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This study aims to analyse a single-centre cohort series of patients who underwent parotidectomy for primary malignant parotid tumours. A retrospective chart review of 64 consecutive patients treated from November 2010 to March 2022 was performed. Outcomes were analysed by Kaplan-Meier curves. Sixty-four patients with a primary parotid malignancy were included in the study, with one bilateral case in this cohort. Patients were classified as stage I–II in 39 cases and stage III–IV in 26 cases. The five-year overall survival (OS), disease-specific survival (DSS), local relapse-free survival (LRFS), and distant metastasis-free survival (DMFS) rates were 78.4%, 89%, 92.5%, and 87.1%, respectively. Univariate analysis showed that high-risk histology, stage IV disease, lymphovascular invasion, perineural invasion, node metastasis, skin involvement, facial nerve involvement, and positive or close margins were risk factors associated with poorer outcomes. At present, the best evidence suggests that radical surgery should be the standard approach, and adjuvant therapy, in terms of radiotherapy/chemoradiotherapy, is recommended in patients with risk factors.

The number of revision surgeries to improve breast asymmetry after deep inferior epigastric perforator (DIEP) flap breast reconstruction is still high worldwide with impact on both patients and healthcare systems. These procedures include fat grafting, contralateral breast symmetrization, scar revision, flap repositioning and remodeling. A previously published DIEP flap insetting algorithm has proven to be effective in selecting patient-tailored strategies to achieve excellent aesthetic outcomes. This study investigated whether this insetting algorithm was effective in reducing revision surgeries in patients undergoing SSM and immediate DIEP flap breast reconstruction to achieve the goal of a one-stage reconstruction.This retrospective case-control study included 60 patients (group A) treated without the DIEP flap standardized insetting algorithm and 60 patients (group B) treated with the standardized insetting algorithm, which considers among its variables the type of breast to be reconstructed, abdominal tissue thickness, rotation due to harvesting side. Demographic data, operative data, complications and number of revision surgeries were recorded.One hundred and twenty primary and 106 revision surgeries were performed. Groups were homogenous for age (p = .32), body mass index (p = .77), flap weight (p = .7), operative time (p = .87) and early complications (p = .78). When excluding isolated nipple reconstruction from the revision surgeries, one-stage reconstruction was successfully performed in 26 patients in group A (43.3%) and 39 patients (65.0%) in group B, with a statistically significant difference between the groups (p = .003).The introduction of a standardized insetting algorithm for immediate unilateral DIEP flap breast reconstruction can be effective in reducing the number of revision surgeries for breast asymmetry, making a one-stage reconstruction an achievable and reliable target.

When patients are unsuitable for deep inferior epigastric perforator (DIEP) flap breast reconstruction, the inferior gluteal artery perforator (IGAP) flap has been used as an alternative option. However, the profunda artery perforator (PAP) flap is also gaining popularity as an alternative to the DIEP flap for several reasons. This retrospective cohort study compares baseline characteristics, peri- and post-operative outcomes following IGAP flap and PAP flap breast reconstructions after mastectomy for cancer.In a single center in the UK, from September 2008 through December 2016, 43 women underwent IGAP Flap(s) breast reconstruction and 51 received PAP flap(s) breast reconstructions. Statistical analysis was performed to compare baseline, peri-operative and post-operative variables between the two reconstruction methods.Perioperative complications requiring reoperation were experienced in women undergoing IGAP flap breast reconstructions only (21% versus 0%, p = 0.001), principally due to the risk of total flap failure (12% versus 0%, p = 0.01). Women undergoing IGAP flap breast reconstructions were at significantly higher odds of revision surgery (OR 17 [95% CI: 5.5-53], p 0.001), which was unchanged after adjusting for bilateral reconstructions (adjusted OR 18 [95% CI: 5.3-58], p 0.001).PAP flaps appear to be associated with significantly fewer complications and revision surgeries than IGAP flaps for breast reconstruction in women undergoing mastectomy for cancer and who are unsuitable for a DIEP flap breast reconstruction.

