Regenerative potential of the sural neuroadipofascial flap in the treatment of chronic ulcers of the lower third of the leg

OBJECTIVE

Surgical reconstruction of soft tissue defects in the distal third of the lower limbs has always been challenging for surgeons. The adipofascial flaps are made up of vascularized adipose tissue, which plastically conforms to the site to be reconstructed with its rich presence of stem cells. In this study, we resumed our case history of reverse neuroadipofascial sural flap, and we evaluated the stability of the scar to verify if this type of reconstruction can ensure long-term results and its regenerative power.

PATIENTS AND METHODS

In this retrospective cohort study, we analyzed 32 patients who had undergone lower limb reconstruction with the sural neuroadipovenous flap.

RESULTS

A total of 32 patients were included in the study. The average age was 62.2 years. Chronic skin ulcer was the cause of the defects in 13 (40.6%) patients, chronic wound after trauma in 7 (21.9%) patients, wheel bedsores in 4 (12.5%) patients, osteomyelitis in 5 (15.6%) patients, exposed internal hardware in 2 (6.3%) patients, dog bite in 1 (3.1%). The site defect comprised 11 heels (34.4%), 4 external malleoli (12.5%), three medial malleoli (9.4%), 12 lower third of the leg (37.5%), and two dorsa of the foot (6.3%). In all cases, defects were covered with reverse sural island flap. The dimension of the flap ranged from 5 to 9 cm in length and from 3 to 7 in width. Six patients showed early or later postoperative complications.

CONCLUSIONS

The neuroadipofascial sural flap is versatile, fast, and easy-to-perform to cover a chronic defect in the distal part of the lower limb, including both the malleoli and the heel, due to its long vascular pedicle. Consistent with the studies carried out in other districts, the present study confirms the remarkable regenerative power of the vascularized adipose tissue at the level of complex wounds of the lower third of the leg.

Lumbrical Muscles Neural Branching Patterns: A Cadaveric Study With Potential Clinical Implications

BACKGROUND

Lumbrical muscles originate in the palm from the 4 tendons of the flexor digitorum profundus and course distally along the radial side of the corresponding metacarpophalangeal joints, in front of the deep transverse metacarpal ligament. The first and second lumbrical muscles are typically innervated by the median nerve, and third and fourth by the ulnar nerve. A plethora of lumbrical muscle variants has been described, ranging from muscles' absence to reduction in their number or presence of accessory slips. The current cadaveric study highlights typical and variable neural supply of lumbrical muscles.

MATERIALS

Eight (3 right and 5 left) fresh frozen cadaveric hands of 3 males and 5 females of unknown age were dissected. From the palmar wrist crease, the median and ulnar nerve followed distally to their terminal branches. The ulnar nerve deep branch was dissected and lumbrical muscle innervation patterns were noted.

RESULTS

The frequency of typical innervations of lumbrical muscles is confirmed. The second lumbrical nerve had a double composition from both the median and ulnar nerves, in 12.5% of the hands. The thickest branch (1.38 mm) originated from the ulnar nerve and supplied the third lumbrical muscle, and the thinnest one (0.67 mm) from the ulnar nerve and supplied the fourth lumbrical muscle. In 54.5%, lumbrical nerve bifurcation was identified.

CONCLUSION

The complex innervation pattern and the peculiar anatomy of branching to different thirds of the muscle bellies are pointed out. These findings are important in dealing with complex and deep injuries in the palmar region, including transmetacarpal amputations.

Giant sacral schwannoma excised under intraoperative neuromonitoring in an elderly patient: case report

Schwannomas are mainly benign tumors arising from the Schwann cells of the peripheral nerve sheath. These tumors can often be associated with non-specific symptoms, such as abdominal heaviness. In this article, we present a detailed description of the surgical management of a giant sacral schwannoma in an elderly patient, for which intraoperative neuromonitoring made it possible to distinguish easily the nerves of the sacral plexus from which the tumor originated and to remove it without complications. Treatment of these rare and symptomatic giant tumors is still a challenge for surgeons; to treat adequately these tumors; a multidisciplinary approach is required to ensure an optimal therapeutic approach to reduce the risk of recurrence and, on the other hand, is not associated with unnecessary iatrogenic neurological damage.

