Basal cell carcinoma (BCC) is the most common variety of non-melanoma skin cancer and its incidence is increasing worldwide. The centrofacial sites (area H) are considered a high-risk factor for BCC local recurrence. Mohs micrographic surgery (MMS) is a technique that allows intraoperative microscopic control of the surgical margins and is a good treatment option when tissue conservation is required for esthetic or functional reasons or for high-risk lesions. The present study aimed to evaluate the recurrence rate of head and neck high-risk BCCs comparing MMS vs conventional surgical excision. Clinical data of patients diagnosed from September 2014 to March 2017, referring to the Dermatology Unit of the Policlinico Sant'Orsola-Malpighi, University of Bologna, were retrospectively evaluated (285 treated with MMS and 378 treated with traditional surgery). Of the 285 patients treated with MMS, 9 experienced a recurrence (3.1%). Of the 378 patients treated with traditional surgery, 53 relapsed (14%), 13 of whom presented residual tumor on the deep or lateral margins of the main surgical specimen. Our study confirms the trend reported in the literature that MMS represents the best treatment option for high-risk BCCs arising in the head and neck region or presenting as a recurrence (P < .00001). Many more MMS centers and more trained dermatologists are needed worldwide in order to deal with the increasing number of BCC diagnosed every year.
The anterolateral thigh flap (ALT) is a versatile flap and very useful for the reconstruction of different anatomical districts. The main disadvantage of this flap is the anatomical variability in number and location of perforators. In general, absence of perforators is extremely rare. In literature, it is reported to be from 0.89% to 5.4%. If no sizable perforators are found, an alternative reconstructive strategy must be considered. Tensor fascia lata (TFL) perforator flap can be a good alternative in these cases: Perforator vessels are always present, the anatomy is more constant and it is possible to harvest it through the same surgical access. The skin island of the flap can be very large and can be thinned removing a large part of the muscle allowing its use for almost the same indications of the ALT flap.We report 11 cases of reconstruction firstly planned with the ALT flap, then converted into TFL perforator flap.The result was always satisfactory in terms of the donor site morbidity and reconstructive outcome.
Abstract Esthetic masculinization of the chest wall is one of the first surgical steps in female-to-male transsexual (FTMTS) reassignment. This surgical procedure is not a simple mastectomy: it is required for removal of breast tissue with glandular resection and skin excess revision, to reduce and replace the nipple-areola complex in the right location, minimizing chest wall scars. The creation of an esthetically pleasing male chest allows the patient to live at ease in the male gender role. In this article, we present our series of 68 FTMTSs who underwent bilateral mastectomies for surgical sexual reassignment (a total of 136 mastectomies) according to our algorithm, in the period between January 2010 and December 2017. We selected 4 different operative procedures, classified as subcutaneous (“pull-through” and “concentric circular” techniques) and skin extended (“ultrathin vertical bipedicle” and free nipple graft). We achieved a total complication rate of 6.6%, less than that reported in the literature; additional procedures for esthetic improvements were performed in 14.7% of cases. The mean patient satisfaction was approximately 4.57% of a maximal value of 5 (excellent). To help surgeons in choosing the most appropriate FTMTS surgical technique and to reduce unfavorable results, we propose the use of our treatment algorithm in preoperative evaluation of the chest wall according to the breast volume, degree of glandular ptosis, and skin elasticity.
Few cases of lower limb giant plexiform neurofibroma have been reported in literature and there are no available guidelines for defining its preoperative evaluation and surgical approach. Lower limb giant plexiform neurofibroma is a rare condition that requires clinical and radiological preoperative evaluation, mainly with MRI. Surgery is the only treatment with no preoperative trans-arterial embolization or vessel ligation. Early excision of superficial lesions may prevent further progression.
