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Reconstruction of large chest wall defects always demand surgeons of having lots of means available (both materials and resourceful) to apply a cover to chest wall defects which can range from a few centimeters to the lack of a few entire ribs. In this study, we present the case of a teenager who suffered from a complete resection of three ribs because of Ewing sarcoma dependent on the sixth rib. Given the size of the defect, a multidisciplinary approach was chosen to provide rigid and soft tissue coverage and minimal functional and aesthetic impact. Custom-made titanium implants were designed based on three-dimensional computed tomography scan reconstruction. The surgical specimen via a left lateral thoracotomy (fifth, sixth, and seventh entire ribs) was resected, leaving a defect of 35 × 12 × 6 cm. A Gore-Tex patch (W. L. Gore & Associates, Arizona, United States) was placed and, after that, the implants were anchored to the posterior fragment of the healthy ribs and to the costal cartilage anteriorly. Finally, the surgical site was covered with a latissimus dorsi flap. The postoperative course was uneventful. After 9 months of follow-up, the patient has full mobility. This case shows that the implant of custom-made ribs, combined with other techniques, is a good surgical choice for reconstruction of large chest wall defects. The implant of custom-made ribs, combined with other techniques, is a good surgical choice for reconstruction of large chest wall defects.

The reconstruction of finger flexor tendons with vascularized flexor digitorum superficialis (FDS) tendon grafts (flaps) based on the ulnar vessels as a single stage is not a popular technique. We reviewed 40 flexor tendon reconstructions (four flexor pollicis longus and 36 finger flexors) with vascularized FDS tendon grafts in 38 consecutive patients. The donor tendons were transferred based on the ulnar vessels as a single-stage procedure (37 pedicled flaps, three free flaps). Four patients required composite tendon and skin island transfer. Minimum follow-up was 12 months, and functional results were evaluated using a total active range of motion score. Multiple linear regression analysis was performed to evaluate the factors that could be associated with the postoperative total active range of motion. The average postoperative total active range of motion (excluding the thumbs) was 178.05° (SD 50°). The total active range of motion was significantly lower for patients who were reconstructed with free flaps and for those who required composite tendon and skin island flap. Age, right or left hand, donor/motor tendon and pulley reconstruction had no linear effect on total active range of motion. Overall results were comparable with a published series on staged tendon grafting but with a lower complication rate. Vascularized pedicled tendon grafts/flaps are useful in the reconstruction of defects of finger flexor tendons in a single stage, although its role in the reconstructive armamentarium remains to be clearly established.

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Bleomycin-induced flagellate erythema is a rare but typical skin toxicity of bleomycin. We report the case of a boy with a left foot venous malformation who developed this skin rash after two sessions of bleomycin intralesional injection. We discuss the mechanism and characteristics of this reaction to bleomycin, which is usually benign and self-limited. We conclude that, although rare, flagellate pigmentation can occur when bleomycin is used as a sclerosant in children.Bleomycin is an antibiotic with cytotoxic properties, commonly used in combination regimens for the treatment of Hodgkin's and non-Hodgkin's lymphoma; squamous cell carcinoma of the head and neck; and germ cell, gynecologic, and skin tumors.1 In addition to its antitumor activity, bleomycin is used as a sclerosant in the treatment of vascular malformations and in recurrent malignant pleural effusions.1 Bleomycin-induced toxicities are more common in the lungs and skin because of a lower activity of bleomycin hydrolase in these organs. 2The reported dermatologic side effects of bleomycin include alopecia, Raynaud's syndrome, hyperkeratosis, nail bed changes, palmar and plantar desquamation, eczematous changes, digital gangrene, and pigmentary alterations. 3,4 Less commonly, skin toxicity presents as flagellate erythema, a unique drug rash that appears as "whiplike" linear streaks. It may affect the face, trunk, or limbs. 5Moulin first described it in 1970. 6Although the use of bleomycin as an antineoplastic agent has been decreasing, 5 there has been growing interest in its use as a sclerosant because of the low risk of side effects and its low cost. In addition, patients recover quickly, with good outcomes. 7We report a case of bleomycin-associated flagellate erythema after intralesional injection of a venous malformation and discuss the mechanism and characteristics of this reaction. | CASE REPOR TWe report the case of a 14-year-old boy with a venous malformation (VM) in the left lower limb. He underwent partial excision of the lesion at the age of 9 years. The postoperative period was complicated by a hematoma and skin ulceration, which was managed using local wound care. There was no other significant past medical or surgical history and no dermatologic disorders or allergies. A skin biopsy of a lesion on his left flank was obtained. Pathologic examination showed lymphocytic and histiocytic infiltration around