Pilomatrixoma of the right thigh: Sonographic-pathologic correlation in a young man

Pilomatrixoma, also known as calcifying epithelioma of Malherbe, is a histological type of benign subcutaneous tumor arising from the cutaneous adnexa. We present our experience and the characteristic findings of a pilomatrixoma of the right thigh in a young healthy man. The lesion had grown slowly in size over the past year and this was the reason for referral to the Department of Plastic Surgery. Ultrasound imaging was performed and, through the use of B-mode, color-Doppler, and elastosonography, the lesion was depicted. The patient was therefore scheduled for surgery.

Pilomatrixomas at times can pose a diagnostic challenge, especially when the location is unusual. Ultrasound and its tools, that is, color-Doppler and elastography, can assist the clinician arising the suspicion of pilomatrixoma.

Activation of the EPOR-β common receptor complex by cibinetide ameliorates impaired wound healing in mice with genetic diabetes

Diabetes is characterized by poor wound healing which currently lacks an efficacious treatment. The innate repair receptor (IRR) is a master regulator of tissue protection and repair which is expressed as a response injury or metabolic stress, including in diabetes. Activation of the IRR might provide benefit for diabetic wound healing. A specific IRR agonist cibinetide was administered in an incisional wound healing model performed mice with genetic diabetes (db⁺/db⁺) and compared to the normal wild-type. Animals were treated daily with cibinetide (30μg/kg/s.c.) or vehicle and euthanized 3, 7, and 14days after the injury to quantitate vascular endothelial growth factor (VEGF), malondialdehyde (MAL), phospho-Akt (pAkt), phospho e-NOS (p-eNOS), and nitrite/nitrate content within the wound. Additional evaluations included quantification of skin histological change, angiogenesis, scar strength, and time to complete wound closure. Throughout the wound healing process diabetic animals treated with vehicle exhibited increased wound MAL with reduced VEGF, pAkt, peNOS and nitrite/nitrate, all associated with poor re-epitheliziation, angiogenesis, and wound breaking strength. Cibenitide administration significantly improved these abnormalities. The results suggest that cibinetide-mediated IRR activation may represent an interesting strategy to treat diabetes-associated wound healing.

The reasons for end-to-side coaptation: how does lateral axon sprouting work?

Nerve fibers are attracted by sutureless end-to-side nerve coaptation into the recipient nerve. Opening a window in the epineurium enhances axon attraction and myelination. The authors analyze the features of nerve repair by end-to-side coaptation. They highlight the known mechanisms of axon sprouting and different hypotheses of start up signals (presence or absence of an epineurial window, role of Schwann cells, signaling from the distal trunk). The clinical literature is also presented and differences between experimental and clinical applications are pointed out. The authors propose their point of view and perspectives deriving from recent experimental and clinical experiences.

Lipograft in cicatricial ectropion

AIM

Cicatricial ectropion is secondary to an excessive scar contraction after trauma, burns, skin conditions, scarring skin tumours, medication, allergies, blepharoplasty complications 1,2. The estimates for ectropion incidence following removal of eyelid lesions have been reported as varying from 2.5% to 7% 3. A variety of surgical techniques can be applied to achieve the correct shape and position of lower lid 4-7. Fat grafts in association with other technique are commonly used in orbital reconstruction in a variety of procedures 8 including of the correction of cicatricial ectropion 9,10.

MATERIAL OF STUDY

The Authors propose the use of fat graft as only procedure for the correction of cicatricial lower eyelid ectropion. Two male patients with cicatricial ectropion were treated with this technique in two time and followed for 12 months.

RESULTS

Lipofilling for cicatricial eyelid ectropion give excellent outcomes, with release of the scar without recurrence, 11.

DISCUSSION

Autologous fat grafting has many clinical applications, and its use in Plastic Surgery is increasing: The key point is the presence into fat of Adipose stem cells (ASCs), that have been identified as an ideal source of cells for regenerative medicine, with potential and rapid improvement of healing process and complete recovery of tissue integrity after surgery to confirm the regenerative effect of fat graft.

CONCLUSION

Lipografting can be considered a safe and effective alternative procedure 12,13.

KEY WORDS

Defect of lower lid, Ectropion, Lipograft.

