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The pelvic anatomy poses great challenges to orthopedic surgeons. Sarcomas are often large in size and typically enclosed in the narrow confines of the pelvis with the close proximity of vital structures. The aim of this study is to report a systematic planned multidisciplinary surgical approach to treat pelvic sarcomas. Seventeen patients affected by bone and soft tissue sarcomas of the pelvis, treated using a planned multidisciplinary surgical approach, combining the expertise of orthopedic oncology and other surgeons (colleagues from urology, vascular surgery, abdominal surgery, gynecology and plastic surgery), were included. Seven patients were treated with hindquarter amputation; 10 patients underwent excision of the tumor. Reconstruction of bone defects was conducted in six patients with a custom-made 3D-printed pelvic prosthesis. Thirteen patients experienced at least one complication. Well-organized multidisciplinary collaborations between each subspecialty are the cornerstone for the management of patients affected by pelvic sarcomas, which should be conducted in specialized centers. A multidisciplinary surgical approach is of paramount importance in order to obtain the best successful surgical results and adequate margins for achieving acceptable outcomes.

INTRODUCTION Venous congestion is the most common vascular complication of the deep inferior epigastric artery perforator (DIEP) flaps. Adding a second venous drainage by anastomosing a flap vein and a recipient vein (super-drainage) is considered the solution of choice. Evidence to support this procedure, had not yet been confirmed by an analysis of the literature. We aimed to provide this evidence. MATERIALS AND METHODS We searched the literature (MedLine, Scopus, EMBASE, Cochrane Library, and Google Scholar), for studies discussing venous congestion and venous super-drainage in DIEP flap for breast reconstruction. Thirteen of the 35 articles compared results between one or two venous anastomoses. Meta-analysis was performed following PRISMA guidelines. Pooled risk ratio (RRs) for congestion, fat necrosis, partial necrosis, and total necrosis with corresponding 95% confidence intervals (CI) were calculated using a fixed-effect model with the Mantel-Haenszel method. The need to return to surgery (95% CI) was estimated with a random effect model using the DerSimonian and Liard method. RESULTS We showed a statistically significant advantage of super-drainage to reduce the venous congestion of the flap (RR: 0.12, 95% CI: 0.04-0.34, p-value

Background 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. Purpose To evaluate the diagnostic performance of a new preoperative CTA protocol and a new reconstruction method in the assessment of DIEP technique. Material and Methods 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. Results 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 Conclusion 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: The goal of microsurgical breast reconstruction is to return to the precancer state, maximizing symmetry with less morbidity. This requires a long learning curve, in particular where modeling is concerned. In this context, reverse engineering technologies found an application, allowing the creation of molds that can be used during the surgery. METHOD: We created 10 molds named DIEP sizers, which help to simplify deep inferior epigastric perforator (DIEP) flap insetting. For this, we designed a virtual model using Geomagic X software to construct the sizers. Our model has a thorax circumference, breast projection, and footprint correspondent to an average of the measurements we collected from 15 patients undergoing such surgery. We made a comparative study between 2 groups each of 24 patients, using as comparison criteria surgical times in patients undergoing breast microsurgical reconstruction with or without DIEP sizers. In both groups, we included immediate and delayed reconstructions as well as monolateral, bilateral and monolateral with contralateral symmetrization. RESULT: In all the cases we performed with DIEP sizers, we achieved an average time saving of 105 minutes in monolateral reconstruction, 80 minutes in monolateral reconstruction with contralateral symmetrization, and 120 minutes in bilateral reconstruction (P < 0.001). No major complications occurred. CONCLUSIONS: We performed 24 breast reconstructions with preformed molds, obtaining a proper "library" with different DIEP sizers that can be used both in preoperative planning and in intraoperative modeling. We recommend the use of a preformed mold in microsurgical breast reconstruction to improve symmetry, to shorten the learning curve and to save time.

