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Introduction When a Deep Inferior Epigastric Artery flap is not suitable, the Profunda Artery Perforator (PAP) flap can be a good alternative for autologous breast reconstruction. Popularity of the PAP flap is expanding, but it is still only slowly being adopted worldwide. We report our experience with 116 consecutive PAP flaps showing refinements and evolution of the technique towards improvement in outcomes and patients' satisfaction. Methods We prospectively collected data from consecutive PAP flap breast reconstructions performed from 2016 to 2019. Patients' demographics, pre-, intra-, postoperative data and revision procedures were analyzed. The BREAST-Q and a specific questionnaire investigating outcomes at the donor site were completed preoperatively and 12 months postoperatively. Results One-hundred and sixteen PAP flaps were performed in 86 patients, 64 unilateral and 22 bilateral breast reconstructions. Mean body mass index was 24.72 kg/m2 (range 18.9-29.2) and mean flap weight was 251.30g (range 152g – 455g). Complications included donor site hematoma (1.7%), seroma (2.6%), fat necrosis (1.7%) and wound dehiscence (2.6%). No arterial/venous thrombosis nor flap losses were recorded. Patients reported high satisfaction in all BREAST-Q domains, with mean postoperative scores being higher than preoperative ones, suggesting a positive effect in quality of life and satisfaction. Scores were significant in the satisfaction with breast domain (p= 0.0016). Conclusions Breast reconstruction with PAP flap yields a high success, low complications and excellent cosmetic outcomes in the breast and donor sites. It improves patients' satisfaction and quality of life; hence it can be considered an excellent option for autologous breast reconstruction.

Background: Safety of reconstructive microsurgery in elderly patients is still a topic of debate, because no conclusive evidence exists that provides indications and risk evaluation in elderly patients. The purpose of this study, which the Italian Society for Plastic, Reconstructive, and Aesthetic Surgery (SICPRE) has promoted, is to evaluate the safety and the complication risk of elective reconstructive microsurgery in elderly patients as well as to identify patient- or procedure-related risk factors. The secondary aim is to evaluate the predictive role for complications of the Geriatric 8 score (G8). Methods: A total of 194 consecutive patients from 18 centers, aged 65 or older, who received an elective microsurgical flap between April 2018 and April 2019 were prospectively evaluated. Patient-related, treatment-related, and outcomes data were recorded and statistically analyzed through multiple-adjusted logistic regression models. Results: Our study showed an increased risk of complications and a longer hospitalization in patients aged ≥75 years with the American Society of Anesthesiologists (ASA) score ≥3 (or G8 score ≤11) as compared to patients >65 years of age and

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.

The study objectiveis to evaluate the utilisation and effectiveness of intensive care unit (ICU) in the postoperative period as to its potential benefits to the head and neck reconstruction services.Materials and methods. This is a retrospective study on 143 consecutive patients who underwent 144 major head and neck microvascular reconstructive procedures performed by a single surgeon, that focused on perioperative management and on the relation between admission to ICU and complications/outcomes.Results.Thirty-four (23.6 %) patients were admitted to ICU during the early postoperative period. Admission to ICU was not associated with lower incidence of complications compared to direct admission to the Head and Neck ward: 29.4 % vs 27.3 % (p = 0.807709).Conclusion.Routinely early postoperative admission to ICU seems not to improve outcomes and/or reduce complications, and, as a consequence, ICU admission should be restricted to selected patients only.