AAV vector encoding human VEGF165-transduced pectineus muscular flaps increase the formation of new tissue through induction of angiogenesis in an in vivo chamber for tissue engineering: A technique to enhance tissue and vessels in microsurgically engineered tissue

In regenerative medicine, new approaches are required for the creation of tissue substitutes, and the interplay between different research areas, such as tissue engineering, microsurgery and gene therapy, is mandatory. In this article, we report a modification of a published model of tissue engineering, based on an arterio-venous loop enveloped in a cross-linked collagen–glycosaminoglycan template, which acts as an isolated chamber for angiogenesis and new tissue formation. In order to foster tissue formation within the chamber, which entails on the development of new vessels, we wondered whether we might combine tissue engineering with a gene therapy approach. Based on the well-described tropism of adeno-associated viral vectors for post-mitotic tissues, a muscular flap was harvested from the pectineus muscle, inserted into the chamber and transduced by either AAV vector encoding human VEGF₁₆₅ or AAV vector expressing the reporter gene β-galactosidase, as a control. Histological analysis of the specimens showed that muscle transduction by AAV vector encoding human VEGF₁₆₅ resulted in enhanced tissue formation, with a significant increase in the number of arterioles within the chamber in comparison with the previously published model. Pectineus muscular flap, transduced by adeno-associated viral vectors, acted as a source of the proangiogenic factor vascular endothelial growth factor, thus inducing a consistent enhancement of vessel growth into the newly formed tissue within the chamber. In conclusion, our present findings combine three different research fields such as microsurgery, tissue engineering and gene therapy, suggesting and showing the feasibility of a mixed approach for regenerative medicine.

Anterolateral adipofascial turnover flap of the leg: Anatomical study

AIM

The aim of this study is to clearly define the vascularisation of the lateral paratibial septum of the leg, defining the basis for a vertical pedicled adipofascial flap harvested from the anterolateral aspect of the leg to cover pretibial soft tissue defects.

MATERIALS AND METHODS

Twelve cadaver legs (eight fixed with formalin and four fresh) were dissected. The vessels running into the lateral paratibial septum were identified. The number of vessels were noted and evaluated at the lateral border of the proximal, middle and distal thirds of the leg. In addition, an angiographic study was performed on two limbs to confirm the connection between tibialis anterior artery and the overlaying fascia through these septal vessels.

RESULTS

All the specimens had periosteo-septal vessels running in the lateral aspect of the tibia. The average number was 6.6. The distribution was constant in all the thirds of the leg.

CONCLUSION

These data are useful to propose the harvesting technique for adipofascial flap with vertical pedicle as a suitable reconstructive option to cover pretibial soft tissue defects.

Inhibition of inflammasome activation improves the impaired pattern of healing in genetically diabetic mice

BACKGROUND AND PURPOSE

Type 2 diabetes impairs the healing process because of an exaggerated and persistent inflammatory response, and an altered expression pattern of angiogenic molecules. We investigated the effects of inflammasome blockade in diabetes-related wound-healings defects, in genetically diabetic mice.

EXPERIMENTAL APPROACH

An incisional skin wound model was produced on the back of female diabetic C57BL/KsJ-m +/+ Lept(db) mice (db⁺ /db⁺) and their normal littermates (db⁺ /m⁺). Animals were treated daily with two inflammasome blocking agents, BAY 11-7082 (20  mg·kg⁻¹ i.p.), or Brilliant Blue G (BBG, 45.5 mg·kg⁻¹ i.p.), or vehicle. Mice were killed on 3, 6 and 12 days after skin injury to measure expression of the NOD-like receptor NLRP3, caspase-1, VEGF, the inflammasome adapter protein apoptosis-associated speck-like protein containing a caspase recruitment domain (ASC) and the chemokine CXCL12. Wound levels of IL-1β and IL-18 were also measured, along with histological assessments of wound tissue and the time to complete wound closure.

KEY RESULTS

During healing, the diabetic mice exhibited increased activation of NLRP3, caspase-1, ASC, IL-1β and IL-18. They also showed a reduced expression of VEGF and CXCL12.Treatment with BAY 11-7082 or BBG, to block activation of the inflammasome, decreased the levels of pro-inflammatory molecules. Histological evaluation indicated that inflammasome blockade improved the impaired healing pattern, at day 12 in diabetic mice, along with a decreased time to complete skin healing.

