Coverage of exposed hardware after lower leg fractures with free flaps or pedicled flaps

Abstract. – OBJECTIVE: The placement of osteosynthetic materials in the leg may be complicated by hardware exposure. Successful soft tissue reconstruction often provides a critical means for limb salvage in patients with hardware exposure in the leg. Free flaps are currently considered the standard surgical procedure for soft tissue coverage of the wounds with internal hardware exposure. However, to date, no conclusive literature shows the superiority of a specific type of flap. MATERIALS AND METHODS: The current review compares data from the literature concerning outcomes and complications of free and pedicled flaps for exposed osteosynthetic material preservation in the leg. RESULTS: A total of 81 cases from twelve different articles presenting internal hardware exposure of the leg were analyzed in our study. Thirty-two patients underwent immediate reconstructive surgery with pedicled flaps, while forty-nine patients underwent free flap reconstruction. The overall survival rate for pedicled flaps was 96.77%, while for free flaps it was 97.77%. The overall implant preservation rate was 78.12% for pedicled flaps and 53.33% for free flaps. With reference to postoperative complications, the overall complication rate was 46.87% for pedicled flaps and 10.20% for free flaps. CONCLUSIONS: No significant difference was found in terms of overall flap survival. However, a significant difference was found regarding successful implant preservation (78.12% in the pedicled flap group vs. 53.33% in the free flap group). In particular, the first observation appears to be in contrast with the current trend of considering the free flaps the first choice procedure for soft tissue coverage of the wounds with internal hardware exposure. Nevertheless, a higher occurrence of postoperative complications was observed in the pedicled flap group (46.87% vs. 10.20%). The choice of the most appropriate reconstructive procedure should take into account several issues including the size of the wounds with internal hardware exposure, the possibility of soft tissue coverage with pedicled flaps, the availability of recipient vessels, general conditions of the patients (such as age, diabetes, smoking history), patients’ preference and presence of a microsurgical team. However, according to the results of this review, we believe that pedicled flap reconstruction should be reconsidered as a valid alternative procedure for skin tissue loss with hardware exposure whenever it is possible

Clinical significance of the buccal fat pad: how to determine the correct surgical indications based on preoperative analysis

Background: Despite the multitude of clinical and aesthetic uses, the correct surgical indications for buccal fat pad (BFP) removal have yet to be fully elucidated. Although the procedure is widely performed and promoted for aesthetic purpose, literature lacks of studies accounting for a proper evaluation of patients undergoing BFP removal. Methods: Between 2012 and 2016 patients seeking an improvement of the malar contour by reduction of the submalar prominence have been visited at the Department of Plastic Surgery of the Institution. A preoperative MRI was requested in order to correctly identify the volume of the BFP and the presence of a masseter muscle (MM) hypertrophy. Results: According to clinical examination and the results of the preoperative imaging, patients were offered different treatment options: patients with BFP hypertrophy underwent BFP removal through an itraoral approach; patients with MM hypertrophy received injection of 50 UI of botulinum toxin (BTX). No complications were observed in the postoperative period and all patients were satisfied with the results. Conclusions: According to the experience, midface contouring procedures should take account of both surgeons’ experience, patients’ expectations and anatomical evaluation. As such, there is no given approach suitable for all cases. Suggested visual criteria, clinical examination and imaging analysis are useful in establishing patient’s condition and determining the appropriate methods of treatment to enhance the facial profile

Acquired ptosis associated with oculomotor and contralateral facial nerve synkinesis: the first reported case

Evidence of oculomotor nerve (ON) synkinesis is a common occurrence following both acquired and congenital III nerve palsy. It is generally accepted that aberrant regeneration is the likely aetiology of synkinesis in acquired III nerve palsy, following intracranial aneurysm, trauma, compressive neoplasms, cavernous sinus thrombosis and basilar meningitis

Botulinum toxin treatment in glaucomatous patients: a pilot study

PURPOSE: The purpose was to evaluate the efficacy of the treatment of iatrogenic entropion (IE), in patients affected by primary open angle glaucoma (POAG), by botulinum toxin injections (BTI). PATIENTS AND METHODS: 20 patients of the "Glaucoma Center" of the Hospital "Umberto I" (Rome) were examined. These patients had POAG and used prostaglandin analogues (PA). Mean age was 75.5 years old (range 68-83); they had been suffering from PAOG since 10 years and were not affected by other relevant systemic diseases. One to three BTI were made into the lower orbicularis muscle using a 0.3 G needle (0.025 to 0.05 units for each injection site). RESULTS: The results were particularly significant in 18 out of 20 patients. Two patients showed slight improvements. A rating scale ranging from 0 to 6 points (0 corresponded to 'no effect' and 6 to the 'complete' resolution of the entropion) was used to evaluate the goals of the treatment. The average rating was 5.37 points. CONCLUSIONS: The entropion due to glaucoma therapy with PA can be successfully treated with BTI in the orbicularis muscle, despite offering temporary therapeutic effects