The elbow area is frequently affected by excessive sagging skin post-massive weight loss. The aim of this study is to present a brachioplasty with distal extension of incision to the anticubital surface, in order to make the transition from middle arm to distal arm/elbow more nuanced and aesthetically pleasing.An observational retrospective comparative study was performed confronting two groups of female patients. All patients treated with brachioplasty between January 2015 and December 2020 due to brachial laxity following massive weight loss were included in the study. Group A consisted of patients who underwent the novel procedure and Group B comprised subjects with the standard brachioplasty technique. Demographics, including age, BMI and comorbidities were taken into account. The mean outcome measure was the Body-QIn the period considered, Group A consisted of 92 patients and Group B of 78. No difference was found between groups concerning BMI and age. The groups were comparable also based on the Body-Q pre-surgery levels. The Body-Q scores at one year postoperatively were 22.80 ± 2.28 in group A and 19.50 ± 2.42 in group B. The postoperative Body-Q scores across the two groups were a higher in group A, and the result is statistically significant (p 0.05).The utilization of the proposed elbow-extended technique allows an improvement of the upper limb profile, with far higher satisfaction of patients, at the price of minimal sequelae in terms of scar. The elbow area is a critical part in post-obese deformities of the brachium, and is frequently neglected. In case of skin laxity and redundancy an elbow extension of the brachioplasty incision is indicated. Results of elbow-extended brachioplasty are p valid and the additional scar well concealed and accepted by patients.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An underdosing of collagenase clostridium histolyticum (0.32 mg) is proposed as a potentially effective option in patients with additional cords in the same hand, after the first cord has been treated with the regular dose of 0.58 mg. The aim of this study was to analyze whether this additional dose is tolerated and effective.Patients with Dupuytren's disease affecting MCP joints with at least two independent pathological cords, causing deformity of two digits, were considered, with their written informed consent, for a simultaneous injection of the two cords with a single vial of collagenase. Digits treated with the standard dose of 0.58 mg were compared with digits injected with the smaller dose of 0.32 mg. Passive extension deficit and range of motion were evaluated after injection. Complications were also compared.A total of 26 patients (29 hands) were included in the study. Of these, nine patients had two independent cords within one hand, and 17 patients had a single cord (three of these with a cord in each hand). Thirty-five digits were injected, 23 with 0.58 mg and 12 with 0.32 mg. Apart from a smaller mean percentage variation in passive extension deficit within 24 hours in the 0.58-mg dose compared with 0.32 mg (29% versus 40%,Underdosing collagenase clostridium histolyticum is equally effective in the treatment of Dupuytren's disease.

Background:To improve the aesthetic outcome of deep inferior epigastric perforator (DIEP) flap breast reconstruction, flaps should be tailored to the patient’s characteristics. A single method of DIEP flap insetting will not suffice for all women seeking breast reconstruction. The authors share the

Compartmental surgery and primary reconstruction with microvascular free flaps represent the gold-standard in the treatment of oral tongue squamous cell carcinoma (OTSCC). However, there are still unclear clinical features that negatively affect the outcomes. This retrospective study included 80 consecutive patients with OTSCC who underwent compartmental surgery and primary reconstruction by free flap. The oncologic outcomes, the reliability of the 8th edition American Joint Committee on Cancer (AJCC) staging system and the prognostic factors were evaluated. Fifty-nine males and 21 females (mean age 57.8 years, range 27–81 years) were treated between November 2010 and March 2018 (one patient had two metachronous primaries). Seventy-one patients (88.75%, 52 males, 19 females, mean age of 57.9 years, range of 27–81 years) had no clinical history of previous head and neck radiotherapy and were considered as naive. Histology showed radical surgery on 80/81 lesions (98.8%), with excision margins >0.5 cm, while in 1 case (1.2%), a close posterior margin was found. According to the 8th AJCC classification, 37 patients (45.7%) were upstaged shifting from the clinical to the pathological stage, and 39 (48.1%) showed an upstaging while shifting from the 7th to the 8th AJCC staging system (no tumors were downstaged). Nodal involvement was confirmed in 33 patients (40.7%). Perineural and lymphovascular invasion were present in 9 (11.1%) and 11 (13.6%) cases, respectively. Twenty-two patients (27.1%) underwent adjuvant therapy. The 5-years disease-specific, overall, overall relapse-free, locoregional relapse-free and distant metastasis-free survival rates were 73.2, 66.8, 62.6, 67.4, and 86%, respectively. Patients with a lymph node ratio >0.09 experienced significantly worse outcomes. Univariate analysis showed that patients with previous radiotherapy, stage IV disease, nodal involvement, and lymphovascular invasion had significantly worse outcomes. Multivariate analysis focused naive patients and showed that lymphovascular invasion, advanced stage of disease, and node involvement resulted reliable prognostic factors, and patients with the same tumor stage and histological risk factors who did not undergo adjuvant therapy experienced significantly worse outcomes. In our series, surgery played a major role in the treatment of local extension; adjuvant therapy resulted strictly indicated in patients with advanced-stage disease associated with risk factors.

