Block Dissection Research Articles

Improvement of Surgical Treatment for Post-Ambustial Cicatrical Deformations Using Vacuum Therapy

Background Improvement of treatment results in patients with cicatrical deformations by means of new surgical techniques and vacuum dressings is the aim of this study. Material and Methods We described clinical results after vacuum therapy application for reconstructive surgical treatment after facial and cervical cicatrical deformation caused by burns. Patients underwent dissection of cicatrical blocks, and then we performed layer-by-layer autodermoplasty with further vacuum dressing placement. Results Engraftment of tissue autotransplant took 507 days and we observed reliable clinical result. Conclusions Vacuum therapy favours optimal conditions for rapid engraftment and adaptation layer-bylayer tissue autotransplants.

Efficacy and Safety of Lateral Approach-Video Endoscopic Inguinal Lymphadenectomy (L-VEIL) over Open Inguinal Block Dissection: a Retrospective Study.

This retrospective study compared the immediate post-operative short-term outcomes of Lateral Approach-Video Endoscopic Inguinal Lymphadenectomy (L-VEIL) and open surgery approach in patients with TNM stage N0 and N1 tumors. Inguinal lymphadenectomies performed for various TNM stage N0 and N1 cancers between January 2011 and December 2015 at a single center were analyzed by collecting data from operation theater records and case files. Mean blood loss, operative time, drain output, nodal yield, nodal positivity, and complications were analyzed as post-procedural outcomes. Among the 116 surgeries performed, 92 were open surgery and 24 were L-VEIL. Compared with open surgery, L-VEIL led to significantly lower blood loss (64.8mL vs. 23.3mL; p = 0.002), mean nodal yield (11.04 vs. 8.38; p = 0.001), and mean hospital stay (3.08 vs. 8days; p < 0.001). However, the operative time was similar for both the groups (94.5 vs. 68.1min; p = 0.08). Complications that were significantly low in L-VEIL were flap necrosis [RR 1.29; 95% CI (1.03-1.72); p < 0.001], wound dehiscence [RR 1.25; 95% CI (1.19-1.51); p = 0.005), wound infection [RR 1.34; 95% CI (1.19-1.51); p = 0.003], readmission [RR 1.3; 95% CI (1.17-1.44); p = 0.005], and re-surgery [p = 0.014]. Occurrence of complications such as lymphocele [RR 1.25; 95% CI (0.33-4.78); p = 0.5], lymphorrhea [RR 1.27; 95% CI (1.15-1.40); p = 0.5], and pedal edema [p = 0.2] were similar for both the approaches. L-VEIL was effective and safe compared with open inguinal block dissection in treatment of various TNM stage N0 and N1 urogenital and skin cancers.

Urogenitalis lokalizációjú mucosamelanoma primer és áttétes esetei klinikánkon

Both primary and metastatic cases of mucosal melanoma in urogenital localization are rare tumors. Only 4-5% of all primary melanomas do not arise from the skin. Extracutaneous melanomas have a complex clinical presentation, but these aggressive tumors have a poor prognosis. In our department, we found 7 patients with malignant melanoma of the genitourinary tract in the past few years. The 7 cases were: primary amelanotic melanoma of the female urethra, a primary melanoma of the bladder, two primary melanomas of the penis, a metastatic melanoma of the urethra and another to the testis and a metastatic melanoma of the bladder with melanuria. We retrospectively analyzed the available data to describe the presentation, management, and clinical outcome of the patients. In the three inoperative cases, palliative, urologic surgical procedures and systemic antitumor therapy were performed. Two of the four primary urogenital tumors were localized to the penis. In one case, local recurrence developed after surgical treatment, but with a radical, repeated surgery, the patient has been asymptomatic for a year and a half. In the other, neglected case, the penis melanoma spread through the urethra and the inguinal lymph nodes two years after radical surgery and inguinal block dissection. In the female primary urethral melanoma case, the first histological study reported a primary mesenchymal tumor, and the recurrent tumor that occurred one and a half years later showed melanoma diagnosis. Radical surgery performed because of urethral involvement resulted in a 5-year asymptomatic state, followed by local recurrence and distant metastasis. In the fourth case of a primary bladder melanoma, the rapid progression of the disease and the BRAF positivity of the tumor suggested that not the firstly diagnosed bladder melanoma was the primary tumor. The occurrence of urinary tract melanoma is very rare and its discovery happens often in a disseminated state, so the expected prognosis of the cases is also poor. The most important factors for increasing therapeutic efficacy are early diagnosis and radical surgical intervention. Tumors appearing in different localizations require different urological surgical approaches. The literature recommendations for treatment are not uniform. Their prognosis is worse compared to the cutaneous melanoma, which may be due to clinical and pathological diagnostic difficulties. The latest targeted and immunotherapeutic agents can significantly improve the survival of metastatic patients. Orv Hetil. 2019; 160(10): 378-385.