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

Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR.The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy.A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment.TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.La mamoplastia terapéutica (therapeutic mammaplasty, TM) puede ser una alternativa a la mastectomía, pero hay pocos estudios bien diseñados que hayan evaluado el éxito de esta estrategia o hayan comparado los resultados a corto plazo de la TM con la mastectomía con o sin (+/-) reconstrucción mamaria inmediata (immediate breast reconstruction, IBR). Para comparar la seguridad y los resultados a corto plazo de la TM y la mastectomía +/- IBR se combinaron los datos de los estudios nacionales iBRA-2 y TeaM. MÉTODOS: En el estudio TeaM se identificó el subgrupo de pacientes al que se realizó una TM para evitar la mastectomía y se compararon los datos demográficos, las complicaciones, los resultados oncológicos y el tratamiento adyuvante con las pacientes sometidas a mastectomía +/- IBR del estudio iBRA-2. La variable principal fue el porcentaje de éxito de la cirugía conservadora de mama en el grupo TM. Las variables secundarias fueron las complicaciones postoperatorias y el intervalo de tiempo hasta el inicio del tratamiento adyuvante.Se incluyeron en el análisis 2.916 pacientes (TM n = 376; mastectomía n = 1.532; IBR n = 1.008). La TM era más frecuente en pacientes obesas o en las sometidas a cirugía bilateral en comparación con las pacientes con IBR. Sin embargo, las pacientes sometidas a una mastectomía +/- IBR tenían más probabilidades de desarrollar complicaciones que las del grupo TM (TM n = 79, 21,0%; mastectomía n = 570, 37,2%; mastectomía y IBR n = 359, 35,6%; P 0,001). La conservación de la mama fue posible en el 87% de las pacientes con TM y el procedimiento no retrasó el inicio del tratamiento adyuvante. CONCLUSIÓN: La TM puede permitir que pacientes de alto riesgo que no serían candidatas a IBR eviten la mastectomía de una forma segura. Se necesitan más trabajos para comparar los resultados percibidos por las pacientes y los estéticos de las diferentes estrategias terapéuticas y establecer la seguridad oncológica a largo plazo.

Highlights • Keystone design perforator island flap (KPIF) has been developed by Behan in 1995. • KPIF seems to be a new innovative and useful solution after a wide vulvar excision. • We found that Key Stone technique is an extremely simple and effective solution. • KPIF seems to be associated minimal morbidity. • KPIF showed less risk of flaps necrosis and lower complications., Objective This study aimed to evaluate the application of the Keystone flap technique and the long-term results of vulvovaginal reconstruction after vulvar surgery. Methods This is the first case series describing the application of the Keystone perforator island flaps (KPIF) technique to close a wide defect after radical vulvectomy. We prospectively collected patient demographics, operative times, complications, pathologic results, and length of stay on all patients. The benefits, cosmetic results and satisfaction of patients were analyzed in the follow up. Results Five patients were selected for the study: four underwent radical vulvectomy for squamous cell vulvar cancer, and one underwent vulvar wide excision for Paget disease followed by reconstruction with the Keystone flap technique. The defects were successfully covered by the Keystone flap technique in all patients. Conclusions Keystone flaps seem to be easy to design and elevate, and it offers rapid fasciocutaneous closure in wide vulvo-perineal defects with excellent long-term results.