Summary Background Several different flaps can reconstruct intraoral defects or lower limb deficits after free fibula osteo-cutaneous flap harvesting for jaw reconstructions. However, commonly used options may not be available for various reasons and can be associated with significant morbidity. We hypothesized that flaps supplied by the superficial peroneal nerve accessory artery (SPNAA) could be a viable alternative reconstructive option. Methods We describe the SPNAA's anatomy using 20 human cadaveric leg dissections and report eight cases involving SPNAA-based perforator flap reconstructions (six propeller flaps and two free flaps) in a retrospective case series. Patient-specific baseline variables and intraoperative and postoperative outcomes are described. Results Cadaveric dissection suggests that the location of the SPNAA is reliable but its origin varies, with 40% (N = 8) of SPNAAs being of type I origin, 20% type II (N = 4), and 40% (N = 8) type III in our series. All reconstructions were successful. No intraoperative complications occurred during propeller or free-flap reconstructions. No flap failures occurred. One propeller reconstruction showed distal superficial skin necrosis and one donor site wound dehisced; both were successfully managed conservatively. No other short-term or long-term complications occurred. Conclusions Flaps based on SPNAA perforators appear effective, reliable, and safe reconstructive methods for covering fibula osteocutaneous donor site defects and for intraoral reconstructions. Controlled trials are required to compare its effectiveness and safety with other reconstructive methods.

Summary Introduction Among the few methods available, none is able to determine accurately the volume of a DIEP flap. Specimen weight is commonly used to assess the amount of flap needed to reconstruct a breast, but the density of breast is different from that of abdominal tissues; therefore, the volume should be used as a unique unit of measure. The purpose of this study was to provide a simple method to calculate the predicted volume of a DIEP flap in order to match the volume of the breast being reconstructed. Material and Method We hypothesised that the shape best resembling a DIEP flap was a truncated pyramid. Based on this shape, we tailored 30 DIEP flap models using the discarded tissue after unilateral DIEP flap breast reconstructions. The awaited volume (AV) of the models was calculated with a free online calculator measuring the length and height with a ruler, and width (fat thickness) with Ultrasound (US). The real volume (RV) of the models was calculated using water displacement method. AV and RV were compared and statistical analysis was performed. Results The mean difference between the AV and the RV was not statistically significant with a mean estimation error of 6.75%. When the AVs were plotted against the RVs, the two data sets were highly statistically correlated (correlation coefficient (r = 0.997). Conclusions The proposed tool can be a useful, precise, easy and accessible tool to improve the current DIEP flap size assessment improving outcomes for both surgeons and patients.

Background: Prior to DIEP flap breast reconstruction, mapping the perforators of the lower abdominal wall using ultrasound, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) reduces the risk of flap failure. This review aimed to investigate the additional potential benefit of a reduction in operating time. Methods: We systematically searched the literature for studies concerning adult women undergoing DIEP flap breast reconstruction, which directly compared the operating times and adverse outcomes for those with and without preoperative perforator mapping by ultrasound, CTA or MRA. Outcomes were extracted, data meta-analysed and the quality of the evidence appraised. Results: Fourteen articles were included. Preoperative perforator mapping by CTA or MRA significantly reduced operating time (mean reduction of 54 minutes [95% CI 3, 105], p = 0.04), when directly compared to DIEP flap breast reconstruction with no perforator mapping. Further, perforator mapping by CTA was superior to ultrasound, as CTA saved more time in theatre (mean reduction of 58 minutes [95% CI 25, 91], p

Background In lower limb reconstruction the cosmetic outcome is influenced by the contouring of the flap at the recipient site as well as by the donor site closure. It is also important to minimise compression of the flap pedicle. We discuss the outcomes of a versatile ALT flap design that allows freedom in skin paddle tailoring without elongating the scar, reduction of the tension over the pedicle and improved cosmetic results of both donor and recipient sites. Methods Between January 2009 and October 2015, 27 patients underwent reconstruction using tear drop ALTs. The age ranged between 20 and 89 years. Seventeen were elective procedures and 10 were urgent. The locations of the defects were: knee (1 case), achilles tendon (2 cases), os calcis (1 case), lateral malleolus (1 case), fibula (3 cases), tibia (6 cases), tibia/fibula (5 cases), and ankle (8 cases). The sizes of the defects ranged from 4 × 3 cm to 9 × 7 cm. Results The size of the flap ranged from 6 × 4 cm to 11 × 7 cm. One venous congestion and a wound dehiscence occurred, no flap loss. Two defatting procedures were performed. The mean follow‐up was 16.44 months. Final outcomes showed good functional and cosmetic results in both the donor and recipient sites. Conclusions The tear drop ALT is a useful tool in lower limb reconstruction allowing to improve skin paddle tailoring without elongating the donor site scar. It allows minimal tension over the pedicle while optimizing the contour of both the donor and recipient sites.

