of upper blepharoplasty technique from the upper eyelid to the paralysed and scarred lower lid can be used as a tool to treat lagophthalmos.

AAV vector encoding human VEGF165–transduced pectineus muscular flaps increase the formation of new tissue through induction of angiogenesis in an in vivo chamber for tissue engineering: A technique to enhance tissue and vessels in microsurgically engineered tissue

In regenerative medicine, new approaches are required for the creation of tissue substitutes, and the interplay between different research areas, such as tissue engineering, microsurgery and gene therapy, is mandatory. In this article, we report a modification of a published model of tissue engineering, based on an arterio-venous loop enveloped in a cross-linked collagen–glycosaminoglycan template, which acts as an isolated chamber for angiogenesis and new tissue formation. In order to foster tissue formation within the chamber, which entails on the development of new vessels, we wondered whether we might combine tissue engineering with a gene therapy approach. Based on the well-described tropism of adeno-associated viral vectors for post-mitotic tissues, a muscular flap was harvested from the pectineus muscle, inserted into the chamber and transduced by either AAV vector encoding human VEGF165 or AAV vector expressing the reporter gene β-galactosidase, as a control. Histological analysis of the specimens showed that muscle transduction by AAV vector encoding human VEGF165 resulted in enhanced tissue formation, with a significant increase in the number of arterioles within the chamber in comparison with the previously published model. Pectineus muscular flap, transduced by adeno-associated viral vectors, acted as a source of the proangiogenic factor vascular endothelial growth factor, thus inducing a consistent enhancement of vessel growth into the newly formed tissue within the chamber. In conclusion, our present findings combine three different research fields such as microsurgery, tissue engineering and gene therapy, suggesting and showing the feasibility of a mixed approach for regenerative medicine.

Evidence of significant sternocleidomastoid atrophy following modified radical neck dissection type III.

Background: Although modified radical neck dissection type III preserves the spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle, the authors believe there is a significant morbidity to retained structures after neck dissection. Although the effects on accessory nerve function and internal jugular vein patency have been documented, there is little information about sternocleidomastoid morphology and function following modified dissection. Methods: Using a SonoSite ultrasound machine, the authors assessed sternocleidomastoid muscle morphology, at rest and during contraction, in a cohort of 45 patients who underwent modified radical neck dissection type III with no radiotherapy. All patients had head and neck cancers and received unilateral neck dissection as part of their primary treatment. Static and dynamic measurements were performed at three different levels of the muscle, with the neck in the neutral position. The contralateral neck of the same patient was used as a control. Local muscle asymmetry patterns were calculated using the Absolute Asymmetry Index. Results: Significant sternocleidomastoid atrophy was noted on the side of modified radical neck dissection type III (p < 0.05). The atrophy was particularly marked in the caudal and middle portions of the sternocleidomastoid muscle and was likely related to damage to the segmental blood supply in the caudal and middle portions of the muscle as well as injury to the innervation. Conclusion: Despite evidence of significant atrophy, the muscle still underwent morphological changes during contraction that were comparable to those on the normal control side.

An anterior-lateral thigh perforator flap on a recipient brachial-radial vein graft for complex wound reconstruction: A case report

A case of challenging microsurgical reconstruction of a difficult defect in a radiated upper limb is reported. A difficult wound, with tendon and bone exposition, developed on the dorsum of the forearm in a 76‐year‐old patient; she had been radiated since almost 50 years and her left hand had also been revascularized twice with venous grafts between the humeral artery and the superficial palmar arch. After failure of a local flap, an anterior‐lateral thigh perforator flap was successfully transferred with end‐to‐side anastomoses on the arterialized venous graft. Up to date follow‐up shows a good outcome. The Authors discuss the case and review the indications for microsurgical reconstruction in difficult wounds after radiation and ischemic limb conditions.

Innervation of a Prefabricated Flap: A New Experimental Model

Introduction. Flap innervation by neoaxonogenesis is a promising field of investigation. The authors evaluated the possibility of innervating an acellular collagen scaffold as component of a potential prefabricated flap. Materials and Methods. Collagen matrix sheets were implanted around the femoral bundle of a murine model to produce two flaps on proximal and distal nerve stumps based on a flow-through model. After thirty days, nerve regeneration and integration into the collagen matrix were evaluated. The specimens were microscopically analyzed to study Schwann cell colonization and axonal integration with the matrix. Axonal count and density were assessed and statistically evaluated. Results. Qualitative structural and ultrastructural evaluation indicated integration, with axonal fibers merged within the collagen matrix, along with a newly formed vascular network on the proximal flap. Wallerian degeneration occurred inside the distal chamber. Axonal count and density did not show statistically significant differences between the nerve inside the proximal flap and the control side. Conclusions. Innervation of an acellular matrix can be obtained by direct nerve stump implantation. The flow-through system was relatively easy to build and reliable to provide adequate blood supply. The collagen scaffold may be a promising support or further studies of preinnervated microsurgical flaps.