BACKGROUND: Carpal tunnel syndrome is a common problem and surgical decompression of the carpal tunnel is the most effective treatment. After surgical decompression, the palmar skin may be closed using either absorbable or non‐absorbable sutures. To date, there is conflicting evidence regarding the ideal suture material and this formed the rationale for our review. OBJECTIVES: To assess the effects of absorbable versus non‐absorbable sutures for skin closure after elective carpal tunnel decompression surgery in adults on postoperative pain, hand function, scar satisfaction, wound inflammation and adverse events. SEARCH METHODS: We searched the following databases on 30 October 2017: the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, and Embase. We searched two clinical trials registries on 30 October 2017. SELECTION CRITERIA: We considered all randomised or quasi‐randomised controlled trials comparing absorbable and non‐absorbable sutures for skin closure after any form of carpal tunnel decompression surgery in adults. DATA COLLECTION AND ANALYSIS: The unit of analysis was the hand rather than the patient. We performed meta‐analysis of direct comparisons to generate standardised mean differences (SMDs) with 95% confidence intervals (CIs) in pain scores and risk ratios (RRs) with 95% CIs for dichotomous outcomes, such as wound inflammation. The primary outcome was postoperative pain. Secondary outcomes included hand function, scar satisfaction, scar inflammation and adverse events (complications). We assessed the quality of evidence for key outcomes using GRADE. MAIN RESULTS: We included five randomised trials (255 participants). The trials were all European (UK, Republic of Ireland, Denmark and the Netherlands). Where quoted, the mean age of participants was between 48 and 53 years. The trials measured outcomes between one and 12 weeks postoperatively. Meta‐analysis of postoperative pain scores for absorbable versus non‐absorbable sutures at 10 days following open carpal tunnel decompression (OCTD) produced a SMD of 0.03 (95% CI ‐0.43 to 0.48; 3 studies, number of participants (N) = 137; I(2) = 43%); the SMD suggests little or no difference, but with a high degree of uncertainty because of very low‐quality evidence. At 10 days following endoscopic carpal tunnel decompression (ECTD), the SMD for postoperative pain with use of absorbable versus non‐absorbable sutures was ‐0.81 (95% CI ‐1.36 to ‐0.25; 1 study; N = 54); although the SMD is consistent with a large effect, the very low‐quality evidence means the results are very uncertain. Only the OCTD studies provided pain data at 6 weeks, when the SMD was 0.06 (95% CI ‐0.72 to 0.84; 4 studies; N = 175; I(2) = 84%), which indicates little or no evidence of difference, but with a high degree of uncertainty (very low‐quality evidence). The RR for wound inflammation using absorbable versus non‐absorbable sutures after OCTD was 2.28 (95% CI 0.24 to 21.91; N = 95; I(2) = 90%) and after ECTD 0.93 (95% CI 0.06 to 14.09; 1 study, N = 54). Any difference in effect on wound inflammation is uncertain because the quality of evidence is very low. One study reported postoperative hand function but found no evidence of a difference between suture types at two weeks (mean difference (MD) ‐0.10, 95% CI ‐0.53 to 0.33, N = 36), with similar findings at six and 12 weeks. Only the ECTD trial reported scar satisfaction, with 25 out of 28 people reporting a 'nice' result in the absorbable‐suture group, versus 18 out of 26 in the group who received non‐absorbable sutures (RR 1.29, 95% CI 0.97 to 1.72, N = 54). These findings are also very uncertain as we judged the quality of the evidence to be very low. All studies were at high risk of bias for most domains. No trials reported adverse events. AUTHORS' CONCLUSIONS: It is uncertain whether absorbable sutures confer better, worse or equivalent outcomes compared to non‐absorbable sutures following carpal tunnel decompression, because the quality of evidence is very low. Use of absorbable suture eliminates the need for suture removal, which could confer considerable savings to patients and healthcare providers alike. We need rigorously‐performed, non‐inferiority randomised trials with economic analyses to inform choice of suture.

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.

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.

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.

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.

Many techniques have been described to create an aesthetic and functional neo-phallus after penile amputation or in female-to-male transsexuals. Microsurgical free-flap phalloplasty seems to be the preferred method of penile reconstruction. For many years the radial forearm free flap has been considered the best procedure, but other flaps have been attempted to minimize donor site morbidity and optimize outcome. Pedicled flaps are considered to be reliable and to decrease the risk of total failure. Recently, a one-stage non-microsurgical technique was described for phallic reconstruction in a young male patient. We report successful total phallic reconstruction in a female-to-male transsexual patient using an island pedicled anterolateral thigh (ALT) flap. Urethral reconstruction was left as a possible further procedure due to patient's preference. A malleable soft silicone penile prosthesis was inserted within the flap and the lateral cutaneous femoral nerve stump was sutured to the dorsal clitoris branch from the pudendal nerve for flap sensation. After 6 months, the patient demonstrated successful aesthetic and functional reconstruction referring to satisfactory sexual activity. To our knowledge, this is the first report of an innervated island pedicled ALT flap used for female-to-male penile reconstruction in a transsexual patient. The pedicled ALT flap may be a reliable option to avoid visible scarring at the donor site on exposed parts of the body, and reduce the risk of total flap failure from microsurgical procedures for reconstruction of a neo-phallus in this increasing population of patients.