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The rising incidence of primary head and neck (H&N) cancers in the elderly presents a dilemma regarding the appropriateness of complex surgery in this assumed frail age group. With limited data on surgical morbidity, survival, and patient quality of life (QOL), this analysis aimed to broaden the understanding of safety and effectiveness of microsurgical treatment in very elderly H&N cancer patients. A prospective database analysis was used to evaluate surgical outcomes (morbidity, survival, and QOL) in all patients aged 80 years and older undergoing microsurgical reconstruction for cutaneous and intra-oral H&N cancers between 2004 and 2014. Outcomes were assessed for their association with surgical, tumour, and patient variables. Comorbidities were categorized by the ACE27 index and postoperative morbidity by the Clavien–Dindo scoring system. QOL was analyzed using the UW-QOLv4. Of 720 microsurgical reconstructions, 96 patients were identified. Median survival was 25 months. The ACE27 index was the only variable significantly associated with survival with a 5-year survival of 59.2 % in the least comorbid group versus 19.7 % in the most comorbid group (p 0.015). ACE-27 showed influence on socioemotional QoL scores. Physical QOL scores were influenced by tumour and operative factors. Patients were found to value physical QOL over socioemotional. Microsurgical reconstructions are well tolerated in the very elderly patients and should be considered predominantly based on comorbidity. Tumour stage, flap type, and cancer site should still form part of the preoperative counseling due to their implication on postoperative physical function.

Summary Background The rate of bilateral mastectomy and bilateral breast reconstruction is increasing. The DIEP flap is an ideal method of breast reconstruction. The difference in risk of adverse outcomes between unilateral and bilateral DIEP flap breast reconstruction is unclear. The aim of this review is to investigate this relationship. Methods Authors searched Ovid EMBASE and MEDLINE from database inception to March 2012, for reports of DIEP flap breast reconstruction studies. After screening, data were extracted on flap-related, donor-site and systemic adverse events. Descriptive statistics were generated for all pooled data. We performed meta-analysis of direct comparisons to generate relative risk (RR) ratios with 95% confidence intervals (CI) using a random-effects model. Results Overall, 17 case-series of 2398 women were included. Compared with unilateral DIEP flap breast reconstruction, bilateral reconstruction was associated with a significantly higher risk of total flap failure (RR 3.31 [95% CI 1.50–7.28]; p = 0.003) and breast seroma (RR 7.15 [95% CI 1.21–42.36]; p = 0.03). Differences between other outcomes were non-significant, although descriptive analysis appeared to favour unilateral reconstruction. Conclusions The current literature related to DIEP flap breast reconstruction appears to be of low quality. However, this is the first systematic review confirming that bilateral DIEP flap breast reconstruction is associated with a significantly higher risk of total flap failure compared to unilateral DIEP flap breast reconstruction. This review will allow clinicians to better inform patients of the risks of adverse outcomes in DIEP flap breast reconstruction. It also highlights the need for higher quality research in this area.

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Summary Introduction PI as an independent indicator of resistance to flow is a widely-accepted alternative index to measurement of flow volume in vessels. This study aimed to determine the normal values and chronological trend of PI of abdominal wall free flaps in breast reconstruction and to revalidate its clinical relevance in post-operative monitoring of these flaps. Materials and methods 47 patients with breast reconstruction using DIEP, MS-TRAM and bi-pedicled DIEP flaps were assessed for PI of the supplying perforator vessels using a hand-held colour Doppler ultrasound device over 6 post-operative days. Triplicate measurements were obtained by one operator once daily concurrently with haemodynamic parameters. Results DIEP flaps demonstrate a descending trend of PI and resistance to blood flow post-operatively ( p = 0.005) similar to non-perforator free flaps. MS-TRAM flaps show higher initial PI values and vascular resistance compared to DIEP flaps ( p = 0.038). PI values show no correlation with haemodynamic parameters ( r = 0.2, n = 38). Flaps with venous insufficiency demonstrate significantly higher values of PI ( p = 0.03). Conclusions PI is an objective, non-invasive, efficient, easy-to-measure, reproducible and quickly-responsive indicator of perfusion of DIEP flaps.

