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Background Loss of elbow flexion is a common sequela of acute brachial plexus injuries (BPIs). The Mackinnon/Oberlin-II double fascicular transfer (DFT) is a widely used method to restore this function in acute C5–6 or C5–7 injuries. This study attempted to evaluate if this technique can be applied reliably for cases involving C8 and/or T1 injuries. Methods Adult patients with acute BPIs who underwent the Mackinnon/Oberlin-II DFT in our center between 2008 and 2018 were retrospectively identified. Group I (n = 37) included patients with only C5–6 or C5–7 injury, while group II (n = 32) patients presented C5–8 ± T1 injuries. The demographic data, pre- and postoperative neurologic evaluations, electrodiagnostic studies, and grip strength assessment were collected. Results A total of 69 patients met the inclusion criteria. Preoperatively, the patients in group II presented poorer nerve conduction and electromyography in both the median and the ulnar nerves and the supply muscles. The percentage of M3 achievement in both groups was 91.9 versus 87.5% and M4 was 73.0 and 71.9%, respectively, which both were not statically significant but the achievement of group II was slower than the group I, 1 to 2 months slower, respectively. Both groups had 57.57 and 46.0% of the postoperative grip power compared with the healthy side, the result of shoulder abduction was not different (p = 0.480). Conclusion With careful preoperative evaluation, early intervention, appropriate intraoperative functional fascicle selection, and aggressive postoperative rehabilitation, indications for the Mackinnon/Oberlin-II DFT technique can safely include acute C5–8 injuries and even partial T1 acute BPIs.

Thoracic sympathectomy to treat palmar hyperhidrosis (PH) has widely been performed. Many patients regret the surgery due to compensatory hyperhidrosis (CH), gustatory hyperhidrosis, arrhythmia, hypertension, gastrointestinal disturbances, and emotional distress. Robotic applications in microsurgery are very limited. We report the technique and long-term patient-reported outcomes of bilateral robot-assisted microsurgical sympathetic trunk reconstruction with a sural nerve graft in an interdisciplinary setting. A 59-year-old female suffered from severe adverse effects after endoscopic thoracic sympathectomy (ETS) for PH 25 years ago. She reported CH over the whole trunk, gustatory hyperhidrosis, excessive dry hands, and emotional distress. An interdisciplinary surgical team performed a bilateral sympathetic trunk reversal reconstruction with an interpositional sural nerve graft per side by a da Vinci® Robot. The nerve graft was microsurgically coapted using 9-0 sutures end-to-end to the sympathetic trunk stumps and side-to-end to the intercostal nerves T2-T4. At 24, 33 and 42 months, palmar dryness and emotional distress were strongly reduced. A highly specialized interdisciplinary setting may provide a precise, safe, and efficient treatment for ETS sequelae. A clinical study is initiated to validate this new therapy.

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.

Facial deformity, facial paralysis, and sensory loss are inevitable after some head and neck tumor resection and reconstruction, especially in high stage cancer. To overcome these obstacles, we present a case of T4a gum cancer patient (41-year-old) who received holistic reconstruction of the mandible defect via an osteo-peroneal-artery-perforator combined flap for defect coverage and cross-mental nerve graft for lower lip and chin sensation at the primary stage, followed by ipsilateral facial nerve (lower trunk) innervated gracilis functioning free muscle transplantation for facial reanimation and correction of the sunken face 3 years later. After 4.5 years of follow-up, the patient was satisfied with his appearance, and obtained a spontaneous and symmetrical smile without sensory deficit. This experience showed a possible solution to the reconstruction for complicated head and neck cancer patients.