To do or not to do: axillary blockdissection after preoperative axillary ultrasound and aspiration cytology

Background: According to international guidelines after positive preoperative axillary ultrasound (axUS) and axUS lymph node needle biopsy the axillary block dissection is recommended. More than half of the patients with preoperative US-guided biopsy proven axillary lymph node metastases had N1 disease. In these cases, the axillary block dissection is overtreatment. The purpose of our study was to investigate whether axUS and lymph node needle biopsy, combined with pathological and clinical factors could be used to identify axillary metastasis and preoperatively differentiate light versus nodal disease burden.

Patient Related Outcomes Measures Following Lymph Node Block Dissection (Axillary/Inguinal) After Melanoma Surgery

Patient Related Outcomes Measures Following Lymph Node Block Dissection (Axillary/Inguinal) After Melanoma Surgery

Cancer penis evaluation of role of prophylactic inguinal lymph nodes dissection

Background: Incidence of penile cancer is considerably variable across the globe; this disease is uncommon in the western world. But it is not uncommon to see the disease in Indian subcontinent. Also, it is not uncommon to see Penile growths with palpable unilateral or bilateral lymph nodes. In this retrospective observational study, we would like to present our data of 31 cases of Penile cancer with variable presentations, in terms of palpable groin lymph nodes. FNAC from palpable lymph nodes may not be diagnostic of metastasis. It is said that battle of cancer penis is either won or lost depends on how you deal with groin. It is a clear understanding that in presence of positive groin nodes Lymphadenectomy is the choice of treatment but it is unclear, how to deal with negative groin? In this study we present experience, in terms of deal with the groin lymph nodes aggressively, even when they not palpable for a better outcome after balancing the morbidity of the procedure. Aim was to evaluate the role of early prophylactic inguinal node dissection in patients with squamous cell cancer of Penis.Methods: This retrospective observational study was carried out at tertiary care teaching institute from 2003 till 2012. The clinical, investigational, operative, pathology details and follow-up data were collected from patient records.Results: Study showed data of 47 patients treated during the period from 2003 to 2012 and included 31 patients in this study, 21 patients (67.74%) presented with palpable inguinal nodes at the time of primary presentation. FNAC from these lymph nodes could prove metastasis, only in 16 patients (76.19 %). 5 patients (23.80) on FNAC had no metastasis. Remaining 10 patients were without lymph node enlargement at the time of primary presentation. Patients presented without palpable lymph nodes were offered modified inguinal block dissection. Histology showing 8 nodes positive for metastatic disease. And were FNAC was negative 4 (80 %) out of 5 patients with negative nodes shown positive for metastasis.Conclusions: This retrospective observational study concludes with fact that palpable lymph nodes in the groin, is no doubt an indication for Inguinal node dissection but even when nodes are negative on FNAC or not palpable then prophylactic lymph nodes dissection should be undertaken. Delay in inguinal lymphadenectomy in non-palpable nodes you may lose the battle on cancer penis, as many reports say that, delayed lymphadenectomy has a strong impact on the survival. The only drawback with prophylactic lymph node dissection is the associated morbidity. But with modified procedures this can be very well minimized.

