Perioperative Hyperspectral Imaging to Assess Mastectomy Skin Flap and DIEP Flap Perfusion in Immediate Autologous Breast Reconstruction: A Pilot Study

Mastectomy skin flap necrosis (MSFN) and partial DIEP (deep inferior epigastric artery perforator) flap loss represent two frequently reported complications in immediate autologous breast reconstruction. These complications could be prevented when areas of insufficient tissue perfusion are detected intraoperatively. Hyperspectral imaging (HSI) is a relatively novel, non-invasive imaging technique, which could be used to objectively assess tissue perfusion through analysis of tissue oxygenation patterns (StO2%), near-infrared (NIR%), tissue hemoglobin (THI%), and tissue water (TWI%) perfusion indices. This prospective clinical pilot study aimed to evaluate the efficacy of HSI for tissue perfusion assessment and to identify a cut-off value for flap necrosis. Ten patients with a mean age of 55.4 years underwent immediate unilateral autologous breast reconstruction. Prior, during and up to 72 h after surgery, a total of 19 hyperspectral images per patient were acquired. MSFN was observed in 3 out of 10 patients. No DIEP flap necrosis was observed. In all MSFN cases, an increased THI% and decreased StO2%, NIR%, and TWI% were observed when compared to the vital group. StO2% was found to be the most sensitive parameter to detect MSFN with a statistically significant lower mean StO2% (51% in the vital group versus 32% in the necrosis group, p < 0.0001) and a cut-off value of 36.29% for flap necrosis. HSI has the potential to accurately assess mastectomy skin flap perfusion and discriminate between vital and necrotic skin flap during the early postoperative period prior to clinical observation. Although the results should be confirmed in future studies, including DIEP flap necrosis specifically, these findings suggest that HSI can aid clinicians in postoperative mastectomy skin flap and DIEP flap monitoring.

Microsurgical reconstruction of the skull base and midface after orbitomaxillary resections for malignant tumors

Background. Orbitomaxillary resection includes exenteration of the orbital contents with resection of the inferior orbital and medial walls. The main goals are: reconstruction of soft tissue and bone structure defects, tamponade of the orbital cavity and/or its preparation for further ocular prosthetics, and reconstruction of the skull base defect. The purpose of the study to present the immediate results of orbitomaxillary resections in patients with malignant neoplasms of the skull base and midface. Material and methods. Between 2014 and 2020, 6 patients who previously underwent surgery for primary cancer (n=3) and recurrent cancer (n=3) were treated at the Head and Neck cancer department of N.N. Blokhin National medical Research center of oncology. To reconstruct defects after resection of bone structures (maxilla, frontal and nasal bones) and skin, a musculocutaneous alt-flap was used in 3 (50 %) cases and a fascial skin radial flap in 3 (50 %) cases. Results. The aesthetic result was assessed in 6 patients. In all cases, a satisfactory result was obtained. None of the patients who underwent resection of the dura mater followed by reconstruction had no symptoms of liquorrhea in the postoperative period. Conclusion. Flap selection depends on the defect size. In cases with a small defect size (up to 70 cm3), reconstruction with the radial fascial skin flap can be performed. If the defect size is more than 71 cm3, reconstruction with musculocutaneous alt flap can be the method of choice.

Cold Atmospheric Plasma, Platelet-Rich Plasma, and Nitric Oxide Synthesis Inhibitor: Effects Investigation on an Experimental Model on Rats

The evolution of reconstructive methods for defects of the human body cannot yet replace the use of flap surgery. Research is still preoccupied with the ideal techniques for offering the best chances of survival of the flaps. In our study, we investigated the effects of cold atmospheric plasma (CAP), N-nitro-L-arginine methyl ester (L-NAME), and platelet-rich plasma (PRP) injectable solutions on flap survival using an in vivo model. Twenty-four Wistar rats (four groups) had the McFarlane flap raised and CAP, L-NAME, and PRP substances tested through a single dose subcutaneous injection. The control group had only a saline solution injected. To the best of our knowledge, this is the first study that evaluated a CAP activated solution through injection on flaps. The flap survival rate was determined by clinical examination (photography documented), hematology, thermography, and anatomopathological tests. The image digital analysis performed on the flaps showed that the necrosis area (control—49.64%) was significantly lower for the groups with the three investigated solutions: CAP (14.47%), L-NAME (18.2%), and PRP (23.85%). Thermography exploration revealed less ischemia than the control group on the CAP, L-NAME, and PRP groups as well. Anatomopathological data noted the best degree of angiogenesis on the CAP group, with similar findings on the L-NAME and PRP treated flaps. The blood work did not indicate infection or a strong inflammatory process in any of the subjects. Overall, the study shows that the CAP activated solution has a similar (better) impact on the necrosis rate (compared with other solutions with known effects) when injected on the modified dorsal rat skin flap, and on top of that it can be obtained fast, in unlimited quantities, non-invasively, and through a standardized process.

