Sergio Razzano

Microvascular free-flap transfer for head and neck reconstruction in elderly patients

BackgroundWith the increase in life expectancy, the incidence of head and neck cancer has grown in the elderly population. Free tissue transfer has become the first choice, among all the reconstructive techniques, in these cases. The safety and success of micro vascular transfer have been well documented in the general population, but its positive results achieved in elderly patients have received less attention.MethodsWe retrospectively studied 28 patients over the age of 60 years. The aim of this paper was to study the success rate of free tissue transfer and investigate the complication incidence in this patient population.ResultsTwenty-eight free flaps were performed to reconstruct medium to large cervico-facial surgical defects in six years. No difference was noted between success and complication rates observed between general and elderly population.ConclusionThis study indicates that free-flap technique for head and neck reconstruction could be considered a safe option in elderly patients when a good pre-operative general status is present.

The venae comitantes clipping test for the evaluation of the venous drainage of the radial forearm free flap

Risks of failure of the radial forearm free flap (FRFF) are mainly related to venous congestion. Two different venous drainage system have been described for the FRFF, but the choice of the best one is still controversial. The superficial systems have a larger diameter and a thicker wall veins which makes them easier to anastomose. The deep system provides most part of the venous outflow if the caliber of the venae comitantes (VCs) is adequate. We propose an intra‐operative method to evaluate the FRFF venous drainage: the VCs clipping test. The test has been used in the choice of the vein to anastomose in 12 consecutive patients with oral cavity post oncological defects reconstructed with the FRFF. The cephalic vein was included in the flap; the VCs were individually clipped with small liga‐clips and divided with the radial artery still patent. The flap was kept with arterial inflow and superficial venous outflow till the recipient site was ready. If there were no signs of venous stasis, the VCs were kept clipped and the cephalic vein anastomosis was made. If clinical signs of venous stasis were revealed, the largest of the VCs was anastomosed to a vein of adequate caliber in the neck. No signs of flap venous congestion were observed in the postoperative period. No flap necrosis occurred. In this small series of patients the venae comitantes clipping test showed to be an easy, reliable and reproducible method to assess intra‐operatively which vein to anastomose.

Combined epigastric hernia repair and mini-abdominoplasty. Case report

The objectives of abdominal hernia repair are to restore the structural integrity of the abdominal wall. Current techniques include primary closure, staged repair and the use of prosthetic materials. Techniques for mini-abdominoplasty include the use of the transverse lower abdominal incision and the resection of excess skin. We report a case of epigastric hernia repair through a transverse lower abdominal incision with the resection of excess of skin. Our purpose is to evaluate the results of the procedure by incorporating these aspects into an epigastric hernia repair, we found out that the procedures are made safer and the results are improved. Proper indication and details of the technique are described.The objectives of abdominal hernia repair are to restore the structural integrity of the abdominal wall. Current techniques include primary closure, staged repair and the use of prosthetic materials. Techniques for mini-abdominoplasty include the use of the transverse lower abdominal incision and the resection of excess skin. We report a case of epigastric hernia repair through a transverse lower abdominal incision with the resection of excess of skin. Our purpose is to evaluate the results of the procedure by incorporating these aspects into an epigastric hernia repair, we found out that the procedures are made safer and the results are improved. Proper indication and details of the technique are described.

Modified Fish-Incision Technique in Brachioplasty: A Surgical Approach to Correct Excess Skin and Fat of the Upper Arm (Restoring the Armpit Contour)

Brachial ptosis is one of the consequences of massive weight loss. At an early stage, brachial ptosis can be corrected by liposuction, dermolipectomy and liposuction, or minibrachioplasty while the most advanced stage requires extended brachioplasty. Since brachioplasty was first described, various techniques have been proposed in the management of upper extremity contour deformities. Modifications to the original technique were mainly made to shape arm contour, to obtain good morphological reconstruction with attention directed toward improving and refining the resulting scar. We describe a modified approach to the “fish incision” technique defining a preoperative marking procedure that permits the reduction of overcorrection problems to reshape and improve the contour of the armpit with camouflage of scar sequelae. Our modifications to the original technique focus on incision placement along the medial bicipital groove and armpit, based on the the drawings of the tails following dynamic lines of the armpit contour established by the underlying muscles. We drew the tails slightly with a 60° angle between the tails and the width depending on patient’s arm contour and on the excess of the skin in the armpit to be removed. The modified technique has obtained satisfactory results for patients and may be considered as a new surgical approach in the management of brachial ptosis.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Fillet of pinna flap in scalp reconstruction

Fillet flaps are commonly used to cover skin defects after trauma or tumors, especially in the extremities [1-5].

