Mario Faenza

Free fibular flap with periosteal excess for mandibular reconstruction

In microvascular transfer of fibular osteocutaneous flap for mandible reconstruction after cancer ablation, good bone union is necessary to allow timely radiation therapy after surgery. As the area of bone contact between fibula and the original mandible at the edge of the mandibular defect is small, a periosteal excess at both ends of the fibula covering the bone junction can be used to increase the chance of bone union. The purpose of this study is to investigate whether a periosteal excess surrounding both ends of the fibula flap can provide better blood supply and, therefore, ensure bone union and wound healing at 6 weeks after surgery and before radiation therapy initiation.

Evaluation of peripheral microcirculation improvement of foot after tarsal tunnel release in diabetic patients by transcutaneous oximetry

According to recent studies, peripheral nerve decompression in diabetic patients seems to not only improve nerve function, but also to increase microcirculation; thus decreasing the incidence of diabetic foot wounds and amputations. However, while the postoperative improvement of nerve function is demonstrated, the changes in peripheral microcirculation have not been demonstrated yet. The aim of this study is to assess the degree of microcirculation improvement of foot after the tarsal tunnel release in the diabetic patients by using transcutaneous oximetry.

Is mammary reconstruction with the anatomical Becker expander a simple procedure? Complications and hidden problems leading to secondary surgical procedures: a follow-up study.

Debate over the role of Becker expander implants (BEIs) in breast reconstruction is still ongoing. There are no clear indications for BEI use. The main indications for BEI use are one-stage breast reconstruction procedure and congenital breast deformities correction, due to the postoperative ability to vary BEI volume. Recent studies showed that BEIs were removed 5 years after mammary reconstruction in 68% of operated patients. This entails a further surgical procedure. BEIs should not, therefore, be regarded as one-stage prostheses. We performed a case-series study of breast reconstructions with anatomically shaped Becker-35™ implants, in order to highlight complications and to flag unseen problems, which might entail a second surgical procedure. A total of 229 patients, reconstructed from 2005 to 2010, were enrolled in this study. Data relating to implant type, volume, mean operative time and complications were recorded. All the patients underwent the same surgical procedure. The minimum follow-up period was 18 months. During a 5-year follow-up, 99 patients required secondary surgery to correct their complications or sequelae; 46 of them underwent BEI removal within 2 years of implantation, 56 within 3 years, 65 within 4 years and 74 within 5 years. Our findings show that two different sorts of complications can arise with these devices, leading to premature implant removal, one common to any breast implant and one peculiar to BEIs. The Becker implant is a permanent expander. Surgeons must, therefore, be aware that, once positioned, the Becker expander cannot be adjusted at a later date, as in two-stage expander/prosthesis reconstructions for instance. Surgeons must have a clear understanding of possible BEI complications in order to be able to discuss these with their patients. Therefore, only surgeons experienced in breast reconstruction should use BEIs.

A scanning electron microscope study and statistical analysis of adipocyte morphology in lipofilling: comparing the effects of harvesting and purification procedures with 2 different techniques.

BackgroundThe aim of this study was to evaluate the effects on adipocyte morphology of 2 techniques of fat harvesting and of fat purification in lipofilling, considering that the number of viable healthy adipocytes is important in fat survival in recipient areas of lipofilling. MethodsFat harvesting was performed in 10 female patients from flanks, on one side with a 2-mm Coleman cannula and on the other side with a 3-mm Mercedes cannula. Thirty milliliter of fat tissue from each side was collected and divided into three 10 mL syringes: A, B, and C. The fat inside syringe A was left untreated, the fat in syringe B underwent simple sedimentation, and the fat inside syringe C underwent centrifugation at 3000 rpm for 3 minutes. Each fat graft specimen was processed for examination under low-vacuum scanning electron microscope. Diameter (&mgr;) and number of adipocytes per square millimeter and number of altered adipocytes per square millimeter were evaluated. Untreated specimens harvested with the 2 different techniques were first compared, then sedimented versus centrifuged specimens harvested with the same technique were compared. Statistical analysis was performed using Wilcoxon signed rank test. ResultsThe number of adipocytes per square millimeter was statistically higher in specimens harvested with the 3-mm Mercedes cannula (P = 0.0310). The number of altered cells was statistically higher in centrifuged specimens than in sedimented ones using both methods of fat harvesting (P = 0.0080) with a 2-mm Coleman cannula and (P = 0.0050) with a 3-mm Mercedes cannula. Alterations in adipocyte morphology consisted in wrinkling of the membrane, opening of pore with leakage of oily material, reduction of cellular diameter, and total collapse of the cellular membrane. ConclusionsFat harvesting by a 3-mm cannula results in a higher number of adipocytes and centrifugation of the harvested fat results in a higher number of morphologic altered cells than sedimentation.

