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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.

The presence of online learning resources has grown tremendously in recent years. They provide powerful and yet easily accessible means of learning and sharing knowledge. Online learning resources now encompass all aspects of medicine, and microsurgery is no exception. International Microsurgery Club is a closed, invitation-only group based on the Facebook social media platform. It was initiated on May 6, 2016, with the primary objectives of providing a convenient forum for discussing challenging cases, sharing valuable resources, and providing opportunities for research collaboration. The membership of International Microsurgery Club has grown to over 8700 at 2 years' existence, and continues to expand. International Microsurgery Club has become one of the largest online platforms for global microsurgeons. Here, the authors share their experience on how to establish a successful online platform for medical education.

BACKGROUND Functioning free muscle transplantation is currently the gold standard for the reconstruction of facial paralysis, focusing more on the upper lip reconstruction rather than on the lower lip. This study aimed to compare different lower lip reconstructive methods when performing functioning free muscle transplantation for facial reanimation. METHODS A retrospective review of functioning free muscle transplantation for facial reanimation from 2007 to 2015 was performed. Patients were divided into three groups: in group 1 (n = 15), a free plantaris tendon graft anchored to the gracilis muscle was passed into the lower lip to create a loop within; in group 2 (n = 12), an aponeurosis tail of the gracilis muscle was attached to the lower lip; and in group 3 (n = 18), no suspension of the lower lip was performed. All patients had at least 2 years of follow-up. Outcomes were assessed by photographs and videos, including subjective evaluation of midline deviation and horizontal tilt and objective analysis of smile dimensions and area. RESULTS A total of 45 patients were included. Results from the subjective evaluation demonstrate group 1 patients having the best improvement (overall score: p = 0.004 and p = 0.005, Fisher's exact test). The objective evaluation showed group 1 and 2 patients with better results compared with group 3 (horizontal component, p = 0.009; vertical component, p = 0.004; area distribution, p < 0.001, Kruskal-Wallis test). CONCLUSIONS Both plantaris tendon graft and gracilis aponeurosis achieved better improvement in subjective and objective evaluations than those who had no reconstruction of the lower lip. In particular, the plantaris tendon graft can achieve the most lower lip excursion with overall improved symmetry. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

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.

The authors present a novel synthetic vascular model for microanastomosis training. This model is suitable for trainees with intermediate level of microsurgical skills, and useful as a bridging model between simple suturing exercise and in vivo rat vessel anastomosis during pre-clinical training.

Double Pacman flap is an ideal option for small defects. The harvest technique is simple. The flap design is straightforward and easy to manipulate with avoidance of tension suture.

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.

The 2nd instructional course for adult brachial plexus injuries is a fantastic opportunity to meet and learn from experts in the field. We cordially invite you to visit Chang Gung Memorial Hospital to participate in this unique learning experience.

The communication among international microsurgeons have switched from one direction (from paper, textbook) to multiway interactions through the internet. The authors believe the online platform will play an immensely important role in the learning and development in the field of microsurgery.

3D bio-model can assist surgeons to evaluate the size of the defect, design osteotomies tailored to the defect, and shaping of the titanium plate to fit the mandible pre-operatively, which shortens the operative time.

A novel technique of sequential ETS micro-venous anastomoses using three vessel loops for IJV occlusion and a single vascular clamp to retract and hold the anastomoses sites in position.

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.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.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.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.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;113:828-834. © 2016 Wiley Periodicals, Inc.

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.

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.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.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.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 36:467-473, 2016.

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%.