Sara Di Lorenzo

An algorithm for oncologic scalp reconstruction.

Background: Modern reconstructive surgery allows for radical resection and reconstruction of any scalp tumor. However, a significant number of patients are still not treated optimally because of incomplete reconstructive guidelines. Methods: The treatment of scalp tumors was documented in 60 patients over a 10-year period. Data regarding tumor type, size, and localization; reconstructive procedure; oncologic, functional, and aesthetic outcome; and complications were collected and analyzed retrospectively. These data were correlated to recurrence and survival rates. The findings extracted from the data were amalgamated to produce the proposed reconstructive algorithm. Results: Five reconstructive categories were defined and their application could be described in an algorithmic approach. Indications, limitations, and adequate reconstructive procedures for each category were identified. The most important decisions are when to use local flaps versus primary closure and when to use free tissue transfer. Conclusions: Radical surgical resection and reconstruction presents the best available method to cure scalp tumors or to establish local disease control in palliative settings. The authors present an algorithm to assist in the planning process of oncologic scalp reconstruction. If this algorithm is applied, the occurrence of inadequate resections and the need for repeated procedures can be minimized.

A Difficult Case of Necrotizing Fasciitis Caused By Acinetobacter baumannii

This study reports the case of a 55-year-old woman with diabetes with a necrotizing fasciitis of the right lower limb and the perineum, first admitted at the emergency department for septic shock with cardiac arrest, and later transferred to the department of surgery. Microbiological and histopathological examination confirmed the diagnosis of necrotizing fasciitis caused by Acinetobacter baumanii. A broad-spectrum antibiotic therapy was administered and later readjusted according to the results of microbiological culture. Intensive hemodynamic support was required. Wounds were dressed daily with a 3 percent boric acid solution and a silver sulfadiazine-impregnated dressing. An extensive surgical debridement was promptly performed and repeated until complete control of the infection. Wounds were finally covered with split-thickness skin grafts. The infection was overcome 35 days after admission. The graft take was 100%. Postoperative rehabilitation was required because of the functional limitation of lower limb movements. Follow-up at 6 months showed no functional deficit and an acceptable aesthetic result. Necrotizing fasciitis is a life-threatening disorder, especially in patients with diabetes, whose clinical diagnosis may sometimes be challenging. Early recognition and treatment represent the most important factors influencing survival.

Prophylactic Chimera Anterolateral Thigh/Vastus Lateralis Flap: Preventing Complications in High-Risk Head and Neck Reconstruction

PURPOSE In high-risk head and neck cases treated with tumor resection and associated radical neck dissection, orocutaneous fistulas and wound breakdowns in the neck are relatively frequent and can have serious consequences, such as carotid blowout syndrome (CBS), the need for salvage reoperations, and prolonged recovery time. The authors present the application of a prophylactic chimeric anterolateral thigh (ALT) and vastus lateralis (VL) flap to prevent complications. MATERIALS AND METHODS A retrospective review was performed of a historical group (96 patients) of patients with head and neck cancer treated with tumor resection, radical neck dissection, and microsurgical reconstruction of the tumor site only and a prospective cohort (21 patients) in which a chimeric ALT-VL flap was used to simultaneously reconstruct the tumor site and sternocleidomastoid muscle to fill dead space and protect the carotid artery. RESULTS The rate of complications was higher in the historical group: CBS occurred in 4.1% and orocutaneous fistulas in 11.5% of patients; 5.2% of patients required major salvage surgery for a wound complication. In the cohort group, no CBS or orocutaneous fistula occurred and no major salvage surgical procedure was needed. CONCLUSIONS Prophylactic ALT-VL flaps in high-risk head and neck cancers provide adequate and long-lasting soft tissue coverage for the carotid artery, with minimal additional morbidity, and could be beneficial in preventing serious and life-threatening wound complications and the need for reoperation.

Composite graft: a simple option for nasal lining.

Background  We present our experience in the reconstruction of full‐thickness losses of the substance of the nose using a forehead flap and a composite graft (taken from the anterior surface of the concha and adequately shaped) as both support and endonasal lining. This technique has never been described for the reconstruction of large full‐thickness losses of the substance of the nose. The donor site of the composite graft in the concha is repaired by a Masson retroauricular flap.

