Joannis Constantinides

Primary squamous cell carcinoma of the nipple: A diagnosis of suspicion

There has been only one documented case in the English literature with the diagnosis of primary Squamous Cell Carcinoma (SCC) of the nipple; we present a further case of a primary SCC of the nipple, thus raising awareness to the skin or breast specialist of this possible presentation for SCC. We present the case of a 34 year old lady who presented to our plastic surgery unit with an erythematous, scaly lesion on her right Nipple Areola Complex (NAC). The lesion was histologically confirmed on biopsy to be an SCC and subsequently formally excised. Histology confirmed complete excision of the lesion with adequate margins with no lymphovascular or perineural invasion. This case report describes a rare presentation of a primary moderately differentiated SCC of the nipple. Although SCC of the nipple is a rare diagnosis, in view of its similar presentation to Paget disease of the nipple, it must be considered and careful examination of the histology must be performed in order to ascertain a definitive diagnosis. Patients presenting with lesions of the NAC cannot be assumed to have either Pagets disease or SCC and biopsy should be performed before arranging further investigations or treatment, as the pathways for the two conditions can be very different.

Customised chest wall implant to correct pectus excavatum and bilateral breast reconstruction with muscle-sparing latissimus dorsi (MS-LD) flap in a single stage

1748-6815/

Supraclavicular osteocutaneous free flap : Clinical application and surgical details for the reconstruction of composite defects of the nose

-seefrontmattera2011BritishAssociationofPlastic,Reconstruc doi:10.1016/j.bjps.2010.12.023 manufacture and use of customised chest implants using alginate impression or CT scan with three-dimensional reconstruction to produce the final mould from which the silicone prosthesis was fabricated. We describe a case of bilateral delayed breast reconstruction with MS-LD flap and pectus excavatum correction with customised chest implant in a single stage. The surface of the silicone implant was textured to reduce capsular contracture and holes were incorporated to allow for tissue integration. A 54 year old lady underwent sequential bilateral mastectomy for breast cancer and implant based reconstruction which resulted in severe capsular contracture and

End-to-patch anastomosis for microvascular transfer of free flaps with small pedicle.

The supraclavicular fasciocutaneous flap is a well‐recognized flap in head and neck reconstruction. In this report, we describe for the first time a variation of this flap, the osteocutaneous supraclavicular (SOC) free flap, which was used to reconstruct a composite nasal defect. The defect arose after resection of a recurrent squamous cell carcinoma and involved dorsal nasal skin, cartilage, and the entire nasal bone. A 6 cm × 4 cm size flap including skin, subcutaneous tissue, and a vascularized cortico‐periosteal segment of the clavicle was raised based on the transverse cervical artery. The flap survived with no complications. A satisfactory aesthetic outcome was achieved following two revision procedures. We believe that the incorporation of bone to the supraclavicular flap may expand its applications in reconstruction of composite nasal and facial defects.

Reconstruction after orbital exenteration using gracilis muscle free flap.

BACKGROUND Although perforator-to-perforator anastomosis in supermicrosurgery may be used in transferring free flaps with small vessels, it is still difficult in certain situations that include potentially infected wounds. Moreover, it is limited to smaller flaps. Anastomosis of large vessels is still safer for transfer of a large flap for most surgeons. The harvesting of a patch of the parent artery together with the perforator supplying the flap allows the surgeon to perform an anastomosis between the vessel ends of larger caliber, and possibly with greater anastomotic success. METHOD When the vascular pedicle of a free flap is < 0.8 mm, an option is to take a cuff of the major artery for an end-to-patch anastomosis. From 1983 to 2013, this method was applied to the anteromedial thigh (AMT) flap (seven cases), the groin flap (81 cases), and the free Beckers flap (five cases). When a patch was taken from the femoral artery, direct anastomosis for the major artery was performed using 5/0 Prolene sutures, followed by coverage with local soft tissue. When a patch was taken from the ulnar artery, a patch of vein graft was used for repair of the ulnar artery. In one case, a segment of the femoral artery was harvested with an AMT flap and a segment of a sartorius muscle flap; the compound tissue was transferred to the neck with the femoral artery to replace the left carotid artery. In the donor site, the defect of the femoral artery was reconstructed with an artificial graft. RESULTS The flaps had no failure or partial necrosis, but one patient developed bleeding from the femoral artery 2 days postoperatively. It was treated by adding one more suture for the femoral artery and coverage with the sartorius muscle. In the ulnar artery, the patients did not complain of cold intolerance and the postoperative angiogram showed good patency of the ulnar artery after an average follow-up of 1 year. CONCLUSION For the majority of plastic surgeons, this method provides a reliable and comfortable anastomosis when transferring a flap with small vessels. The only concern is to repair the donor artery carefully and ensure coverage of the repair site with local tissue.