The demand for bilateral breast reconstructions is rising worldwide. In the UK, approximately 30% of breast cancer patients undergoing mastectomy choose autologous tissue breast reconstruction. Although the deep inferior epigastric perforator (DIEP) flap is gaining popularity, bilateral DIEP flap breast reconstruction remains a complex procedure and reliable outcome data are lacking. In the absence of clinical trials, evidence from cohort studies is needed to better inform clinicians and patients.Over a 6-year period, all consecutive patients undergoing DIEP flap breast reconstruction were prospectively included and categorized as unilateral or bilateral reconstruction for comparative analyses of outcomes and complications, with the patient as the unit of analysis.Overall, 565 DIEP flaps were performed on 468 women (371 unilateral and 97 bilateral reconstructions [194 flaps]). Postoperative complications requiring reoperation were twice as likely for bilateral reconstructions (risk ratio [RR] 2.1, 95% CI 1.4-3.4, p = 0.002) and were mainly due to venous congestion (RR 3.1, 95% CI 1.2-7.5, p = 0.011). The risk of total flap loss was six times greater in bilateral reconstruction (RR 6.4, 95% CI 1.6-26, p = 0.011). The rates of revision breast and abdominal surgery were similar between groups.Both unilateral and bilateral DIEP flap breast reconstructions are safe, with a low risk of complications; however, bilateral reconstruction was associated with a higher risk of complications and total flap loss. This information should be highlighted to patients requesting bilateral breast reconstruction, particularly those requesting risk-reducing mastectomy and reconstruction.

Summary Introduction Women undergoing unilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction may be offered a contralateral symmetrisation either at the time of reconstruction (simultaneous/immediate) or at a later stage (delayed). Simultaneous contralateral breast symmetrisation may be more beneficial to patients and healthcare institutions by avoiding staged surgery, although there is limited evidence on which to base practice. This deficit formed the rationale for our study. The primary outcome was the overall rate of revision surgery. Methods Over a 6-year period, this prospective cohort study recorded the demographics, cancer treatments and operative outcomes of all consecutive unilateral DIEP flap breast reconstructions with or without contralateral symmetrising surgery. Patients were categorised into three groups: (1) simultaneous symmetrisation, 2) delayed symmetrisation and (3) no symmetrisation for comparative analysis. Results During the study period, 371 women underwent unilateral DIEP flap breast reconstruction 194 (52.3%) were not symmetrised, 155 (41.8%) were simultaneously symmetrised and 22 (5.9%) underwent delayed symmetrisation. Simultaneous symmetrisation of the contralateral breast and unilateral DIEP flap breast reconstruction increased the mean total operative time by 28 min. There were no differences in the rates of peri-operative complications. There were significantly higher rates of all-cause revision surgery (OR 3.97 [1.58, 9.94], p = 0.003) in women undergoing delayed symmetrisation, because of higher rates of revision lipomodelling, scar revision and revision contralateral symmetrisation. Conclusion Simultaneous contralateral breast symmetrisation was associated with a lower risk of all-cause revision surgery. It is safe, beneficial and likely to be more cost-effective for women undergoing unilateral free DIEP flap breast reconstruction.

Umbilical repositioning is a main step in performing abdominoplasty. The surgical aims are minimal visible scars and a natural-appearing result. Reported techniques do not completely satisfy the aesthetic targets for all types of patients. A previous study reported a versatile technique for umbilicoplasty based on an elliptical vertical incision of the umbilical skin and a double opposing “Y” incision on the abdominal flap to create a new umbilicus. This report describes the long-term results with this technique. A total of 111 abdominoplasties were performed. Patient satisfaction and postoperative results were evaluated over a 5-year follow-up period. A modified 5-ml syringe was used to assess the depth and volume of the umbilical stalk. Depth value variations were statistically compared using the Wilcoxon test. For all the patients, a three-dimensional umbilicus with an adequate depression was created. In four cases, deepithelialization of the umbilical skin occurred. After 1 postoperative year, no significant changes in umbilical shape, dimension, depth, or appearance were observed. After 5 years, no significant changes in shape or appearance were observed. The cicatricial umbilical stenosis occurrence was 4.5%. A small significant decrease in umbilical depth was noted. Overall, the results remained satisfying at this writing. The reported technique is easy to learn, simple to perform, and stable over time. It gives a natural depth appearance, ensures optimal position, pulls scars deeply, and allows achievement of different shapes according to the patient’s habitus.

We report the clinical, EEG and neuroradiologic findings from three adult patients who developed new-onset seizure disorders as early clinical manifestations of de novo high grade glioma. The malignancies could not be recognised at the time of the first epileptic seizure because of minimal non-specific brain abnormalities, which showed no signs of necrosis or significant contrast enhancement on computed tomography and magnetic resonance imaging. Focal EEG abnormalities were recorded in all cases and appeared consistent with the neuroradiologic findings. The patients regained normal neurological status after the first seizure but rapidly developed space-occupying necrotic lesions. Two patients underwent surgery and received histological diagnoses of the tumours. Another patient was finally diagnosed with a malignant glioma based on the neuroradiologic picture and rapid progression of the cerebral lesion. It should be noted that in adult patients, new-onset epileptic seizures might reveal the presence of malignant gliomas at a very early stage in the tumour formation process. This report indicates that typical anatomoradiologic features of de novo high grade glioma, such as necrosis and rim-contrast enhancement, could be absent at the time of the first epileptic seizure but become clear within a short period after clinical presentation.