Histology of the Oral Mucosa in Patients With BRONJ at III Stage: A Microscopic Study Proves the Unsuitability of Local Mucosal Flaps

Background Bisphosphonate Osteonecrosis of the Jaw (BRONJ) is a newly recognized condition reported in patients treated with aminobisphosphonates (BF). BRONJ is defined as the presence of exposed necrotic alveolar bone that does not resolve over a period of 8 weeks in a patient taking bisphosphonates who has not had radiotherapy to the jaw. Treatment protocols have been outlined, but trials and outcomes of treatment and long-term follow-up data are not yet available. In 2004 an expert panel outlined recommendations for the management of bisphosphonate-associated osteonecrosis of the jaws. Through the histological study of the oral mucosa over the bone necrosis and around the osteonecrosis area in 8 patients affected by BRONJ at III stage, the authors highlight the inappropriateness of the local mucosal flaps to cover the losses of substance of the jaw, BF-related. Methods Mucosa tissue was taken from 8 patients, affected by BRONJ, III stage. The samples taken from the mucosa around and over the osteonecrosis area were fixed with formalin and an ematossilina-eosin dichromatic coloring was carried out. Results The samples of mucosa showed pathognomonic signs of cell suffering that prove that in these patients using local mucosa flaps is inappropriate. Conclusions The authors suggest that only a well vascularized flap as free flap must be used to cover the osteonecrosis area in patients with BRONJ stage III. Because of the structural instability of the mucosa in patients suffering of osteonecrosis Bf related the local flaps are prone to ulceration and to relapse.

Botulinum toxin in preparation of oral cavity for microsurgical reconstruction

Conclusions. Infiltration of botulinum toxin in the major salivary glands allows a temporary reduction of salivation that begins 8 days afterwards and returns to normal within 2 months. The inhibition of salivary secretion, carried out before the oral cavity reconstructive surgery, could allow a reduction of the incidence of oro-cutaneous fistulas and local complications. Objectives. Saliva stagnation is a risk factor for patients who have to undergo reconstructive microsurgery of the oral cavity, because of fistula formation and local complications in the oral cavity. The authors suggest infiltration of botulinum toxin in the major salivary glands to reduce salivation temporarily during the healing stage. Patients and methods. During the preoperative stage, 20 patients with oral cavity carcinoma who were candidates for microsurgical reconstruction underwent sialoscintigraphy and a quantitative measurement of the salivary secretion. Injection of botulinum toxin was carried out in the salivary glands 4 days before surgery. The saliva quantitative measurement was repeated 3 and 8 days after infiltration, sialoscintigraphy after 15 days. Results. In all cases, the saliva quantitative measurement revealed a reduction of 50% and 70% of the salivary secretion after 72 h and 8 days, respectively. A lower rate of local complications was observed.

Absence of germline CDKN2A mutation in Sicilian patients with familial malignant melanoma: Could it be a population-specific genetic signature?

ABSTRACT Germline CDKN2A mutations have been described in 25% to 40% of melanoma families from several countries. Sicilian population is genetically different from the people of Europe and Northern Italy because of its historical background, therefore familial melanoma could be due to genes different from high-penetrance CDKN2A gene. Four hundred patients with cutaneous melanoma were observed in a 6-years period at the Plastic Surgery Unit of the University of Palermo. Forty-eight patients have met the criteria of the Italian Society of Human Genetics (SIGU) for the diagnosis of familial melanoma and were screened for CDKN2A and CDK4 mutations. Mutation testing revealed that none of the families carried mutations in CDK4 and only one patient harboured the rare CDKN2A p.R87W mutation. Unlike other studies, we have not found high mutation rate of CDKN2A in patients affected by familial melanoma or multiple melanoma. This difference could be attributed to different factors, including the genetic heterogeneity of the Sicilian population. It is likely that, as in the Australian people, the inheritance of familial melanoma in this island of the Mediterranean Sea is due to intermediate/low-penetrance susceptibility genes, which, together with environmental factors (as latitude and sun exposure), could determine the occurrence of melanoma.

Propeller flap for treatment of a poststernotomy sternal fistula: A case report.

