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Background Cranioplasty is both a functional and aesthetical therapeutic option. In the clinical scenario every cranioplasty's material is potentially qualified to achieve the goal of calvarian reconstruction but there is a lack of agreement about the optimum choice, especially between the heterologous ones. The choice of cranioplasty widely depends on surgeon's personal preferences. In this retrospective multicentric study a comparative analysis of hydroxyapatite or titanium cranioplasties was carried on analyzing the main factors considered by the surgeon to choose a material rather than another one. Our results and data were compared with those reported in the scientific literature and a flow-chart regarding the therapeutic approach in the choice of the most suitable cranioplasty was proposed and discussed. Methods The authors present a multicentric study considering 2 groups of patients who underwent 2 different kinds of cranioplasty: hydroxyapatite and titanium. The outcomes measures included the surgical timing and the maintenance of post-operative subgaleal drain. Results A total of 40 patients that had cranioplasty treatment were evaluated. The surgical technique was analyzed. In patients that underwent titanium cranioplasty we observed a reduction in the operative times and in subgaleal drain maintenance. In relation to the age, comorbidity, and neurological status a score, called most suitable material (MSM), was elaborated and a therapeutic algorithm is proposed. Conclusions This study confirms the known advantages and drawback of titanium and hydroxyapatite prostheses. Thanks to the lessons learned from our experience on this field, we elaborated the MSM score that coupled with the therapeutic flow-chart proposed could address the choice of the MSM for a specific patient.

"Orthoplastics" is a relatively new approach to lower limb reconstruction, where an integration of both plastic and orthopedic expertise is required, together with the availability of well-equipped facilities. Acute shortening and long-term frames for lengthening are generally considered alternatives to length preservation and soft tissue microsurgical reconstruction, but an integration of external fixation and reconstructive microsurgery is gaining an increasing role with refinements of joint approaches.Data on sixteen patients who underwent microsurgical lower limb reconstruction and external fixation with an orthoplastic approach, following acute or chronic tibial injury, were retrospectively reviewed. All patients presented a post traumatic soft tissue defect associated with a Gustilo III tibial fracture or a tibial septic pseudarthrosis. Data on type and timing of bone and soft tissue reconstruction, outcomes, complications and need for re-operation were extrapolated and compared to an historic group of patients treated with an orthopedic-based approach.In the orthoplastic group, soft tissues were reconstructed with an ALT flap in most cases; a muscle-sparing VL or ALT-VL chimeric flap was necessary in cases with a very extensive defect. In the orthopedic group, soft tissues were left to heal by second intention or patients were lately referred to plastic surgeons. Statistical comparison between the two groups has showed significant differences on the following data: time for soft tissue healing, time to bone union, number of reinterventions, post-operative deep infection rate, time to return to work.The orthoplastic approach to complex leg defects yields shorter treatment time and better functional results compared to the orthopedic-based approach. External fixation and microsurgical reconstruction are not necessarily alternative procedures but can integrate in an orthoplastic path to address at best both soft tissue and bone reconstruction.Die „Orthoplastie“ ist ein relativ neuer Ansatz zur Rekonstruktion der unteren Extremitäten, der eine Integration von plastisch-chirurgischer und orthopädischer Fachkompetenz sowie die Verfügbarkeit gut ausgestatteter Einrichtungen erfordert. Die akute Verkürzung mit längerfristig angelegtem Rahmen zur Verlängerung gelten generell als Alternativen zum Längenerhalt mit mikrochirurgischer Weichteilrekonstruktion, doch gewinnt die integrierte Behandlung mit Fixateur externe und rekonstruktiver Mikrochirurgie zunehmend an Bedeutung und die gemeinsamen Ansätze werden weiter verfeinert.Es erfolgte eine retrospektive Analyse der Daten von sechzehn Patienten, die sich nach akuter oder chronischer Tibiaverletzung einem orthoplastischen Verfahren mit mikrochirurgischer Rekonstruktion der unteren Extremität und Fixateur externe unterzogen. Bei allen Patienten fand sich ein posttraumatischer Weichteildefekt in Verbindung mit einer Tibiafraktur vom Grad III nach Gustilo oder einer septischen Pseudarthrose der Tibia. Die Daten zu Art und Zeitpunkt der Knochen- und Weichteilrekonstruktion, Ergebnissen, Komplikationen und Notwendigkeit einer Reoperation wurden extrapoliert und mit denen einer historischen Patientengruppe verglichen, die orthopädisch behandelt worden war.In der orthoplastischen Gruppe wurden die Weichteile in den meisten Fällen mit einem anterolateralen Oberschenkellappen (ALT-Flap) rekonstruiert. Bei Patienten mit großflächigem Defekt war eine muskelschonende Vastus-lateralis-Lappenplastik (VL) oder eine chimäre ALT-VL-Lappenplastik erforderlich. In der orthopädischen Gruppe wurden die Weichteile einer Sekundärheilung überlassen oder die Patienten wurden später an einen plastischen Chirurgen überwiesen. Ein statistischer Vergleich zwischen den beiden Gruppen ergab signifikante Unterschiede hinsichtlich folgender Daten: Zeit bis zur Heilung der Weichteile, Zeit bis zur knöchernen Durchbauung, Anzahl der Reinterventionen, Rate tiefer postoperativer Infektionen und Zeit bis zur Wiederaufnahme der Berufstätigkeit.Der orthoplastische Ansatz bei komplexen Beindefekten bietet im Vergleich zu orthopädischen Verfahren kürzere Behandlungszeiten und liefert bessere funktionelle Ergebnisse. Die Behandlung mit Fixateur externe und die mikrochirurgische Rekonstruktion müssen sich nicht gegenseitig ausschließen, sondern können in einem orthoplastischen Behandlungspfad miteinander kombiniert werden, um eine bestmögliche Rekonstruktion sowohl der Weichteile als auch des Knochens zu erzielen.