We read with interest the commentary by Atiyeh et al. to our paper ‘‘Defining the Inframammary Fold by Liposuction: An Essential Tool in Aesthetic Shaping of the Reconstructed Breast. Technique and Long-Term results in a Series of Patients’’. We are grateful for their interest in our work and their constructive comments on the important role of a well-defined inframammary fold as a critical visual landmark for breast aesthetics

BACKGROUND: The surgical management of rectovaginal fistulae associated with Crohn's disease is often frustrated by poor results regardless of the different techniques. The outcomes of the gracilis muscle transposition (GMT) for the treatment of recurrent Crohn's-associated fistulae are still debated. The aim of the study is to determine whether the success rate of GMT is similar in Crohn's disease patients and in a control group. MATERIALS AND METHODS: All patients undergoing GMT for rectovaginal or pouch-vaginal fistula were collected from a prospectively maintained database (2005-2016). The primary study outcome was the comparison of the success rate of GMT in Crohn's disease and control group patients. RESULTS: Twenty-one patients with a rectovaginal fistula due to Crohn's disease (8, 38.1%) or other etiologies (13, 61.9%) were included. The groups had similar characteristics and postoperative outcomes. After a median follow-up time of 81 and 57 months (p 0.34), the success rate of GMT was 75% in patients with Crohn's disease and 68.4% in control group (p 0.6). The median time to recurrence was 3.5 months (1-12). The success rate in patients who had more than two previous attempts of repair was lower regardless of the etiology (50 vs 79.4%, p 0.1). CONCLUSION: GMT is associated with a high success rate, especially in Crohn's disease-related rectovaginal fistula. In consideration of the low morbidity rate and the fact that an increasing number of previous local operations might be associated with failure, the procedure should be considered as a first line of treatment for recurrent rectovaginal fistulae.

PURPOSE: Computer-aided design/computer-aided manufacturing (CAD/CAM) methods for mandibular reconstruction have improved both functional and morphological results. We evaluated the accuracy of the CAD/CAM method for mandibular reconstruction and assessed the quantitative and qualitative reproducibility of virtual preoperative planning. MATERIALS AND METHODS: A total of 34 consecutive patients treated with mandibular reconstruction using the CAD/CAM method between January 2011 and October 2017 were included in this study. The accuracy of the reconstruction was assessed using the automated Hausdorff distance function of the simulation software, which set the postoperative mesh as the target. This made it possible to calculate the minimum error, the maximum error, and the mean error for each reconstruction in exactly the same way and with the same settings as the difference between the postoperative mesh and virtual planning. Finally, the coloured quality mapper function was applied to superimposition of the STL files, allowing us to visually render the obtained data on differences between preoperative planning and surgical outcome. RESULTS: The average mean error obtained after performing an accuracy evaluation of our reconstructions was 1 mm (range 0.4-2.46 mm). Based on the colour map areas, the maximum error was located in the symphysis area. The body and ramus areas showed the greatest accuracy in terms of planning reproducibility. CONCLUSION: This is the first study to assess the three-dimensional reproducibility of virtual planning using the CAD/CAM method for mandibular reconstruction, in a homogeneous sample of 34 cases. Our data suggest that CAD/CAM microvascular reconstruction can result in a very high degree of reproducibility. This occurs in complex areas as well as the condylar region and in the case of extensive mandibular reconstructions.

Objective:To evaluate the features and prognosis of melanoma of glans penis and urethra, with the presentation of a significant case report.Materials and methods:A systematic literature review was performed using the MEDLINE (PubMed) and Cochrane Libraries databases to identify all cases of male mucosal melanoma reported.Results:Two hundred fifty-two patients with male mucosal primary melanoma were found. Glans penis and fossa navicularis as primary site includes the 81.6% of all lesions considered. Median Breslow’s depth is 2.1 mm, whereas nine in situ melanomas have been reported. At the diagnosis, the disease was at a non-localized stage in 21.4% for glans penis melanomas and 11.7% urethral lesions, respectively. The 2 and 5-year survival for glans melanoma is 62.5% and 38.4%; higher rates were observed in the 2012–2020 period (76% and 58.8%, respectively). Two-year survival for urethral melanomas is 66.7%, while 5-year survival is 12.5%. 22 patients survived over 5 years with a Breslow’s depth reported always Conclusion:Melanoma of the glans penis and urethra is a rare neoplasm associated with a poor prognosis, however recent reports show higher survival rates. Surgery remains the mainstay for a localized disease. Taking into account the small number of cases reported, topical imiquimod seems to be a valid non-surgical alterative for melanoma in situ. The use of immunotherapy and targeted therapy should be considered only in an adjuvant setting according to the recommendations of cutaneous melanoma; however, additional clinical data on male mucosal melanoma are needed to draw definitive conclusions.