Background This study investigated the morbidity of the marginal mandibular nerve (MMN) post vascularized submental lymph node (VSLN) harvest. Methods The VSLN with sacrifying or preserving the medial platysma was retrospectively classified as group I or II. Midline deviation and horizontal tilt were subjectively evaluated. Horizontal, vertical, and "area distribution" of the lower lip excursions of the surgical site were objectively compared with the nonsurgical site. Results Seventeen patients in group I and 12 patients in group II were included. At a median follow-up of 48.6 ± 16.8 months in group I and 14.8 ± 7.5 months in group II, no MMN palsy was found in both groups. Median midline deviation and horizontal tilt were 4.53 ± 0.52 and 5 ± 0 in group I and 4.67 ± 0.65 and 5 ± 0 in group II, respectively (P = .419 and 1.000). Median horizontal, vertical and area of distribution of lower lip excursions were 97.5 ± 12.3%, 98.8 ± 14.4% and 87.2 ± 14.7% in group I, and 99.3 ± 15.1%, 95.8 ± 8.2% and 84.2 ± 14.2% in group II, respectively (P = .679, .948 and .711). Conclusion The VSLN flap was a safe procedure with minimal MMN morbidity.

Background Various surgical effects have previously been studied in an attempt to improve the functional outcome of the functioning free muscle transplantation (FFMT). However, the effect of the recipient arterial inflow on the FFMT has remained uninvestigated. This study was to investigate whether or not high flow versus low flow will affect the functional outcome of FFMT. Methods Rat's left gracilis FFMT model was devised and the nutrient arterial inflow was modified. Twenty-four Lewis rats were divided evenly into relatively high (0.071 mL/min) and relatively low (0.031 mL/min) blood flow groups (p Results Compared groups were: control (n = 13), low blood flow (n = 10), high blood flow (n = 8), and functional failure (n = 5). The control group showed superior functional results over the experimental groups (p Conclusion This is the first study to evaluate the effect of arterial inflow on the FFMT. The rate of blood flow (relatively high vs. low) has little effect on the functional outcome of transferred muscle. Survival of FFMT is the major concern while performing FFMT surgery. Arterial inflow while choosing the recipient artery is not the factor for consideration.

Background The distinction between supraclavicular and infraclavicular acute brachial plexus injuries (BPIs) could be challenging in cases of combined shoulder and elbow paresis. The reliability of several preoperative predictors was investigated to avoid unnecessary dissection, prolonged operation time, increased postoperative morbidity, and long scars. Methods Between 2004 and 2013, 75 patients, who sustained acute BPI and presented with motor paresis of shoulder and elbow with preservation of hand function, were included and studied retrospectively. Various predictors including muscles function, sensation, fractures, Tinel's sign and nerve conduction velocity (NCV) studies were reviewed. Results The highest odds ratio (OR) values for infraclavicular BPI were healthy clavicular head of pectoralis major and biceps, presenting with OR = 36.5 and 31.76, respectively, which were identified the most important predictors. Conclusion A combination of functioning pectoralis major or biceps, scapular fracture, an infraclavicular Tinel's sign, and normal NCV in the musculocutaneous nerve was highly predictive of an infraclavicular level.

Background: Endoscopic thoracic sympathectomy (ETS) may provide a permanent surgical cure for primary palmar hyperhidrosis. Unfortunately, some patients can experience intensive post-operative compensatory sweating (CS) that ultimately impairs quality of life. Sympathetic nerve reconstruction (SNR) may be used to counteract severe post-operative CS through the restoration of sympathetic pathways. In this case series, we describe the technical feasibility of a robot-assisted micro-peripheral nerve reconstruction method for achieving SNR in patients with post-operative CS. Methods: Between January 2017 and May 2019, seven cases with severe post-operative CS underwent robot-assisted SNR using a sural nerve graft. We report the pre-operative assessment, the surgical technique, and the clinical outcomes of the study patients. Results: The study sample consisted of five men and two women (median age: 41 years). Primary hyperhidrosis affected the face in one case and the palms in six patients. The median time between ETS and SNR was 20 years. All robotic surgery procedures were successfully accomplished, and neither conversion to open surgery nor the creation of additional ports were required. Sural nerve grafts (median length: 8 cm) were used in all cases, and the median operating time was 10.5 h. There was no operative mortality, with the median length of post-operative hospital stay being 4 days. One patient developed a post-operative pneumothorax—which was treated conservatively. Conclusions: Our case series demonstrates the safety and clinical feasibility of microsurgical robot-assisted sural nerve grafting for achieving SNR in patients with post-operative CS.

