Roberto Pirrello

Vascular anatomy of the supraclavicular area revisited: feasibility of the free supraclavicular perforator flap.

Background: The supraclavicular skin has been studied extensively and used as a pedicled flap for face and neck reconstruction. Its use as a free flap has not paralleled its use as a pedicled flap. The authors performed an anatomical investigation to assess the possibility of harvesting a free supraclavicular flap with the donor-site scar lying in the supraclavicular crease. In this article, the authors present the results of their anatomical study together with the preliminary clinical applications. Methods: Skin vascularization and feasibility of a free supraclavicular perforator flap were studied on 25 cadavers (15 fresh cadavers injected with colored latex at the Universiteé René Descartes in Paris; and 10 formalin-fixed, noninjected cadavers at the Innsbruck Medical University). The flap was used in two patients at the Plastic Surgery Department of the University of Palermo for a cutaneous facial reconstruction and intraoral reconstruction after cancer excision. Results: An average of four perforators were consistently found in the supraclavicular area coming from the transverse cervical artery. Venous perforators drain into the superficial venous plexus rather than into the venae comitantes of the transverse cervical artery. Two flaps were successfully used based on these vessels. Conclusions: The vascularization of the supraclavicular skin depends on skin perforators coming from the transverse cervical artery and draining into the superficial venous plexus. Based on these vessels, a reliable free supraclavicular flap seems to be safe to harvest, with the scar hidden in the supraclavicular crease. The preliminary clinical applications of such a flap gave promising results, suggesting its potential applications.

Anatomic study on the transverse cervical vessels perforators in the lateral triangle of the neck and harvest of a new flap: the free supraclavicular transverse cervical artery perforator flap

BackgroundVessels in the supraclavicular area and their contribution to skin vascularization have always been studied for flaps planning in head and neck reconstruction and many pedicled flaps have been described based on those vessels. Little has been written instead about the vascularization of the supraclavicular skin itself for the use as a free flap. The purpose of this anatomical study was to assess the vascularization of the supraclavicular skin and the possibility of finding an adequate pedicle to harvest it as a free flap in order to close the donor site directly.MethodsA total of 25 cadavers, 10 formalin fixed and 15 fresh, have been studied in cooperation with the Division for Clinical–Functional Anatomy, Department of Anatomy, Histology and Embryology, Innsbruck Medical University, Innsbruck, Austria and the Laboratoire d’Anatomie, Universiteé R. Descartes, Paris, France.ResultsThe supraclavicular skin was nourished by perforators coming from the transverse cervical artery and constantly present in an average number of four. Venous drainage was accomplished through the superficial cervical vein, and not through the venae comitantes of the transverse cervical artery.ConclusionsBased on the results of this investigation, a free supraclavicular transverse cervical artery perforator (STCAP) flap seems to be feasible pedicled on perforators from the transverse cervical artery and drained by the superficial cervical vein. Due to its thickness and skin texture, it can be indicated for facial and intraoral defects, with the limitations of a relatively short pedicle. Primary closure of the donor site can be accomplished concealing the scar in the neck crease.

Perioperative antibiotic prophylaxis in plastic surgery: A prospective study of 1100 adult patients

BACKGROUND Although guidelines for antibiotic prophylaxis to prevent surgical site infections (SSIs) exist, specific guidelines for plastic surgery are missing and there is a tendency towards excessive administration of antibiotics. A total of 1100 patients were prospectively studied according to an evidence-based protocol to investigate if limiting antibiotic prophylaxis to high-risk cases does increase the infection rate. METHODS Between April 2009 and April 2010, 1100 consecutive patients undergoing elective reconstructive or cosmetic procedures were enrolled. Procedures were classified into four groups, and prophylactic antibiotics were only administered perioperatively in 23.4% of cases, according to patient-related and procedure-related risk factors. RESULTS The overall SSI incidence was 1.4% (1.1% for clean surgery and 3.8% for clean-contaminated surgery). Oral oncologic surgery showed the highest infection rate (5.3%). CONCLUSIONS Specific guidelines are provided to encourage judicious use of antibiotics. Antibiotic prophylaxis is administered based on the type of operation and the patients characteristics. No prophylaxis was carried out in superficial skin surgery and simple mucosal excisions. Antibiotic prophylaxis is always indicated in microsurgery, prosthetic surgery, incisional hernias, clean non-prosthetic osteoarticular surgery and clean-contaminated procedures such as oral cavity or genitourinary system. In clean surgery and rhinoplasty, antibiotic prophylaxis is only indicated when the operation lasts more than 3 h and/or the American Society of Anesthesiologists (ASA) score is 3 or more. With the protocol reported, the risk of infection can be kept very low, avoiding the negative effects of indiscriminate use of antibiotics.