A novel “continuous-interrupted” method for microvascular anastomosis: Letter to the Editor

Orbital exenteration (OE) is a disfiguring procedure, which typically includes the removal of the entire eyeball including the globe, extraocular muscles, and periorbital soft tissues after malignancies excision or trauma. Several methods of orbital reconstruction have been attempted with varying success. In this report, we analyze results of the use of gracilis muscle free flap for reconstruction of OE defects and its feasibility for prosthetic rehabilitation.

Alternative vascular constructs of lymph node flap transfer

The conventional method of microvascular anastomosis with interrupted sutures is well proven method, with high successful rate. However, this method is time consuming, especially when multiple anastomosis are required. Even though several techniques have been described to minimize the time of anastomosis, none of these have been widely accepted. Vessel anastomosis with a continuous suture has the advantage of being faster than the conventional method but due to the high risk of stricture at the anastomotic site is not recommended for microvascular anastomosis. Herein, we present a novel method of performing microvascular anastomosis, which combines the advantages of the continuous and interrupted sutures. After proper setup of the vessels, the anastomosis begins with the application of two 10-0 sutures at 0 and 180 angle (Fig. 1A). Then a loose running suture is applied at the anterior wall of the vessel. Depending on the size of the vessel, usually 3 to 4 passes of the suture are required, creating 2 or 3 loops, respectively. (Figs. 1B and 1C) Then the end of the first suture is tied with the corresponding suture of the opposite site and the knot is cut leaving one suture-loop less (Figs 1D and 1E). The same procedure is repeated for the rest sutures as well as at the posterior vessel wall (Figs. 1F and 1G). We performed this technique in 30 venous and 15 arterial anastomoses during free tissue transfer. In 15 free flaps, both the arterial and venous anastomoses were performed with the described method, meanwhile in other 15 free flaps, the arterial anastomoses were performed with the conventional method and the venous anastomosis with the “continuous-interrupted” technique. In both of the groups, no complications were noted performing this technique as all the flaps survived well. Furthermore, the same surgeon in anterolateral thigh flap (ALT) flaps performed 20 venous anastomoses, 10 with the conventional technique, and 10 with the proposed method in order to compare the time difference between the two methods in vessels with the same size. Statistically significant less time was required (P< 0.05) for the venous anastomosis with the “continuous-interrupted” method. The described method for microvascular anastomosis has several advantages. First of all, the application of the sutures can be very precise as the loosely running suture leaves spaces between the vessels, allowing the lumen to be visible without extensive manipulation of the vessel. This is very useful especially when the last suture of the anterior and posterior wall is applied, which with the conventional method there is limited space between the two edges of vessels. Similarly, during the anastomosis, the posterior vessel wall is always visible, avoiding inadvertent two-wall sewing. Additionally, even though the suture is applied continuously, finally tied as the interrupted fashion, hence there is no risk of stenosis at the anastomotic site. Finally, the anastomosis is performed faster than the conventional method, as the surgeon saves time applying the sutures with a running manner. *Correspondence to: Stamatis Sapountzis, Department of Plastic Surgery, China Medical University Hospital/, China Medical University, 2, Yuh-der Road, Taichung, Taiwan. E-mail: ssapountzis@yahoo.com Received 16 May 2013; Accepted 19 July 2013 Published online 13 September 2013 in Wiley Online Library (wileyonlinelibrary. com). DOI: 10.1002/micr.22174