Patient: Female, 82 Final Diagnosis: Giant basal cell carcinoma Symptoms: Anemia Medication: — Clinical Procedure: — Specialty: Plastic Surgery Objective: Rare disease Background: Basal cell carcinoma (BCC) greater than 5 cm in diameter is called giant basal cell carcinoma (GBCC), or super giant basal cell carcinoma if it has a diameter larger than 20 cm. Giant BCC only accounts for 0.5% of BCCs and super giant BCC is exceedingly rare. On account of their rarity, there are no established guidelines for GBCC treatment. Case Report: We describe a peculiar case of an 82-year-old woman with a GBCC carcinoma of the lower abdominal wall. The tumor was surgically removed with ipsilateral inguinal lymph nodes and the abdominal wall was reconstructed immediately with a pedicled deep inferior epigastric artery perforator (DIEP) flap. Conclusions: Treatment of giant basal cell carcinoma is often difficult, especially in elderly patients with poor general health and multiple pathologies. The pedicled DIEP flap is rotated to cover the loss of substance without tension, and it is easy to harvest and transfer. This flap allowed a good result without local or systemic complication. We present this report as a reminder of the occasional occurrence of extremely aggressive BCCs. We believe that, especially for rare tumors like these, it is very useful for the entire scientific community to publish these cases and the therapeutic strategies used to treat them.

Background: The aim of this study was to assess the effect of seeding the distal nerve suture with nerve fragments in rats. Methods: On 20 rats, a 15 mm sciatic nerve defect was reconstructed with a nerve autograft. In the Study Group (10 rats), a minced 1 mm nerve segment was seeded around the nerve suture. In the Control Group (10 rats), a nerve graft alone was used. At 4 and 12 weeks, a walking track analysis with open field test (WTA), hystomorphometry (number of myelinated fibers (n), fiber density (FD) and fiber area (FA) and soleus and gastrocnemius muscle weight ratios (MWR) were evaluated. The Student t-test was used for statistical analysis. Results: At 4 and 12 weeks the Study Group had a significantly higher n and FD (p =.043 and.033). The SMWR was significantly higher in the Study Group at 12 weeks (p =.0207). Conclusions: Seeding the distal nerve suture with nerve fragments increases the number of myelinated fibers, the FD and the SMWR. The technique seems promising and deserves further investigation to clarify the mechanisms involved and its functional effects.