The First Stage of Acquired Syndactyly Reconstruction - A Rare Case Report

Background: Acquired syndactyly is a very rare disorder on the interdigital area. Syndactyly with only soft tissue involvement can be a sequela of trauma, such as burn, inflammation or infection in the interdigital area, resulting in bony fusion following crush injury. Case Report: An 8-year-old boy came to our department with fusion from the base to the tip of the first to fourth right toes since the accidental step on burnt plastic 5 years ago. He complained of a poor appearance and discomfort when walking. Then we performed zigzag incision for first to second toes and third to fourth toes. Skin graft closure was performed to cover the defect on third to fourth toes. The second reconstruction surgery will be scheduled 6 months later. Discussion: The surgical techniques for foot syndactyly were derived from those for hand syndactyly, which are to separate the digital fusion by creating local skin flap. Additionally, skin graft might be necessary when recent surgeons avoid the use of skin graft for open treatment, primary closure by defatting, or intricate local flaps. These can shorten the operation time and minimize donor site morbidity. However, surgeons should consider the free tension closure of the wound by combining the skin graft after the flap. Conclusion: Reconstruction procedure for foot syndactyly aims to improve the appearance and function of the toes as well as to avoid progressive deformity through development. The skin graft addition in combination of skin flap shows promising outcome. Key words: acquired syndactyly, syndactyly reconstruction, zigzag flap, skin graft.

Infected Epidermoid Cyst Including Multiple Nails at the Amputated Thumb Stump: A Case Report

Fingertip amputation is a common injury among trauma occurring in the upper extremity. After amputation of the fingertip, there are several treatment options according to the degree of damage. Also, the skin flap is sometimes performed when skin defects are accompanied. Among the complications associated with fingertip injury, cyst formation at the amputation stump is rare but some cases have been reported based on the pathologic findings. There was a case of an infected epidermal inclusion cyst containing multiple nail plates at the amputation stump of the thumb, so we would like to report it with a review of the literature.

Oral Mucosa vs. Penile Skin Flap in Substitution Urethroplasty for Anterior Urethral Strictures: A Systematic Review and Meta-Analysis

Background: The purpose of this study is to compare the effectiveness and safety of oral mucosa and penile skin flaps in the treatment of anterior urethral stricture.Methods: This meta-analysis was carried out according to the principle of preferred reporting items for systematic reviews and meta-analysis (PRISMA) and registered at PROSPERO (CRD42021277688). The Cochrane Library, PubMed, Embase, CKNI databases were searched and reviewed up to Sep 2021. Quality evaluation was performed with Newcastle-Ottawa Scale (NOS) system for non-randomized studies and Cochrane stools for randomized studies. Data synthesis was conducted with RevMan 5.4 software (Cochrane) and a Stata 15.0 environment (Stata Corpor, College Station, TX, USA).Results: After the research screening, eight studies (comprising 445 patients) were finally included in the quantitative analysis. In the success rate comparison, there was no significant difference between oral mucosa and penile skin flaps (oral mucosa vs. penile skin flap, Mantel-Haenszel statistic [M-H] fixed model, OR: 0.80, 95% CI: 0.47–1.34, P = 0.39). There was no significant difference in the post-operative complication comparison (oral mucosa vs. penile skin flap, Mantel-Haenszel statistic [M-H] fixed model, OR: 0.68, 95% CI: 0.40–1.16, P = 0.15). However, considering that the site of oral mucosa is far from the anterior urethra, it may have advantages in operation time through simultaneous operations (oral mucosa vs. penile skin flap, MD: −40.05, 95% CI: −79.42, −0.68, P = 0.046).Conclusion: When the oral mucosal graft was used in the anterior urethra urethroplasty, it had a similar success rate and post-operative complication rate, and oral mucosa substitution had a shorter operation time. This evidence-based medical research further supports the view that oral mucosa is the preferred substitution material for the anterior urethra urethroplasty.

