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Background: The innervated vastus lateralis flap (IVLF) is a barely used possibility for facial palsy reconstruction because of its thickness compared to the gracilis, latissimus dorsi, and pectoralis minor flaps. The aim of this study is to perform a precise description of the intramuscular distribution of the nerve motor branches and its relationship with the vascular pedicle in order to harvest a segmental muscle flap with the best contractile strength to restore facial reanimation., Methods: The study was performed on 16 adult cadaver thighs identifying the vastus lateralis muscle and the distribution and relationships of its neurovascular pedicle and branches. We evaluated where the nerve pierced the muscle and the course of the nerve within it. Transverse segments of the nerve were obtained from the proximal and distal ends of the nerve and stained using anti-ChAT (Choline acetyltransferase) antibodies which are specific of motor neurons., Results: A nerve for the vastus lateralis from the posterior division of the femoral nerve divided into 2 branches in 56% of cases; the principal branch coursed along the vascular pedicle and pierced the muscle more proximally than the respective vessels, and a minor branch that pierced the muscle 25-60 mm proximally. There were 3 main intramuscular branches. The nerve length (mean 132.65 ± 22.89 mm) allowed to reach the contralateral side of the face in almost all cases (95%). The mean ChAT positive fibers was 351.0 ± 92.4/mm 2 at the proximal end, and 270.3 ± 87.9/mm 2 at the distal end (p = 0.49). The number of ChAT negative fibers was higher than ChAT positive in both proximal and distal ends of the nerve., Conclusion: We propose the IVLF as a one-step surgical flap for facial paralysis reanimation due to the constant neurovascular pattern and lengthy pedicle. The amount of motor fibers in several segments of the nerve is appropriate to produce a powerful contraction for dynamic reconstruction., (© 2023 Wiley Periodicals LLC.)