Multimodal Surgical and Medical Treatment for Extensive Rhinocerebral Mucormycosis in an Elderly Diabetic Patient: A Case Report and Literature Review

Diabetes is a well-known risk factor for invasive mucormycosis with rhinocerebral involvement. Acute necrosis of the maxilla is seldom seen and extensive facial bone involvement is rare in patients with rhino-orbital-cerebral mucormycosis. An aggressive surgical approach combined with antifungal therapy is usually necessary. In this report, we describe the successful, personalized medical and surgical management of extensive periorbital mucormycosis in an elderly diabetic, HIV-negative woman. Mono- or combination therapy with liposomal amphotericin B (L-AmB) and posaconazole (PSO) and withheld debridement is discussed. The role of aesthetic plastic surgery to preserve the patients physical appearance is also reported. Any diabetic patient with sinonasal disease, regardless of their degree of metabolic control, is a candidate for prompt evaluation to rule out mucormycosis. Therapeutic and surgical strategies and adjunctive treatments are essential for successful disease management. These interventions may include combination therapy. Finally, a judicious multimodal treatment approach can improve appearance and optimize outcome in elderly patients.

Superior pedicle retroauricular island flap for ear and temporal region reconstruction: anatomic investigation and 52 cases series.

Background:On the basis of a previously published anatomic study on the superior auricular artery (SAA) and on a series of 52 consecutive cases, the authors propose a new superior pedicle retroauricular island flap (SP-RIF) for defects of the upper half of the ear and for temporal region or superficial helical defects. Methods:Twenty five auricular regions were dissected after colored latex injection in the carotid artery of 13 fresh cadavers to investigate the SAA. A SP-RIF was used in 52 consecutive cases after tumor excision. In 51 cases, the defect involved the upper half of the ear. In one case, the defect was in the temporal region. Results:The SAA originates either from the superficial temporal artery (44%) or from its parietal branch (56%). Length, caliber, and course have been assessed. Esthetic results of the reconstruction were excellent. There were no major complications in this series. No sequelae at the donor site were recorded. Conclusions:The SP-RIF can be considered as a first choice option to repair nonmarginal losses of substance of the upper half of the ear. Because of its wide arc of rotation, it can also be used for superficial marginal defects of the helix and in selected cases of temporal region defects.

Static Treatment of Paralytic Lagophthalmos with Autogenous Tissues

BackgroundLong-standing facial paralysis is frequently seen in patients who have undergone surgical procedures with sacrifice of the facial nerve and have never been counseled about limiting its consequences. Lagophthalmos must always be treated in these patients to protect vision. The authors describe their techniques of static treatment for lagophthalmos using autologous tissues and their classification system for standardizing patients.MethodsFrom July 2001 to September 2005, 12 patients (9 men and 2 women) ranging in age from 37 to 77 years (mean, 58.5 years) were treated. Their paralysis was attributable to acoustic neuroma resection in seven cases, to resection of a cerebral vascular anomaly in two cases, and to total parotidectomy with facial nerve sacrifice in three cases. The patients were treated with elongation of the levator palpebrae superioris muscle using a fascia lata graft, bolstering of the lower eyelid with a conchal cartilage graft, or both, combined with a Kuhnt type resection when needed.ResultsComplete closure was achieved for nine patients (75%). For all the patients, resolution of symptoms and keratitis was achieved. No complications were observed. The follow-up period ranged from 14 to 51 months (mean, 39.5 months). The cosmetic outcome also was satisfactory.ConclusionsFor candidates eligible to undergo static treatment of lagphthalmos, the techniques described may be considered valuable options for the correction of lagophthalmos using autologous tissues, thus avoiding the complications related to alloplastic material implantation.