Skin tumours of the anterior auricular concha are not uncommon. Wider excision and immediate reconstruction are required to reduce the risks of recurrence of the disease, cartilage infection and external ear distortion. Many surgical methods have been described for reconstruction of conchal defects. Post-auricular island flaps, such as the revolving-door (RD) flap, and full-thickness skin grafts (FTSGs) are the most-performed procedures. Although the RD flap has been fully described, it is not widely accepted and many surgeons, in their daily practice, prefer to use FTSG. It is a common experience that FTSGs are more subjected to centripetal contraction, decreasing the structural firmness of the conchal cavity and affecting functional and aesthetic outcomes. Furthermore, FTSGs are more prone to delay in wound healing due to the difficult access to this region that hinders adequate tie-over dressings. Between March 2003 and January 2007, 40 patients affected by T1 and T2 non-melanotic skin cancer and T1 melanoma of the anterior conchal surface of the external ear were included in a prospective study and randomly assigned to the RD reconstructed group or to the FTSG reconstructed group to investigate, compare and define advantages and disadvantages of both the techniques. Visual Analogue Scale (VAS) was used to evaluate the overall outcome and the colour and texture match. No flap or skin graft total loss was observed. Six patients (30%) showed partial failure of FTSG. The RD group demonstrated excellent cosmetic outcome, ideal colour match, adequate structure of external ear, projection and shape. Wilcoxon matched-pairs rank-sum test demonstrated statistically significant higher scores for the RD group compared to the FTSG group (p

Unusual and probably underestimated complications following breast reconstruction with a latissimus dorsi (LD) flap and sub-pectoral implant are the LD muscle twitching and the breast contour deformities from pectoralis major (PM) muscle contraction. Surgical muscle denervation is usually indicated for these complications. Botulinum toxin A (BTX-A) infiltration has been described in reducing breast contour deformity in sub-pectoral implant after breast augmentation or reconstruction. Between January 2002 and April 2006, 71 consecutive patients underwent delayed unilateral breast reconstructions with LD flap and sub-pectoral implant after mastectomy. All patients reporting discomforting signs and symptoms from muscle contraction in the reconstructed breast were included in this prospective study. Thirteen patients (18.3%) were selected and treated with BTX-A percutaneous local injections. Signs and symptoms were evaluated, after 4, 8 and 12 months, by the patients and by a panel of three physicians not involved in the study, using a five-point scale. During the study period all patients reported a decrease or disappearance of the signs and symptoms. After 12 months, 11 patients received three BTX-A infiltrations, demonstrating considerable improvements compared to the pre-treatment status. Wilcoxon matched pairs rank sum test showed a statistical difference between pre-treatment and post-treatment scores after 14 days (P

Summary Toxic epidermal necrolysis (TEN) is an acute drug-induced life-threatening disorder characterised by extensive epidermal exfoliation and high rate of mortality. Between October 2000 and April 2003, five severe TEN patients were evaluated using a specific TEN severity-of-illness scale (SCORTEN) and treated for the first time, with a combined therapy using Intravenous Human Immunoglobulins (IVIG) and plasmapheresis. The standardised mortality ratio (SMR) analysis ([Σ observed deaths/Σ expected deaths]×100) was applied to establish how IVIG and plasmapheresis treatment could reduce TEN patient mortality. The observed mortality was one out of five patients corresponding to 20%. The expected mortality based on SCORTEN was 3.319 corresponding to 66%. The SMR analysis revealed a 70% reduction in mortality (SMR=0.30; 95% confidence interval, 0.0–0.96). Our series show a low mortality rate (20%) related to the severity of the patients (66% expected mortality). The use of IVIG in association with plasmapheresis has a rational basis and may be effective in severe TEN patients.

Whether the palmar skin has a role in the development, propagation or recurrence of Dupuytren’s disease remains unclear. Clinical assessment for skin involvement is difficult and its correlation with histology uncertain. We prospectively biopsied the palmar skin of consecutive patients undergoing single digit fasciectomy (for primary Dupuytren’s disease without clinically involved skin) and dermofasciectomy (for clinically involved skin or recurrence) in order to investigate this relationship. We found dermal fibromatosis in 22 of 44 patients (50%) undergoing fasciectomy and 41 of 59 patients (70%) undergoing dermofasciectomy. Dermal fibromatosis appeared to be associated with greater preoperative angular deformity, presence of palmar nodules and occupations involving manual labour. Dermal fibromatosis exists in the absence of clinical features of skin involvement and we hypothesize that the skin may have a greater role in the development and propagation of Dupuytren’s disease than previously thought. Level of evidence: III