Marco Pagnoni

The mushroom-shaped anterolateral thigh perforator flap for subtotal tongue reconstruction.

Background: Reconstruction of a functional tongue with proper motility and sensation after subtotal resection is a demanding procedure. The authors describe the reinnervated mushroom-shaped anterolateral thigh perforator flap for subtotal tongue reconstruction. Methods: Thirteen patients (mean age, 54.8 years; range, 49 to 71 years) diagnosed with T3 and T4 squamous cell carcinomas were allocated prospectively to anterior total mobile (n = 7) or subtotal tongue resection (n = 6). All patients received the mushroom-shaped anterolateral thigh perforator flap. A Likert scale ranging from 1 to 4 was used to assess speech intelligibility, swallowing function, and cosmetic results. Epicritic and proprioceptive sensitivity testing was performed with the Pressure-Specified Sensory Device on the tip of the tongue preoperatively, on the neotongue at the donor site preoperatively, and at the recipient site 12 months postoperatively; protopathic thermoreceptor and nociceptors were clinically investigated. Outcomes were analyzed, and values of p < 0.05 were considered significant. Results: All flaps healed uneventfully (mean follow-up, 18 months). Six patients (46.2 percent) recovered a nearly natural deglutition, whereas seven (53.8 percent) had mild impairment (p = 0.274). Normal intelligible speech was achieved in seven cases (53.8 percent), and acceptable intelligible speech was achieved in six (46.2 percent) (p = 0.286). Aesthetic results were excellent in eight patients (61.5 percent) and good in five (38.5 percent) (p = 0.592). All patients recovered epicritic, proprioceptive, and protopathic sensitivity; cortical upgrading phenomena of the recipient nerve were observed. Conclusion: The reinnervated mushroom-shaped anterolateral thigh perforator flap was found to be an innovative and effective option for subtotal tongue reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The axillary versus internal mammary recipient vessel sites for breast reconstruction with diep flaps: A retrospective study of 256 consecutive cases

The aim of this study is to present our experience on the use of various recipient sites for deep inferior epigastric perforator (DIEP) flap breast reconstruction and compare them by means of objective data. Two hundred fifty six DIEP flap breast reconstructions, performed between March 2004 and May 2011, were retrospectively analyzed. Only unilateral reconstructions were included in the study and divided into three groups depending on the recipient site choice: internal mammary vessels (IMV) (n = 52), thoracodorsal vessels (TDV) (n = 109), and circumflex scapular vessels (CSV) (n = 95). Clinical records of each patient were reviewed to acquire relevant data such as operative time, postoperative complications, and use of a second vein anastomosis. CSV group showed a statistically significant lower operative time (4.92 ± 0.54 hours) compared to TDV (5.67 ± 1.01 hours) and IMV groups (6.75 ± 1.09 hours) (P < 0.001). Second vein anastomosis was performed in 84 cases (88.1%) of CSV, in 85 cases (77.9%) of TDV, and in 18 cases (35.1%) of IMV groups (P < 0.001). No significant differences were observed among groups regarding risk factors and complications (P > 0.05). The axillary vessels seem to be the ideal recipient site because of reduced operative time and increased possibility to perform a second vein anastomosis. Among them, CSV can be safely used due to following advantages: easy dissection, larger vessel caliber, and optimal flap insetting. Moreover, their location does not expose them completely to radiotherapy consequences.

Accidental injury of the latissimus dorsi flap pedicle during axillae dissection: types and reconstruction algorithm.

The intra‐operative latissimus dorsi (LD) pedicle damage during axillary lymph‐node dissection by the general surgeon is a rare complication leading to flap failure and poor outcomes. The authors present their experience on this topic and develop a classification of the thoracodorsal (TD) pedicle injuries and reconstruction algorithm. Pedicle damage of LD occurred in five cases, three of which were experienced during immediate breast reconstruction and two observed in patients who underwent prior surgery. In two cases the thoracodorsal vein (TDV) was damaged in its proximal segment, thus end‐to‐end anastomosis was performed between distal stump of TDV and circumflex scapular vein (CSV). In one case the TDV required simple microsurgical repair while in other two cases the severe damage of vein and artery required more complex surgical strategies in attempt to salvage the flap. Four cases completely survived with one case of rippling phenomenon. One case had partial flap necrosis that required subtotal muscle resection. Based on these cases, the authors have developed a reconstruction algorithm in attempt to repair LD pedicle damage while preserving breast reconstruction. Taking into account its anatomical conformation, TD pedicle injuries are classified in four different types and available options are suggested for all of them according to the anatomical site and to the mechanism and timing of injury.