Reconstruction of Nasal Alar Defects with Freestyle Facial Artery Perforator Flaps

In 2009, we have described the use of freestyle facial artery perforator flaps for one-stage nose reconstruction. Since then, several articles have reported the use of facial artery perforator flaps for nose reconstruction. The purpose of this article is to provide an update of the published technique after 10 years of experience. Since 2004, 21 patients have been treated with a freestyle facial artery perforator flap for one-stage reconstruction of the nasal ala. The flaps were 16 propellers, 4 V-Y, and 1 island transposition. A single venous congestion leading to a minor flap tip necrosis and a wound dehiscence was observed. All other flaps healed uneventfully. The V-Y design and multiple subunit reconstruction gave suboptimal results. It was concluded that indications for freestyle facial artery perforator flaps are total nasal alar subunit reconstruction or reconstruction of lateral alar defects when perforator anatomy allows. In these cases, freestyle facial artery perforator flaps are the first choice technique at our institution because they allow excellent results in one-stage operation. One-stage nasal ala reconstruction with freestyle facial artery perforator flaps.

The Face Lift SMAS Plication Flap for Reconstruction of Large Temporofrontal Defects: Reconstructive Surgery Meets Cosmetic Surgery

Background: Reconstruction of large defects in the temporal region can be performed with skin grafts or pedicled or free flaps. Results are often not optimal because of the patch of a skin graft, lack of availability of local flaps, and distant skin from free flaps. A technique for reconstruction of these defects with local tissue is presented in this article that uses superficial musculoaponeurotic system (SMAS) plication to allow wide advancement of a cervicofacial flap. Methods: Once the defect is outlined, a face-lift–like skin incision is used to raise the flap. The SMAS is plicated with two purse-string sutures that relieve tension on the flap and allow maximal advancement. Thirteen face-lift SMAS plication flaps were used in 12 patients (mean age, 70.2 years) after cancer resection, which was bilateral in one case. Defects up to 8 cm in largest diameter can be closed. In one case of an 8 × 6-cm defect, a 1 × 1.5-cm skin graft was necessary. Results: All flaps healed uneventfully, and no reoperation was necessary. Scars are almost completely hidden and the cosmetic result is satisfactory. The asymmetrical face-lift effect fades out within 6 months. Conclusions: The face-lift SMAS plication (FLISP) flap allows reconstruction of large defects in the temporal region with a local flap providing an excellent cosmetic result and avoiding the need for distant tissue and multiple scarring. This flap provides an example of how reconstructive surgery and cosmetic surgery are complementary and can be mutually beneficial.

Surgical treatment of pharyngostomes in irradiated patients. Our experience with musculocutaneous pectoralis major flap and hyperbaric oxygen therapy

Conclusion. Our experience confirms that pectoralis major flap is the first-choice technique for repairing recurrent hypopharyngeal fistulae in previously irradiated patients in whom microsurgical techniques are not indicated, and that hyperbaric oxygen therapy helps to solve this complex pathology.Objectives. A pharyngostome is a complication encountered when performing surgical operations on pharyngolaryngeal structures. The authors present their experience of treating recurrent complex pharyngostomes in previously irradiated patients in poor physical health. These patients need a simple, safe reconstruction with a low incidence of postoperative complications.Material and methods. A pedicled pectoralis major flap was used for reconstruction: the skin side of the flap was used to restore the continuity of the pharyngeal mucosa, while the muscle was used to reconstruct the intermediate layer. The skin layer was completed by means of a free skin graft. In all cases, surgical treatment was combined with hyperbaric oxygen therapy before and after the operation.Results. A total of 10 patients, all of whom had previously undergone surgery and radiotherapy, had recurring or pluri-recurring pharyngostomes. All patients (8 males, 2 females; age range 52–80 years) had previously been affected by carcinoma of the pharyngolaryngeal region. All underwent major local Ablation together with radical neck dissection and radiotherapy. In all cases there was mucosa on the posterior wall; a musculocutaneous pectoralis major flap was used in all cases for reconstruction.

Posterior compartment of the lower leg reconstruction with free functional rectus femoris transfer after sarcoma resection

A 72-year-old man with the third recurrence of a low-grade liposarcoma of the right lower leg came to our attention seeking limb-salvage surgery. The tumour was removed en bloc with all the superficial posterior compartment of the leg. Appropriate foot flexion was restored by means of a free-functional rectus femoris musculocutaneous flap harvested from the ipsilateral thigh. The patient was kept on a postoperative splint for 6 weeks. Three months after the operation, clinical and elecromyographic signs of reinnervation were observed. The patient was able to walk, run and climb stairs and no donor-site morbidity was observed. Thigh extension was rated M4, comparable to the contralateral thigh. Foot flexion, without any postoperative exercise, was rated M3 with a 30 degrees excursion. To the best of our knowledge, this is the first report of reconstruction of the posterior compartment of the leg r with a free functional rectus femoris flap. We believe this muscle could be the ideal option for such reconstruction.