Matteo Atzeni

Angio computed tomography preoperative evaluation for anterolateral thigh flap harvesting.

The vascular anatomy of the anterolateral thigh flap (ALTF) has many possible variations, and none of the currently used mapping techniques (eg, Echo Color Doppler) gives a thorough knowledge of all details. Among the last generation of angiographic diagnostic techniques, multi detector computed tomography, popularly known as Angio CT, has emerged as an outstanding noninvasive operator independent option, and has been described for deep inferior epigastric perforator and pedicled transverse rectus abdominis muscle planning. This study was conducted to evaluate its usefulness prior to ALTF harvesting. Nine consecutive patients were considered for oral or lower extremity reconstruction with the ALTF. After written informed consent was obtained from all patients, a preoperative Angio-CT study was performed for surgical planning. Accurate identification of septocutaneous or musculocutaneous perforator vessels was achieved and their location, course, and anatomic variations were reported and influenced surgery. Angio CT allows a complete vascular study of the donor area of the ALTF and evaluation of the best perforator vessels before surgery allows surgeons to get an ideal planning of the flap. This imaging method is currently proposed to every patient undergoing ALT flap reconstruction.

Current state of the art in perforator flap imaging with computed tomographic angiography

Computed tomographic angiography (CTA) has become increasingly adopted for preoperative imaging in perforator flap surgery, as it has been shown to improve operative outcomes and decrease operating times prior to deep inferior epigastric artery perforator (DIEP) flap and anterolateral thigh perforator flap surgery. Current technologies are readily available for the preoperative imaging of all perforator flaps, however only sporadic reports of the use of CTA for the imaging of other perforators have been described. We describe our experience with 325 CTAs performed for the preoperative imaging of perforators prior to 370 perforator flaps throughout several body regions. The scanning techniques, software reconstructions and technical issues are explored. In all cases, CTA was scored by the radiologist as at least “sufficient”, and described as “optimal” in the majority of cases. Similarly, the surgeon described the correlation of imaging to operative findings as at least “good”, and described the correlation as “optimal” in the majority of cases. As such, a standardized protocol for the use of CTA prior to perforator flap surgery is provided, which has been shown to be successful prior to a range of perforator flap operations.

Intraoperative parathyroid hormone assay during focused parathyroidectomy: the importance of 20 minutes measurement

BackgroundParathyroid hormone (PTH) monitoring during the surgical procedure can confirm the removal of all hyperfunctioning parathyroid tissue, as the half-life of PTH is approximately 5 min. The commonly applied Irvin criterion is reported to correctly predict post-operative calcium levels in 96-98% of patients. However, the PTH baseline reference concentration is markedly influenced by surgical manipulations during preparation of the affected glands, interindividual variability of the PTH half-life and modifications in the physiological state of the patient during surgery. The aim of this study was to evaluate the possible impact of the measurement of intraoperative PTH 20 minutes after surgery.MethodsBetween 2003 and 2012, 188 patients underwent a focused parathyroidectomy associated to rapid intraoperative PTH assay monitoring. Blood samples were collected: 1) at pre-incision time, 2) at 10 min after gland excision and 3) at 20 min after excision, if a sufficient reduction of PTH value was not observed. On the bases of the Irvin criterion, an intra-operative PTH drop>50% from the highest either pre-incision or pre-excision level after parathyroid excision was considered a surgical success.ResultsA >50% decrease of PTH after gland excision compared to the highest pre-excision value occurred in 156/188 patients (83%) within 10 min and in further 12/188 after 20 minutes (6.4%). In the remaining 20 patients (10.6%) values of PTH remained substantially unchanged or decreased less than 50% and for this reason bilateral neck exploration was performed. An additional pathologic parathyroid was removed in 9 cases, a third in one. In the other 10 cases further neck exploration by a standard cervical approach was negative and in four of these persistent postoperative hypercalcemia was demonstrated. The overall operative success was 97.3%. Intraoperative PTH monitoring was accurate in predicting operative success or failure in 96.3% of patients.ConclusionsThe 20 minutes PTH measurement appears very useful, avoiding unnecessary bilateral exploration and the related risk of complications with only a slight increase of the duration of surgery and of the costs. PTH values decreasing appeared to be influenced by surgical manipulations during minimally invasive parathyroidectomy.

Vulnerable plaque: Detection of agreement between multi-detector-row CT angiography and US-ECD

OBJECTIVES The purpose of this work was to evaluate the agreement between ultra-sound echo-color Doppler (US-ECD) and multi-detector-row CT angiography (MDCTA) in the characterization of vulnerable plaque. METHODS From January 2004 to January 2007 658 patients who underwent both MDCTA and US-ECD for the study of carotid arteries, were retrospectively evaluated (453 males, 205 females). For all subjects the following parameters were analysed: plaque morphology (regular versus irregular), type of the plaque (fatty, mixed and calcified) and presence of ulcerations. Statistical analysis was performed to calculate concordance between the two techniques employed. RESULTS In the definition of the type of plaque, the observed agreements were 77.2% and the kappa value was 0.657 (95% confidence interval: 0.615-0.699). The weighted kappa resulted 0.644. In the definition of ulceration plaque, the observed agreements were 88.4% but the kappa value was only 0.325 (95% confidence interval: 0.201-0.449). Agreement observed in the evaluation of plaque morphology was 78.3% with a kappa value of 0.513 (95% confidence interval: 0.452-0.574). CONCLUSION We observed a good agreement between US-ECD and MDCTA in the assessment of plaque type whereas a poor agreement resulted in the evaluation of plaque ulceration. The use of US-ECD and MDCTA provides different results in the evaluation of plaque. Our results suggest that information deriving from US-ECD should be always critically compared with other diagnostic techniques.

