Background: Perforator flaps have been introduced for various kinds of reconstruction and resurfacing; in particular, the free thin anterolateral thigh flap is becoming one of the most preferred options for reconstruction of soft-tissue defects. Methods: Between 1999 and 2002, the authors used this flap as a free flap for nine cases for covering hand defects after burn, crushing injuries, or severe scar contracture release. There were eight men and one woman, the mean age of the patients was 31 years, and the size of the flaps ranged from 7 × 3.5 cm to 15 × 9 cm; thinning was performed in all flaps. Results: All flaps survived completely, and the donor site was closed directly in seven cases; in two cases, the exposed muscle was covered with split-thickness skin graft. Conclusions: The anterolateral thigh flap was thin enough for defects on the dorsum and/or palm of the hand and for first web reconstruction after scar contracture release. It has many advantages in free flap surgery including a long pedicle with a suitable vessel diameter, and the donor-site morbidity is acceptable. The thin anterolateral thigh flap is a versatile soft-tissue flap that achieves good hand contour with low donor-site morbidity.
Many patients undergoing intestinal or multivisceral transplantation have a past history of complete midgut removal with the loss of the domain of the abdominal compartment or have severely damaged abdominal walls from repeated laparotomies, tumours or enterocutaneous fistulae. These patients may encounter severe abdominal wall closure problems at the end of transplantation, resulting in increased morbidity and mortality. It is, therefore, of paramount importance to properly cover transplanted organs in order to reduce postoperative complications.Abdominal wall transplantation was recently proposed for closure of patients undergoing both small-bowel and multivisceral transplantation: the results are encouraging. However, the technical procedure proposed requires the procurement of long segments of iliac vessels as far as the vena cava and the aorta. Since donor multiorgan procurement involves many surgical teams, the removal of these vessels, with the abdominal graft, led to their unavailability for vascular surgeons.Here we present three consecutive cases of abdominal wall transplantation in which, by taking advantage of microsurgical experience, we were able to carry out a transplantation of the abdominal wall by direct anastomosis of the epigastric vessels, obtaining a very good outcome. Many patients undergoing intestinal or multivisceral transplantation have a past history of complete midgut removal with the loss of the domain of the abdominal compartment or have severely damaged abdominal walls from repeated laparotomies, tumours or enterocutaneous fistulae. These patients may encounter severe abdominal wall closure problems at the end of transplantation, resulting in increased morbidity and mortality. It is, therefore, of paramount importance to properly cover transplanted organs in order to reduce postoperative complications. Abdominal wall transplantation was recently proposed for closure of patients undergoing both small-bowel and multivisceral transplantation: the results are encouraging. However, the technical procedure proposed requires the procurement of long segments of iliac vessels as far as the vena cava and the aorta. Since donor multiorgan procurement involves many surgical teams, the removal of these vessels, with the abdominal graft, led to their unavailability for vascular surgeons. Here we present three consecutive cases of abdominal wall transplantation in which, by taking advantage of microsurgical experience, we were able to carry out a transplantation of the abdominal wall by direct anastomosis of the epigastric vessels, obtaining a very good outcome.
ABSTRACT Background: Now-a-days, deep inferior epigastric perforator (DIEP) flap breast reconstruction is widespread throughout the world. The aesthetical result is very important in breast reconstruction and its improvement is mandatory for plastic surgeons. Materials and Methods: The most frequent problems, we have observed in breast reconstruction with DIEP flap are breast asymmetry in terms of volume and shape, the bulkiness of the inferior lateral quadrant of the new breast, the loss of volume of the upper pole and the lack of projection of the inferior pole. We proposed our personal techniques to improve the aesthetical result in DIEP flap breast reconstruction. Our experience consists of more than 220 DIEP flap breast reconstructions. Results: The methods mentioned for improving the aesthetics of the reconstructed breast reported good results in all cases. Conclusion: The aim of our work is to describe our personal techniques in order to correct the mentioned problems and improve the final aesthetical outcome in DIEP flap breast reconstruction.
Reflectance confocal microscopy (RCM) is a useful tool for the diagnosis of skin cancers and inflammatory disorders.1-5 We present the case of a 75-year-old woman with a history of infiltrating lobular right breast cancer (pT2N0M0, UICC TNM 5th edition), treated with radical mastectomy, cobalt radiotherapy and breast reconstruction with an abdominal flap in 1997. Recent mammography and CT scan were negative for tumour recurrence. In October 2023, the patient was referred to our unit for the evaluation of an erythematous plaque located in the right mammary area. At clinical examination, an erythematous macule surmounted by a large crusted, fibrinous plaque was observed (Figure 1A). Dermoscopic examination of the lesion revealed an atypical vascular pattern at the periphery of the central keratin mass (Figure 1B). The whole skin appeared intensely photodamaged. Two incisional biopsies of the ulcerated plaque were performed. Histopathological evaluation led to the diagnosis of a post-radiotherapy atypical vascular lesion (sec. WHO 2020). We further performed RCM for presurgical mapping of the lesion, which revealed, at the level of the stratum corneum, a severely disrupted corneal layer with presence of parakeratoses and detached corneocytes, whereas at the level of the stratum granulosum areas of necrosis corresponding to dark spaces with irregular demarcation and pronounced disruption of the epidermal architecture. Surrounding keratinocytes displayed the presence of spongiosis, seen as increased brightness of intercellular spaces, accentuating the honeycombed pattern of the granular layer. RCM changes observed were compatible with chronic radiodermitis (Figure 2A). Due to the presence of severe photodamage, RCM was performed contralaterally on the left mammary skin, and displayed an irregular epidermal honeycomb pattern with curled collagen in the dermis (Figure 2B). Subsequently, the patient underwent complete surgical excision of the atypical vascular lesion confirming the histopathologic analysis of the first incisional biopsies. Post-radiation vascular lesions (including angiosarcoma and atypical vascular lesions) are a rare complication of irradiated skin in breast cancer patients. The latter present clinically as solitary or multiple reddish-brown papules and enter the differential diagnosis with breast cancer recurrence, post-traumatic haemorrhage, and benign dermatological conditions. They rarely progress to angiosarcoma, so the treatment of choice is surgical excision and follow-up. In the literature, RCM has been used for the evaluation of acute radiation dermatitis toxicity, but there are no described cases of the application in chronic radiodermatitis. In acute radiation dermatitis histopathologic changes were detectable by RCM after a mean time of 15 days, compared with 30 days for clinical manifestations, and include spongiosis, exocytosis and inflammatory cells, dendritic-shaped cells, streaming-like figures, broken geographic papillae, epidermal architectural disarray, effacement of rete ridges, melanophages and hyperpigmentation of the basal layer5. Conversely, from what can be deduced from RCM examination in our case, the characteristics of chronic radiodermatitis with concomitant post-radiation atypical vascular lesion are severe parakeratoses and detached corneocytes, together with areas of necrosis and spongiosis. To date, this is the first report of RCM features of chronic radiodermatitis. Further studies with larger samples are needed to clearly define RCM presentation of such entity. The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose.