Background: Facial paralysis reconstruction can be difficult in extensive defects after complex facial or cranial base tumor resection and radiotherapy or when primary smile reanimation attempt has failed. The surgical challenge is more complicated when defects are associated with recipient vessels or nerves depletion. This scenario has not been well described in the literature, and the present article will address the alternatives that plastic surgeons may use in these circumstances., Methods: Seventy-five patients operated in the Hospital Gregorio Marañon between 2008 and 2020, for dynamic reconstruction of facial paralysis, were retrospectively evaluated, collecting data about previous facial nerve surgeries, radiotherapy, chemotherapy, recipient nerve for motor restoration and vessels used for free flaps, type of neurovascular free flap (NVFF), and functional score before and after the facial reanimation surgery. Patients presenting recipient vessel and/or nerve depletion after several facial surgeries requiring a variation from the common NVFF surgical protocol were included in this study., Results: Six cases (8%) with facial paralysis and absent recipient homolateral vessels or nerves after severe cranial base surgery, parotid malignancies, or schwannoma surgery were included. Two patients had an immediate functional reconstruction during the oncologic resection surgery, and 4 patients had a delayed reconstruction. Three patients had previous reconstruction with free flaps, and the vascular pedicles of previous flaps were used for the new NVFF. In the other 3 cases, interposition vein grafts to the contralateral recipient vessels were required to perform NVFF. Masseteric nerve in 4 cases, hypoglossal nerve and posterior branch of the deep temporal nerve in 1 case each, were used as recipient nerves. House-Brackmann score improved in all patients after surgery., Conclusions: Neurovascular free flap can be successfully performed to restore facial motion after depletion of homolateral recipient vessels or nerves after previous facial or cranial base surgeries. In these cases, interposition vascular grafts or the pedicle of previous flaps are essential to provide vascularization as well as an optimal orientation of flaps, to reach recipient nerves in a 1-step procedure., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Lymphovenous anastomoses (LVA) techniques for the treatment of lymphedema are well defined, and results restoring lymph function are reported in the literature. However, unsatisfactory results (poor-responders) are common, leading to persistent nonpitting edema. Blind liposuction eliminates fat and fibrous tissue but may result in inadvertent damage to the lymph vessel system. Indocyanine green imaging of the lymphatic system provides the potential preservation of functioning lymphatics while conducting liposuction to address the excess adipose and fibrous tissue in these patients. Our study reports the results of a prospectively conducted technique in patients with nonpitting edema after failing previous LVA. It consists of indocyanine green-guided liposuction., Patients and Method: Twenty poor-responders patients to LVA who presented with persistent nonpitting edema were operated with liposuction. Limb volume measurements, SPECT-CT/lymphoscintigraphy, and ICG lymphography were recorded and complemented with a satisfaction inquiry., Results: The overall percentage of volume reduction was 46.2% after liposuction (p = 0.001). None of our patients reported any set back with respect to the improvements they had achieved after LVA nor new infections. Satisfaction showed a mean improvement of 5 points in a 20-point scale. SPECT-CT/lymphoscintigraphy showed further improvements in 17 cases after liposuction, such as dermal back-flow reduction, spots along the lymphatic system, or lymph nodes not described in preoperative reports, without showing significant differences when compared with overall volume reduction (p = 0.12)., Conclusion: Controlled liposuction with ICG seems to be an effective technique for the reduction of residual non-pitting edema in poor responder patients after LVA. Overall, volume excess reduction after liposuction was 42.6%., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Although a wide variety of topical microbicides provide promising in vitro and in vivo efficacy, most of them failed to prevent sexual transmission of human immunodeficiency virus type 1 (HIV-1) in human clinical trials. In vitro, ex vivo, and in vivo models must be optimized, considering the knowledge acquired from unsuccessful and successful clinical trials to improve the current gaps and the preclinical development protocols. To date, dendrimers are the only nanotool that has advanced to human clinical trials as topical microbicides to prevent HIV-1 transmission. This fact demonstrates the importance and the potential of these molecules as microbicides. Polyanionic dendrimers are highly branched nanocompounds with potent activity against HIV-1 that disturb HIV-1 entry. Herein, the most significant advancements in topical microbicide development, trying to mimic the real-life conditions as closely as possible, are discussed. This review also provides the preclinical assays that anionic dendrimers have passed as microbicides because they can improve current antiviral treatments' efficacy. This article is categorized under: Nanotechnology Approaches to Biology > Nanoscale Systems in Biology Therapeutic Approaches and Drug Discovery > Nanomedicine for Infectious Disease Toxicology and Regulatory Issues in Nanomedicine > Regulatory and Policy Issues in Nanomedicine., (© 2022 The Authors. WIREs Nanomedicine and Nanobiotechnology published by Wiley Periodicals LLC.)

Background: In the practice of breast augmentation and reconstruction, implant irrigation with various solutions has been widely used to prevent infection and capsular contracture, but to date, there is no consensus on the optimal protocol to use. Recently, application of povidone iodine (PI) for 30 min has shown in vitro to be the most effective irrigating formula in reducing contamination in smooth breast implants. However, as 30 min is not feasible intraoperatively, it is necessary to determine whether shorter times could be equally effective as well as to test it in both smooth and textured implants., Methods: We tested the efficacy of 10% PI at 1', 3', and 5' against biofilms of 8 strains (2 ATCC and 6 clinical) of Staphylococcus spp . on silicone disks obtained from Mentor ® and Polytech ® implants of different textures. We analyzed the percentage reduction of cfu counts, cell viability and bacterial density between treatment (PI) and control (sterile saline, SS) groups for each time of application. We consider clinical significance when > 25% reduction was observed in cell viability or bacterial density., Results: All textured implants treated with PI at any of the 3 exposure times reduced 100% bacterial load by culture. However, none of the implants reached enough clinical significance in percentage reduction of living cells. Regarding bacterial density, only 25-50 μm Polytxt ® Polytech ® implants showed significant reduction at the three PI exposure times., Conclusion: PI is able to inhibit bacterial growth applied on the surface of breast implants regardless of the exposure time. However, no significant reduction on living cells or bacterial density was observed. This lack of correlation may be caused by differences in texture that directly affect PI absorption., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Fernández-Ibarburu, Díaz-Navarro, Ibarra, Rivera, Hafian, Irigoyen, Carrillo, Pérez-Cano, Muñoz, García-Ruano, Lasso and Guembe.)

