Background Additional second vessels may be required to handle multiple flaps used to add breast volume, boost blood flow for supercharging, or use salvage recipient vessels. In these situations, retrograde internal mammary vessel flow can be used although this causes doubts and concerns. Patients and Methods Forty sides of the chests of 20 fresh cadavers with intact thoracic cages and internal mammary veins (IMV) were used in the study. IMV valve numbers and locations were checked, and the bifurcation was confirmed. A retrograde fluorescent angiography and a saline infusion test were followed to confirm flow direction. Results Twenty-eight vessels were identified in 40 sides of the chest; of them, 45% had no valves. A mean 0.7 valves per chest side were identified; 23 (82.1%) of 28 valves were located above the second intercostal space (ICS). A mean 1.76 communicating veins were found between the IMV bifurcation. In all cadavers, a crossing vein connecting the left and right medial IMV was confirmed just below the xiphoid process. Fluorescent angiography and a saline infusion test proved that the retrograde flow was caudal through the bifurcated IMV to the communicating, intercostal, and crossing veins. Conclusion The IMV valve was present in 55% of our subjects and located concentrically above the second ICS level. It is highly unlikely that the retrograde flow was disturbed because the retrograde anastomosis level was below the second ICS. Furthermore, the bifurcation, intercostal, and crossing veins across the xiphoid process enabled valve-less detour flow. Thus, retrograde IMV flow is considered safe.

Safety of Retrograde Flow of Internal Mammary Vein: Cadaveric Study and Anatomical Evidence.

Primary mucinous adenocarcinoma (PMA) of the eyelid is an exceptionally rare clinical entity. Often, it mimics with benign lesions on clinical examination and with metastatic mucinous adenocarcinoma on histological examinations. We report a case of PMA in a 60-year- old male patient who came with a slow-growing, painless swelling near the lower lid of the left eye. Excisional biopsy from the mass revealed a mucinous adenocarcinoma. To differentiate it from a metastatic mucinous adenocarcinoma, a wide range of immunohistochemistry panel was run. The tumor cells showed strong positivity for cytokeratin7, cytokeratin5/6, P63, estrogen receptor, progesterone receptor and negativity for cytokeratin20. Moreover, extensive metastatic work-up did not show any primary malignancy elsewhere, hence a final diagnosis of PMA was made. We believe that, this is the second reported case from the Middle East and the first in the Madinah region of Saudi Arabia.

Primary mucinous adenocarcinoma of the eyelid: A case report and literature review

Background Gynecological reconstruction is difficult, particularly in cases with recurrence and received previous surgeries and/or radiotherapy and necessitate secondary reconstruction. Perforator flaps can preserve other donor sites for potential later reconstruction, and they also can be better tailored to the defect. We hypothesized that the use of perforator-based flaps can better restore the defect with less complications. Methods A retrospective review was conducted of all patients who underwent vulvar-perineum reconstruction between 2011 and 2018 by the senior author, and oncologic and reconstructive outcomes and complications were analyzed. Results Thirty-three patients underwent 55 soft tissue reconstructions for vulvar-perineum defects during the study period. The mean follow-up time was 27.6 ± 28.9 months. Squamous cell carcinoma was the most common cancer (45.5%). For 11 patients (33.3%), the procedures were performed for the treatment of recurrent cancer. The average defect size was 39.8 ± 34.3 cm2. The overall survival rate was 90.3%. Profunda artery perforator flaps were the most commonly applied flap for reconstruction in both the primary and recurrent groups. Poor wound healing was the most common complication which occurred in 10 of the 55 flaps (18.2%). Perforator flaps presented fewer complications than myocutaneous flaps or traditional random flaps. Similarly, Island pedicle flap design also presented fewer complications than traditional rotation flaps. With proper reconstruction, previous surgery or radiotherapy did not contribute to an increase in complications. Conclusion In our experience, perforator flaps can provide satisfactory reconstruction for perineum reconstruction with low postoperative complications while preserving other donor sites in the event of disease recurrence for repeat resection and reconstruction. Previous surgery or radiotherapy did not increase the complications or preclude its usage. A redefined reconstructive ladder was created to help selecting the best state-of-the-art technique for reconstruction to achieve better results.

Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps.