UNLABELLED The treatment of post-operative deep sternal wound infections is a real challenge for surgeons. Conservative treatment with debridement and vacuum-assisted closure (VAC) therapy is not always successful. In the most severe and chronic cases, a surgical debridement and reconstruction of the defect is mandatory. In this report, the authors present a case of a 61-year-old female patient with a chronic cutaneous fistula in the sternal region following a median sternotomy after coronary artery bypass. The patient had already undergone treatment with antibiotics, drainage of an abscess and local debridement, but the infection continued to relapse periodically. The authors decided to treat the fistula with debridement and reconstruction with a local freestyle propeller flap mobilised from the right parasternal region. RESULTS The fistula healed without any complications. There has been no relapse, and the aesthetic result is satisfactory. The scar at the donor site is acceptable with a minimum alteration to the mammary region. CONCLUSIONS Sternal fistulas after medial sternotomy are difficult to treat. The treatment method of debridement followed, in certain cases, by VAC therapy is quite controversial. A surgical procedure is sometimes necessary to speed healing. Mobilisation of a freestyle propeller flap represents a less invasive surgical approach to the treatment of sternal fistulas in cases of conservative treatment failure.

U-stitches in microvascular anastomosis in an animal model

Dear Sirs, We read with interest the letter “The double stitch everting technique in end-to-side vascular anastomoses” (Volovici & Dammers, 2017) and we would like to congratulate the authors for the interesting work and to present our experience with U-stitches in experimental microsurgery and the results of this experimentation. Many suturing techniques in microvascular anastomosis of vessel of unequal diameter have been described in the literature but the clinical application of these techniques is still limited (Ahn, Borud, & Shaw, 1994; De Perrot & Keshavjee, 2002; Escamado & Carrol, 1999; Taylor, Kats, & Singh, 2006). This experimentation, authorized by the Local Ethics Commission in 2005, started on January 2006. In 20 Sprague Dawley rats (male, weight 300–400 g), we performed end-to-end anastomoses on the femoral vessels using only two everting stitches and four simple stitches to complete every anastomoses. After the placement of the clamps, the anterior wall of the vessel was sutured immediately by placing the first simple stitch at “12 o’clock”(Figure 1A) and the second stitch at 1808 from the first (Figure 1B), while one everting stitch (U-stitch) was placed at “3 o’clock” (Figure 1C). The anterior wall was sutured and the clamp was turned to complete the posterior wall of the vessel with the same technique as described in points A, B, C (Figure 1D-F). The hypothesis of this experimentation was that everting stitches (or U-stitches) may be employed in order to reduce the amount of the useful stitches to perform an anastomoses (only six stitches, three for the anterior and three for the posterior wall of the vessels), to reduce the surgical times for an anastomosis and finally, the most important indication, to reduce the mismatch between vessels with different diameters by the eversion of the edges of the vessel wall at the anastomotic site. We supposed that the eversion of the edges could limit the presence of redundant tissue in the lumen of the anastomosis, that is a risk of thrombosis. Furthermore, we believed that the risk of thrombosis could be lower when horizontal U-stitches were used because the suture material never contacts the lumen and this technique allows a good intima-to-intima contact. In this way the endothelial trauma was

Melanoma Extirpation with Immediate Reconstruction: The Oncologic Safety and Cost Savings of Single-Stage Treatment.

BACKGROUND The timing of reconstruction following melanoma extirpation remains controversial, with some advocating definitive reconstruction only when the results of permanent pathologic evaluation are available. The authors evaluated oncologic safety and cost benefit of single-stage neoplasm extirpation with immediate reconstruction. METHODS The authors reviewed all patients treated with biopsy-proven melanoma followed by immediate reconstruction during a 3-year period (January of 2011 to December of 2013). Patient demographic data, preoperative biopsies, operative details, and postoperative pathology reports were evaluated. Cost analysis was performed using hospital charges for single-stage surgery versus theoretical two-stage surgery. RESULTS During the study period, 534 consecutive patients were treated with wide excision and immediate reconstruction, including primary closure in 285 patients (55 percent), local tissue rearrangement in 155 patients (30 percent), and skin grafting in 78 patients (15 percent). The mean patient age was 67 years (range, 19 to 98 years), and the median follow-up time was 1.2 years. Shave biopsy was the most common diagnostic modality, resulting in tumor depth underestimation in 30 patients (6.0 percent). Nine patients (2.7 percent) had positive margins on permanent pathologic evaluation. The only variables associated with positive margins were desmoplastic melanoma (p = 0.004) and tumor location on the cheek (p = 0.0001). The mean hospital charge for immediate reconstruction was