Introduction: Sacropelvic resection is the treatment of choice for pelvic bone tumors and can be associated with intraoperative electron radiotherapy (IOERT) to optimize local control of the disease. Reconstruction with flaps also is essential to avoid pelvic complications. There is scarcity of publications evaluating outcomes of reconstructive procedures associated with IOERT., Methods: A prospective study in 53 patients between 2005 and 2018 was performed. Thirty-four patients received IOERT (group I [GI]) and 19 did not (GII). We examined demographic characteristics, tumor pathology, type of resection and volume of surgical specimen, timing of surgery, IOERT doses, postoperative stay, and complications. We used it for reconstruction rectus abdominis, gluteal, omental and gracilis, superior gluteal artery perforator flap, and free flaps., Results: Colonic adenocarcinoma and chordoma were the most frequent tumors. The median (interquartile range) IOERT dose was 1250 (1000-1250) cGy; operating time was 10.15 (8.6-14.0) hours versus 6.0 (5.0-13.0) hours, hospital stay was 37 (21.2-63.0) days versus 26.0 (12.0-60.0) days, and volume of surgical specimen was 480.5 (88.7-1488.0) mL versus 400 (220.0-6700.0) mL in GI and GII, respectively. Operating time was significantly longer in GI (P < 0.03). There were significant positive correlations between operating time, hospital stay, and volume of surgical specimen. Main complications were exudative wounds (50% vs 31.5%), wound dehiscence (41.1% vs 31.5%), and seroma (29.4% vs 26.3%) in GI and GII, respectively. Complications were similar to previous studies with or without radiotherapy., Conclusions: Under a reconstructive approach, IOERT did not harm flap survival nor increased pelvic complications when compared with similar cases without IOERT., Competing Interests: Conflicts of interest and sources of funding: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Reconstruction of posterior cervical trunk defects secondary to tumor resection carries significant morbidity when vertebral hardware or the spinal cord is exposed, and neck extension is interrupted. Complete reconstruction includes the coverage and obliteration of dead spaces, but functional outcomes are necessary to prevent the head dropping. This report documents the first known technique, using a free latissimus dorsi neurovascular flap to provide neck extension after ablative oncological surgery affecting trapezium and paraspinal muscles of the neck. The author explains the method by using a branch of the accessory nerve as the donor nerve. While keeping the head in a neutral position, the tendinous part of the neurovascular flap was firmly attached to the occipital periosteum and to the cephalad remnants of the trapezius, splenius capitis, and semispinalis muscles. At the caudal portion of the defect, cardinal notches were used to set the muscle at rest, avoiding excessive fiber tension. The maximal length of the muscle at rest was measured before flap elevation, calculated via the anatomical 3D print model. The thoracodorsal nerve was stimulated until the muscle shortened its length to 50%. Head extension was tested several times via neurostimulation and electromyographic control. The described procedure may provide neck extension and circumvent the problem with donor nerve providing synergy to the desired function., (Copyright © 2021 The Author. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

The masseteric nerve (MN) and the anterior branch of the obturator nerve (ON) that innervate the transferred gracilis muscle have proved highly efficient for reanimating paralyzed facial muscles when muscle transfer is required. Previous researchers have published the total axonal load for myelinated fibers in both nerves. However, the real motor axonal load has not been established. We performed the study on 20 MN and 13 ON. The segments of the MN and the ON were embedded in paraffin, sectioned at 10 μm, and stained following a standard immunohistochemical procedure using anti-choline acetyltransferase to visualize the motor fibers. The MN has a higher axonal load than the ON. There were statistically significant differences between the axonal load of the proximal segment of the MN and the ON. These findings confirm that end-to-end anastomoses between the MN and the ON should preferably use the proximal segment. However, MN neurotomy should ideally be performed between the proximal and distal segments, preserving innervation to the deep fascicles. Our results show that the MN is ideal as a donor motor nerve for reinnervating transplanted muscle for dynamic reanimation of the paralyzed face. The neurotomy should ideally be performed between the first and second collateral branches of the MN. Clin. Anat. 32:612-617, 2019. © 2019 Wiley Periodicals, Inc., (© 2019 Wiley Periodicals, Inc.)