Background Facial paralysis and postparalysis facial synkinesis both cause severe functional and aesthetic deficits. Functioning free muscle transplantation is the authors' preferred method for reconstructing both deformities. Methods From 1985 to 2017, a total of 392 patients underwent 403 gracilis functioning free muscle transplantations for facial reanimation. Different motor neurotizers were used: cross-face nerve graft (74 percent), spinal accessory nerve (17 percent), and masseter nerve (8 percent). Smile excursion score, cortical adaptation stage, patient questionnaire, Hadlock lip excursion, and the Terzis evaluation systems were used to assess outcomes. Results For smile excursion score, the spinal accessory and masseter nerve groups showed higher scores than the cross-face nerve graft group in the first 2 years, but no difference by 3-year follow-up. For cortical adaptation stage, nearly all cross-face nerve graft patients achieved stage IV or V spontaneity, the spinal accessory nerve group achieved at least stage III (independent) movement, but individuals in the masseter nerve group achieved only stage III or less. The cross-face nerve graft group also achieved higher scores according to the Hadlock system and the Terzis evaluation system compared with the other two groups. Conclusions The concept of "sugarcane chewing" where the sweetness is the least at the tail but the most at the head can be simply applied for surgeons and patients in weighing the benefits and drawbacks during the motor neurotizer selection. Cross-face nerve graft-innervated gracilis is analogous to chewing sugarcane from tail to head; despite lower outcome measures earlier, it yields the highest scores at 3 years postoperatively. Masseter-innervated gracilis is akin to chewing sugarcane from head to tail, with greater outcome scores initially but little improvement at longer follow-up. Spinal accessory-innervated gracilis results fall in between these two groups. Clinical question/level of evidence Therapeutic, IV.

Background Robotic-assisted techniques are a tremendous revolution in modern surgery, and the advantages and indications were well discussed in different specialties. However, the use of robotic technique in plastic and reconstructive surgery is still very limited, especially in the field of peripheral nerve reconstruction. This study aims to identify current clinical applications for peripheral nerve reconstruction, and to evaluate the advantages and disadvantages to establish potential uses in the future. Methods A review was conducted in the literatures from PubMed focusing on currently published robotic peripheral nerve intervention techniques. Eligible studies included related animal model, cadaveric and human studies. Reviews on robotic microsurgical technique unrelated to peripheral nerve intervention and non-English articles were excluded. The differences of wound assessment and nerve management between robotic-assisted and conventional approach were compared. Results Total 19 studies including preclinical experimental researches and clinical reports were listed and classified into brachial plexus reconstruction, peripheral nerve tumors management, peripheral nerve decompression or repair, peripheral nerve harvesting, and sympathetic trunk reconstruction. There were three animal studies, four cadaveric studies, eight clinical series, and four studies demonstrating clinical, animal, or cadaveric studies simultaneously. In total 53 clinical cases, only 20 (37.7%) cases were successfully approached with minimal invasive and intervened robotically; 17 (32.1%) cases underwent conventional approach and the nerves were intervened robotically; 12 (22.6%) cases converted to open approach but still intervened the nerve by robot; and 4 (7.5%) cases failed to approach robotically and converted to open surgery entirely. Conclusion Robotic-assisted surgery is still in the early stage in peripheral nerve surgery. We believe the use of the robotic system in this field will develop to become popular in the future, especially in the fields that need cooperation with other specialties to provide the solutions for challenging circumstances.