Background Interplast Italy is a nongovernment, nonprofit organization with the aim of providing high-quality standard reconstructive procedures, contributing to local medical and nursing education, in those countries where this is not available or where the local resources are inadequate to meet local needs. A recent debate about the real aim and the effectiveness of this kind of health support strategy in developing countries has been raised. Methods The authors report a 20-year experience, explaining operative strategy, activities, and results, and contributing to the development and improvement of the philosophy of humanitarian missions. Results Since 1988, 47 missions and 5235 operations have been performed. A total of 2286 patients (43.7 percent) were younger than 18 years, and 2949 (56.3 percent) were above that age. Congenital cleft deformity was the most common diagnosis in 2415 patients (46.13 percent). Patients suffering from postburn contractures were operated on in 1956 cases (37.36 percent). The number of postburn children operated on was 922 (17.6 percent). Conclusions Cooperation with local physicians is considered mandatory to guarantee adequate patient preselection, to organize the activity in situ, and to plan continuous effective work on a regular basis to build local capacity and facilitate sustainable models for health care. Furthermore, as local surgeons become interested in reconstructive surgery, continuous teaching through a multidisciplinary approach must be paramount. The activity of Interplast Italy contributed to building a plastic surgery service in Bangladesh. Combined multidisciplinary activities linked to established organizations such as the Interplast confederation are desirable to improve results. A link with structured organizations is needed to obtain financial resources to extend targets and to improve activities and outcomes.

The goals of the treatment of chronic osteomyelitis are infection eradication with systemic antibiotic therapy and local management with radical excision of the infected tissue and obliteration of the remaining dead space. Adequate debridement and coverage with a well-vascularised tissue are mandatory for successful outcomes. Use of muscle covering for chronic osteomyelitis in the lower extremities is considered the best procedure. However, there have been instances where debridement of the bone tissue did not leave a deep cavity along the leg bones and fasciocutaneous flaps can be used in these instances to cover the defect and to restore function without recurrence of the disease. Recently, free non-muscle flaps have been used and assessed for chronic osteomyelitis or covering of exposed bone. Perforator flaps have been shown to be well vascularised due to a structural haemodynamic enhancement. In the light of these findings we report a successful case of chronic osteomyelitis of the right fibula treated with excision of the affected tissue and covering with a propeller flap. Instead of free flap covering, in order to optimise surgical reconstruction, reducing the operative time, donor and recipient site morbidity and risk of total flap failure, local perforator flaps and particularly the propeller flap may be indicated in the treatment of chronic osteomyelitis in selected patients when the defect is limited and there is no need to fill a deep bone cavity or a dead space. To our knowledge, this the first report of the use of a propeller flap in the treatment of chronic osteomyelitis in the lower extremities.

Recent advances in breast reconstruction allow for high expectations regarding long-term symmetry and aesthetic appearance. The DIEP flap is currently considered as an ideal autologous reconstruction. However, there are situations in which the amount of tissue from a DIEP flap is not enough to achieve adequate symmetry. Indications and outcomes for a combined use of DIEP flap and implants are discussed in order to describe and examine a further scenario in optimising breast reconstruction. Between January 2004 and January 2006, all patients who underwent combined DIEP/implant breast reconstruction have been collected and followed prospectively. When clinical assessment demonstrated inadequate amount of tissue in the abdominal region to achieve a suitable unilateral or bilateral reconstruction with DIEP flaps, the patients were counselled about the opportunity of primary augmentation of the DIEP flaps. In cases where DIEP breast reconstruction has been done previously and there is a considerable asymmetry, delayed flap augmentation was considered. Patient's age, indication for surgery, preoperative and postoperative radiotherapy (RT), operative procedure, implant size, location and timing of insertion, complications, outcomes, and follow-up have been gathered. In all cases, textured round silicone gel implants have been used. After 12 months, four-point scales were used to analyse patients' satisfaction and aesthetic outcome. During the study period, 156 patients underwent breast reconstruction with 174 DIEP flaps. Fourteen patients (8.9%) had breast reconstruction with 19 DIEP flaps and 18 implants. The mean follow-up was 20.6 months (range 12-32 months). Fourteen implants were placed primarily at the time of DIEP reconstruction. The average implant weight was 167.2g with range between 100 and 230 g. Implant/flap weight ratio is about 1:5 corresponding to 20%. In six flaps, the patients had RT before the reconstruction, whilst in three cases of delayed DIEP flap augmentation the patients had RT after the DIEP post-mastectomy reconstruction. One infection and one haematoma, both followed by flap partial necrosis, occurred. After 12 months following the completion of reconstruction, aesthetic scores were all between good and excellent. Surgical indications and outcomes available from this series demonstrate that primary and delayed DIEP/implant augmentation can be a safe and effective option in optimising breast reconstruction with autologous tissue.