COMPARTMENT SYNDROME AT THE FIBULA FLAP'S DONOR SITE AND SALVAGE BY ANEROLATERAL THIGH CHIMERIC FLAP

We report a challenging case of chimeric anterolateralthigh flap reconstruction to cover peroneus longus andcalcaneal tendons exposure as a consequence of a donorsite compartment syndrome after fibula flap harvesting.A 61-year-old patient was referred to the Maxillo-Fa-cial Unit for a squamous cell carcinoma (T4-N3-M0) ofthe buccal mucosa involving the inferior premolar alveo-lar ridge. The patient underwent right emi-mandibulec-tomy, tumor en-bloc excision, and bilateral radical neckdissection. An immediate reconstruction was performedwith a free osteocutaneous fibula flap with two differentskin paddles. The first one was used to reconstruct theskin defect and the second one to reconstruct the mucosaldefect. The donor site was closed by direct suture undertension. A suction drain was positioned.The initial postoperative period was uneventful. Onthe fifth postoperative day, the negative-pressure drainagewas pulled out. A week after surgery, the donor site wasedematous and dark brown fluid flowed from the wound.Only mild pain occurred with active or passive movementof the toes. During the second week after surgery, theswelling and dark fluid secretion from the donor sitebecame more obvious. A necrotic area appeared in thecontext of donor site closure; this area rapidly increasedits dimensions in a few days. The only clinical symptomstill was a mild pain. Two weeks from surgery, the clini-cal diagnosis was compartment syndrome, due to exces-sive tension.This compartment syndrome led to a large loss ofskin and muscles of the lateral compartment of the legwith peroneus longus tendon and part of calcaneal tendonexposure (Fig. 1), then the patient was referred to ourPlastic Surgery Unit in order to plan a repair.After a surgical debridement, a two week of VacuumAssisted Closure

What's new on primary Hodgkin's lymphoma of the breast? A case report and review of the literature

Highlights • A subtle case report of primary Hodgkin’s disease of the breast.• Definition and staging of primary lymphomas of the breast.• A comprehensive review of the Literature about this kind of disease.

Reply: An original technique for securing the inflation port in Becker implant-based breast reconstruction.

Reply: An Original Technique for Securing the Inflation Port in Becker Implant–Based Breast Reconstruction Sir: We read carefully and with great interest the original technique described by Dr. Demiri and colleagues for securing the inflation port in Becker implant breast reconstruction. Port displacement, or flip-over, is, in our findings, the most common complication following Becker implant mammary reconstruction.1 In a more recent study regarding our largest Becker reconstruction series (275 implants), we found the port flip-over rate to be much higher than that reported before, at about 15 percent of reconstructed patients.2 We believe port flip-over is scarcely reported in the literature, probably because there are few studies analyzing complications in large series of Becker reconstructions. Therefore, we appreciate every single study trying to reduce or prevent port flip-over. Again, we welcome this new technique developed to secure the Becker port in place. Over the years, we have tried to stabilize the Becker port by securing the connection tube between the expander and the port with a single 4-0 Vicryl stitch directly on the subdermal tissues along the midline at the inframammary sulcus level, just before the beginning of the subdermal pocket. We cannot secure the port directly because of the difficulty working in such a small area as the subdermal tunnel, undermined to allocate the port. Again, we tried to prevent port flip-over using sterile strips directly on the skin around the port, trying to spread far from the port the postoperative edema. Both of these techniques were ineffective in preventing port flip-over. Fixing the port directly on the skin, as described in this interesting work, seems to us a great idea, really effective in preventing port displacement. However, a few concerns arise in reading about this technique. First of all, how do the authors make the needle pass through the subdermal tunnel without damaging the expander or the connection tube? Do they go blindly, or do they enlarge the tunnel so as to see directly where to stitch? Second, sutures lying directly on the skin for more than 2 weeks, even if a bolster technique is used, may sometimes leave unpleasant marks in situ. Did the authors find this complication? Third, might this technique promote bacterial port contamination? Skin stitches could carry bacteria directly to the port. Further study will be necessary to confirm the safety of this technique. In conclusion, we congratulate the authors on their great idea for avoiding Becker port flip-over. Moreover, we thank them again for having focused their attention on this complication that in our experience is much more frequent than has been reported in the literature. DOI: 10.1097/PRS.0b013e31829accdf