Neck dissection in node negative oral malignancies: is it justified

Background: Oral cancer is one of the ten most common cancers in world, prevalence being highest in India. The objective of the study was to decide whether it is justifiable to do neck dissection in every case of oral malignancy in true negative necks diagnosed by investigative modalities and to decide whether we can avoid unnecessary block dissection in patient of oral malignancy with negative necks diagnosed by investigation.Methods: It was proposed randomized controlled study conducted over period of 2 years including all patients diagnosed of having oral squamous cell carcinoma. Lymph nodes were assessed by clinical examination and ultrasonography (USG). FNAC was done with the help of USG guidance. After thorough evaluation, the patient was subjected for treatment either surgery or radiotherapy and sometimes chemotherapy. After neck dissection, whole block was sent for histopathological examination. Data collected was analysed on various statistical parameters.Results: For clinical examination consistency and fixity is having high reliability than size and shape. On USG central necrosis, ECS, shape and RI were having specificity and accuracy. Sensitivity, specificity and accuracy of USG FNAC is more.Conclusions: USG and USG FNAC are helpful methods in directing further work up in more efficient and cost-effective manner and these help in reaching diagnosis more accurately than the clinical examination alone and thus it is considered second step in evaluation of neck only after clinical examination.

Non-intubated, uniportal, video assisted thoracic surgery [VATS] lobectomy, as a new procedure in our department

Due to the emerging experience in VATS (video assisted thoracic surgery) lobectomies, in some centers the so called "non-intubated" VATS lobectomies (NITS - non-intubated thoracic surgery) gained increased authority, during which endotracheal intubation and muscle relaxation of the patient is not carried out, thus surgery is being performed with the patient breathing spontaneously. The recent study deals with our initial experience gained during uniportal NITS VATS lobectomies. Between 24.01.2017 and 10.03.2017, 16 patients (female: 8; male: 8) with lung cancer underwent NITS VATS uniportal lobectomy. Mean age was 59.6 years (42-73 years). Mean FEV1 was 87.7% (62-109). Mean BMI was 27.1 (18.8-32.8). Prior to surgery, the patients received benzodiazepine premedication, local anesthetic (Lidocaine) for incision and Bupivacaine for intercostal and vagus nerve blockage. Besides routine monitoring Bispectoral Index (BIS) guided target-controlled infusion (TCI) Propofol sedation was carried out, with the help of laryngeal mask anesthesia. Skin and soft tissue incision was performed at the fifth intercostal space, in the axillary line. This single incision sight was the only one needed for the introduction of the camera, together with the instruments needed for dissection and resection of the lobe and placement of the chest tube. Complete atelectasis can develop. The following lobes were removed: 7 right upper lobes, 2 mid-lobes, 1 right lower lobe, 1 right lower lobe + right upper lobe wedge resection, 5 left lower lobes. After the resections, extended mediastinal sampling or block dissection was performed. There was no perioperative mortality. Conversion to endotracheal intubation was needed in non of the cases. Mean operative time was 96,5 minutes (80-120 min.), mean drainage periode was 2.9 days (2-8 days). Prolonged air leak was 1/16 (6.25%). Postoperative fever occurred in 1 patient and subcutaneous emphysema in 1 case, and 1 pneumonia. Because of a recurrent pneumothorax, a re-drainage was necessary in 1 case. Pathology of the resected lobes were as follows: 1 endobronchial hamartochondroma causing complete atelectasis of the lobe, 1 chronic pneumonia, and 10 adenocarcinomas, 2 squamous cell carcinomas, 1 carcinosarcoma, and 1 typical carcinoid. Staging of the 14 malignant cases were as follows: 8 IA, 2 IB, 1 IIA, 2 IIB, and 1 IIIA. The average number of the removed mediastinal lymph nodes is 12 (7-20). Non-intubated (NITS) VATS lobectomy is considered a safe procedure, satisfying all aspects of oncological guidelines. The postoperative drainage period was shorter caused by the complete atelectasis during the surgery.

Is intraoperative touch imprint cytology indicated in the surgical treatment of early breast cancers?

IntroductionIntraoperative touch imprint cytology (TIC) of the sentinel lymph node(s) (SLN(s)) in the treatment of breast cancer has significantly reduced the number of axillary block dissections (ABD) required during second surgeries. Based on recent studies, ABD was not considered necessary if the presence of tumor cells/micrometastasis was confirmed in the SLN(s) or in the case of macrometastases in a patient group meeting the inclusion criteria for the ACOSOG Z0011 study. Our aim was to determine the sensitivity and usefulness of TIC with regard to these results. MethodsTICs of the SLN(s) were examined in 1168 patients operated on for breast cancer. The method was also analyzed retrospectively based on the guidelines for the Z0011 study. During TIC, new samples were cut every 250 μm; impression smears were evaluated after being stained with hematoxylin eosin. ResultsTIC confirmed metastasis in 202 cases (202/1168, 17.29%). Metastasis was confirmed in SLN(s) in 149 additional cases during a final histological examination. The sensitivity of TIC was found to be 57.18%, and its specificity was 99.63%. An analysis was then performed except for cases that met the inclusion criteria for the Z0011 study and with metastasis smaller than 2 mm (micrometastasis/isolated tumor cells) considered to be positive during intraoperative cytology. The sensitivity of the method decreased to 34.23%, while its specificity was still high at 99.76%. ConclusionsBased on the new guidelines for ABD, imprint cytology cannot be considered a beneficial and cost-effective intervention in the surgical treatment of early breast cancer.