CONCLUSIONS AND IMPLICATIONS

These data strongly suggest that activation of the NLRP3 inflammasome is one of the key contributors to the delayed healing of wounds in diabetic mice.

Dorsalis Pedis Adipofascial Perforator flap for great toe reconstruction: anatomical study and clinical applications

Defects of the dorsum of the foot can be challenging to reconstruct, none more so than the dorsum of the toe. The reverse Dorsalis Pedis Adipofascial Perforator (DPAP) flap is one possible reconstructive option for defects in this region. The aim of this study was to first demonstrate the anatomy of this flap, particularly the consistency of the perforators arising from the dorsalis pedis artery. Second, we present a clinical series based on this flap to demonstrate how it can be used. For the anatomical studies, 22 fresh cadaveric lower extremities were dissected, and injection studies were used to delineate the vascular territories. The presence of the distal perforator, distance to the first metatarso-phalangeal joint and diameter of each perforator were recorded. The cadaveric studies confirmed the presence of distal perforators to the first metatarso-phalangeal joint in 100% of limbs examined. The clinical study demonstrated the feasibility of the use of the adipofascial turn-over perforator flap for dorsal foot reconstruction. These anatomic findings provide an alternative method of reconstruction of great toe defects using the reverse DPAP flap.

Invasive macrodystrophia lipomatosa of the hand

OBJECTIVE

The Authors point out the interest of differential diagnosis and conservative surgical treatment of a rare case of digital and ulnar side of the hand gigantism, with massive fatty infiltration of soft tissues and a neurovascular bundle, to be included into Macrodystrophia Lipomatosa with fibrolipomatous hamartomata.

PATIENTS AND METHODS

Excision of the mass included 4th ray disarticulation (the fifth had been amputated several years ago) as well as microsurgical external and internal neurolysis of the ulnar nerve, the ulnar neurovascular bundle being exposed and covered with dermal substitute INTEGRATM, with a good result both from a cosmetic and functional point of view at three year follow up.

RESULTS

This is the first report of INTEGRATM covering of a neurovascular bundle. Samples taken from the dermal substitute matrix interface at day 6 and day 25 were examined with transmission Electron Microscopy: a newly formed tissue, rich in precursor cells, was detected.

CONCLUSIONS

Conservative surgery, requiring particular microsurgical skills and use of dermal templates, plays an outstanding role in treatment of these rare but aggressive soft tissues masses of the upper limb.

Should fat graft be recommended in tendon scar treatment? Considerations on three cases (two feet and a severe burned hand)

OBJECTIVES

Lipostructure has been reported as a successful ancillary tool for surgery in tenolysis procedures, but to date no reports of its capability to resolve tendon adherence without further surgery have been reported. The aim of this study is to highlight the role of lipografting in the treatment of tendon and joint adherences.

PATIENTS AND METHODS

In our experience, we started treating important tendon adherences together with nerve entrapment on the dorsal aspect of the foot in two cases and in a severe burned hand.

RESULTS

We achieved good results both in terms of function and sensory recovery. A twenty four month follow up showed good maintenance of the ROM. We also reported gaining of almost 30-40 degrees of a flexion contracure in the second finger of a burned hand, minimizing further surgery for scar contracture and tenoarthrolysis, with a stable follow up.

CONCLUSIONS

We suggest that prior to refer to surgery scars involving tendons as well as joints should be considered for lipografting.

Homodigital dorsal adipofascial reverse flap: anatomical study of distal perforators and key points for safe dissection

Dorsal adipofascial flaps have been used in the surgical reconstruction of complex injuries distal to the eponychial fold. Such injuries produce nail matrix devascularization/necrosis so that nail bed reconstruction can be a challenging technical problem. Irregular scarring of the nail bed and regrowth anomalies of the nail lamina can result, with both functional and cosmetic impairment of the finger. This study aimed to define the precise vascular anatomy of the dorsal adipofascial flap that has previously been used to reconstruct such complex soft tissue defects. Specifically, the purpose was to identify the key points of safe dissection for these flaps. Anatomical dissections were performed on 32 long fingers. The vascular tree was injected with suitable contrast and the distal dorsal region of the long fingers was studied.