Introduction We present our pre-operative virtual planning of complex mandibular reconstruction with a microvascular fibular composite free flap and its harvesting using our novel cutaneous positioning guide based on the perforator vessels for our soft tissue reconstructive surgery. Technical report We applied our protocol to 42 consecutive patients needing mandibular composite reconstruction. All patients were preoperatively studied with a CTA scan to evaluate the fibular pattern of vascularization and the perforator vessels three-dimensional path and position. Computer assisted surgery (CAS) was performed: a skin paddle outlining guide (SPOG) was designed to reproduce the shape and area of the planned soft tissue resection. CTA measurements and in vivo findings were compared. After performing the CTA, we classified the viable perforators in High Perforators, Medium Perforators and Low Perforators. The average diameter of the perforator vessels was 3 mm. The average difference between the measurements performed on the CTA and the intra-operative measures was 1, 4 mm. The SPOG was based on calf proximal and distal diameters. The anatomical fitting of the guide was obtained thanks to two customized flanges that embrace circumferentially the proximal and distal portions of the leg. The SPOG encompassed appropriate skin/leg regions, allowing the surgeon to localise the required perforator vessel. Conclusions CTA protocol appears to be a valuable approach to asses and virtually simulate composite mandibular reconstructions. The SPOG seems to be a valuable tool to reproduce intra-operatively the planned soft tissue area to be reconstructed.

Introduction Mandibular reconstruction performed after virtual planning has become more common during recent years. The gold standard for extensive mandibular reconstruction is of course a fibular free flap. In designing an osteomyocutaneous fibula flap, poor planning, aberrant anatomy and/or inadequate perforator vessels are the most frequent causes of complications and may force the surgeon to modify the flap design, explore the contralateral leg or harvest an additional microvascular flap. The goal of our study was to pre-operatively evaluate the vascular anatomy of the fibula and localize the cutaneous perforator vessels, so to create the fibular cutting guide based on the position of the cutaneous perforator and safely harvest the reconstructive flap. Materials and methods Twenty consecutive patients who were candidates for mandibular reconstruction using a fibular microvascular free flap were enrolled in this study between January 2016 and August 2016. The patients were preoperatively assessed with a Computed Tomographic scan of head and neck and with a Computed Tomographic Angiography (CTA) scan of the lower limbs to evaluate the vascular anatomy of the fibula. Virtual planning was carried out for all patients. The fibular cutting guide was based on the position of the perforator cutaneous vessels, which were used to harvest the cutaneous part of the flap. Preoperative CT measurements were performed in order to identify the cutaneous perforators on the patients’ skin. Intraoperative checking was performed to evaluate the accuracy of the perforators’ position and the reproducibility of the virtual planning. Results In 5 patients out of 20 (25%), anatomical anomalies were discovered, without clinical evidence. The perforator vessels were localized in all patients. The average difference between the CTA and the intraoperative perforator localization was 1 mm (range 0–2 mm). Fibular cutting guide was positioned and fitted the anatomy of the patients in all treated patients. This allowed us to perform the planned segmentation of the fibula, obtaining the correct number of segments. In all cases, flap insetting was carried out and skin paddle was positioned as preoperatively planned. Neither donor site complications nor flap complications occurred. Conclusions Preoperative evaluation of the legs using CTA, in patients who undergo an osteomyocutaneous fibular free flap for mandibular reconstruction, is a valuable approach to reduce altered-anatomy related complications and to improve the accuracy and outcomes of the reconstruction, especially in reconstructions of complex defects. In these cases, a soft tissue-based cutting guide can be planned based on the perforator vessels of the skin paddle, minimizing the harvesting risks of vascular lesions. Further studies and longer follow-ups are needed to evaluate the long-term outcomes and advantages of this procedure.