Ways to solve the issues of surgical treatment of stomach cancer

Surgical method is the only effective method of stomach cancer treatment. On the basis of dividing the stomach into angiological segments, lymphogenic metastasis was studied, classification of gastric cancer and extraligamentous lymph nodes localizations was created. Based on the performed surgeries working classification of extended lymphodissection was suggested. The data on the formation of esophageal-intestinal anastomosis, identification of the origin of key complications after gastrectomy are given. By introducing single-raw esophago-jejunal anastomosis it was possible to almost completely eliminate complications leading to death which together account for up to 90% of the complications: suture failure, pancreatitis and pancreatic necrosis. The volume of the resected stomach was revised without worsening long-term treatment results. During gastrosplenectomies for ablastic block dissection of lymph nodes the author proposes standard binding of the splenic vessels - proximal to the left gastroepiploic artery arising from the splenic artery. The remaining part of the pancreas after gastrosplenectomy with pancreas resection is proposed to be stitched using atraumatic sutures, which avoids formation of pancreatic fistula. In the clinic we developed esophagogastrosplenectomy from laparoscopic mediastinal access with isoperistaltic right colon graft for esophageal reconstruction with anastomosis located in the neck, antethoracic esophageal reconstruction with graft from the large curvature of the stomach, as well as created original drainages of our own design, which allowed excluding peritonitis without inconsistency of the sutures and abscesses of the abdominal cavity. The author concludes that gastrectomy and subtotal distal gastric resection according to his original methods are an effective tool in the surgical treatment of gastric cancer.

Percutaneous balloon atrial septostomy on top of venoarterial extracorporeal membrane oxygenation results in safe and effective left heart decompression.

Transcatheter techniques are emerging for left atrial (LA) decompression under venoarterial extracorporeal membrane oxygenation (VA-ECMO). We aimed to assess whether balloon atrioseptostomy (BAS) is a safe and efficient strategy. All patients who underwent percutaneous static BAS under VA-ECMO at four tertiary institutions were retrospectively reviewed. From 2000 to 2014, BAS was performed in 64 patients (32 adults and 32 children). Indications for ECMO support included acute myocarditis (31.3%) and non-myocarditis cardiac disease, mostly end-stage dilated cardiomyopathy (32.8%). BAS was required because of pulmonary oedema/haemorrhage and left ventricular (LV) distension. The mean balloon diameter was 21.8 ± 8.4mm. Adequate LA decompression was achieved in all patients. Mean LA pressure fell from 24.2 ± 6.9 mmHg to 7.8 ± 2.6 mmHg ( p < 0.001). The left-to-right atrial pressure gradient fell from 17.2 ± 7.1 mmHg to 0.09 ± 0.5 mmHg ( p < 0.001). Echocardiography showed an unrestrictive left-to-right atrial shunting in all patients. Improvement of day 1 chest X-ray was observed in 76.6% of patients, clinical status in 98.4% of patients and pulmonary haemorrhage in 14 out of 14 patients. Complications occurred in 9.4% of patients, representing pericardial effusion, fast atrial fibrillation, ventricular fibrillation requiring defibrillation, transient complete heart block and femoral venous dissection requiring covered stent placement. In the 37 (57.8%) patients who were successfully decannulated, the median ECMO duration was 9 (range: 4-24) days. After a median follow-up of 12.3 (range: 0.1-142) months, 35.9% patients died, 17.2% received a LV assist device as a bridge to transplantation, 31.2% were transplanted and 56.2% were home discharged and alive. Percutaneous BAS may be a safe and efficient strategy for discharging the LA in both adults and children supported by VA-ECMO.

