Matteo Rossi

Evaluation of the Upper Limb Lymphatic System: A Prospective Lymphoscintigraphic Study in Melanoma Patients and Healthy Controls.

Background: Current research on the upper limb lymphatic system mainly studies breast cancer patients with unilateral lymphedema. Without preoperative lymphoscintigraphy, the contralateral limb is used as a control, assuming that it is functionally intact. Few lymphoscintigraphic studies investigate patients before any axillary surgery. The purpose of this study was to evaluate, through lymphoscintigraphy, the preoperative condition of the upper limb lymphatic system in melanoma patients and healthy controls. Methods: Two groups were studied: the study group (16 patients with trunk/upper limb melanoma candidates for axillary sentinel lymph node biopsy) and the control group (10 healthy volunteers). All subjects underwent upper limb lymphoscintigraphy. Lymphoscintigraphic images were classified into three patterns based on the tracer appearance time in the axillary nodes. Type I, 20 minutes; type II, 60 minutes; and type III, 120 minutes. Statistical analysis was used to assess the relationship between lymphoscintigraphic patterns and clinical variables and to compare patterns of distribution. Results: Lymphoscintigraphic patterns were asymmetric in 37.5 percent (study group) and 50 percent (control group). Type III was the most common pattern. There was no significant association between lymphoscintigraphic patterns and considered clinical variables. There was no significant difference in the lymphoscintigraphic pattern distribution of the two groups (p = 0.870). Conclusion: The authors’ findings show wide differences and an often “slow” tracer appearance time in patients with intact lymphatic system, questioning the use of contralateral limb as control and transportation time greater than 30 minutes as criteria for identification of lymphatic alterations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Male breast cancer: Modified radical mastectomy or breast conservation surgery? A case report and review of the literature

Introduction Male breast cancer (MBC) is a rare disease that accounts for <1% of breast cancer cases. The most common treatment is modified radical mastectomy (MRM). Recently, breast conservative surgery (BCS) is getting popular for MBC treatment. We report a case and reviewed the literature to investigate whether emerging BCS can be considered as an alternative of a more radical surgery. Presentation of case A 46 y.o. patient, presented with a painless left breast lump over a period of six months. The patient underwent a quadrantectomy at another institution. Pathology revealed an intraductal carcinoma in close proximity to the margins of excision. Adjuvant hormonal therapy was proposed to the patient, who refused and was referred to our Institution. We performed a MRM and a sentinel lymph node biopsy (SLNB). A contralateral breast liposuction and an adenectomy were also performed. The patient underwent also a nipple-areolar complex reconstruction. The patient didn’t receive adjuvant therapy. Discussion Both oncological safety and satisfactory cosmetic outcomes are the goals of MBC treatment. No specific guidelines for MBC treatment have been proposed. MRM is currently the surgical gold standard of MBC (approximately 70% of all cases). Some authors reported that male BCS associated with radiation therapy is a feasible alternative MRM. Taking into account data from the literature and considering the previous surgery, in the case we report, we offered a MRM, SLNB and a contralateral breast symmetrization. Conclusion MRM with SLNB and reconstruction of male breast asymmetry should be still considered as the treatment of choice of MBC.

Freestyle-Like V-Y Flaps of the Eyebrow: A New Outlook and Indication of an Historical Technique

The eyebrow region is of utmost importance for facial movement, symmetry, and the overall cosmetic appearance of the face. Trauma or tumor resection often leave scars that may dislocate the eyebrow producing an alteration both in static symmetry of the face and in the dynamic expressivity. The authors present a technique for eyebrows defects repair using the remaining eyebrow advancement by means of a “freestyle-like” V-Y flap. In the past two years a total of eight consecutive patients underwent excision of skin lesions in the superciliary region and immediate reconstruction with this technique. On histology, six patients were affected from basal cell carcinomas, one from squamous cell carcinoma, and one from congenital intradermal melanocytic nevus. The pedicle of the flap included perforators from the supratrochlear, supraorbital, or superficial temporalis artery. Advancement of the entire aesthetic subunit that includes the eyebrow using a V-Y perforator flap was performed successfully in all cases achieving full, tension-free closure of defects up to 3.0 cm. “Freestyle-like” V-Y flaps should be considered as a first-line choice for partial defects of the eyebrow. The greater mobility compared to random subcutaneous flaps allows to reconstruct large defects providing an excellent cosmetic result.