Introduction: The extrapetrous course of the facial nerve has been a matter of study and debate since XIX century. Two different classifications have been classically proposed and widely accepted by most of the authors. Nevertheless, there are reported cases which do not fit in any of those. The aim of this study is to propose a new and useful classification., Material and Methods: We have used 23 embalmed Caucasian adult cadavers (11 male and 12 female) belonging to the Bodies Donation and Dissecting Rooms Centre of the University Complutense of Madrid. The extra-petrous facial nerve was dissected in the possible specimens resulting in 38 facial nerves. The studied parameters were length, diameter of divisions, terminal branches, and nerve connections., Results: In every specimen two main divisions were found, temporofacial and cervicofacial. They divided into five terminal branches from cranial to caudal: temporal, zygomatic, buccal, marginal or mandibular, and cervical. Based on the comparison with previous proposed classifications, we have unified the patterns in 12 types being the most frequent types the type 3 (eight cases, 21.05%), with connections between temporal, zygomatic and buccal branches and the type 8 (eight cases, 21.05%), a complex network between temporal, zygomatic, buccal, and mandibular branches. The number of terminal branches was so variable., Conclusion: We propose a new 12-patterned classification which summarizes the previous ones. However, we consider that a good study of the number of terminal branches, connections between branches or with other cranial nerves are more useful for surgeons to avoid injuries to the facial nerve during surgery than complex classifications. Anat Rec, 302:599-608, 2019. © 2018 Wiley Periodicals, Inc., (© 2018 Wiley Periodicals, Inc.)

Reconstruction of total circumferential pharyngeal defects following caustic or stenosant lesions of the pharynx present major challenges with respect to minimizing surgical morbidity and restoring functional deficits. With recent advances in microvascular free tissue transfer, the options for pharyngeal reconstruction have multiplied in order to maximize swallowing and voice. There is long experience in the reconstruction of the pharynx and the cervical esophagus in oncological patients after total pharyngolaryngectomy, but there are not many publications concerning circumferential pharyngeal reconstruction preserving the larynx. Here, we discuss 2 new techniques for total circumferential pharyngeal reconstruction respecting swallowing and voice by means of extra-anatomical bypasses (visceral or fasciocutaneous), upholding the larynx in its original placement.

Wegener granulomatosis (WG) is a necrotizing vasculitis that involves the upper respiratory tract, the lungs, and the kidneys. It also causes deformities of the nose in practically all patients, altering the cartilaginous and bony structure as well as the inner lining of the nose.The surgical repair of these nasal distortions is a challenge mainly due to the impairment of wound healing and graft take that is caused both by the disease itself and by the prolonged immunosuppressant treatment.Many different reconstruction plans have been developed, using costal or calvarial bone grafts, cartilage grafts and local skin and mucosa flaps. Results have been diverse.The authors present the case of a 56-year-old patient who suffered from WG and consulted for nasal sequelae. She initially underwent several failed attempts at reconstruction; finally, the authors performed a nasal repair using a double strip of fascia lata as a dorsal graft, with no complications and a good aesthetic result.Fascia lata graft is a new and good option for nasal reconstruction in patients with WG because it is easily obtainable, it can be set in place through closed rhinoplasty and it can achieve good vascularization with low risk of resorption or disease reactivation.