The maxilla provides support to the overlying structures and contributes significantly to the overall facial appearance and to critical functions such as mastication, speech, and deglutition. Many different techniques have been used over the years to achieve this reconstructive goal. Modern computer-assisted surgery affords new methods for planning resections, as well as optimising reconstructive outcomes and functional rehabilitation. The aim of this study was to describe our experience with, and technique for, the functional, structural, and aesthetic reconstruction of maxillary bone defects using a computer-assisted design (CAD)/computer-assisted manufacturing (CAM)-printed titanium mesh to provide structural support for free flap reconstruction. Four patients who underwent reconstruction with a CAD/CAM-printed titanium mesh were included in this study. The preoperative computed tomography (CT) data set used for virtual planning was superimposed onto the postoperative CT scan to calculate the difference between the virtually planned position and the postoperative position of the titanium mesh. The orbital floor and alveolus were the most frequent sites of deviation, and good reproducibility could be obtained with less than 1 mm of deviation between planning and results in most regions. Printed titanium meshes obtained with CAD/CAM technology and used to structurally support free flaps provide a valuable method for the achievement of good aesthetic, structural, and functional outcomes in maxillary reconstruction. Reconstructive accuracy using this technique is reasonably high. Further studies with a larger number of patients would be useful to confirm these results.

Background Microsurgical reconstruction has become the worldwide gold standard for repairing surgical defects in head and neck cancer. The aim of this article is to describe a standardized reconstructive approach to the oral cavity and oropharynx soft tissue defects. Patients and methods Since 1992, the authors have treated 163 patients affected by oral cavity and oropharynx cancer, performing a total of 175 flaps. A systematic postoperative functional study prompted a surgical strategy, in terms of flap choice, shape, and insetting. A two-dimensional template was used to obtain a three-dimensional reconstruction for the best functional and aesthetic outcome. To simplify preoperative planning, surgical resections were divided into a set number of classes. The templates, flap choice, and insetting are described for each region. Results Complications consisted of seven partial necroses of the flap which easily resolved with a local toilette and 12 complete necroses of the flap due to vascular thrombosis, these patients required a secondary reconstruction with another free flap. Functional results were systematically evaluated in the first 60 patients of our series with particular attention to the swallowing function, which was analyzed by both videofluoroscopy and functional endoscopic evaluation of swallowing. Results showed a good functional recovery with the described reconstructive techniques. Conclusion A standardized surgical strategy based on reproducible templates might facilitate less experienced surgeons in analyzing the problem, choosing the best technical solution and foreseeing the functional outcomes. V C 2012 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2012. Microsurgical reconstruction has become the worldwide gold standard in head and neck oncology, because it enhances both the healing process and the patient’s quality of life. Any surgical defect can be reconstructed by choosing from a number of flaps with appropriate structural features for the resected area. 1–3 However, resection patterns

The treatment of complex wounds often requires multiple surgical debridement and eventually reconstruction with skin grafts or flaps, under local or general anesthesia. When the patient's general conditions contraindicate surgical procedures, topical negative pressure with Vacuum Assisted Closure (VAC ®) device can achieve wound healing with reduction of healing time and simpler management. We treated with VAC ® device four patients with complex wounds and important contraindications to surgery. In all the patients, we used VAC ® device with common protocol of topical negative pressure. The healing was obtained in a period variable between 18 and 40 days; the results were satisfactory in three cases, one patient developed an aesthetically unpleasant scar. We present our experience to propose VAC ® when surgical procedures are contraindicated.

A number of techniques have been described to reconstruct lower lip defects. A microsurgical total lower lip reconstruction was performed in a 48-year-old female patient affected by a squamous cell carcinoma of the lower lip. The patient underwent a wide lower lip resection and an immediate aesthetic and functional lower lip reconstruction. The lower lip was reconstructed with a composite radial forearm palmaris longus flap. The subcutaneous layer of the residual upper lip was undermined and palmaris longus tendon was transfixed to the paranasal portion of the orbicularis oris muscle, giving to the flap a good aesthetic “hammock” effect and achieving a nearly impairment free function. The use of a forearm free flap for lower lip reconstruction has previously been described, with poor functional results. We have described a different technique to inset and fix the flap using palmaris longus tendon: the suspension vector of the flap and the preservation of the residual orbicularis oris fibers seem to be of great importance to achieve a satisfactory functional recovery. We propose that the radial forearm free flap comprising palmaris longus tendon, inset and fixed with the described technique, may be a good alternative among the surgical options for full-thickness lower lip defects in order to achieve a satisfactory aesthetic and functional reconstruction.