Swan neck deformity is a progressive and disabling condition that commonly affects rheumatoid arthritic hands. During a 4-year period, 101 fingers in 43 patients had this deformity corrected using a new procedure combining the distally based extensor lateral band technique described by Littler and the flexor digitorum superficialis (FDS)-palmar plate pulley introduced by Zancolli. The ranges of motion of the metacarpophalangeal, proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints were assessed pre-operatively and 12 months after surgery. An average PIP joint hyperextension of −13.3° was converted to +13.4°. The ranges of motion of the proximal and DIP joints were significantly different (Student’s t-test). No patient suffered recurrence of the deformity during an average follow-up of 20 months. This new technique improves some unappealing aspects of previous techniques and provides a stable and reliable correction of swan neck deformity.

Deep partial or full-thickness burns if untreated, neglected, or managed conservatively can develop dysfunctional scar contractures with severe deformities and significant reduction in patient's activities of daily life. These burn sequelae can require multistage procedures to restore anatomy and function. These include single scar release, use of skin grafts, skin expansion, regional or free musculocutaneous or fasciocutaneous flaps to achieve adequate functional improvement. The use of dermal regeneration template (Integra), initially used in primary burns reconstruction, has been already described and compared in single scar contracture-releasing procedures, but to our knowledge, it has not been used in the simultaneous releasing of multiple severe extensive postburn contractures. A simultaneous approach with total scar tissue excision and resurfacing with Integra may reduce the number of operations and the prolonged time period of treatment required by conventional procedures of multistage scar contracture release. A 7-year-old girl, who developed severe postburn scar contractures involving the right upper limb, right axilla, neck, and face after healing of a deep 16% total body surface area burn injury, was treated with this approach. Restoration of anatomy and function, with significant improvement in the range of movement of the involved regions, was achieved in a relatively short period of time (15 weeks) with limited donor-site morbidity and preservation of donor areas for possible future procedures. Total scar tissue excision and resurfacing with Integra should be considered as a valid option in case of simultaneous management of severe multiple extensive scar contractures.

Background: It is accepted that major injuries of the upper limb may require not only fasciotomies but also nerve decompressions. That nerve compression(s) may occur after less dramatic injuries and “routine” surgery distal to the elbow is less well documented in the literature but well known to experienced clinicians. The aim of this study was to identify a possible link between injuries or elective surgery to the distal upper limb and “subacute nerve compressions.” Methods: Over a 5-year period, data of patients who developed clinical symptoms of nerve compressions distal to the elbow within 6 months after trauma or elective surgery to the same upper limb that affected postoperative management were collected prospectively. Results: This study identified 91 patients (49 after trauma and 42 after elective surgery). Compression of the median nerve in the carpal tunnel was the most common syndrome (73 cases). Fasciectomy for Dupuytren’s disease was the most frequent operation involved (23 cases). The average time from injury or surgery to diagnosis of nerve compression(s) was 8 weeks (range, 1 to 24 weeks). Surgical decompression of the involved nerves was performed in 43 patients (47.2 percent), with an average time from diagnosis to surgery of 30.4 weeks (range, 28 to 44 weeks). In the carpal tunnel syndrome group (47 men and 26 women), mean age was 49 years (men, 48 years; women, 50 years) and the male-to-female ratio was 1.8:1. Conclusion: Subacute nerve compressions should be considered as a complication during the recovery period after injury and surgery of the upper limb.