Involvement of cannabinoid type 2 (CB2) receptors in the favorable effects of sumatriptan on the random-pattern skin flap survival in rats: a novel potential target

Introduction: Recent investigations have indicated the potential therapeutic role of cannabinoid type 2 (CB2) receptors in various inflammatory-related disorders. However, the role of these receptors has not been studied in skin flap models previously. In this study, we aimed to evaluate the possible involvement of CB2 receptors in the anti-inflammatory effects of sumatriptan and improvement of the random-pattern skin flap survival in rats. Methods: In a controlled experimental study, 36 male Wistar rats were randomly divided into six study groups (n = 6 per group). Two doses of sumatriptan (0.1 and 0.3 mg/kg) were administered intraperitoneally (i.p) 30 minutes before harvesting the flap tissue. In a separate group, SR144528 (a selective CB2 receptor inverse agonist) was injected before the most effective dose of sumatriptan to determine the possible involvement of CB2 receptors in its action. Histopathological examinations, the expression level of CB2 receptors (by western blot analysis), and IL-1 and TNF-α concentrations (ELISA) were explored in the skin flap samples. Results: Sumatriptan 0.3 mg/kg remarkably enhanced the skin flap survival in all macroscopic and microscopic investigations compared to the control group (P <0.001). IL-1 and TNF-α levels were significantly attenuated (P <0.001), and the expression of CB2 receptors in skin cells was amplified in rats treated with sumatriptan 0.3 mg/kg (p <0.05) compared to the control group. However, the administration of SR144528 (2 mg/kg) nullified all the protective effects of sumatriptan (0.3 mg/kg). Conclusion: We discovered that CB2 receptors play a crucial role in the favorable effects of sumatriptan on skin flap survival as a novel mechanism of action. So, targeting these receptors seems to be a dependable method in skin flap surgeries to ensure its survival and prevent tissue necrosis. Further experimental and clinical investigations are needed to ensure the safe clinical application of this method.

A clinical case of successful treatment of a giant serous endometrial carcinoma imitating ovarian cancer

Background: Giant tumors of the abdominal cavity, as a rule, occur in elderly patients with characteristic features and represent a serious problem in terms of choosing a radical method of therapy. Of particular difficulty are cases of giant serous endometrial cancer, requiring a differential diagnosis with ovarian cancer. Clinical case description: A clinical case of giant serous endometrial cancer mimicking ovarian cancer in a 55-year-old woman is presented. The patient came to the oncology department with complaints of abdominal enlargement, difficulty breathing and bloody discharge from the genital tract. The examination revealed the following: a giant formation (4065 cm), occupying the entire pelvic and the entire abdominal cavities, ascites, lesions of the retroperitoneal lymph nodes, and the greater omentum, an umbilical hernia. A chest CT showed multiple contrast-accumulating circular shadows of 313 mm (metastases). By the decision of the council, after the preliminary chemoembolization of both the uterine and ovarian arteries, a supravaginal amputation of the uterus with appendages was performed, along with the resection of the greater omentum, removal of the umbilical hernia with positioning a plastic mesh implant and excision of an excess skin flap. The histological examination of the intraoperative material made it possible to verify the diagnosis of a serous endometrial carcinoma with subtotal tumor necrosis, the myometrium invasion of more than a half of its thickness, with the egress to the perimetrium, metastatic lesions of both ovaries, the greater omentum, anterior abdominal wall. Stage T3b (FIGO IIIB). In the postoperative period, 6 courses of Paclitaxel / Carboplatin (AUC4-5) chemotherapy were carried out with a pronounced clinical effect. The patient was discharged in a satisfactory condition. The control PET-CT scan after the 6th chemotherapy course showed no pathology in the thoracic cavity, and no process progress in the abdominal cavity. Currently, the remission of the disease is 9 months. Conclusion: An algorithm for the diagnostic measures aimed at making the correct diagnosis is presented, and the tactics of treating a patient with giant serous endometrial cancer is described.

The Prevalence of Surgical Wound Infection in Post-Mandibular Resection of Ameloblastoma Patients

Ameloblastoma, a common form of odontogenic tumor, is usually treated by surgery. However, wound infections remain a significant source of postoperative morbidity, accounting for about a quarter of the total number of nosocomial conditions. Surgical wound infection (SWI) is common after surgery, and in particular, wound infection has been linked with an intraoral surgical opening in 20–40-year-old patients. Common incisional closure complications in oral and maxillofacial surgery include postoperative wound infection, dehiscence, formation of hematomas, and skin flap necrosis, which lead to delayed healing of the incision. The data relating to the incidence of post-mandible resection SWI in Dr. Hasan Sadikin Bandung Hospital are not yet known. Therefore, the objective of this research was to assess the incidence of SWI in ameloblastoma patients after mandible resection treatment. This research adopted an observational and descriptive approach. Based on the inclusion and exclusion criteria, the research subjects were recruited between January 2018 and December 2019. This study showed the occurrence of SWI in 7 patients (2 men and five women) who had mandibular resection treatment for ameloblastoma and whose age range was 30–40 years. The results also revealed that the surgical openings in these patients were intraoral. In conclusion, findings demonstrated a higher prevalence of SWI in women after mandibular resection treatment than in men.