A New One-Stage Method for Nose Reconstruction: The Supratrochlear Artery Perforator Propeller Flap

LETTER TO EDITO

Freestyle pedicled perforator flaps: safety, prevention of complications, and management based on 85 consecutive cases.

Background: Despite the widespread use of free perforator flaps, pedicled perforator flaps seem not to be as widely accepted, probably because of the fear of vascular complications caused by transfer of a flap attached only by its vascular pedicle, prone to shearing, kinking, and trauma. In this article, the authors report on their experience with 85 consecutive cases, focusing on incidence, prevention, and management of complications. Methods: Eighty-five consecutive cases were treated over 6 years at the Plastic and Reconstructive Surgery Department of the University of Palermo for defects of different causes that were reconstructed with a freestyle pedicled perforator flap, in every region of the body, including the head and neck (41.2 percent), trunk (20 percent), upper limb (7.1 percent), and lower limb (31.8 percent). The majority of flaps (67.1 percent) were 180-degree propeller perforator flaps. Results: Complete flap survival was observed in 93 percent of cases. Six flaps (7 percent) had vascular complications that were managed with venous supercharging (two cases), derotation (one case), conservative management (two cases), or secondary skin grafting (one case). The authors provide their approach to each situation to prevent or manage complications. Conclusions: The 93 percent success rate in this series seems to be acceptable and demonstrates that these flaps might be safely included in the authors’ routine. If the flaps are appropriately planned and executed, with the suggestions provided in this article, some mistakes can be avoided to make these flaps even safer

Exposed subcutaneous implantable devices: an operative protocol for management and salvage

Implantable venous and electrical devices are prone to exposure and infection. Indications for management are controversial, but-especially if infected-exposed devices are often removed and an additional operation is needed to replace the device, causing a delay in chemotherapy and prolonging healing time. We present our protocol for device salvage, on which limited literature is available

Reply: Comparison of preoperative and postoperative lymphatic function is essential to understand the changes in lymphatic function

Reply to a Letter to Edito

Advancement Perforator Cheek Flap for Aesthetic One-Stage Reconstruction of Postoncological Extended Split-Thickness Defects of the Nasal Sidewall

Aesthetic reconstruction of soft tissue nasal sidewall loss has an important influence on the appearance of the nose. The unique character of this subunit and the complex relationships with a number of different facial or nasal subunits make the excision of large tumors difficult to manage. Numerous techniques are described in the literature, but a primary reconstruction with a final good result is not often possible. The authors develop an advancement cheek flap for an aesthetic one-stage reconstruction of post- oncological extended nasal sidewall defects. Between January 2009 and July 2012, 16 patients (mean age, 63.3 yr) underwent excision of skin tumors of nasal sidewall and immediate reconstruction with an advancement cheek flap nourished by perforators from the transverse facial branch of the superficial temporal artery. The tumors were excised with 0.4–0.6 cm lateral margins and defects size ranged from 2.6 × 2.6 cm to 3.5 × 5 cm. Oncological radicality was obtained in all cases. The aesthetic results were excellent in all patients. No scar revision was needed. The authors’ advancement cheek flap can be considered the first choice for reconstruction of split-thickness defect of nasal sidewall larger than 2.5 cm because it reestablishes in one stage the nasal contour detail

PEDICLED PERFORATOR FLAPS IN NASAL RECONSTRUCTION: A REVIEW

The use of perforator flaps in face reconstruction is becoming increasingly common. They are particularly useful in nose reconstruction, where they can be tailored to match the complex three-dimensional structure of the nasal concave and convex subunits. In this paper, we present a review of the literature on the use of pedicled perforator flaps in nose reconstruction, discussing current indications and outcomes. Literature on this topic is still limited, with only 12 studies reporting data on 129 reconstructions. Reconstruction of nasal defects with pedicled perforator flaps is a novel and expanding field. It allows for the achievement of good aesthetic results, with a single operation and low donor site morbidity. Temporary venous congestion frequently occurs, but resolves spontaneously without leaving sequelae. Also, perforator flaps have precipitated a novel approach to nose reconstruction, allowing for the modification of both random and axial flaps according to a “perforator-like technique”

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 reoperatio

Traumatic Isolated Intramural Duodenal Hematoma Causing Intestinal Obstruction

A 21-year-old man was admitted 36 hours after a blunt abdominal trauma occurred during a sporting competition. He complained of colic epigastric abdominal pain, nausea, and vomiting. He was hemodynamically stable; blood counts and metabolic panel were normal. Abdominal CT showed an intestinal obstruction caused by an 8 × 6 × 11 cm hematoma on the right lateral duodenal wall without signs of active bleedin

Multiple food hypersensitivity as a cause of refractory chronic constipation in adults

Chronic constipation that is unresponsive to laxative treatment is a severe illness, but children unresponsive to laxatives have been successfully treated with an elimination diet. We report the first cases of refractory chronic constipation caused by food hypersensitivity in adults. Four patients with refractory constipation who were unresponsive to high doses of laxatives were put on an oligo-antigenic diet and underwent successive double-blind, placebo-controlled, food challenges (DBPFC). Routine laboratory tests, immunological assays, colonoscopy, esophago-gastroduodenoscopy and rectal and duodenal histology were performed. While on an elimination diet, bowel habits normalized in all patients and a DBPFC challenge triggered the reappearance of constipation. In comparison with another 13 patients with refractory constipation unresponsive to the elimination diet, observed over the same period, the patients with food-hypersensitivity-related constipation had the following characteristics: longer duration of illness (p < 0.03), lower body mass index (p < 0.03), higher frequency of self-reported food intolerance (p < 0.01), higher frequency of nocturnal abdominal pain and anal itching (p < 0.01). In patients with food hypersensitivity, hemoglobin concentrations and peripheral leukocytes were lower than those in controls (p < 0.03). The duodenal and rectal mucosa histology showed lymphocyte and eosinophil infiltration, and the duodenal villi were flattened in two cases. In adult patients, refractory chronic constipation may be caused by food hypersensitivity and an elimination diet is effective in these subjects