Upper airway volume after Le Fort III advancement in subjects with craniofacial malformation

Aim:There are no quantitative standards for the volumetric measurements of the airway space after Le Fort III advancement. Computed tomographic (CT) scans have provided the opportunity to compare with the accuracy of real anatomic changes, thus the functional improvements, resulting after a surgical treatment. Materials and Methods:Three-dimensional CT scans processed by Digital Imaging and Communications in Medicine files in Dolphin 3D software were used to assess the airway space volume in 4 subjects affected by craniofacial syndromic malformations treated with Le Fort III advancement. The preoperative (T0) and postoperative (T1: 6 mo after surgery) three-dimensional craniofacial CT scans of the subjects were collected and retrospectively analyzed. Image segmentation of the anatomic structures of interest and the three-dimensional graphic rendering were done by using the Dolphin Imaging Plus 11.0 software. Results:The airway space volume was significantly increased after surgery (mean [SD]: from 9166.57 [1861.48] mm3 to 15,300.45 [5114.09] mm3; P < 0.01). The sagittal surfaces had an expansion from 798.92 (74.88) to 1151.45 (218.47) mm2. The coronal surfaces grew from 226.75 (62.85) to 390.42 (102.21) mm2, and axial surfaces increased 473.32 (62.34) to 676.00 (151.07) mm2 from T0 to T1. Conclusions:In conclusion, this study showed an increase in the upper airway space volume in white subjects after Le Fort III advancement.

One-stage DIEP flap breast reconstruction: Algorithm for immediate contralateral symmetrization

The aim of this study was to investigate clinical and aesthetic results of simultaneous contralateral balancing procedures in unilateral DIEP flap reconstructions by means of a symmetrization algorithm. Between 2004 and 2013, 335 patients underwent DIEP flap breast reconstruction with 48 patients (mean age 51.8 years, range 32–69 years) undergoing contralateral procedure. Patients were divided in Group‐A including 31 cases who underwent one‐stage procedure and Group‐B including 17 cases who underwent staged procedure. A symmetrization algorithm was proposed to plan immediate breast reduction/mastopexy. The groups were homogeneous regarding patients age, BMI, mastectomy and flap weight (P > 0.05). All flaps survived. No complications were observed to the mastectomy skin flaps and to the reduction mammaplasty/mastopexy procedures in both groups. The mean operation time was 5 h in Group‐A while 5 h and 37 min in Group‐B (P = 0.0682). Contralateral procedures included 23 breast reductions and 8 mastopexies in Group‐A, while 10 breast reductions and 7 mastopexies were performed in Group‐B. Two and 6 patients required revision of the balancing procedure in Group‐A and Group‐B, respectively. The follow‐up time was 47.3 months (range 14–120 months) in Group‐A and 91.3 months (range 41–110 months) in Group‐B. Volume, upper/lower pole shape, projection, breast mound placement, IMF, symmetry, overall appearance, and general satisfaction sub‐items obtained high‐score evaluation without significant difference between the two groups (P > 0.05). One‐stage DIEP flap reconstruction by means of the symmetrization algorithm resulted in comparable aesthetic outcomes and patient satisfaction to a staged procedure.

Compression of the digital nerves by a giant periosteal chondroma

Abstract We describe a left-handed man who had a giant periosteal chondroma of the proximal phalanx of the left third finger with compression of the digital neurovascular structures, and the flexor and extensor tendons. Cutaneous pressure thresholds of the digital nerves were tested, showing complete sensory recovery 24 months postoperatively.

One-stage DIEP flap reconstruction: algorithm for immediate contralateral breast symmetrization

The aim of this study was to investigate clinical and aesthetic results of simultaneous contralateral balancing procedures in unilateral DIEP flap reconstructions by means of a symmetrization algorithm. Between 2004 and 2013, 335 patients underwent DIEP flap breast reconstruction with 48 patients (mean age 51.8 years, range 32–69 years) undergoing contralateral procedure. Patients were divided in Group‐A including 31 cases who underwent one‐stage procedure and Group‐B including 17 cases who underwent staged procedure. A symmetrization algorithm was proposed to plan immediate breast reduction/mastopexy. The groups were homogeneous regarding patients age, BMI, mastectomy and flap weight (P > 0.05). All flaps survived. No complications were observed to the mastectomy skin flaps and to the reduction mammaplasty/mastopexy procedures in both groups. The mean operation time was 5 h in Group‐A while 5 h and 37 min in Group‐B (P = 0.0682). Contralateral procedures included 23 breast reductions and 8 mastopexies in Group‐A, while 10 breast reductions and 7 mastopexies were performed in Group‐B. Two and 6 patients required revision of the balancing procedure in Group‐A and Group‐B, respectively. The follow‐up time was 47.3 months (range 14–120 months) in Group‐A and 91.3 months (range 41–110 months) in Group‐B. Volume, upper/lower pole shape, projection, breast mound placement, IMF, symmetry, overall appearance, and general satisfaction sub‐items obtained high‐score evaluation without significant difference between the two groups (P > 0.05). One‐stage DIEP flap reconstruction by means of the symmetrization algorithm resulted in comparable aesthetic outcomes and patient satisfaction to a staged procedure.