Horner's Syndrome after Scalene Block and Carotid Dissection

BackgroundHorner's syndrome refers to the clinical triad of ptosis, miosis, and anhidrosis resulting from disruption of the ocular and facial sympathetic pathways. A myriad of etiologies can lead to Horner's syndrome; awareness of the underlying anatomy can assist physicians in identifying potential causes and initiating appropriate care. Case ReportTwo patients presented to our Nashville-area hospital in 2014. Patient 1 was a 26-year-old man who noticed facial asymmetry one day after an outpatient orthopedic procedure. His symptoms were attributed to his posterior interscalene anesthesia device; with deactivation of this device, the symptoms rapidly resolved. Patient 2 was a 42-year-old man who presented to our emergency department with persistent headache and ptosis over several weeks. Computed tomography angiography revealed ipsilateral carotid dissection and the patient was admitted for further management. Why Should an Emergency Physician Be Aware of This?The pathologies underlying Horner's syndrome are exceedingly diverse. Although classic teaching often focuses on neoplastic causes, and more specifically Pancoast tumors, neoplasms are discovered only in a small minority of Horner's syndrome cases. Other etiologies include trauma, cervical artery dissection, and infarction. With a better understanding of the pertinent anatomy and array of possible etiologies, emergency physicians may have more success in identifying and treating the causes of Horner's syndrome.

Inguinal Lymph Nodes in Carcinoma Penis-Observation or Surgery?

In Indian sub-continent the presentation of carcinoma penis is variable. Mostly presents with palpable inguinal lymph nodes but not confirm of metastases. To evaluate whether all clinically positive nodes are metastatic and decide when to address inguinal lymph node. A retrospective observational study on carcinoma penis from a regional cancer centre of south India over a period from 2001 to 2012. All the clinical, investigational, operative, pathology details and follow-up data were collected from patient records. Two hundred and thirty cases of carcinoma penis have been identified and 112 cases had clinically positive nodes. In 74 cases fine needle cytology was positive for malignancy and they have been addressed with block dissection with surgery of primary lesion. At two years follow up, 70 patients were identified with inguinal lymph node metastasis and block dissection was performed and all was were positive for malignancy on histology. The rate of recurrence is related to the T stage of the primary tumour. It can be concluded that elective surgery is appropriate for palpable inguinal lymph nodes and prophylactic nodal dissection in high risk cases of carcinoma penis.

Tensor fascia lata flap is a workhorse for defects after inguinal lymph node block dissection

Enlarged inguinal lymph nodes very often present a site of metastatic disease. Inguinal lymph node block dissection is a demanding procedure, which usually requires at least one of reconstructive modalities. Among different reconstruction options we selected the tensor fascia lata (TFL) musculocutaneous flap. The paper aims at presenting a series of inguinal block dissections, followed by immediate reconstruction, using the TFL flap, and evaluation of tumor type, flap dimension, complication rate and the duration of hospital stay. We present a consecutive case series of 25 conducted block dissections. The defects were reconstructed using TFL flap, because of the extent and site of the tissue defects, reliability of the flap, and potentially primarily infected exulcerated tumors. The reconstruction was successful in all cases, the incidence of surgical complications was 16%, no further complications, such as lymphedema or gait disturbances, were noted. Primary skin tumors were predominant (13 cases), followed by genitalia tumors (four cases). The male sex was more frequently affected (14 vs. 11 cases). Having in mind that TFL presents as a flap of adjustable size, length, shape, and volume, with negligible donor site morbidity, and after comparing of our results to those of other authors, we advise broader use of TFL flap. As a reliable flap, not too difficult to harvest, with a low complication rate, it must be taken into consideration regarding the benefits for the patient, and, on the other hand, the surgery cost and duration.