An anterior-lateral thigh perforator flap on a recipient brachial-radial vein graft for complex wound reconstruction: a case report

A case of challenging microsurgical reconstruction of a difficult defect in a radiated upper limb is reported. A difficult wound, with tendon and bone exposition, developed on the dorsum of the forearm in a 76-year-old patient; she had been radiated since almost 50 years and her left hand had also been revascularized twice with venous grafts between the humeral artery and the superficial palmar arch. After failure of a local flap, an anterior-lateral thigh perforator flap was successfully transferred with end-to-side anastomoses on the arterialized venous graft. Up to date follow-up shows a good outcome. The Authors discuss the case and review the indications for microsurgical reconstruction in difficult wounds after radiation and ischemic limb conditions.

The use of sentinel node biopsy and selective lymphadenectomy in squamous cell carcinoma of the upper limb. Usefulness of sentinel node biopsy to avoid useless lymphadenectomies in high-risk upper limb SCC

BACKGROUND

Squamous cell carcinoma (SCC) is the second most common skin cancer in humans. Because the incidence of metastasis from SCC of the skin is rare, regional lymphadenectomy is generally not recommended for the patients with clinically node-negative disease. However, in patients with an intermediate and high risk of metastasis, evaluation of the lymph nodes to detect the absence of metastatic nodal disease is a difficult task.

PATIENTS AND METHODS

The authors reviewed the pertinent demographic and surgical data in a consecutive series of six patients with squamous cell carcinoma who underwent sentinel lymph node staging. The tumour size was greater than 2 cm (T2) and the patients had clinically non-palpable regional lymph nodes (N0). All nodes were examined using haematoxylin-eosin staining. Sentinel Lymph Node Biopsy (SLNB) and Selective Lymphadenectomy (SL) using preoperative lymphoscintigraphy and intraoperative radiolymphoscintigraphy and vital dye injections was used to identify the sentinel lymph node avoiding complete axillary node dissection.

RESULTS

No false-negative results were observed. At a median follow-up of 10 months (mean 15 months), neither local or regional recurrences in sentinel node-negative basins have been noted.

CONCLUSIONS

Sentinel node biopsy is a minimally invasive staging procedure useful in identifying occult regional lymph node disease in selected patients with squamous cutaneous malignancies of the arm. Furthermore sentinel lymph node histology is possibly the most important negative predictor of early recurrence and survival in patients with American Joint Committee on Cancer stage I and II squamous cell carcinoma. Although sentinel node-negative patients are a prognostically favourable group, this small series of patients demonstrates that further studies to verify these findings and develop formal guidelines are indicated

The distally based sural flap for lower leg reconstruction: versatility in patients with associated morbidity

INTRODUCTION

Coverage of soft tissue defects in the lower leg is often made by use of free flap, also because of the improving of anaesthesiology techniques in the last decades. However, there are disadvantages in the use of free flaps like the need for a remote donor site, increased operative time, use of a major vessel to the leg, and microsurgical skills. Besides these, trauma in the lower limb are often cause of damage for a major vessels of the leg, so the use of free flaps in these patients may be related to an higher incidence of complications; also associated pathologies, like diabetes and vascular pathology, can increase the incidence of complications when a free flap is utilized. In all these cases local fascio-cutaneous flaps, like the sural reverse flap, because of their easy and short time harvesting, can be a very good alternative to free flaps. Superficial sural artery flap is a adipofasciocutaneous flap based on the vascular axis of the sural nerve, which gets reverse blood flow through communication with the perforating branch of the peroneal artery, situated in the region of lateral malleolar gutter.

PATIENTS AND METHODS

Between 2000 and 2005, 11 patients, mean age 68 (range 58-78 years), were treated at the Plastic and Reconstructive Surgery Unit of Messina University, for soft tissue defects of lower limb and foot, using the distally based sural artery flap. The defects were related to post-traumatic damage of soft tissue, diabetic and vascular ulcers, osteomyelitis and oncological resection. Mean follow-up time was 20 months (range 6-55 months). All patients were pre-operatively assessed for vascular patency of peroneal axis and associated morbidity that could increase risk offlap necrosis. This included diabetes mellitus type II, osteomyelitis and peripheral arterial diseases.

RESULTS

All flaps survived with the exception of one that sustained partial skin necrosis, in the ratio of 25% of the skin island. All defects were covered with no major complications and none of the patients required a blood transfusion. Moreover aesthetic results were good with satisfaction of all the patients.