The myriad etiologies, symptoms on presentation, and clinical course pose a substantial sum of variables that affect reconstructive planning and outcome tracking for the facial palsy patient. Thus, standardized and detailed documentation are of paramount importance for assessing the need for reconstruction, surgical planning, and tracking outcomes. To date, while no universally standardized method of facial palsy documentation exists, substantive methods incorporate the factors of disease etiology, degree of facial nerve involvement, presence of synkinesis, and progression of symptoms. To this end, standardized scales such as the House–Brackmann, Chuang Smile Excursion Score, and others are indispensable for characterizing defects and tracking outcomes. Modern photo-videography offers further essential tools for tracking outcomes, and the patient should be recorded with attention to the at rest and voluntary contraction of the muscles in each facial nerve division. Attention must also be paid to the presence of synkinesis. While it remains up to the surgeon to determine which methods suit his or her practice best, it remains important to employ consistent and thorough documentation for the purposes of reconstructive planning, tracking a clinical course, and measuring outcomes.

Background Replantation of a single digit at the distal phalanx level is not routinely performed since it is technically challenging with questionable cost-effectiveness. The purpose of this study was to analyze international microsurgeons' clinical decisions when faced with this common scenario. Methods A survey of a right-middle finger distal phalanx transverse complete amputation case was conducted via online and paper questionnaires. Microsurgeons around the world were invited to provide their treatment recommendations. In total, 383 microsurgeons replied, and their responses were stratified and analyzed by geographical areas, specialties, microsurgery fellowship training, and clinical experiences. Results Among 383 microsurgeons, 170 (44.3%) chose replantation as their preferred management option, 137 (35.8%) chose revision amputation, 62 (16.2%) chose local flap coverage, 8 (2.1%) chose composite graft, and 6 (1.6%) favored other choices as their reconstruction method for the case study. Microsurgeons from the Asia-Pacific, Middle East/South Asia, and Central/South America regions tend to perform replantation (70.7, 68.8, and 67.4%, respectively) whereas surgeons from North America and Europe showed a lower preference toward replantation (20.5 and 26.8%, respectively p Conclusion From the present study, the geographic preferences and microsurgery fellowship experience influence the method of reconstruction for distal phalanx amputation. Multiple factors are taken into consideration in selecting the most suitable reconstructive method for each case scenario. In addition to the technical challenges of the proposed surgery, the cost of the procedure and the type of facility needed are important variables in the decision making process.

Background: Desmoid tumor and leiomyoma are abdominal wall tumors with similar clinical, radiographic, and histological features. However, differentiation between these two diseases is important because each may be linked to different systemic diseases, and their managements are entirely different. We proposed that misdiagnosis is possible in some cases. Patients and Methods: Between 1983 and 2010, patients with a history of uterine surgeries and diagnosed with either abdominal wall desmoid tumors or leiomyomas were studied. All the images reviewed by an independent radiologist and surgical specimen were reexamined by immunohistochemistry (IHC) techniques as a standard method to confirm the diagnoses. Results: Fifteen female patients (desmoid tumors, n = 10; leiomyomas, n = 5) were included. The diagnosis of IHC revealed that two cases initially thought to be leiomyomas were desmoid tumors, whereas the remaining 13 cases maintained their initial diagnoses. The accuracy of hematoxylin and eosin staining was 86.7%. All tumors excised without complications, except for one desmoid tumor that recurred and underwent another excision. Conclusion: Preoperative magnetic resonance imaging (MRI) can be considered to differentiate the two diseases, as well as the elimination of other associated systemic diseases should be performed routinely. If MRI is inaccessible or unavailable, preoperative fine-needle biopsy is recommended. Optional IHC staining is required if the primary histological assessment is equivocal or inconclusive.

Background The best reconstructive strategy for upper lip defects is still in debate. The purpose of this study was to analyze the decisions made by international microsurgeons, who were participated through online questionnaire, distributed by email and social media network. Materials and Methods A case of a two-thirds upper lip oncologic defect was presented via an online questionnaire and 402 microsurgeons replied their treatment options. The data were then analyzed according to the geographic area, microsurgical fellowship, seniority, and subspecialty. All the data were analyzed using SPSS 22. Results A total of 27.7% of microsurgeons chose a free flap, while 72.3% chose a local/pedicle flap as their preferred method for reconstruction. The most common choice of free and local/pedicle flaps was radial forearm (73.6%) and Abbé (36.2%), respectively. The microsurgeons in Europe preferred local/pedicle flaps than free flap when compared with Middle/South America, Asia-Pacific, Africa and South Asia/Middle East (11.6% versus 50%, 43.4%, 29.3% and 27.3%, respectively, multivariant p Conclusions The online questionnaire is valuable and feasible for obtaining experts' opinions. This study provides a current global overview of surgical preferences for this common complicated clinical scenario.