Are all palpable lymph nodes positive in penile cancer? retrospective study

Background: Though rare in western countries the incidence of penile cancer in India is much higher and can represent 10-20% of malignant diseases in men ranging from 0.7-3 per 100,000. Important risk factors include phimosis, chronic inflammatory conditions, treatment with sporalene and ultraviolet A photo chemotherapy, smoking, sexual history and HPV DNA. Smegma as a carcinogen has been clearly excluded. In our country where incidence of inguinal nodes are high due to bare foot walking and infection, there must be balance between loosing patients from lack of follow-up and presenting later with inoperable inguinal nodes and the morbidity of a groin dissection. Methods: This is 5 year retrospective study of carcinoma penis from a single institute (2007-2012). 50 cases have been included in this study. 20 of the 50 cases had clinically significant nodes of which only 14 cases were fine needle aspiration cytology positive nodes and they had been addressed with an inguinal block dissection in the same sitting with the primary. In first 6 months 8 cases had positive nodes on follow-up and between 6 months to 2 years 10 patients developed node recurrence and underwent block dissection. Results: Median follow-up was 21.8 months. Among these 6 patients lost to follow up. All the follow up patients who underwent surgery on later date had one or more of these factors: High primary tumour grade, > pT2 status, lymphovascular invasion, pelvic lymph node involvement, extra nodal extension. Pelvic lymph node dissection was done in 4 patients. Adjuvant radiotherapy was given in 12 patients (37%) and chemotherapy in 4 patients (12%). Overall 5-year cancer specific survival was 61%. Men with extra nodal extension and pelvic lymph node involvement had significantly decreased 5-year cancer specific survival compared with men without it (42% vs. 80%). Complications of inguinal block dissections were flap necrosis, wound infection, seroma formation, lymphedema and deep vein thrombosis. Recognised adverse prognostic factors for survival in carcinoma penis were pathological T stage (>T2), differentiation grade (high grade > low grade), positive margin status, extra nodal extension, 4 or more unilateral metastatic inguinal nodes, bilateral versus unilateral metastatic involvement and pelvic lymph node involvement. Conclusions: In Indian population, cases with carcinoma penis are generally of higher T status on presentation. Lymph nodes were palpable in majority of cases but most were not pathologically positive. Prophylactic block dissections are not practical as it carries its own morbidity and complications. High incidence of pathologically positive nodes were seen in patients with high grade, T status and lymphovascular invasion.

A case of Squamous Cell Carcinoma (SCC) of the tongue in a young girl with no detectable risk factors

Background Oral cancer incidence in Sri Lanka is 1813/100,000 with male to female ratio, 3.55:1 and commonest after 55 years of age. SCC involves >90% of oral cancers. Oral SCC in young age shows weaker relationship with risk factors and more aggressive clinical course. Case Description 26 year old girl with no detectable risk factors for oral SCC, was presented with 2 month history of non healing solitary ulcer in the anterior 2/3rd of tongue left side. She had been treated for aphthous ulcer initially and due to poor response undergone excision. Excision biopsy revealed well differentiated SCC with positive margins. Radiologically no suspicious neck lymph nodes detected. Disease was staged as II (T2N0M0). Following multidisciplinary discussion, further excision with Supra Omohyoid Block Dissection performed. She recovered uneventfully. Histology confirmed the primary diagnosis with negative nodes, and underwent adjuvant treatment with brachytherapy. Discussion This patient didn’t give a history of alcohol consumption, tobacco use or beetle chewing, which are the commonest risk factors. Examination didn’t show any dentinal abnormalities causing chronic local irritation. Human Papilloma Virus (HPV) infection is a well known risk factor of oral SCC in west especially among young patients. Even though she denies of sexual contact still HPV testing would be beneficial, but difficult in local setup. Conclusions This highlights the need of early precise diagnosis, providing better prognosis, chance of better survival and quality of life for patient with SCC.

The adequacy of lymph node harvest in concomitant neck block dissection and submental island flap reconstruction for oral squamous cell carcinoma; a case series from a single Egyptian institution.

BackgroundSquamous cell carcinoma (SCC) is a fairly common tumor of the oral cavity. This tumor may affect any part of the mucosa of the oral cavity especially the tongue, the floor of the mouth and lips. The encountered intra-oral defects after tumor resection are often large and require climbing up the reconstruction ladder to more complex reconstructive options for accepted functional and cosmetic results to be achieved. However, most of the patients are old with medical co-morbidities requiring fast, simple, less morbid reconstructive option such as local flaps. The myocutaneous submental island flap has emerged as a simple and fast reconstructive technique that provides thin, pliable tissue with adequate volume and reliable blood supply. However, one major concern regarding the utility of the submental flap for repair of post-ablative tumor defects is the presumed interference with adequate lymph node neck dissection.MethodsIn this study, we present a cohort of thirty-six consecutive patients who were operated for oral SCC. All patients were offered submental island flap reconstruction of their resultant defects together with ipsilateral selective neck block dissection of levels I, II, III and IV; and the nodal yield of each level was tested pathologically.ResultsNodal harvest was ≥12 in 88 % of the patients. Complications were encountered in two patients (5.5 %).ConclusionOur data suggest that adequate cervical lymph nodes dissection, specifically level I and II cervical lymph nodes, can be fulfilled with concomitant submental island flap elevation.