CONCLUSION

In our cases we found the sural reverse flap to have a good reliability with low incidence of complication and surgical outcomes. This flap is an excellent option for covering defects of minor deficiency of skin in the third distally of lower limb, ankle and heel. It allows rapid, reliable coverage of defects extending as far distally as the forefoot. Because of the sparing of major vessels, the short surgery time in harvesting the flap, and the good vascular pattern of the flap, we retain the flap a first choose technique for reconstruction in lower leg, especially in politrauma and in patients with associated pathology as vascular diseases or diabetes.

Topical negative therapy and vacuum assisted closure. New strategies and devices in surgical reconstruction

Topical negative pressure (TNP) has been introduced in complex surgical reconstruction and difficult wound healing, having proven to be effective in both drainage of wound secretions and calling for a new, sterile granulating tissue. In the last 15 years many reports have been focusing on TNP in different surgical specialties (orthopedic surgery in exposed fractures, general surgery in eventration, cardiothoracic surgery in sternal dehiscences, plastic surgery in difficult wounds and pressure sores). The authors report their personal experience being among the first Units to use TNP systematically in Italy.

The orbicularis oculi myocutaneus flap in the repair of the medial canthal region. A new strategy for canthal resurfacing

The aim of this study was to review the surgical anatomy and the variants of the orbicularis oculi myocutaneus flap (OOMF) for reconstruction of inner canthus defects. Anatomic studies in fresh heads were carried out to demonstrate its blood and nerve supply. Four cases of epitheliomas of the inner canthus were treated with surgical excision and reconstructed with medially based island and nonisland OOMF. A 36-months follow-up showed no deformities of the flap, good colour matching and satisfaction scars. The flap is recommended for small to medium size defects of the inner canthus in patient with skin excess in the eyelid.

[Surgery and rehabilitation of flexor tendons injuries in zone 1 and 2]

BACKGROUND

Prevention of adhesions that restrain tendon gliding is based on early mobilization techniques. Such approach, anyway, does not guarantee positive outcomes.

METHODS

Seventy-five patients for a total number of 98 flexors tendons have been treated at the University Hospital of Messina between December 1993 and January 2000. Twenty-five patients, for a total number of 26 tendons, have been seen at follow-up. Seventeen lesions involved zone 2 and 9 involved zone 1. The modified Kessler suture has been generally used. All the repairs have been followed by an adequate early mobilization protocol, according to Kleinert (passive extension/active flexion) in nine patients and according to Risitano and Savage (active extension/active flexion) in 16.

RESULTS

Minimum follow-up was 12 months. We present results with an assessment performed according to Strickland and to Elliot for lesion in zone 1 and according to Strickland and using Total Active Motion of the finger for lesions in zone 2.

CONCLUSIONS

The suturing technique and mobilization protocol did not affect results, but we made some considerations about respective advantages and disadvantages of either method.

[Traumatic lesions of the hand extensor system: epidemiology and surgical considerations]

AIMS

To investigate demographics, modalities and type of injuries among a population of isolated traumatic injuries of extensor tendons in order to evaluate the consequences on health service and on prevention.

METHODS

Retrospective study of injuries treated at the divisions of Plastic Surgery and Orthopedics in a third level referral center among the years 1993-1999.

MAIN RESULTS

Data from 173 patients were analyzed, a prevalence of males (81%) and injuries at home (55%) has been observed. Especially young adults (46.88%) have been involved, the thumb has been most interested finger and the middle finger the least, with two peaks of incidence in spring and autumn. The lesions, exposed through an extension of the existing wound, have been usually sutured according to Kessler, adding an early protected motion protocol.

CONCLUSIONS

We discuss the possible causes and consequences of data observed, with special reference to the possibility of treating isolated extensor tendon injuries at district hospitals by non-hand surgeons, and primary actions of prevention.

An active intervention on flap vasculature: flap prefabrication by pedicle implantation, delay, pre-expansion, pre-grafting, tissue engineering, biomaterials and perforators surgery

The technology of flap prefabrications is a new, powerful tool in plastic and reconstructive surgery. It is based on an old idea, while applying the latest innovations in surgery. It involves any modification of a surgical flap done before its transfer to the final donor site, including surgical delay, pre-expansion, pre-grafting, the use of tissue engineering, biomaterials and perforators surgery, or the creation of a new pedicle by staged transfer of a vascular bundle. The different possibilities are discussed, with special reference to their biologic basis.