Compared with upper extremity injuries, toe amputations and their replantations are rare because of the difficulty of their relatively thinner soft tissue envelope. Consequently, fewer reconstructive options are available for toes and they are rarely reported in the literature. In this study, we reported a case of right third to fifth toe amputations and their subsequent reconstruction with iliac bone grafts and a free anterolateral thigh flap. After serial debulking and division procedures, 3 toes were divided successfully. Ten months after the initial operation, the patient regained pain-free functional ambulation despite some bone resorption noted on follow-up radiographs. The patient showed high satisfaction on her new toes in terms of aesthetical and functional outcomes. She was able to stand for over 30 minutes without pain. At the 2-year follow-up, the Foot Function Index was 18.3%. Although toe reconstruction is frequently considered unnecessary because of its relative high demand of surgical techniques and little gain on gait; nonetheless, in selected cases, toe reconstruction may still be beneficial if the metatarsophalangeal joints were intact and there is a strong individual desire for aesthetical restoration.

Summary Isolated vulvar reconstruction using profunda artery-based perforator flaps have good functional as well as quality of life restoration. Surgical techniques, complications, and final evaluation using questionnaires are presented. Background Vulvar reconstruction remains a great challenge to reconstructive surgeons. A local fasciocutaneous flap from the medial thigh is a good option with multiple choices of the donor arteries. Here, we extended the clinical application of a profunda perforator artery (PAP) flap with the design of an island pedicle flap. Methods From 2012 to 2015, 12 female patients with vulvar cancer received tumor ablation and immediate reconstruction using a PAP flap. The flaps (n = 19) were divided into V-Y advancement perforator flap (group I, n = 4) and island pedicle perforator flap (group II, n = 15). All of the demographic data were collected and analyzed. Results All of the flaps were transferred successfully, and all of the donor sites were closed without morbidities. Group II was superior to group I because of the smaller required flap size (P = 0.004), the smaller defect size/flap size ratio (P = 0.001), and a lower rate of post-op debridement (P = 0.037). The other parameters were not statistically significant. Conclusions PAP flap is a good choice for vulvar reconstruction. We preferred an island pedicle setting for its thin and pliable fasciocutaneous component and robust flap circulation. The favorable functional and aesthetic results can be achieved with limited donor site morbidities. J. Surg. Oncol. © 2016 Wiley Periodicals, Inc.

BACKGROUND Replantation is technically demanding and requires long operation time and hospitalization duration, Therefore, replantation for a single digit at the distal phalanx level is not routinely performed. OBJECTIVE There is no definite answer of single-digit distal phalangeal amputation. The purpose of this study is to analyze international microsurgeons’ decisions when faced with this common clinical scenario. METHODS A case survey of a right middle finger distal phalanx transverse complete amputation (Tamai zone II) was conducted via an online and paper questionnaire. Microsurgeons around the world were invited to provide their treatment recommendations. In total, 383 microsurgeons replied, and their responses were stratified and analyzed by geographical areas, subspecialties (hand surgeon / plastic surgeon/orthopedics), had microsurgery fellowship or not, and clinical experiences (number of years as an attending physician). RESULTS Within 383 microsurgeons, 170 (42.3%) chose replantation as their preferred management option, 137 (35.8%) chose revision amputation, 62 (16.2%) chose local flap coverage, and 8 (2.1%) chose composite graft as their reconstruction method for the case study. Microsurgeons from the Asia-Pacific, the Middle East/South Asia, Central/South America regions tent to perform replantation (70.7%, 68.8%, and 67.4%) whereas surgeons from North America and Europe showed a lower preference (20.5% and 26.8%, p CONCLUSIONS From the present study, the geographic preferences and microsurgery fellowship experience influence the method of reconstruction for distal phalanx amputation. Reconstructive decision making is multifactorial, besides the technical aspect, the type of facility and cost-effectiveness of the procedure are also variables to consider. Proper informed consent to include the patient in the decision-making process is also of paramount importance.