Do the ears grow with age

Studying ear dimensions in the population of a specific geographic area helps in the planning of both reconstructive and aesthetic operations. We have researched on the anthropometrical measurements of the auricle in a normal Caucasian population of the South of Italy; this paper was presented at the 56 Italian meeting of Plastic, Reconstructive and Aesthetic Surgery Society (SICPRE) in September 2007. We evaluated the mean dimensions of the ear and their relationship with age, sex and height. Other authors have studied the mean dimensions of normal auricles in a North America population [1], while Gualdi-Russo [2], Ferrario et al. [3] and Sforza et al. [4] published on the mean dimensions of the ear in a Caucasian Italian population. In our study, we measured the dimensions of both ears in 740 healthy subjects (380 men, 360 women). We used a direct manual measurement technique based on the establishment of four classical landmarks, two for the length (super-aurale and sub-aurale) and two for the width (pre-aurale and post-aurale) and on the calculation of the distances between them. We also considered independently the lengths of the earlobe and of the cartilaginous part of the ear. We classified the subjects according to gender, height and age; we ended with ten groups for each gender classified by height in 170 cm and [170 cm for males and in 160 cm and [160 cm for females and by age as follows: 15–30 years, 31–45 years, 46–60 years, 61–75 years and [75 years. Results are showed in Tables 1 and 2. We found that both ear length and ear width were larger in men than in women (p 0.001) and were larger in taller subjects than in shorter ones (p 0.001). We also found that ear length and width increased with age in both genders even in subjects over 75. Recently Alexander et al. [5], in a research conducted with a very accurate measurement method, commented about ear growth. They reported on the age related modification of both ear soft and cartilaginous tissues supporting the theory that the way the ear size increases may be attributable to different facts including the reduced resilience and elasticity of skin with age [6], the reduced tensile strength of connective tissue [7] and the gravitational forces over time [8]. We also want to stress that the ear length increasing along with aging cannot just be attributed to earlobe lengthening; in fact, similarly to Alexander et al., our separate measurements of the length and width of the cartilaginous portion of the ear and of the earlobe length showed that they both grow with age (p 0.001 for earlobe, p 0.01 for cartilaginous portion) even if the soft tissue portion of the ear suffers much more from the gravitational forces. This is in contrast with the paper by Brucker et al. [1], on a North America population, where they stated that the lobule was the only ear structure that changed significantly with age. In conclusion, we feel that the ear continues to grow with age, even if a more appropriate method of studying the population should include measurements and follow ups of the same subjects during their entire life.

The Selective Centrifugation Ensures a Better In Vitro Isolation of ASCs and Restores a Soft Tissue Regeneration In Vivo

Autologous fat grafting procedures in plastic surgery have been extensively used to reinforce soft tissue in congenital or acquired tissue impairments. With this background, the aim of this study is firstly to examine the impact of a selective centrifugation on existing adipose stem cells (ASCs) in terms of stemness profile maintenance and, secondly, to investigate the effect of restoring volume in reconstruction on patients affected by soft tissue damage. After centrifugation, the fat graft products were separated into two layers and subsequently examined in vitro for the expression of CD34, CD90, CD117, CD105, CD29, CD31, CD44, CD73, CD133, CD14 and CD45 markers by flow cytometry and gene expression analyses were performed for Sox2, WNT3A, END, CD44, FUT4, COLL1, CTNNB1, hbEGF, KRTLG, MMP2 and VIM genes. The results showed that in the middle-high density (MHD) layer there was a peak concentration of ASCs, compared to another layer obtained after centrifugation. Research carried out on patients under treatment for soft tissue regeneration using cells obtained from MHD layer selection will be fundamental in comparative analysis. These studies will lead to an adequate standardization of outcomes, provided that treatment is performed through cell selection. Therefore, a unique procedure in tissue reconstruction and regeneration through fat grafting is presented here.