Lower Urinary Tract Symptoms in Male-to-Female Transsexuals: Short Terms Results and Proposal of a New Questionnaire

Presented at the 64th Annual Meeting of the SICPRE, September 17–19, 2015, Milan, Italy. SICPRE: La SICPRE, Societa Italiana di Chirurgia Plastica Ricostruttiva ed Estetica, national meeting, in Milano, Italy on September 17–19, 2015. Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was supported by a grant of family Dioguardi, in memory of Professor Domenico Dioguardi, MD.

An algorithm to improve outcomes of radial forearm flap donor site

Abstarct Background: Due to the high rate of donor site complications the Radial Forearm Flap (RFF) has lost ground in favor of the Antero-lateral tight flap (ALT) and other flaps. We have designed a reconstruction algorithm for reconstruction of its donor site. The goal of this study was to retrospectively evaluate the impact of this algorithm on RFF donor site complication rates. Methods: The authors analyzed retrospectively 31 patients who underwent free radial forearm flap reconstruction between November 2009 and May 2013. Donor site complications were compared with data from patients treated before introdutction of the algorithm. Within the group were compared patients in which the flap was harvested suprafascial with those in which the flap was harvested as subfascial. Results: Before application of the algorithm, there was a 23.3% complication rate at the RFF donor site, in our experience. After introduction of the algorithm, complication rate has dropped to 3.2%, consisting in a partial skin graft necrosis treated by local wound-care and healed without further intervention. Conclusions: Application of the algorithm described has led to a significant reduction in RFF donor site complication rates. This demonstrates that if flap donor sites are analyzed and tailor treated in the same way as primary defects are, instead of being given secondary importance and just grafted, outcomes improve.

Solitary Fibrous Tumor of the Lower Leg: A Rare and Difficult Diagnosis.

Summary: Solitary fibrous tumor (SFT) is a rare neoplasm that commonly originates in the pleura. Extrapleural locations are rare and for this reason sometimes difficult to diagnose. Malignant forms with local recurrence or distant metastases have been reported, also as a consequence of inappropriate treatment. In this article, we report the case of an SFT of the lower leg in a 37-year-old man. Leg SFT is a rare occurrence, and differential diagnosis may be difficult because they can mimic a variety of benign and malignant mesenchymal tumors; immunohistochemical analysis for CD34, CD99, vimentin, and Bcl-2 is necessary. Misdiagnosis carries a significant risk of inadequate removal with subsequent increased risk of recurrence and distant metastases.

The role of the vastus lateralis flap in head and neck reconstruction

Introduction The Vastus lateralis (VL) flap is a very versatile flap: it is easy to harvest, has a long pedicle, and can be tailored to several reconstructive needs. It was first described as a free flap in 1992 (1); however, despite its positive features, it has only seen a limited take up over time. Reviewing the literature we found that only 15 papers with a total of 1999 patients detail the use of this flap in the head and neck. Over the last few years, the VL flap has become one of our preferred techniques for the repair of wide head and neck defects of various types and in various locations. This flap, which can be harvested as a muscle, musculo-cutaneous or chimeric flap, is particularly suitable for head and neck reconstruction, as it allows for a two-team approach, and can be tailored to the complex three-dimensional structure of this district. In this paper, we describe our experience and a review of the literature on the use of the free VL flap in the head and neck region, analyzing its indications, advantages and limitations. We also provide technical tips to minimize donor site morbidity.

PEDICLED PERFORATOR FLAPS IN NASAL RECONSTRUCTION: A REVIEW

Introduction Multiple factors must be considered in the reconstruction of nasal defects. These include size and location of the defect, previous surgical treatments and patient’s general health status. The patient’s and surgeon’s aesthetic aims should also be included in the decision making process. Among the numerous options available, from simple skin grafts to free flaps, local flaps are still the preferred method for reconstruction of nasal defects, because they provide matching color and texture, resulting in a far superior aesthetic outcome. Classical flaps for nasal defect reconstruction, such as forehead or nasolabial flaps, have some disadvantages with regard to limitations in their arc of rotation and the multiple stages of surgery necessary. Perforator flaps have greatly expanded our reconstructive tools in all body regions and often allow us to overcome these limits. Since their first description by Koshima and Soeda (1) in 1989, these flaps have become popular in many areas of reconstructive surgery, because they provide design freedom, reduce donor site morbidity and allow thinner flaps to be tailored for more accurate reconstruction in single stage surgery. Review