The use of the serratus anterior muscle vascular pedicle as recipient site in DIEP flap transfer for breast reconstruction

Currently, the choice for recipient vessels in microvascular breast reconstruction is made between axillary and internal mammary regions. The authors report their experience with anastomosis to a new, unconventional, axillary recipient vessel, the serratus anterior muscle vascular pedicle. Among 340 deep inferior epigastric perforator (DIEP) flap breast reconstructions performed between 2004 and 2013, 11 were successfully revascularised to the serratus anterior (SA) pedicle: In three cases, complications led to a salvage procedure, while in eight cases, anastomosis to this recipient site was electively planned. The pedicle was constantly present, with calibre always comparable to that of flaps pedicle. At the mean 24-month follow-up, no recipient site complications were observed. The SA muscle pedicle resulted as a reliable choice in salvage procedures and a suitable option for recipient vessel selection in elective cases.

Sensate anterolateral thigh perforator flap for ischiatic sores reconstruction in meningomyelocele patients.

Recidivating pressure sores are a frequent complication in meningomyelocele patients because of their limitation in motility and their scarce ability to monitor the pressure applied on insensate areas while seated. We report the utilization of the sensate pedicled anterolateral thigh perforator flap for reconstruction of ischiatic sores in meningomyelocele patients. Between May 2011 and September 2013, five patients underwent transfer of a sensate pedicled anterolateral thigh flap, by an intermuscular passageway through the upper thigh, to reach the ischial defect. Flap was properly harvested from the thigh after assessment of the lateral cutaneous femoral nerve sensitive area with the Pressure‐Specified Sensory Device. In all cases the flap reached the ischial defect harmlessly, healing was uneventful with no immediate nor late complications. Each patient showed persistence of sensitivity at the reconstructed area and no recurrent ischiatic sore was observed at mean follow‐up of 26.4 months. The sensate pedicled anterolateral thigh flap is a valuable solution for coverage of recurrent ischial sores in meningomyelocele patients, in which pressure consciousness is fundamental. The intermuscular passageway allows to reduce the distance between flaps vascular pedicle origin and the ischial defect, hence to use the more reliable skin from the middle third of the anterolateral thigh.

Diep flap sentinel skin paddle positioning algorithm

Although clinical examination alone or in combination with other techniques is the only ubiquitous method for flap monitoring, it becomes problematic with buried free‐tissue transfer. We present a DIEP flap sentinel skin paddle (SSP) positioning algorithm and its reliability is also investigated using a standardized monitoring protocol. All DIEP flaps were monitored with hand‐held Doppler examination and clinical observation beginning immediately after surgery in recovery room and continued postoperatively at the ward. Skin paddle (SP) position was preoperatively drawn following mastectomy type incisions; in skin‐sparing mastectomies types I–III a small SP (sSP) replaces nipple–areola complex; in skin‐sparing mastectomy type IV, SSP is positioned between wise‐pattern branches while in type V between medial/lateral branches. In case of nipple‐sparing mastectomy SSP is positioned at inframammary fold or in lateral/medial branches of omega/inverted omega incision if used. Three hundred forty‐seven DIEP flap breast reconstructions were reviewed and stratified according to SP type into group A including 216 flaps with large SP and group B including 131 flaps with SSP and sSP. Sixteen flaps (4.6%) were taken back for pedicle compromise, 13 of which were salvaged (81.25%), 11 among 13 from group A and 2 among 3 from group B. There was no statistical difference between the groups concerning microvascular complication rate (P = 0.108), and time until take‐back (P = 0.521) and flap salvage rate (P = 0.473) resulted independent of SP type. Our results suggest that early detection of perfusion impairment and successful flaps salvage could be achieved using SSP for buried DIEP flap monitoring, without adjunctive expensive monitoring tests.