Efficacy and safety of far infrared radiation in lymphedema treatment: clinical evaluation and laboratory analysis

Vascularized lymph node transfer is a quite innovative physiological surgical procedure for the lymphedema treatment. Although is gaining more popularity due to its promising results, there are some concerns regarding difficult to harvest it and the potential risk of iatrogenic lymphedema. Here, we present alternative vascular constructs of lymph node flap for the treatment of lymphedema, which provide the benefits of a technically easier dissection and physiological reconstruction of the damaged lymphatics. Furthermore, we introduce a classification based on the flap vascular supply including six types of flaps and we provide the details of the surgical technique.

Far infrared ray (FIR) therapy: An effective and oncological safe treatment modality for breast cancer related lymphedema

Swelling is the most common symptom of extremities lymphedema. Clinical evaluation and laboratory analysis were conducted after far infrared radiation (FIR) treatment on the main four components of lymphedema: fluid, fat, protein, and hyaluronan. Far infrared radiation is a kind of hyperthermia therapy with several and additional benefits as well as promoting microcirculation flow and improving collateral lymph circumfluence. Although FIR therapy has been applied for several years on thousands of lymphedema patients, there are still few studies that have reported the biological effects of FIR on lymphatic tissue. In this research, we investigate the effects of far infrared rays on the major components of lymphatic tissue. Then, we explore the effectiveness and safety of FIR as a promising treatment modality of lymphedema. A total of 32 patients affected by lymphedema in stage II and III were treated between January 2015 and January 2016 at our department. After therapy, a significant decrease of limb circumference measurements was noted and improving of quality of life was registered. Laboratory examination showed the treatment can also decrease the deposition of fluid, fat, hyaluronan, and protein, improving the swelling condition. We believe FIR treatment could be considered as both an alternative monotherapy and a useful adjunctive to the conservative or surgical lymphedema procedures. Furthermore, the real and significant biological effects of FIR represent possible future applications in wide range of the medical field.

Lymphedema Fat Graft: An Ideal Filler for Facial Rejuvenation

BACKGROUND The incidence of breast cancer related lymphedema is approximately 5%. Far infrared ray (FIR) treatment can potentially reduce fluid volume and extremity circumference as well as the frequency of dermato-lymphangitis (DLA). However, there is no published data on the oncological safety of FIR and the potential for activation of any residual breast cancer cells. The aim of this study is to investigate the safety of far infrared ray (FIR) treatment of postmastectomy lymphedema, clinically and in vitro. METHODS Patients who underwent mastectomy more than 5years ago complicated by upper extremity lymphedema for more than 1year were included. The enrolled patients were divided into an FIR treatment group and a control group (conservative treatment using bandage compression). Outcome measures included tumor markers (CA153, CA125), ultrasonography of relevant structures and monitoring for adverse reactions 1year after treatment. For the in vitro part of the study, the effects of FIR on human breast adenocarcinoma cell lines (MCF7, MDA-MB231) compared to the effects of FIR on human dermal fibroblasts as a control were considered. The viability, proliferation, cell cycle and apoptotic statistics of the adenocarcinoma and human dermal fibroblast cell lines were analyzed and compared. RESULTS Results demonstrated that after treatment with FIR, tumor marker (CA153, CA125) concentrations in both the FIR and control groups were not elevated. There was no statistically significant difference between FIR and control group marker expression (p>0.05). Furthermore, no patients were diagnosed with lymphadenectasis or newly enlarged lymph nodes in these two groups. Importantly, there were no adverse events in either group. The in vitro experiment indicated that FIR radiation does not affect viability, proliferation, cell cycle and apoptosis of fibroblasts, MCF-7 and MDA-MB-231 cells. CONCLUSIONS FIR should be considered as feasible and safe for the treatment of breast cancer related lymphedema patients 5years after mastectomy. FIR does not promote recurrence or metastasis of breast cancer and is a well-tolerated therapy with no adverse reactions.