Background: The treatment of patients affected by unilateral cleft lip–cleft palate is based on a multistage procedure of surgical and nonsurgical treatments in accordance with the different types of deformity. Over time, the surgical approach for the correction of a nasal deformity in a cleft lip–cleft palate has changed notably and the protocol of treatment has evolved continuously. Not touching the cleft lip nose in the primary repair was dogmatic in the past, even though this meant severe functional, aesthetic, and psychological problems for the child. McComb reported a new technique for placement of the alar cartilage during lip repair. The positive results of this new approach proved that the early correction of the alar cartilage anomaly is essential for harmonious facial growth with stable results and without discomfort for the child. Methods: The authors applied the same principles used for the treatment of the alar cartilage for correction of the septum deformity, introducing a primary rhinoseptoplasty during the cheiloplasty. The authors compared two groups: group A, which underwent septoplasty during cleft lip repair; and group B, which did not. Results: After the anthropometric evaluation of the two groups, the authors observed better symmetry regarding nasal shape, correct growth of the nose, and a strong reduction of the nasal deformity in the patients who underwent primary JJ septum deformity correction. Conclusion: The authors can assume that, similar to the alar cartilage, the septum can be repositioned during the primary surgery, without causing growth anomaly, improving the morphologic/functional results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Posttraumatic wounds of the lower leg with soft tissue defects and exposed fractures are a reconstructive challenge due to the scarce availability of local tissues and recipient vessels. Even when a free tissue transfer can be performed the risk of failure remains considerable. When a free flap is contraindicated or after a free flap failure, the cross-leg flap is still nowadays a possible option. We report a case of a male with a severe posttraumatic wound of the lower leg with exposed tibia fracture firstly treated with two consecutive latissimus dorsi muscular free flaps, failed for vascular thrombosis; the coverage was then achieved with a cross-leg flap with acceptable results.
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.
BACKGROUND Infection of pressure ulcers constitutes the most frequent complication in spinal cord–injured patients; evidently, the surgical treatment of infected pressure ulcers is effective only when combined with a selected antibiotic therapy. However, the choice of the appropriate antibiotics is not simply due to the widespread variety of bacterial species involved in such infections. Only a few studies in the literature compare wound swabs with biopsies for the diagnosis of chronic infected wounds.1 Until now, the Levine technique has been considered as the most reliable and valid method. Still, the best sampling technique for taking a swab has not yet been identified and validated.2 The objective of our study is to assess the predictive value of ulcer swab specimen culture in identifying etiological agents of infection in patients with spinal cord injury (SCI) and pressure sores. METHODS Prospective, observational, single-centre study on adult patients with SCI undergoing surgical debridement and reconstruction for pressure ulcers was conducted at Montecatone Rehabilitation Institute from July 2011 to January 2014. Before surgery, an ulcer swab specimen was taken with Levine technique and sent for culture. During surgery, bone and soft-tissue specimens were collected and sent for culture and histological evaluation. The results of cultures of swabs and intraoperative specimens were compared. RESULTS During the study period, 64 patients were treated. On admission, 37 patients (58%) had fever and the median C-reactive protein serum level was 2.3 mg/dL (interquartile range, 1.4–5.2). According to histology of intraoperative specimens, diagnostic certainty of osteomyelitis was present in 53% of patients (34/64). Culture of intraoperative specimens yielded monomicrobic infection in 30% and polymicrobic infection in 47% of cases; culture was negative in 23% of cases. The most common microorganisms found were Staphylococcus aureus, Proteus mirabilis, and Pseudomonas aeruginosa, which were cultured in 33%, 19%, and 12.5% of cases, respectively. Results of culture of swabs and intraoperative specimens were concordant in 25% of cases (16/64). Different microorganisms were the main reason for nonconcordance in 40% of cases: false positives (swab culture positive/intraoperative culture negative) were 13 (20%) and false negatives (swab culture negative/intraoperative culture positive) were 10 (15%). At univariate analysis, the presence of osteomyelitis was associated with nonconcordance (P = 0.001). CONCLUSION In our cohort of patients with SCI and infected pressure ulcers, results of culture of swab specimen were predictive of etiology of infective process only in 25% of cases. These findings suggest that ulcer swab specimen culture is not reliable enough to guide the choice of antimicrobial therapy in clinical practice, especially when osteomyelitis is present.