Contralateral axillary silicone lymphadenopathy, following skin sparing mastectomy and immediate reconstruction with latissimus dorsi myocutaneous flap and implant

Sir, Dorogi et al. reported a case of contralateral axillary silicone lymphadenopathy after mastectomy, ipsilateral axillary clearance and immediate reconstruction with a Becker 25 expander implant. The authors commented the effect of axillary block dissection on lymphatic drainage pattern. More interestingly, silicone lymphadenopathy reported in this case was associated with an intra-capsular implant rupture only [1]. In our experience, we have also encounter a similar breast reconstruction case of contralateral axillary silicone lymphadenopathy, secondary to an intra-capsular implant rupture: a 69-year-old female underwent a right-sided mastectomy for ductal carcinoma in situ (DCIS) and immediate reconstruction with latissimus dorsi (LD) myocutaneous flap and a cohesive gel implant 14 years ago. Recently, she found a tender mobile lymph node in her left axilla and was referred promptly for further investigations. MRI scan suggested an intra-capsular implant rupture on the right and a reactive left axillary lymph node. Open biopsy of two enlarged left axillary lymph nodes (Fig. 1) confirmed the presence of numerous histiocytes containing foreign body type giant cells, which are appearances in keeping with a reaction to silicone. Patient subsequently underwent a right implant exchange, and the intra-capsular implant rupture was apparent intra-operatively. In our case, mastectomy was indicated for DCIS only, and therefore, ipsilateral axillary lymph nodes were not previously cleared. However, the significance of scarring from combined autologous and implant breast reconstruction has alternated the lymphatic drainage and later resulted in contralateral silicone lymphadenopathy, when an implant ruptured. As Dorogi et al. suggested, silicone leakage from ruptured breast implants has previously been reported; many of these cases were indicated for esthetic augmentation [2–4]. Very often, silicone leak remains localized and to ipsilateral axillary lymph nodes [2]. Patients who have had mastectomy and axillary lymph node dissection are thought to have disrupted or obstructed lymphatic drainage, and may therefore present recurrent pathology to alternate lymphatic pathways, such as the contralateral intramammary lymph nodes [5]. We have presented here an unusual case, which highlighted the consequence of scarring from combined

Use of tensor fascia lata flap for reconstruction of the defect created following inguinal block dissection in a case of carcinoma penis: a case report and brief review of literature

Use of tensor fascia lata flap for reconstruction of the defect created following inguinal block dissection in a case of carcinoma penis: a case report and brief review of literature

Reverse vastus lateralis musculocutaneous flap for Marjolin's ulcer over the knee joint

Marjolin's ulcer is a rare and often aggressive cutaneous malignancy that arises in previously traumatized or chronically inflamed skin, particularly after burns. Treatment modalities of Marjolin's ulcers include wide local excision, block dissection of the regional nodes, amputation in advanced lesions of limbs, radiotherapy, and chemotherapy. Wide local excision, together with skin grafting, is usually considered appropriate in the treatment of Marjolin's ulcers. For lesions that are located at critical places skin grafting cannot be done because either the excised bed will not take the graft or skin grafting can be done but due to the unstable nature is often avoided preferring a flap cover. Defects over the knee is challenging especially when the defect is quiet large and the surrounding skin is scarred and unhealthy. In such situations neither any local fasciocutaneous flap nor muscle flap is possible, the only option left are in the form of free tissue transfer. But if this type of situation can be managed by transferring tissue from the upper part of the thigh in the form of pedicled flap then other complex reconstructions can be avoided. We describe a case of a 45-year-old male with Marjolin's ulcer over the post burn scar of right knee for 5 years duration with no regional or distant metastasis managed with wide local excision and cover with reverse vastus lateralis musculocutaneous flap. The post op outcome is uneventful with better patient satisfaction.