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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 <75 years of age who undergo reconstruction with a microsurgical flap. Instead, flap survival did not significantly vary with age, but was associated only with ASA score ≥3 (or G8 score ≤11) and surgeries that last longer than 480 min; however, flap survival (92.3%) was slightly lower than that commonly reported for in the general population., Conclusions: Reconstructive microsurgery in the elderly is generally safe. The ASA score is easier and quicker than the G8 score and equally useful for risk stratification., (Copyright © 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background:  The purpose of this study is to document the vascular anatomy of the free ulnar artery proximal perforator flap and to highlight the possibility of harvesting it based on the perforators originating from the posterior ulnar recurrent artery (PURA), to spare both the main axis of vascular supply to the hand. In addition, we present a case series of five patients treated for soft tissue defects of the hand with free ulnar artery proximal perforator flaps., Methods:  Ten specimens of anterior forearm were dissected in this study to register number and characteristics of ulnar perforators. The dissection was focused on the perforators originating from the larger branch of the ulnar artery, the PURA, at the proximal third of anteromedial forearm. The anatomical dissections were evaluated in relationship with clinical dissections performed during flap harvesting in five patients., Results:  In three of the specimens dissected, the proximal perforator originated from the PURA, and in the other seven specimens, it originated directly from the ulnar artery. Five cases of reconstruction of the hand were performed with success using the free ulnar artery proximal perforator flap, and in two cases, the perforator from the PURA was found and it was possible to raise the flap based on this branch of the ulnar artery., Conclusion:  The free ulnar artery proximal perforator flap can be harvested in two different manners for the same skin island of the forearm. When possible, harvesting it form the PURA allows lengthening of the pedicle. In our experience, this flap presents many advantages such as thinness and hairlessness; it allows preservation of the ulnar neurovascular bundle with an acceptable donor site morbidity., Level of Evidence: IV., Competing Interests: None declared., (Thieme. All rights reserved.)

The closure of wounds associated with soft tissue defects is surgically challenging, frequently requiring extensive plastic surgery and free flaps. The combination of ADM and STSG is an innovative method used to cover such wounds. The human-derived ADMs (H-ADMs) are the most described in the literature but according to European legislations, Companies H-ADMs outside the EC are not allowed to commercialize them in Europe, H-ADMs being "human products" and not "medical devices", so being ruled by European legislations on transplants. The Skin Bank of the Bufalini Hospital (Cesena, Italy) obtained in 2009 the approval for the production and distribution of the first human cadaver-donor derived ADM from the Italian National Transplant Center and National Health Institute, we called with the Italian acronym M.O.D.A. (Matrice Omologa Dermica Acellulata). We present here the first use of a new H-ADM for treatment of distal lower extremity wounds with exposed tendons managed in one-stage pocedure with STSG. The excellent performance suggests that in cases where autologous tissue is unavailable or undesirable, the use of M.O.D.A. in one-stage procedure represents a promising alternative for covering wounds associated with tendons exposition.

A heterogeneous range of malignant pathologies affects vulvar and perineal regions. Today standard radical mutilating surgery for the treatment of invasive vulvar carcinoma is being replaced by a conservative and individualized approach. Defects of the external pelvis and perineal lining are usually reconstructed with local or regional fasciocutaneous flaps. However, in particular situations, the asymmetrical distribution of the defect and its location, close to sources of infec-tion such as the perineal area, may suggest a different approach. This report presents a patient who underwent conservative vulvectomy bilaterally and reconstruction with a unilateral modified gracilis flap. A V shaped incision was designed in the skin paddle of the flap, allowing it to fit the loss of substance around the remaining vulvar skin. Patient was highly satisfied with the result, she had no pain, no problem in defecation or urination nor during deambulation. In case with asymmetrical defect in the vulvo-perineal area the modified gracilis flap can be considered as a valid reconstructive option. KEY WORDS: Modified gracilis flap, Vulvo-perineal reconstruction.

Background: The aim of this study was to investigate clinical outcomes and risk factors related complications in patients who had undergone nipple-sparing mastectomy (NSM) followed by implant-based or autologous reconstruction., Methods: Between 2004-2014 a single-institution retrospective review was collected on NSMs reconstruction. Patient demographics, comorbidities, breast morphological factors, type and timing of radiotherapy, type of incision, reconstruction type and timing, implant volume and complications were collected., Results: A total of 288 patients had undergone 369 NSMs, 81 (28.1%) of which were bilateral while 207 (71.9%) unilateral. One-hundred mastectomies were performed for prophylactic purposes whereas 269 were therapeutics. Thirteen (4.5%) patients were active smokers, while 2 (0.7%) were diabetics. Fifty-five breasts (14.9%) were previously irradiated and average time elapsed between radiotherapy and NSM was 9-year, (range, 5-15 yrs). Total complication rate was 13.5% at mean follow-up of 47.98 months (range, 6-114 months). Partial-thickness and full-thickness mastectomy skin flap and NAC necrosis occurred in 39 (78%) and in 10 (20%) breasts, respectively. Previous radiotherapy and implant volume were significant predictors of complications (OR: 10.14, 95% CI: 3.99-27.01; OR × 100 g: 3.13, 95% CI: 1.64-6.33). Overall mastectomy type incision was not predictive of complications (p = .426). No association was observed between radiotherapy and mastectomy type access (p = .349)., Conclusions: From our experience NSM followed by implant-based and autologous reconstruction had a relative high rate of complications comparable to previous reports. Despite this, it should be carefully offered to patients in whom potential risk factors are identified.