Primary mucinous adenocarcinoma (PMA) of the eyelid is a rare eccrine gland cancer with an incidence of 0.07 per million person-years. We report a case of a 62-year-old African American female who presented with a tender lesion over her left upper eyelid which was gradually progressive over four years. It was initially presumed to be benign but histopathology after excision was suggestive of a mucinous colloid carcinoma with positive margins. She underwent repeat excision with wide margins and reconstruction and immunohistochemical studies were suggestive of PMA. Workup for metastatic disease and rare possibility of underlying occult malignancy was negative. PMA is uncommon, more so in the African American population and in females. Given the uncommon occurrence of this tumor and similarities in histopathology to colon and breast cancers, underlying occult malignancies need to be ruled out prior to confirming the diagnosis of PMA. The most effective treatment modalities are Mohs micrographic surgery or excision with frozen section control of margins with regular follow up over a prolonged period of time. However, there are no large clinical studies with regard to treatment and follow up. More literature on this tumor would therefore be beneficial to clinicians.

Primary Mucinous Adenocarcinoma of the Upper Eyelid in an African American Female: A Rare Clinical Entity. A Case Report and Literature Review.

Introduction Paranasal sinus (PNS) mucoceles may involve orbit and have ophthalmic manifestations. The objective of this study was to investigate the clinical and radiological features affecting the ophthalmic manifestations in patients with PNS mucoceles involving the orbit. Methods Fifty-two patients underwent endoscopic sinus surgery for PNS mucoceles with orbital involvement were investigated. Ophthalmic manifestations included exophthalmos, ocular pain, diplopia, visual disturbance. The correlation between ocular symptoms and the mucocele volume, origin site of mucocele, and the involvement of extraocular muscles or optic nerve were evaluated. Results Ophthalmic manifestations were significantly higher in the anterior ethmoid and frontal sinus involvement. Exophthalmos was significantly increased in the involvement of anterior ethmoid sinus, frontal sinus, and superior group ocular muscles, but decreased in the mucocele of maxillary sinus. Ocular pain was significantly lower in the involvement of anterior ethmoid sinus, frontal sinus, and superior group ocular muscle. Diplopia showed no significant differences among clinical and radiological parameters. Visual disturbance was significantly higher in the involvement of posterior ethmoid sinus and sphenoid sinus. The volume of mucocele, relation to optic nerve, adjacent bony change, and duration of ocular symptom had no significant effect on ocular symptoms in patients with PNS mucoceles involving the orbit. Conclusion The volume of mucocele did not affect the ophthalmic manifestations in patients with PNS mucoceles involving the orbit. Exophthalmos, ocular pain, and visual disturbance were significantly correlated with the involved sinus of PNS mucoceles.

The Clinical and Radiologic Features Affecting the Ocular Symptoms in Patients With Paranasal Sinus Mucoceles Involving the Orbit.

Perineal reconstruction historically has been guided by the vertical rectus abdominis myocutaneous flap. In oncologic patients, because of prior surgical intervention, this donor site is often unavailable, the pelvis has been irradiated, and defects can be deep or irregularly contoured. Using plastic surgery principles of perforators, geometrically defined local tissue rearrangement, and flap inset, the authors have developed a modification of the gracilis flap to include a second soft-tissue arm similar to a bilobed flap. The authors performed five bilobed gracilis/medial circumflex femoral vascular pedicle myocutaneous flaps for perineal reconstruction secondary to oncologic defects and one secondary to Fournier gangrene at a tertiary care center. Oncologic patients had undergone adjuvant chemotherapy and radiation therapy and had compromised abdominal donor sites. Given their results, the authors recommend that a bilobed gracilis flap be used in patients with moderate to large defects, defects that require ample soft-tissue bulk, or in patients with limited abdominal donor sites. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Bilobed Gracilis Flap: A Novel Alternative for Pelvic and Perineal Reconstruction.

Utilizing the Retrograde Descending Internal Mammary Vein in DIEP Flap Anastomosis.

Primary Cutaneous Mucinous Carcinoma of the Eyelid.

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Bilobed Gracilis Flap: A Novel Alternative for Pelvic and Perineal Reconstruction.

Utilizing the Retrograde Descending Internal Mammary Vein in DIEP Flap Anastomosis.

Primary Cutaneous Mucinous Carcinoma of the Eyelid.