Background: Paralysis of one vocal fold leads to glottal gap and vocal fold insufficiency that has significant impact upon a patient's quality of life. Fillers have been tested to perform intracordal injections, but they do not provide perdurable results. Early data suggest that enriching fat grafts with adipose-derived regenerative cells (ADRCs) promote angiogenesis and modulate the immune response, improving graft survival. The aim of this study is to propose ADRC-enriched adipose tissue grafts as effective filler for the paralyzed vocal fold to use it for functional reconstruction of the glottal gap., Method: This is the first phase I-IIA clinical trial (phase I/IIA clinical trial, unicentric, randomized, controlled, and two parallel groups), to evaluate the safety of a new therapy with ADRC-enriched fat grafting (ADRC: group I) for laryngoplasty after unilateral vocal fold paralysis. Control group patients received centrifuged autologous fat (CAF: group II) grafts. Overall mean age is 52.49 ± 16.60 years. Group I (ADRC): 7 patients (3 males and 4 females), 52.28 ± 20.95 year. Group II (CAF): 7 patients (3 males and 4 females), 52.71 ± 12.59 year., Results: VHI-10 test showed that preoperative mean score was 24.21 ± 8.28. Postoperative mean score was 6.71 ± 6.75. Preoperative result in group I was 21.14 ± 3.58 and postoperative result was 3.14 ± 3.53. Preoperative result for group II was 27.29 ± 10.66. Postoperative score in group II was 10.29 ± 7.52. Wilcoxon and the Student t -tests showed that the patient's self-perception of posttreatment improvement is larger when ADRCs are used. Comparing pre- and posttreatment voice quality analysis, group I showed a p = 0.053. Group II showed a p = 0.007. There would be no significant differentiation between pre- and posttreatment results. This is true for group II and limited for group I., Conclusions: This prospective trial demonstrates the safety and efficacy of the treatment of glottal gap defects utilizing ADRC-enriched fat grafts. This trial is registered with NCT02904824.

Background Context: Sacral chordoma is a rare entity with high local recurrence rates when complete resection is not achieved. To date, there are no series available in literature combining surgery and intraoperative radiotherapy (IORT)., Purpose: The objective of this study was to report the experience of our center in the management of sacral chordoma combining radical resection with both external radiotherapy and IORT., Study Design: This is a retrospective case series., Patient Sample: The patient sample included 15 patients with sacral chordoma resected in our center from 1998 to 2015., Outcome Measures: The outcome measures were overall survival (OS), disease-free survival (DFS), and rates of local and distant recurrences., Methods: We retrospectively reviewed the records of all the patients with sacral chordoma resected in our center from 1998 to December 2015. Overall survival, DFS, and rates of local and distant recurrences were calculated. Results between patients treated with or without IORT were compared., Results: A total of 15 patients were identified: 8 men and 7 women. The median age was 59 years (range 28-77). Intraoperative radiotherapy was applied in nine patients and six were treated with surgical resection without IORT. In 13 patients, we performed the treatment of the primary tumor, and in two patients, we performed the treatment of recurrence disease. A posterior approach was used in four patients. Wide surgical margins (zero residue) were achieved in six patients, marginal margins (microscopic residue) were achieved in seven patients, and there were no patients with intralesional (R2) margins. At a median follow-up of 38 months (range 11-209 months), the 5-year OS in the IORT group was 100% versus 53% in the group of non-IORT (p=.05). The median DFS in the IORT group was 85 months, and that in the non-IORT group was 41 months. In the group without IORT, two patients died and nobody died during the follow-up in the group treated with IORT. High-sacrectomy treated patients had a median survival of 41 months, and low-sacrectomy treated patients had a median survival of 90 months. Disease-free survival in patients without gluteal involvement was 100% at 5 years, and that in patients with gluteal involvement was 40%. All patients with a recurrence in our study had gluteal involvement., Conclusions: Multidisciplinary management of sacral chordoma seems to improve local control. The use of IORT, in our experience, is associated with an increase in OS and DFS. The level of resection and gluteal involvement seems to affect survival. The posterior approach is useful in selected cases. Multicenter studies should be performed to confirm the utility of IORT., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Pyoderma gangrenosum (PG) is a rare cutaneous ulcerative disease that does not respond to antibiotics and worsens with surgical manipulation. This is the first report in the literature revealing that this disease complicates total microsurgical breast reconstruction associated with the transfer of free lymph nodes., Case Report: We report the case of a female patient who underwent left-breast microsurgical reconstruction with a deep inferior epigastric perforator (DIEP) flap and simultaneous transfer of vascularized free lymph nodes for the surgical treatment of secondary left upper-limb lymphedema, and who developed a severe PG of both the skin of the flap and the donor zone on postoperative day 7. After exclusion of other etiologies, treatment with high-dose corticosteroids and topical zinc sulfate was initiated. The flap was salvaged and breast cancer-related lymphedema (BCRL) surgery was definitively effective despite the PG., Conclusions: PG should be considered in the differential diagnosis of progressive cutaneous ulcers following surgical interventions, once infectious and ischemic etiologies have been excluded. Early initiation of immunosuppressive treatment can lead to preservation of the initial flap and function of the transferred lymph nodes in the case of microsurgical breast reconstruction with associated lymph node transfer.