Brachial plexus imaging is challenging due to its anatomical complexity. Multiple sequences of MRI may be performed pre-operatively for an accurate radiological diagnosis of brachial plexus injury. This image shows the useful role of MRI in localization of acute brachial plexus injury.

BACKGROUND Brachial plexus injuries are devastating. Current reconstructive treatments achieve limited partial functionality. Vascularized brachial plexus allotransplantation could offer the best nerve graft fulfilling the like-with-like principle. In this experimental study, we assessed the feasibility of rat brachial plexus allotransplantation and analyzed its functional outcomes. METHODS A free vascularized brachial plexus with a chimeric compound skin paddle flap based on the subclavian vessels was transplanted from a Brown Norway rat to a Lewis rat. This study has 2 parts. Protocol I aimed to develop the vascularized brachial plexus allotransplantation (VBP-allo) model. Four groups are compared: no reconstruction, VBP-allo with and without cyclosporine A immunosuppression, VBP autotransplantation (VBP-auto). Protocol II compared the recovery of the biceps muscle and forearm flexors when using all 5, 2 (C5 + C6) or 1 (isolated C6) spinal nerve as the donor nerves. The assessment was performed on week 16 and included muscle weight, functionality (grooming tests, muscle strength), electrophysiology and histomorphology of the targeted muscles. RESULTS Protocol I showed, the VBP-allo with cyclosporine A immunosuppression was electrophysiologically and functionally comparable to VBP-auto and significantly superior to negative controls and absent immunosuppression. In protocol II, all groups had a comparable functional recovery in the biceps muscle. Only with 5 donor nerves did the forearm show good results compared with only 1 or 2 donor nerves. CONCLUSIONS This study demonstrated a useful vascularized complete brachial plexus allotransplantation rodent model with successful forelimb function restoration under immunosuppression. Only the allotransplantation including all 5 roots as donor nerves achieved a forearm recovery.

Background Using functioning free muscle transplantation (FFMT) for facial paralysis and postparalysis facial synkinesis reconstruction is our preferred technique. Gracilis was the first choice of muscle. Three motor neurotizers: cross-face nerve graft (CFNG), spinal accessory nerve (XI) and masseter nerve (V3) have been used as neurotizers for different indications. Methods A total of 362 cases of facial reanimation with FFMT were performed between 1986 and 2015. Of these, 350 patients with 361 FFMT were enrolled: 272 (78%) patients were treated by CFNG-gracilis, 56 (15%) by XI-gracilis, and 22 (6%) by V3-gracilis. Smile excursion score, cortical adaptation stage with tickle test for spontaneous smile, facial synkinesis, satisfaction score by questionnaire, and functional facial grading were used for outcome assessment. Results The CFNG-gracilis in a 2-stage procedure achieved most natural and spontaneous smile when longer observation (≥2 years) was followed. The single-stage procedure using the XI-gracilis has proven a good alternative. V3-gracilis provided high smile excursion score in the shortest rehabilitation period, but never obtained spontaneous smile. Conclusions The CFNG-gracilis remains our first choice for facial paralysis reconstruction which can achieve natural and spontaneous smile. XI- or V3-gracilis can be selected as a save procedure when CFNG-gracilis fails. The V3-gracilis is indicated in some specific conditions, such as bilateral Mobius syndrome, older patients (age, >70 years), or patients with malignant disease.