Preoperative Angio-CT Preliminary Study of the TRAM Flap After Selective Vascular Delay

Background:The pedicled TRAM (pTRAM) flap is one of the best options for autologous breast reconstruction, but vascular complications reported in the standard versions are about 30%. To reduce complication rate, especially in high-risk patients, surgical delay has been suggested. Individual precise preoperative location and evaluation of perforating vessels and of variations of the diameter of the deep superior epigastric artery (DSEA) are highly desirable for improving surgical strategy. Previous reports using color duplex scanning, although generally confirming the validity of the delay maneuver, have showed several pitfalls. The aim of this report was to demonstrate the usefulness of multidetector computed tomography angiography (MDCTA) for preoperative planning in patients undergoing pTRAM flap breast reconstruction after selective vascular delay. Methods:Three patients were considered for breast reconstruction with the pTRAM flap. An MDCTA was performed before and after selective delay to locate the muscle perforators and to show increase in DSEA diameter. Axial images, multiplanar reconstruction, and 3D volume images were analyzed. Results:Accurate identification of the main perforators was achieved. Location, course, and anatomic variations of DSEA were reported. The average increase in diameter of the DSEA was 29.3%. Conclusion:Preoperative planning of pTRAM flap with MDCTA allows surgeons to visualize and locate the dominant perforators and to select the best DSEA. Consequently, the choice between the homolateral or contralateral rectus muscle is facilitated. The high sensitivity and specificity and the ease of interpreting data have made MDCTA a highly promising diagnostic tool for planning a pTRAM flap.

Multiple melanoma arising on a burn scar and extensive sunburn: a case report and a review of the literature.

Melanoma arising in a burn scar is very uncommon. We report a recent case of a female patient in whom two different melanomas arose on a wide back burn scar at different times, focusing attention on three different potential risk factors for melanoma the patient had: sunburns, laser therapy on back and burn scar.

Non-invasive vascular imaging in perforator flap surgery.

Preoperative imaging using a range of imaging modalities has become increasingly popular for preoperative planning in plastic surgery, in particular in perforator flap surgery. Modalities in this role include ultrasound (US), magnetic resonance angiography (MRA), and computed tomographic angiography (CTA). The evidence for the use of these techniques has been reported in only a handful of studies. In this paper we conducted a non-systematic review of the literature to establish the role for each of these modalities. The role of state-of-the-art vascular imaging as an application in perforator flap surgery is thus offered.

Analysis of deep inferior epigastric perforator (DIEP) arteries by using MDCTA: Comparison between 2 post-processing techniques

PURPOSE Our purpose was to compare two post-processing techniques, Maximum-Intensity-Projection (MIP) and Volume Rendering (VR) for the study of perforator arteries. METHODS Thirty patients who underwent Multi-Detector-Row CT Angiography (MDCTA) between February 2010 and May 2010 were retrospectively analyzed. For each patient and for each reconstruction method, the image quality was evaluated and the inter- and intra-observer agreement was calculated according to the Cohen statistics. The Hounsfield Unit (HU) value in the common femoral artery was quantified and the correlation (Pearson Statistic) between image quality and HU value was explored. RESULTS The Pearson r between the right and left common femoral artery was excellent (r=0.955). The highest image quality score was obtained using MIP for both observers (total value 75, with a mean value 2.67 for observer 1 and total value of 79 and a mean value of 2.82 for observer 2). The highest agreement between the two observers was detected using the MIP protocol with a Cohen kappa value of 0.856. The ROC area under the curve (Az) for the VR is 0.786 (0.086 SD; p value=0.0009) whereas the ROC area under the curve (Az) for the MIP is 0.0928 (0.051 SD; p value=0.0001). CONCLUSION MIP showed the optimal inter- and intra-observer agreement and the highest quality scores and therefore should be used as post-processing techniques in the analysis of perforating arteries.

Implant Breast Reconstruction in the Setting of Postoperative Radiotherapy with Protective Lipofilling

Immediate two-stage prosthetic breast reconstruction in the setting of postmastectomy radiotherapy (PMRT) currently is hardly achieved because of high rates of complications and poor cosmetic outcomes as: higher risks of hematoma, seroma, wound dehiscence with possible implant exposure, infections (short-term) and resistance to expansion, pain, capsular contracture, thinning of the skin (long-term). In order to overcome these problems, some techniques have been proposed, each one with important drawbacks and complications. The authors describe a protocol based on lipofilling on irradiated expanders in patients undergoing planned or unplanned PMRT with predictable results, having eliminated the risk of tissue ulceration and implant exposure.

Vertical Breast Reduction

Before the 1900s, attempts to reduce breast size were limited to volume reduction without regard to nipple position and viability, not to breast shape. In the first part of the twentieth century, multiple techniques were described to move the nipple-areola complex and to reduce bulk. To maintain viability, two-stage procedures were often recommended, even if this is nowadays hard to believe.