Basal Cell Carcinoma: 10 Years of Experience

Introduction. Basal cell carcinoma (BCC) is a locally invasive malignant epidermal tumour. Incidence is increasing by 10% per year; incidence of metastases is minimal, but relapses are frequent (40%–50%). The complete excision of the BCC allows reduction of relapse. Materials and Methods. The study cohort consists of 1123 patients underwent surgery for basal cell carcinoma between 1999 and 2009. Patient and tumor characteristics recorded are: age; gender; localization (head and neck, trunk, and upper and lower extremities), tumor size, excisional margins adopted, and relapses. Results. The study considered a group of 1123 patients affected by basal cell carcinoma. Relapses occurred in 30 cases (2,67%), 27 out of 30 relapses occurred in noble areas, where peripheral margin was <3 mm. Incompletely excised basal cell carcinoma occurred in 21 patients (1,87%) and were treated with an additional excision. Discussion. Although guidelines indicate 3 mm peripheral margin of excision in BCC <2 cm, in our experience, a margin of less than 5 mm results in a high risk of incomplete excisions

Therapeutic Management of Hypothenar Hammer Syndrome Causing Ulnar Nerve Entrapment

Introduction. The hypothenar hammer syndrome is a rare traumatic vascular disease of the hand. Method and Materials. We report the case of a 43-years-old man with a painful tumefaction of the left hypothenar region. The ulnar artery appeared thrombosed clinically and radiologically. The patient underwent surgery to resolve the ulnar nerve compression and revascularise the artery. Results. The symptoms disappeared immediately after surgery. The arterial flow was reestablished. Postoperatively on day 20, a new thrombosis of the ulnar artery occurred. Conclusion. Hypothenar hammer syndrome is caused by repetitive trauma to the heel of the hand. The alterations of the vessel due to its chronic inflammation caused an acute compression of the ulnar nerve at the Guyon's canal and, in our case, do not allow a permanent revascularisation of the ulnar artery

The round-the-clock technique for correction of gynecomastia

Background Gynecomastia is a common condition that can cause severe emotional and physical distress in both young and older men. Patients in whom symptomatic recalcitrant gynecomastia persists for a long time are potential candidates for surgery. Methods From January 2014 to January 2016, 15 patients underwent correction of gynecomastia through a single 3-mm incision at our institution. Only patients with true gynecomastia underwent surgery with this new technique. Through the small incision, sharp dissection was performed in a clockwise and counterclockwise direction describing two half-circles. Health-related quality of life and aesthetic outcomes were evaluated using a modified version of the Breast Evaluation Questionnaire (BEQ). Results The patients’ average age was 23.5 years (range, 18–28 years), and their average body mass index was 23.2 kg/m2 (range, 19.2–25.3 kg/m2). One case was unilateral and 14 cases were bilateral. The weight of glandular tissue resected from each breast ranged from 80 to 170 g. No excess skin was excised. Bleeding was minimal. The mean operating time was 25 minutes (range, 21–40 minutes). No complications were recorded. All lesions were histologically benign. The patients’ average score was 3.5 (on a 5-point Likert scale) in all domains of the BEQ for themselves and their partners. Conclusions In this study, we demonstrated the safety and reliability of a new technique that allows mastectomy through an imperceptible 3-mm incision. We obtained high patient satisfaction scores using our surgical technique, and patients reported considerable improvement in their social, physical, and psychological well-being after surgery

An Alternative Treatment Strategy for Complicated Chronic Wounds: Negative Pressure Therapy over Mesh Skin Graft

Extensive skin defect represents a real problem and major challenge in plastic and reconstructive surgery. On one hand, skin grafts offer a practical method to deal with skin defects despite their unsuitability for several complicated wounds. On the other hand, negative pressure wound therapy (NPWT), applied before skin grafting, promotes granulation tissue growth. The aim of the study is to evaluate the improvement in wound healing given by the merger of these two different approaches. We treated 23 patients for large wounds of multiple factors. Of these, 15 were treated with the application of V.A.C.® Therapy (KCI Medical S.r.l., Milan, Italy), in combination with skin grafts after a prior unsuccessful treatment of 4 weeks with mesh skin grafts and dressings. Another 8 were treated with only mesh skin graft. Pain reduction and wound area reduction were found statistically significant (p < 0.0009, p < 0.0001). Infection was resolved in almost all patients. According to our study, the use of the negative pressure wound therapy over mesh skin grafts is significantly effective especially in wounds resistant to conventional therapies, thereby improving the rate of skin graft take