Purpose The aim of this report is to evaluate the utility of negative pressure wound therapy (NPWT) for rescuing flaps with venous congestion not attributable to a mechanical etiology and that cannot be surgically salvaged. Patients and methods A total of 12 patients suffered from partial or total flap congestion after pedicle or free-flap reconstruction was included. All patients underwent NPWT between 3 and 10 days postoperatively. Results All congested flaps survived after the application of NPWT. Nine patients suffered partial flap loss and this was addressed through debridement of the devitalized tissue and primary closure. Three patients required blood transfusions during the course of their management. All patients presented complete coverage of the defects without further problems in the flaps after the treatment. Conclusion NPWT may be considered an alternative management strategy for flaps, which has undergone venous congestion not due to a mechanical cause. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016.

Lymphangiomas are rare malformations of the lymphatic system and can often be found in the neck region, where its proximity to the brachial plexus may cause compressive neuropathy and possible iatrogenic injuries during dissection. We report 4 cases of lymphangiomas with compression of the brachial plexus that were successfully removed without permanent nerve injuries and present a literature review of the preoperative approach and surgical techniques. A preoperative multidisciplinary approach can help surgeons predict what they may encounter during the surgery. A careful and stepwise dissection of the vital structures surrounding the tumor, especially the brachial plexus anatomy, is critical to avoiding severe complications. Incomplete resection or leakage of the lymph could result in higher rate of recurrence.

BACKGROUND Surgical strategy to treat incomplete brachial plexus injury with palsies of the shoulder and elbow by using proximal nerve graft/transfer or distal nerve transfer is still debated. The aim of this study was to compare both strategies with respect to the recovery of elbow flexion. METHODS One hundred forty-seven patients were enrolled: 76 patients underwent reconstruction using proximal nerve graft/transfer, and 71 patients underwent reconstruction using distal nerve transfer. All patients were evaluated preoperatively and postoperatively to assess the recovery rate and muscle strength of elbow flexion. Shoulder abduction and hand grip power were also recorded to assess any concomitant postoperative changes between the two methods. RESULTS The best recovery rate for functional elbow flexion (p = 0.006) and the fastest recovery to M3 strength (p < 0.001) were found in the double fascicular transfer group. However, recovery of shoulder abduction with proximal nerve graft/transfer was significantly better than with distal nerve transfer (80.3 percent versus 66.2 percent in shoulder abduction ≥60 degrees; and 56.6 percent versus 38.0 percent in shoulder abduction ≥90 degrees). A significant decrease in grip strength between the operative and nonoperative hands was also found in patients undergoing distal nerve transfer (p = 0.001). CONCLUSIONS Proximal nerve graft/transfer offers more accurate diagnosis and proper treatment to restore shoulder and elbow function simultaneously. Distal nerve transfer can offer more efficient elbow flexion. Combined, both strategies in primary nerve reconstruction are especially recommended when there is no healthy or not enough donor nerve available. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

A 29-year-old male suffered from total loss of function of his left shoulder and upper limb after a traffic accident while riding a motorcycle. He was treated by a brachial plexus specialist at another hospital and managed surgically under the impression of total root avulsion.

Background: Thoracic outlet syndrome (TOS) is a highly controversial clinical entity. There is much debate on its terminology, existence, diagnosis, and treatment. The purpose of this study was to describe our opinions about these controversial topics of TOS and the treatment of TOS over the past 30 years. Methods: From 1985 to 2014, a total of 80 patients underwent decompressive surgery for TOS. Eight patients requested a second surgery on the contralateral limb. They all had at least 1-year follow-up. Preoperative evaluation included provocative tests, plain X-ray, magnetic resonance angiography/computed tomography angiography, and electromyography. Surgical intervention for each patient involved a supraclavicular approach and near-total resection of the anterior scalene muscle and the first rib and of any cervical rib if it was present. Rib resection was performed with the use of Kerrison bone punch forceps. The operative time was typically 2 hours. Results: Major postoperative complications were rare. Nearly all patients (98%) experienced significant symptom relief, with improvement in soreness and tightness of the shoulder, neck, and arm immediately on the first postoperative day or within a few weeks thereafter. There were no cases with symptoms recurring. Conclusions: It is evident that decompressive surgery through a supraclavicular approach for TOS not only is an effective and safe procedure but also provides a diagnosis of the cause of TOS. For a patient who meets the criteria for surgical indication, decompressive surgery usually results in resolution of symptoms and no recurrence.