Background. Stomal recurrence after total laryn- gectomy is 1 of the most serious issues in head and neck sur- gery, both because of the complexity of its management and because of its morbidity. Prior to the introduction of free-tissue transfer, mediastinal tracheostomy has been the standard reconstructive procedure with high rate of complications. The ideal reconstructive solution to these problems must provide well-vascularized soft tissues that can cover the defect after resection and also allow suturing of the tracheal remnant to skin edges without tension. Methods and Results. We describe a case of a 56-year-old man with stomal recurrence after total laryngectomy treated by the use of a tubed anterolateral thigh (ALT) flap to elongate the shortened trachea and simultaneously cover the cervical skin defect. Conclusions. The ALT can be accepted as an ideal free- flap choice for stomal recurrence, because it has maximal reconstructive capacity and produces minimal donor-site mor- bidity. V C 2009 Wiley Periodicals, Inc. Head Neck 31: 1107- 1111, 2009

Deep Inferior Epigastric Artery Perforator flap (DIEAP) is now-a-days considered the gold standard in autologous breast reconstruction. The aesthetical outcome in breast reconstruction is very important and its improvement is mandatory for plastic surgeons. The most frequent aesthetics problems observed with DIEAP flap are the 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. In this chapter the authors describe their personal strategies adopted to correct the mentioned problems in order to improve the final aesthetical outcome in DIEAP flap breast reconstruction.

BACKGROUND: : The aim of the present study was to evaluate the accuracy of prosthetically guided maxillofacial surgery in reconstructing the mandible with a free vascularized flap using custom-made bone plates and a surgical guide to cut the mandible and fibula. METHODS: : The surgical protocol was applied in a study group of seven consecutive mandibular-reconstructed patients who were compared with a control group treated using the standard preplating technique on stereolithographic models (indirect computer-aided design/computer-aided manufacturing method). The precision of both surgical techniques (prosthetically guided maxillofacial surgery and indirect computer-aided design/computer-aided manufacturing procedure) was evaluated by comparing preoperative and postoperative computed tomographic data and assessment of specific landmarks. RESULTS: : With regard to midline deviation, no significant difference was documented between the test and control groups. With regard to mandibular angle shift, only one left angle shift on the lateral plane showed a statistically significant difference between the groups. With regard to angular deviation of the body axis, the data showed a significant difference in the arch deviation. All patients in the control group registered greater than 8 degrees of deviation, determining a facial contracture of the external profile at the lower margin of the mandible. With regard to condylar position, the postoperative condylar position was better in the test group than in the control group, although no significant difference was detected. CONCLUSIONS: : The new protocol for mandibular reconstruction using computer-aided design/computer-aided manufacturing prosthetically guided maxillofacial surgery to construct custom-made guides and plates may represent a viable method of reproducing the patient's anatomical contour, giving the surgeon better procedural control and reducing procedure time.

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Modern techniques of mandibular reconstruction, such as CAD-CAM technology and rapid prototyping, offer new means by which reconstructive surgery can be planned to optimise aesthetic outcomes and prosthetic rehabilitation. The high degree of accuracy afforded by these approaches is principally attributable to high-precision fibular sectioning and insertion of the bone into a customised bone plate. CAD-CAM mandibular reconstruction procedures using vascularised bone free-flap transfers were performed on 10 patients with benign or malignant neoplasms. Five were not treated with the aid of CAD-CAM technology, and served as the control group. Five were scheduled for maxillofacial surgery using surgical cutting guides and customised bone plates. A generalised linear model for linear measures was used to compare the accuracy of reconstruction between the two groups. A difference, even though not significant, in the lateral shift of the mesial and distal positions of the fibular units was evident between groups. CAD-CAM-generated fibular surgical guides afford improved accuracy when used to restore native anatomy, especially in the context of mandibular arch restoration, and both operating room time and related costs are reduced during fibular sectioning.