Although multiple benefits have been reported from post-mastectomy reconstruction and particularly from an immediate procedure, limited psychiatric evaluation has been published. The present study was planned to evaluate the psychosocial and psychopathological outcome in patients who had undergone post-mastectomy breast reconstruction. We also investigated if any psychopathological condition could significantly affect the benefits of the reconstructive procedure. We compared 33 breast-reconstructed patients with 33 patients with mastectomy alone and 33 healthy women. All women underwent a psychiatric interview with four questionnaire-based scales (SASS, QL-index, HAM-A, HAM-D) to assess social adaptation, quality of life, anxiety and depression. A 4-point scale evaluated reconstructed patients' satisfaction. After a year, there was no statistical difference in social, sexual relationships and quality of life among reconstructed patients and healthy women. Regarding anxiety, no statistical difference was found between reconstructed and mastectomy groups. Statistically different lower depression levels in the healthy group and higher levels in the mastectomy group were found. Depression in the reconstructed group decreased compared to the mastectomy group. Differences between timing and reconstructive techniques were not statistically validated. Eight patients were dissatisfied (24.2%). Immediate reconstructed patients who had pre-existing major depressive disorder were dissatisfied. Breast-reconstructed patients' quality of life, social and sexual relationships are not significantly different to those of healthy women. Anxiety does not decrease. Timing and techniques do not seem to influence, significantly, outcome and satisfaction. Pre-existing diagnosis of major depressive disorder may be a contraindication to immediate breast reconstruction.

This study reports the outcome of immediate re-repair of primary flexor tendon repairs in zones 1 and 2 of the fingers which had ruptured. Between June 1989 and May 2003, a total of 62 fingers in 61 patients presented with ruptured flexor tendon repairs within 48 hours from rupture. Immediate re-repair and rehabilitation was carried out in 44 fingers (71%) in 43 (70%) patients. Thirty-six patients completed the 8-week therapy programme after re-repair in 37 fingers. Nine (24%) had excellent, 10 (27%) good, 5 (14%) fair and 13 (35%) had poor results when assessed by the original Strickland method. Five fingers in five patients ruptured the re-repair. Poor results and second ruptures were particularly common after re-repair of ruptured tendon repairs in the little finger. In the light of these findings, a policy for dealing with ruptured primary flexor tendon repairs in the fingers is suggested.

The deep inferior epigastric perforator (DIEP) flap is ideally suited for breast reconstruction. The DIEP flap reduces abdominal wall morbidity when compared to a transverse rectus abdominis (TRAM) flap, however, there maybe a compromise of the flap vascularity. Early venous problems and late fat necrosis in DIEP flaps can occur. There is a limited literature on the haemodynamic and microcirculation of the DIEP flap. Sixteen consecutive patients who underwent immediate breast reconstruction with DIEP flap were prospectively monitored during the post-operative time for a minimum period of 48h using laser Doppler flowmetry (LDF) and lightguide reflectance spectrophotometry (LRS) to analyse blood flow and oxygenated haemoglobin percentage in the cutaneous microcirculation of the flap. LDF demonstrated an increase of capillary flow in comparison to the pre-operative levels. LRS showed an initial decrease of the values and a varying pattern of increase in relation to time, to reach the pre-operative levels. A correlation between lower values of post-operative LDF and LRS measurements and late fat necrosis and early venous congestion was demonstrable in this series. This study demonstrates a change in the cutaneous microcirculation of the lower anterior abdominal wall following its elevation as a DIEP flap. These findings could explain the clinical phenomenon occurring in this flap in the early post-operative period. Significant correlation between longer harvesting time and re-exploration and between longer ischaemia time and localised fat necrosis was found.

Avulsion Thighplasty: What about the Consent for Loss of Reconstructive Options for Microsurgical Breast Reconstruction?(

Background: Hidradenitis suppurativa (HS) is a chronic, inflammatory disease affecting the apocrine glands of the axillary, groin and mammary regions with significant physical and psychosocial sequelae. Surgical excision of the affected tissue is the gold standard treatment. Severe axillary HS is associated with high rates of recurrence and requires extensive surgical resection with challenging reconstruction associated with risk of post-operative complications. The most effective method for reconstruction of the axilla after excision of HS is yet to be identified. We present a prospective observational study comparing thoraco-dorsal artery perforator (TDAP) flap and split-skin graft (SSG). Methods: Over 4 years, we enrolled 27 consecutive patients with Hurley's Stage III HS of the axilla who underwent surgical excision with reconstruction using either SSG (n = 12) or TDAP flap reconstruction (n = 15). We evaluated and compared intraoperative and post-operative data, quality of life (dermatology life quality index questionnaire) and pain/discomfort (visual analogue scale) before and after surgery. Results: Patients who underwent TDAP flap reconstruction had significantly faster recovery, fewer complications and fewer overall number of procedures than those who underwent SSG reconstruction. All patients reported an improved quality of life (QOL) after their operation and the TDAP group showed significantly more improvement than the SSG group. All patients reported a reduction in pain/discomfort but there was no significant difference between groups. Conclusion: TDAP flap and SSG both improve QOL for patients with severe axillary HS. The TDAP flap showed greater benefits in terms of QOL, recovery, rate of complications and number of overall procedures.