Supplemental Digital Content is available in the text., Background: Postparalysis facial synkinesis (PPFS) can occur after any cause of facial palsy. Current treatments are still inadequate. Surgical intervention, instead of Botox and rehabilitation only, for different degrees of PPFS was proposed. Methods: Seventy patients (43 females and 27 males) with PPFS were enrolled since 1986. They were divided into 4 patterns based on quality of smile and severity of synkinesis. Data collection for clinically various presentations was made: pattern I (n = 14) with good smile but synkinesis, pattern II (n = 17) with acceptable smile but dominant synkinesis, pattern III (n = 34) unacceptable smile and dominant synkinesis, and pattern IV (n = 5) poor smile and synkinesis. Surgical interventions were based on patterns of PPFS. Selective myectomy and some cosmetic procedures were performed for pattern I and II patients. Extensive myectomy and neurectomy of the involved muscles and nerves followed by functioning free-muscle transplantation for facial reanimation in 1- or 2-stage procedure were performed for pattern III and many pattern II patients. A classic 2-stage procedure for facial reanimation was performed for pattern IV patients. Results: Minor aesthetic procedures provided some help to pattern I patients but did not cure the problem. They all had short follow-up. Most patients in patterns II (14/17, 82%) and III (34/34, 100%) showed a significant improvement of eye and smile appearance and significant decrease in synkinetic movements following the aggressively major surgical intervention. Nearly, all of the patients treated by the authors did not need repeated botulinum toxin A injection nor require a profound rehabilitation program in the follow-up period. Conclusions: Treatment of PPFS remains a challenging problem. Major surgical reconstruction showed more promising and long-lasting results than botulinum toxin A and/or rehabilitation on pattern III and II patients.

Background: Abdominal wall leiomyoma is extremely rare in the literature. However the information of the previous reported cases was incomplete. Even some cases which were diagnosed before were actually desmoid tumors, because these two diseases are very similar clinically, radiologically and pathologically. In this article we propose that, the definite diagnosis must be under immunohistochemical (IHC) stain. Method: Two 36-year-old female with the history of previous laparoscopic myomectomy suffered from palpable mass in the abdominal wall near the trocar site. Surgical intervention with excision biopsy of the mass was done. The specimen was sent for both conventional Hematoxylin and Eosin (H&E) a nd immunohistochemical (IHC) stain . Results: Both H&E a nd IHC stain confirmed leiomyoma . The two patients recovered well, without recurrence. Conclusions: Abdominal wall leiomyoma may relate to the previous myoma fragment retain at the trocar site of laparoscopic myomectomy and regenerate. However, the diagnosis of leiomoma should be under IHC stain confirmation, because it may easily get confused with desmoid tumors. Financial disclosure statement: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

Results: Between December 2005 and April 2009, 112 eligible patients were enrolled. The median age was 55 (range, 25-88) years with the majority being males (81%). The predominant primary site and T and N staging were oropharynx 74%, T2 36% and N2 75% (N2b 38%). The median pre-treatment nodal size of the dominant node was 30mm (range, 11-90mm). Residual CT/MRI nodal abnormalities were present in 41 of the 103 (40%) patients with a neck negative PET (median size 15mm, range 10-40mm). All PET negative patients were observed and, with a median follow-up of 24 months (range, 9-60), the 2-year isolated regional failure rate for this group was 0% (95% CI 0-3.5%). of the 9 PET neck positive patients, 8 underwent a post-RT neck dissection with 3 subsequently experiencing an isolated regional failure. The 2-year isolated regional failure rate for the entire cohort was 2.5% (95% CI 0.6 -10.0%) with a neck dissection rate of 7%.