Current microsurgical techniques are used in single stage repair of distal lower limb defects. The previously popular cutaneous and fasciocutaneous flaps have been practically shelved. However, in selected cases, the vessels of a lower limb can still be employed to vascularize a harvested flap for the repair of a contralateral defect. In cases where the vessels of a traumatized leg are severely damaged or jeopardized, vascular components of the opposite limb can be exploited to provide the blood supply for the flap chosen to cover the defect. There are times when trauma to both legs may require a single large flap (latissimus dorsi) which if properly vascularized can bridge a bilateral defect. This could bring about the revival of the cross-leg flaps. Four cases are reported: in one, the flap was vascularized from a healthy limb to cover a contralateral exposed fracture and an avulsed heel. In three other cases, the latissimus dorsi was utilized to fill large post-traumatic bilateral defects at the distal lower limb level. In these cases the limb with the best vascular system was chosen for flap anastomoses and fixation was then applied.

Abdominal wall closure after intestinal transplantation in adult patients can be a difficult procedure. The main possibility offered by international experience is the use of myocutaneous flaps and abdominal wall transplantation. We report our experience in intestinal/multivisceral transplantation, including four difficult cases among 27 adult transplant recipients. Three patients underwent prosthetic mesh alone and one, a myocutaneous flap for abdominal closure after primary mesh positioning. We selected a mesh with a structure that allowed us to close the abdomen without creating adhesions and, at the same time, stimulating tissue repair. Two patients experienced local mesh infection, which has been kept under clinical control by antibiotics and daily medications till neoabdominal wall formation. The mesh was then removed. Another patient underwent mesh substitution for a suspicious fever. The last patient had mesh as a bridge for a subsequent myocutaneous flap from the thigh. All patients are in good health with well-functioning grafts and no need for parenteral nutrition. No enterocutaneous fistulae were detected.

Introduction: 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. Materials and Methods: We report 11 cases of reconstruction firstly planned with the ALT flap, then converted into TFL perforator flap. Results and Conclusion: The result was always satisfactory in terms of the donor site morbidity and reconstructive outcome.

none 10 no Summo, Valeria; Sgarzani, Rossella; Negosanti, Luca; Fabbri, Erich; Vietti Michelina, Veronica; Villani, Riccardo; Bertachini D'Angelo, Giorgio; Antoniazzi, Elisa; Cipriani, Riccardo; Morselli, Paolo Giovanni Summo, Valeria; Sgarzani, Rossella; Negosanti, Luca; Fabbri, Erich; Vietti Michelina, Veronica; Villani, Riccardo; Bertachini D'Angelo, Giorgio; Antoniazzi, Elisa; Cipriani, Riccardo; Morselli, Paolo Giovanni

The highly variable anatomic distribution of lower leg perforators is explored, with a standardization based on leg length. The possibility of a correlation between leg length and number of perforators is investigated. Twenty-two lower limbs of cadavers were utilized for an anatomic study on the leg perforators branching from the three major vascular axes, anterior tibial, posterior tibial, and fibular. The parameters considered were the number of vascular pedicles per each major axis, the caliber, the distance of the fascial hole from the bony landmark (knee joint line), and the route of the vessels (muscular, septal). Arteries taken into account had a caliber of 0.5 mm or greater, with a maximum of 1.7 and a mean of 0.78. The perforators of the anterior tibial artery distribute along the entire length of the leg, but the peak of concentration is between second and third tenth and around the middle tenth. The fibular system provides perforators between the fourth and seventh tenth. The posterior tibial perforators concentrate to the middle third and to the supramalleolar region. A correlation exists between leg length and number of perforating vessels for the tibial vascular systems, possibly due to neoangiogenesis during growth, at the level of the metaphyseal plates. On the contrary no relationship was noticed for the fibular artery, whose perforators concentrate far from the growth cartilages. Some tenths where perforators concentrate are identifiable. Tibial systems have a perforator incidence depending on leg length, which, on the contrary, does not influence the number of fibular perforators. Clin. Anat. 23:593–605, 2010. © 2010 Wiley-Liss, Inc.