Background The use of vascular grafts is indicated in case of insufficient pedicle length or for complex defects involving both soft tissues and vessels. Venous grafts (for both venous and arterial reconstructions) and arterial grafts (arterial reconstruction) can be used. This study retrospectively evaluated the needs for vascular reconstruction and its results in a clinical series of lower limb reconstructions with microsurgical free flaps. Materials and Methods From 2010 to 2015, a total of 16 vascular grafts or flow-through flaps were used in 12 patients out of a total of 150 patients undergoing microsurgical reconstruction (8%). Arterial reconstruction was performed in seven cases (six flow-through flaps, one arterial graft), combined arterial and venous reconstruction in four cases (three vein grafts, one combined venous/arterial graft), and venous reconstruction in one case (one venous graft). The rate of complications and donor-site morbidity related to vascular graft harvest were evaluated. Results Reconstruction was successful in all cases, despite an overall complication rate of 17 and 8% of surgical revision. Donor-site morbidity, subjectively evaluated, was minimal with respect to functional deficits and aesthetic outcome. Indications for the different types of grafts are discussed. Conclusion The use of vascular grafts is needed in a relevant percentage of microsurgical reconstruction cases. Venous and arterial vascular grafts, transient arteriovenous fistulas, and “flow-through” microsurgical flaps showed a safe reconstruction comparable to microsurgical reconstructions without the use of grafts. Donor-site morbidity secondary to vascular graft harvest is minimal, and in almost 70% of cases no additional scars are needed.

Background Several authors described the presence of malignant tumors that rarely can grow hidden over rhinophymatous skin. Basal cell carcinoma (BCC) is the most commonly reported tumor and it should always be sought and diagnosed in presence of a rhinophyma.

Background: Keloid is a fibroproliferative disorder characterized by an abnormal deposition of collagen within a wound. Despite an increased understanding of wound healing and collagen metabolism, the exact cause, the clinical behavior, and gold standard of treatment for keloids remain an enigma. There is no one right way of treatment, the results are variable, and the management of ear keloids can be difficult and frustrating both for patients and physicians. Traditional techniques include intralesional steroids, topical applications of silicone, vitamins, and segmental excision by lasers or surgery. The purposes of this article are to review the literature concerning the current therapies as well as to present the authors’ experience in the treatment of major ear keloids. Methods: Twenty-seven consecutive black race patients (18 cases and 9 controls) underwent surgery for major keloids of the external ear at the Plastic and Reconstructive Surgery Unit of University of Palermo. The authors performed the radical excision and intralesional triamcinolone acetonide injection intraoperative and 1month after surgical treatment. Results: No complications were noticed in the early postoperative period, and no recurrence was noticed in all the patients. Conclusions: The radical excision and the intralesional triamcinolone acetonide injection appear to be a successful option of treatment for major ear keloids. Compared to other methods, it does not necessitate several stages of treatment, moreover, it has the advantages to lower the risk of recurrence, the healing process is rapid, and improvement of quality of life is significant. Level of evidence: Level IV, therapeutic study

Background: Reconstruction of large defects in the temporal region can be performed with skin grafts or pedicled or free flaps. Results are often not optimal because of the patch of a skin graft, lack of availability of local flaps, and distant skin from free flaps. A technique for reconstruction of these defects with local tissue is presented in this article that uses superficial musculoaponeurotic system (SMAS) plication to allow wide advancement of a cervicofacial flap. Methods: Once the defect is outlined, a face-lift–like skin incision is used to raise the flap. The SMAS is plicated with two purse-string sutures that relieve tension on the flap and allow maximal advancement. Thirteen face-lift SMAS plication flaps were used in 12 patients (mean age, 70.2 years) after cancer resection, which was bilateral in one case. Defects up to 8 cm in largest diameter can be closed. In one case of an 8 6-cm defect, a 1 1.5-cm skin graft was necessary. Results: All flaps healed uneventfully, and no reoperation was necessary. Scars are almost completely hidden and the cosmetic result is satisfactory. The asymmetrical face-lift effect fades out within 6 months. Conclusions: The face-lift SMAS plication (FLISP) flap allows reconstruction of large defects in the temporal region with a local flap providing an excellent cosmetic result and avoiding the need for distant tissue and multiple scarring. This flap provides an example of how reconstructive surgery and cosmetic surgery are complementary and can be mutually beneficial. (Plast. Reconstr. Surg. 127: 2068, 2011.)