Adipose tissue-derived mesenchymal stem cells (AdMSCs) are useful in the regeneration of neural tissues. Furthermore, xenotransplantation of human adipose tissue-derived mesenchymal stem cells (hAdMSCs) into animal models has already been tested and the results encouraged us to study peripheral nerve regeneration in rabbits, in order to test the feasibility of a xenotransplantation of hAdMSCs., Animals and Method: To promote end-to-end nerve fiber contacts of a 4-cm gap in the peroneal nerve of white New Zealand rabbits, an autologous vein conduit was used and three groups of animals were evaluated. In Group I, the gap was repaired with a vein conduit refilled with fibrin. Group II was similar, but the animals were treated with cyclosporine A. In Group III, a fibrin scaffold with hAdMSCs was placed inside the autologous vein conduit, and animals were treated with cyclosporine A. Neurofilament immunohistochemistry results showed 100% nerve regeneration at the vein guidance channel 90 days after the surgery in the hAdMSC-transplanted group but lesser neural regeneration in the neurofilaments of groups I and II. The analysis of variance (ANOVA) test showed statistically significant differences among all groups (p < 0.04). Group III exclusively tested positive for human monoclonal anti-mitochondrial antibody. Electron microscopy images showed tiny bundles, with a predominance of nonmyelinated axons. Myelinated axons caused irregular thickness of the myelin sheath, which was especially observed in group III., Conclusions: Xenotransplantation of hAdMSCs into a fibrin scaffold promoted nerve regeneration through a vein conduit that connected a 4-cm gap created at the peroneal nerve of rabbits. Animals treated with hAdMSCs presented negative inflammatory response at the regenerated nerve gaps, but it was demonstrated that hAdMSCs were incorporated to the new nerve creating neural tissue and endothelial cells. However, hAdMSCs required immunosuppression with cyclosporine A to achieve axonal regeneration., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Xeroderma pigmentosum (XP) is characterized by photohypersensitivity of sun-exposed tissues and several thousand-fold increased risk of developing malignant neoplasms of the skin and eyes. Inherited molecular defects in nucleotide excision repair genes cause the autosomal recessive condition XP. A 56-year-old woman with XP presented with an extensive multirecurrence basal cell carcinoma in the left naso-orbital region. At the time of the first visit, the patient had already received several interventions with local reconstructive techniques, a full course of radiotherapy, and bilateral neck dissection. A large tumor resection and free flap reconstruction were performed. Three years 9 months afterward, an aggressive recurrence occurred, and a second resection was needed. A new free flap was transferred, and microvascular anastomoses were done to the pedicle of the previously transferred flap. Nine months later, the patient returned with frontal bone tumoral lesions, and third microsurgical intervention was done. At that time, the reconstruction was practiced by a composite chimeric flap with a rib portion. Its pedicle was anastomosed to the one of the second free flaps. The objective of this article was to report the authors' experience concerning a unique case of XP requiring a complex reconstruction of the anterior skull base. Xeroderma pigmentosum patients need an early diagnosis and removal of cutaneous tumor lesions as some of them behave aggressively, especially those affecting the face. Free flaps are good solutions for reconstruction and should proceed from non-sun-exposed areas of the body. If reconstructed areas are highly radiated and/or skin tumors affect deep anatomical areas, complications are frequent.