Free osteocutaneous scapular apophysis flap for reconstruction of the lateral malleolus

Lateral malleolus avulsion is uncommon, and fusion of the syndesmosis of the ankle joint is usually performed in such cases. Others have reported successful reconstruction of the lateral malleolus with a vascularized fibular head. A case of reconstruction in a 17-year-old girl, with a free scapular apophysis flap, is presented and compared with alternative flaps available. The anatomy and development of the scapular crest with its cartilaginous apophysis are discussed.

The umbilicus: a rare site for melanoma. Clinical considerations in two cases. Case reports

The umbilicus is a rare site for malignant melanoma. We report two cases of umbilical melanoma and analyse the mechanisms of diffusion of the neoplasm in relationship to the arterial, venous, and lymphatic anatomy of the region. Because of the peculiarity of these connections, we propose a revision of the concept of melanoma stage for the umbilical region.

[Gynecomastia: diagnostic and surgical approach in the treatment of 61 patients]

Gynaecomastia is a disease with a high incidence (approximately 65% of adult males between 15 and 40 Ys.). In this paper the authors present their experience about the medical and surgical treatment comparing different surgical techniques: adenomammectomy, liposuction and liposuction associated with adenomammectomy. 61 patients ageing 17-42 Ys. (54 with bilateral gynaecomastia and 7 with monolateral disease) were, treated in the Dept. of Plastic Surgery of the Niguarda Ca' Granda Hospital in Milan from 1985 up to 1995. 26 patients were treated with adenomammectomy; Suction assisted lipectomy was used alone in 4 cases and associated with adenomammectomy in 34 cases. The authors suggest that the associated method is the most effective, the aesthetic results being excellent with an important reduction of post-operative complications (mostly referred as haematoma, seroma).

Use of free scapular crest flap in pediatric epiphyseal reconstructive procedures

Studies have been underway since 1981 on the scapular anatomic unit as a new donor site for reconstructive surgery. Anatomic studies have proven that this diaphyseal bone has a large osteocartilaginous growth epiphysis at its inferior pole, which is responsible for development of 80% of the surface of the scapula. Experimental investigations and clinical studies have revealed minimal functional limitation because of loss of the scapular crest and that its growth plate can be used beneficially for vascularized bone transfer. Four cases are reported with good results based on 2 to 14 years followup without significant impairment of the donor site.

[The ASL and hospitals: a model of emerging management]

The authors analysed the advantages and drawbacks of the legislative rules in the Italian medical services. They underline the impediments to the improvement in the quality and efficiency of both the organizing models and the control system of administration. The authors consider a new trend in the administration system taking place in the most innovative and dynamic units and they analyze the efficacy and speediness of diffusion of this new system. The new model could be extended to the ASL and Hospital as a possible improvement of the present situation. The article is structured in two main parts; in the first one the legal changing, that took place in the last year, in the organization of the national medical system is critically examined; the second one summarized the most significant innovation brought by the new administrative system of ASL and hospital.

[The palliative surgical treatment of paralysis of the hand]

Restorative tendon transfer in upper limb palsy should be regarded as an important tool in hand surgery. An adequate planning and patient selection must be required, as well as several techniques can be used. Particularly, associated articular lesions must be detected and cured in the same time. Wrist extension palsies should be treated surgically with PT or LS transfer, whereas flexion palsies can be corrected with opportune balance in movements. Finger palsies can be treated with Zancolli's methods, including MP plasties and "lazos". Thumb palsies can be considered for extensor muscles transposition or reflexionplasties.

[Treatment of high-voltage electric injuries of the hand and forearm]

Electric injuries produce deep tissue destruction and in a large number of cases involve the forearm, entering from the hand. The authors report their experience, consisting of 13 cases, with satisfying results, particularly in relation to limb salvage. Salvage procedures, avoiding the amputation and including venous grafts and use of flaps, among which the inguinal flap is mostly used, are considered. Late necrosis occurring under grafted tissues often requires further surgery, including tendon and nerve grafts and scar revisions with skin grafts or flaps.