We report the case of a newborn with acute myeloid leukaemia, who developed perineal necrotizing fasciitis due to Pseudomonas Aeruginosa, after twenty days of life. Following surgical debridement, she was effectively treated with topical negative pressure therapy (V.A.C.(R) device) with silver foam dressings, this achieved complete closure in thirteen days. Negative pressure therapy should be considered when conventional wound care fails to achieve complete wound closure, even in neonates.

BACKGROUND: We sought to determine the best strategy to overcome difficult abdominal wall closures in intestinal transplantation (ITx). METHODS: Among 38 adult recipients of 39 ITxs from deceased donors, the median number of previous laparotomies was 2.0 per patient, with a median donor-to-recipient body weight ratio of 1.1. Eight patients (21%) had full residual intestinal length before transplant. Abdominal wall closure after transplant was considered difficult in 15 (39.5%) patients (group A). To overcome size mismatching, we performed two graft reductions, five skin-only closures, one two-step abdominal wall closure, four prosthetic mesh closures, and three abdominal wall transplants. In the remaining 23 (60.5%) patients, a regular abdominal closure was performed (group B). RESULTS: Twelve patients (32%) experienced complications related to abdominal wall closure, 10 (67%) in group A and 2 (8.7%) in group B (P

Oral cavity reconstruction after removal of locally advanced tumors is particularly difficult because anatomical restoration must accurately reproduce the original structure and enable effective and fast rehabilitation of mastication, swallowing, and phonation. The authors report their 2-year experience with 17 patients surgically treated for oral cavity cancer with reconstruction performed with the free anterolateral thigh flap. Thanks to its thinness and pliability, this flap has proven to be perfectly adaptable to the structural peculiarities of the resected areas and has enabled the authors to considerably reduce the cosmetic and functional complications in the donor area observed with other flaps (such as the radial forearm flap). Flap grafting has always been complete and regular, and no intraoperative and postoperative complications have been observed. Swallowing recovery has always been satisfactory. On the basis of the authors' results, their current approach to oral cavity reconstruction is based on the use of flaps that enable anatomical restoration of the resected areas and reduce morbidity of the donor site. They believe that the anterolateral thigh flap can offer all of these opportunities, and the surgery can be simultaneously performed by two surgical teams.

BACKGROUND. Pouch-vaginal fistulae (PVF) affect 4 to 16% of women after ileal-pouch-anal anastomosis (IPAA) and significantly impact the patients’quality of life. They indeed represent a challenge for the surgeon. A variety of surgical options have been described but the reported pouch failure rate varies between 20 and 30% after the development of a PVF. Gracilis muscle transposition (GMT) is often considered a last resort treatment after the failure of multiple previous attempts. CASE REPORT. A 45 years old women came to our tertiary IBD surgical department due to a recurrent PVF. She had already been treated elsewhere with multiple surgical repairs (mucosal advancement flaps, local injection of Adalimumab and redo-pouch). She had a severe pelvic sepsis and an IPAA stricture. Therefore, a pelvic surgical toilette, a diverting loop ileostomy and the dilatation of the anastomotic stricture were performed. After twelve months, a left GMT was fashioned. Unfortunately, three months after the procedure, a pouchoscopy and a contrast enema revealed an early recurrence of the fistula. After further six months, the patient was scheduled for a redo GMT as a rescue procedure of a pouch salvage strategy. After the transversal incision through the perineal body the pouch-vaginal fistulous track was identified and repaired. The left gracilis muscle was still in place, viable and well-vascularized. The right gracilis mucle was transposed to the perineum and secured to the apex of the dissection in the cavity between vagina and pouch, lying along the left muscle previously placed. After three months healing, of the PVF was assessed and confirmed with pouchoscopy. So, the patient was scheduled for closure of the ileostomy. Twelve months after reversal of fecal diversion, the successful healing is maintained. DISCUSSION. GMT is usually advocated as a last resort strategy for PVF before declaring a pouch failure. However, redo gracilis GMT is a faesible and effective pouch salvage procedure in a tertiary IBD surgical center.