Deep inferior epigastric perforator (DIEP) flap reconstruction is the gold standard reconstructive technique for women undergoing breast cancer surgery. A preoperative computed tomography angiography (CTA)-dedicated protocol and 3D reconstructions are mandatory for correct surgical planning.To evaluate the diagnostic performance of a new preoperative CTA protocol and a new reconstruction method in the assessment of DIEP technique.A total of 263 women (median age 49 years, age range 26-73 years) underwent preoperative CTA examination before DIEP flap breast reconstruction. A CTA-dedicated protocol followed by 3D-reconstructions were performed. Identification, branching pattern, and caliber at origin were assessed for each perforator. Intraoperative findings were the standard of reference. The sensitivity, positive predictive value, and diagnostic accuracy of the preoperative CTA protocol were calculated.In 255/263 (97%) patients, the dominant perforators assessed by CTA resulted adequate for surgical reconstruction. In 260/263 (99%) cases, the imaging localization of the dominant perforators corresponded with those seen intraoperatively (mean errors ≤1 cm). The preoperative CTA imaging sensitivity, positive predictive value, and diagnostic accuracy in determining the localization of perforators were 99% (95% CI 98-100), 100% and 99% (95% CI 98-100), respectively. No statistically significant differences were found between the CTA findings and the surgical findings for the assessment of branching pattern and caliber of the dominant perforators (P < 0.001).The present protocol has demonstrated high accuracy in the CTA imaging assessment of the perforators before DIEP flap reconstruction with high reproducibility between CT and surgical findings.
BACKGROUND
Research efforts are been directed in the last few years on tissue- engineering and the possibility of tissue creation by laboratory device. In fact biochemistry, immunology and experimental surgery has been provided new solutions for organs transplant or anatomical structure replacement. Variously method were described to obtain decelullarized matrix from organ or part of them, and how that bioengineered scaffolds can be integrated into recipient organism. The aim of the studies is to provide a source, from animal or cadaver, of engineered organs or tissue flaps available from transplant or reconstructive surgery, free from infective disease, completely functional and without rejection phenomenon.
AIM OF THE STUDY
The aim of this study is to investigate the bio integration potential of a tissue engineered abdominal wall obtained from a donor, even after a protocol of decellularization than after recellularization with stem cell of recipient, obtained from adipose tissue, in vitro and microsurgical transfer in vivo, in order to create a biocompatible free flap without rejection phenomenon (omo-autologous flap). Similarly a sample of decellularized muscle are transferred to a recipient and histological and sonographic result were evaluated.
MATERIAL AND METHODS
Samples of the abdominal wall were collected with iliac arterial and vein pedicle as a free flap from rabbits, before sacrifice (donor). At the same time a sample of adipose tissue was collected from a different rabbit (recipient). The abdominal wall samples underwent a 7 days decellularization protocol. Small samples of the tissues were collected before and after that procedure for histological evaluation of the process. The adipose tissue sample of the recipient were treated to obtain a full rich stem cells tissue. Similar sample of muscle without vessel are collected and underwent a decellularization protocol and so on for major vessel sample with a specific one for vascular tissue. A decellularized muscle patch are implanted in vivo and rejection phenomenon, survival of the patch and herniation presence were observed after three weeks even by sonography than by histological evaluation after sacrifice.
RESULTS
The histological evaluations shown a progressive degeneration and loss of cellular content of the rabbit abdominal wall samples. In parallel, the general ECM structure maintain their staining properties. Particularly relevant is the preservation of vascular channels. Muscle decellularized sample implanted in vivo demonstrated good biointegration at sonography exam and no herniation was observed; histologic evaluation demonstrated presence of limitated granulomatosis reaction , numerously vessels and conservation of original muscle architecture, substituted by fibrosis,without evident rejection. Histological and moreover evaluation of free flap transplant, stem cells seeding and vessel decellularization are in process.
CONCLUSION
Decellularized muscle patch provide the evidence of a new bioingeneered tissue that could be useful for abdominal wall repair or reconstruction. Biointegration could be improve by use of stem cells and growth factor seeding. Similarly the demonstration of the preservation of the vascular network and extra cellular matrix of abdominal wall sample provide the possibilities of being bio integrated after vascular anastomoses that is the aim of the studies actually on going