Avulsion thighplasty: what about the consent for loss of reconstructive options for microsurgical breast reconstruction?

1069e territory of the transverse upper gracilis (the insertion of the gracilis muscle is one of the markings). Neither the liposuction nor the skin resection seems to violate the profunda artery perforator donor-site area or the perforator itself as described by the authors. For these reasons, we would like to suggest the need to mention in the thigh lift consent form this potential future consequence, specifying which flap option is lost according to the technique proposed. DOI: 10.1097/PRS.0000000000002795

Ear lobe angioleiomyoma and aggressive keloid

Sir, Angioleiomyoma is a rare, benign smooth muscle tumor originating from the tunica media of blood vessels. It may be localized anywhere in the body. Ear lobe angioleiomyoma is rarely diagnosed before surgery. The usual treatment is surgical excision. Ear lobe keloids are very common. Often, this entity comes as the result of ear piercing. The question of coexistence of an angioleiomyoma with an aggressive keloid is unusual. In February 2008, a 12-year-old female presented a nodular lesion of the right ear lobe. The patient referred previous ear piercing history at both earlobes without familiarity for keloids. A similar lesion had been excised at the same site in 2001. The histological diagnosis was “vascular leiomyoma.” The lesion recurred in April 2003; a second excision was performed and the histology was the same as the first one. Between April 2003 and February 2008, a new lesion appeared at the same site. In February 2008, it was ovalshaped, with well-defined margins, and painless. This new local recurrence was excised with 0.3 cm clear margins and a postauricular flap was performed for right ear lobe reconstruction. Histology showed “remarkable nodular fibrosis with keloid-like aspects at the periphery; lesion completely excised.” In May 2009, a new recurrence occurred at the junction between the new ear lobe and preauricular region (Fig. 1). A second patient, 24 years old female, in December 2011 presented a lesion at the left ear lobe site. A nodular lesion was first noted in August 2007, adjacent to the site of a previous ear piercing. The lesion was round-shaped and painless. After its first excision (2007), the histology was “cutaneous leiomyoma incompletely excised; the inferior margin of the excision is still involved.” In December 2007, she presented a recurrence and a second excision was performed; histology reported “cutaneous angioleiomyoma” again, with “unclear deep excision margins.” In September 2010, a new recurrence appeared at the scar site. A wide surgical excision was performed again; histology reported “hypertrophic scar tissue with keloid focal features.”All the procedures were performed by the same general surgeon. In September 2011, the scar became hypertrophic, then she came to our clinic. We applied the same protocol for both patients consisting in intralesional injections of triamcinolone acetonide 40 mg/ml diluted 1:1 in saline solution and “U-shaped” Zimmer splint ear lobe compression (Fig. 2). The incidence range of angioleiomyoma is between the third and sixth decade of life, with a female prevalence. The lesion is usually a unique lesion, small, round, firm, skin-colored, and well-encapsulated [1, 2]. On the other hand, ear lobe keloid is very common. Often, this entity comes as the result of ear piercing. The exact pathogenesis of keloids is unknown. Most important factors involved in keloid formation are chronic inflammation, infection, excessive wound tension, foreign material, or other impurities in earrings [3, 4]. Many options have been proposed for keloid treatment: simple excision, intralesional injection of corticosteroids, application of pressure, and application of silicone gel or patches. The occurrence of an angioleiomyoma that ends into an aggressive keloid is extremely unusual. Luo and Pan [5] studied leiomyomas, keloids, surgical scars, and peritoneal adhesions to identify genes that could individually distinguish these fibrotic disorders despite differences in the nature of their development and growth. Leiomyomas in Caucasians compared with keloids in African-Americans showed a limited difference in their gene expression profile. This suggested the existence of a comparable environment for leiomyomas and keloids. Their results indicated that the molecular features S. Razzano (*) : E. Di Sergio Naples, Italy e-mail: razzanosergio@gmail.com