Lymphedema is a chronic debilitating disease affecting a considerable part of the population that results from impairment of the lymphatic system. Lymphovenous anastomosis (LVA), a technique that attempts to achieve a physiologic lymphatic load of the edematous limb, is an accepted treatment. Techniques make anastomosis of 0.3 to 0.8 mm lymphatics to subdermal veins possible, but it is a challenge for microsurgeons because it requires a high degree of concentration and skill. An associated problem that we sometimes face when doing LVA is the absence of suitable veins in the proximity of an ideal lymphatic vessel. In situations like this, the presence of large veins with a higher diameter than the lymphatics is an alternative to consider. In these cases, end-to-side anastomosis is recommended. We describe a helpful technique to perform end-to-side LVA, using a thin catheter to create a round hole in the lateral wall of subdermal veins having the same diameter as the neighboring lymphatic that is going to be anastomosed. We also describe our personal modification of the intravascular stenting technique., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Aims: Women undergoing breast conservation therapy (BCT) for breast cancer are often left with contour defects and few acceptable reconstructive options. RESTORE-2 is the first prospective clinical trial using autologous adipose-derived regenerative cell (ADRC)-enriched fat grafting for reconstruction of such defects. This single-arm, prospective, multi-center clinical trial enrolled 71 patients post-BCT with defects ≤150 mL., Methods: Adipose tissue was collected via syringe lipoharvest and then processed during the same surgical procedure using a closed automated system that isolates ADRCs and prepares an ADRC-enriched fat graft for immediate re-implantation. ADRC-enriched fat graft injections were performed in a fan-shaped pattern to prevent pooling of the injected fat. Overall procedure times were less than 4 h. The RESTORE-2 protocol allowed for up to two treatment sessions and 24 patients elected to undergo a second procedure following the six month follow-up visit., Results: Of the 67 patients treated, 50 reported satisfaction with treatment results through 12 months. Using the same metric, investigators reported satisfaction with 57 out of 67 patients. Independent radiographic core laboratory assessment reported improvement in the breast contour of 54 out of 65 patients based on blinded assessment of MRI sequence. There were no serious adverse events associated with the ADRC-enriched fat graft injection procedure. There were no reported local cancer recurrences. Injection site cysts were reported as adverse events in ten patients., Conclusion: This prospective trial demonstrates the safety and efficacy of the treatment of BCT defects utilizing ADRC-enriched fat grafts., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Extensive posterior chest wall defects, especially those closer to the midline of the trunk, pose surgical challenges in plastic surgery. In these cases, prior to tissue coverage, the status of the pleural cavity and skeletal support need to be addressed to obtain a functional and anatomical reconstruction. We recently operated upon a patient presenting with an aggressive ossifying fibromyxoid tumour located in the lower dorsal paraspinal region on the right side. After ablative surgery and intra-operative radiotherapy, a broad defect in the chest wall of 15 x 10 cm, including the proximal part of five posterior ribs, was presented. It required immediate bony frame reconstruction, which was resolved with a Goretex patch wrapped with a de-epithelised myocutaneous pedicled transverse rectus abdominus myocutaneous (TRAM) flap, transposed through the right hemithorax. The patient was extubated 2 days after surgery and discharged in 10 days. We describe the use of an intra-thoracic TRAM flap to reach the posterior chest wall defects, and we propose its specific indication for reconstruction of extensive posterior chest wall defects when other options are unavailable., (Copyright (c) 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The development of the DIEP flap established an accepted concept of reconstructive surgery, but in patients who demonstrate inadequate in vivo flap perfusion, alternative surgical options to improve vascularisation are limited. We present a 42-year-old patient, with a left mastectomy whose breast was reconstructed with a DIEP flap. After anastomosis to the internal mammary vessels there was insufficient arterial perfusion of the flap. The situation was resolved by using an independent medial perforator artery emerging from the peritoneal layer (epiperitoneal vessels). This new pedicle was anastomosed end-to-end to the distal portion of the inferior epigastric artery. We consider that epiperitoneal vessels can be an emergency pedicle when needed and a possible alternative to the main pedicle of the DIEP flap.