Up until recently severe foot defects have been underestimated and amputation considered the treatment of choice. Inadequate treatment of foot defects is generally responsible for impaired deambulation resulting in physical and psychological handicap to the patient and producing a negative impact on social life. Foot reconstruction represents a recent advancement but is still a great challenge to the plastic surgeon; indeed the absence of a comprehensive anatomical classification of foot defects makes sharing clinical experiences difficult, slowing down the progress in this field. We report a single surgeon experience on a consecutive series of 47 complex foot reconstructions performed on 45 patients with microvascular free flaps over a 27-year period. A retrospective review of the cases was performed, a detailed analysis of the defects is presented and possible solutions debated so as to outline the key points in the diagnosis and treatment of foot defects. In the decision making process, soft tissue defect location, dimension, and functional relevance have proven to be as important as the exact definition of the bone defect. A new anatomical classification scheme for composite defects of the foot, involving both bone and soft tissue, is proposed in order to allow for a correct evaluation of the wound and an easier identification of the ideal treatment., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The vascular architecture within a perforator flap is different from a conventional muscle or myocutaneous flap. The purpose of this paper is to understand the correlation between flow rate and flap size in perforator flaps. With extrapolation of these data, we have provided an indirect analysis of the venous drainage and its correlation with flap size. A prospective study was planned. Twenty-five patients were enrolled in this study: six patients were operated on using an anterolateral thigh (ALT) flap and 19 using a deep inferior epigastric artery perforator (DIEAP) flap. One month postoperatively, echo-colour-Doppler measurements were performed on pedicle and perforator arteries to calculate blood flow rate in the flaps. A correlation between weight and flow rate was analysed. Spearman rho statistic was calculated. A linear regression model was made from patient data of flow rate/flap weight and predicted values of flow per flap weight were calculated. Then, flow rate values of veins of various diameters were estimated using Hagen-Poiseuille's formula. Our data show that flow rate measured postoperatively on flap arteries is significantly correlated with flap weight [rho(23 d.f.)=0.725, P<0.01 (two-tailed)]. Moreover, we have calculated the minimum size of veins able to drain flaps of increasing weights with different patterns, i.e. our data show that veins of 1.30, 1.50 and 1.75 mm diameter could safely drain flaps of, respectively, 300, 500 and 900 g in weight. This can be useful preoperatively to estimate the risk of flap congestion and in planning additional drainage.

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.

Background: Anterior scoring with the use of simple or dedicated instruments, toothed forceps, endoscopic carpal tunnel release instruments, and needles has been described previously. The upper third of the ear easily maintains the original shape because memory and elasticity are stronger than in the middle or the lower part of the ear. This report describes a further refinement to the Chong-Chet anterior scoring technique, consisting of anterior scoring of the upper helical cartilage to correct the helical radix upper prominence., Methods: A retrospective study analyzed 20 surgeries for prominent ears. All the subjects had undergone otoplasty softening the helix., Results: There were no residual ear prominence/upper third prominence or cartilage irregularities at the 1-year follow-up evaluation. Anterior auricular cartilage scoring is an effective technique for controlling the degree and position of the antihelical fold. Furthermore, the upper third of the pinna seems to have a stronger memory than the middle third. To prevent this late complication the authors routinely perform anterior scoring up to the helix, weakening that cartilage usually untouched with other procedures., Conclusion: This refinement, in combination with other procedures is safe, easy, and fast, giving reproducible and good aesthetic results.

Background and Objective: Full thickness reconstruction of more than half of an eyelid, mainly of the upper one, is a challenge for the surgeon. In 1992, for the first time, the authors reported the use of an axial chondro-mucosal flap from the nose for reconstruction of the tarsoconjunctival plane of a full thickness defect of an eyelid. This article reports and discusses the results of the follow-up of 18 patients operated on using the above technique during the period June 1991-March 1997., Patients and Methods: Apart from the oncological evaluation, the following parameters were assessed: position, closure, the presence of epiphora, length of the palpebral rim, rim opening, levator function, an aesthetic balance of the eyelids, and donor site morbidity. The follow-up ranged from 6 to 40 months., Results: The axial chondro-mucosal flap was clinically viable in all patients. One patient showed a 2 mm lagophthalmos. Static parameters were within normal ranges. In upper eyelid reconstruction, an 8 to 18 mm. levator function (mean 13 mm) was shown., Conclusion: The authors discuss their complications and results and feel that this flap, associated with full thickness skin grafts, may be considered a first choice technique, in expert hands, in complex full thickness upper eyelid reconstruction, and a possible alternative in lower eyelid reconstruction, for wide defects when the use of other flaps is compromised.