Aggressiveness pattern and second primary tumor risk associated with basaloid squamous cell carcinoma of the larynx

Basaloid squamous cell carcinoma (BSCC) is a rare, aggressive and distinct variant of squamous cell carcinoma (SCC) of the upper respiratory and digestive tract. We have evaluated disease specific survival (DSS) and overall survival (OS) through Kaplan-Meier method and mortality risk through univariate statistical analysis of Cox in 42 cases of BSCC and other 42 of laryngeal SCC (LSCC) matched for both age and sex. We demonstrated that laryngeal BSCC is a more aggressive tumor than LSCC as is associated to higher nodal recurrence of pathology (5 vs 2 patients, overall risk, OR 2.7), a reduced survival (median survival 34 vs 40 months, OR 3.2 for mortality); in addition, basaloid patients have a higher risk to be affected by second primary tumors (13 vs 3 patients, OR 5.8) and a higher probability to die for this second tumor (Hazard Risk, HR 4.4). The analysis of survival shows an increased mortality risk concurrent with the parameters assessed by univariate analyses that assume a predictive and statistical significance in second tumor and grading in basaloid LSSC.

Limberg fasciocutaneous transposition flap for the coverage of an exposed hip implant in a patient affected by ewing sarcoma

Highlights • Hemipelvectomy with immediate reconstruction with prosthetic devices for the surgical treatment of malignant tumors is an invasive procedure.• The treatment of an exposed hip implant in these cluster of patient is extremely challenging and the literature shows how negative pressure wound therapy and myocutaneous, both pedicled and free, flaps are workhorses in these situations.• The literature shows that the gold standard in the coverage of exposed prosthetic devices and in the treatment of infected non healing wounds is represented by muscular or myocutaneous flap.• In this paper we report a successful coverage of exposed prosthetic hip implant with a local fasciocutaneous flap in a patient in which any other kind of reconstruction was not feasible.

Low Versus High Vacuum Suction Drainage of the Submuscular Pocket in Primary Breast Reconstruction: A Retrospective Study

Background Placement of suction drainage in submuscular pockets is routinely performed in breast reconstruction. Days of drain permanence (DDP) are associated with hospital stay and related health care costs. The aims of this study are to retrospectively compare data related to DDP and total drainage volume between high and low vacuum suction drainage groups and to identify correlations with patient or surgery-related factors. Methods We retrospectively analyzed data of 100 patients undergoing immediate or delayed breast reconstruction with expanders and implants. We considered 2 groups depending on suction pressure applied by 2 different surgical teams: group A (number, 50 patients) with high vacuum suction and group B (number, 50 patients) with low vacuum suction. Results Days of drain permanence was not significantly different between group A and group B (P = 0.451). The same was found for total drainage volume (P = 0.183). The distribution of DDP was statistically different only between patients with or without intraoperative bleeding in group A (P = 0.005) and smoking or nonsmoking patients in group A (P = 0.045). Statistical significance was kept in multivariate regression. Conclusions There is no significant difference in DDP and total drainage volume using low or high vacuum suction drainage in breast reconstruction. The only factors affecting drainage permanence were intraoperative filling of expander, smoking, and intraoperative bleeding. Therefore, we can reduce the DDP, avoiding overfilling of expander and using of high vacuum suction in nonsmoking patients and in patients with significant intraoperative bleeding.