Unlabelled: The benefits of a VEGF-secreting endothelised scaffold on the survival of distal flaps with early pedicle flap division were evaluated in a rabbit model. We bioengineered a scaffold based on a fibrin matrix in which endothelial cells, genetically modified with a VEGF-encoding adenoviral vector were embedded. We distributed subjects in four groups., Control: Eight rabbits conditioned with endothelial cells embedded in a fibrin scaffold. The pedicle was divided after a period of 5 days; and eight rabbits conditioned with endothelial cells embedded in a fibrin scaffold but in this group the pedicle was divided after a period of 2 days., Treatment: Eight rabbits conditioned with VEGF-secreting endothelial cells embedded in a fibrin scaffold; the pedicle was divided after a period of 5 days. And eight rabbits conditioned with VEGF-secreting endothelial cells but the pedicle was divided after a period of 2 days. The percentages of survival were 95.62+/-4.95% for the VEGF-producing scaffold vs. 51.25+/-45.88% for a non-VEGF secreting scaffold when sectioning the pedicle after 5 days. The percentage of survival of flaps in the group grafted with the VEGF-secreting scaffold was 55.62% compared to 2.5% in the group receiving the non-VEGF scaffold when the pedicle was sectioned after 2 days. The CD 31 immunostaining studies showed a dramatic increase in angiogenesis in the flaps conditioned by the VEGF-producing scaffolds. These data revealed that endothelised VEGF-secreting scaffold during flap creation could be a suitable approach in reconstructive surgery.

Infiltrating lipoma is a rare variety of lipoma, characterized by an infiltration of the adipose tissue of the muscles. Infiltrating lipomas are usually classified in two groups: intermuscular infiltrating lipoma and intramuscular infiltrating lipoma. Most are acquired, and they usually appear in middle-aged individuals. Exceptionally, they are congenital. In such cases they are not related to other diseases. We report an 8-year-old boy with a congenital infiltrating lipoma of the upper limb and von Willebrand disease. Both diseases are linked to an alteration in chromosome 12, but this clinical association seems to be random rather than causal.

Gorlin-Goltz syndrome is an autosomal dominant disorder with variable penetration characterized primarily by five major findings: multiple basal cell carcinomas presenting at a young age, pits on the palms and soles, skeletal abnormalities, jaw cysts, and ectopic calcification of the falx cerebri and other structures. When the basal cell carcinomas are located in the head and neck there is a high risk of invasion of deep structures if early and radical treatment is not performed. The authors present a 59-year-old man affected by basal cell carcinoma in the context of Gorlin-Goltz syndrome. Although patients with this syndrome can present aggressive basal cell carcinomas, it is unusual to find them involving the craniofacial bones. In this patient the basal cell carcinoma involved the middle ear, the intrapetrous aspect of the facial nerve, and the dura mater. The reconstruction of a wide three-dimensional defect, in which the brain was exposed, was achieved with local flaps and a free musculocutaneous rectus abdominis flap. Factors affecting reconstruction in the lateral cranial base are discussed.

We have done an experimental study in lambs in which we investigated the influence of flow rate on free microvascular flaps using polytetrafluoroethylene (PTFE) vascular grafts. We set up five surgical groups in which blood flow was progressively increased through the PTFE vascular graft. In group I (venous autograft) we observed just one vascular thrombosis which was located at the site of the anastomosis. In group II (PTFE 3 x 10 mm) all the microvascular flaps became necrosed after the third postoperative day. In group III (PTFE 3 x 10 mm) necrosis also developed in all cases, but the anastomoses remained permeable no longer than eight days. In group IV (3 x 15 mm) the permeability in the microvascular free flaps was about 40% after 21 days, and in group V (3 x 10 mm) it reached 70%. To match graft flow rates with flap survival we did a regression analysis of flow rates for groups II, III, and V and the corresponding survival periods for the flaps. There was a clear and highly significant relationship (r = 0.717, p = 0.0001). In conclusion, it is necessary to maintain blood flow through the prosthesis at a rate higher than the thrombogenic threshold. When the flow rate in the vessels through the PTFE grafts was higher, the viability of the flaps was better. The ideal surgical technique should always be based on an arteriovenous fistula distal to the PTFE vascular graft. It is necessary to maintain blood flow through a prosthesis at a rate higher than the thrombogenic threshold.