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This study highlights the benefits of carpal tunnel release (CTR) in four patients presenting with complex regional pain syndrome (CRPS) after hand surgery who also had carpal tunnel syndrome (CTS) diagnosed clinically and by nerve conduction studies. Three of the patients underwent preand postoperative volumetric, circumference, grip strength and range of motion measurements. The Disabilities of the Arm, Shoulder and Hand (DASH) functional outcome measure and pain scores were also used. There was almost complete resolution of CRPS symptoms in all four patients, with notable reductions in oedema and improvements in grip strength and range of motion. There were also improvements in DASH outcome scores and pain scores after CTR. [ABSTRACT FROM AUTHOR]

Background: Autologous reconstruction with the deep inferior epigastric artery (DIEA) perforator (DIEP) flap is increasingly utilized for breast reconstruction. However, situations arise in which the DIEP flap is not an appropriate option, including the presence of a midline abdominal scar or an inadequate volume of abdominal tissue. While other donor sites may be considered, the stacked DIEP flap, in which the perforators of both hemi-abdominal walls are utilized in a single vascular pedicle, provides a safe technique to utilize the integument of both hemi-abdominal walls. Methods: Five consecutive patients underwent a stacked DIEP flap for breast reconstruction. Preoperative imaging with computed tomographic angiography (CTA) of the abdominal wall was undertaken, with each DIEA, its branching pattern, and all musculocutaneous perforating branches mapped using three-dimensional software reconstructions. The anatomical basis, operative technique and outcomes are discussed. Results: In all cases, CTA was able to demonstrate individual vascular anatomy, and guide planning for a stacked DIEP flap. Unique anatomy between individuals required a range of variations in flap anatomy, with the contralateral DIEA, SIEA, or perforators each used to perfuse the contralateral hemi-abdominal wall. There was a 100% flap survival, with no donor site morbidity reported. Conclusion: The stacked DIEP flap is a safe and reliable technique for augmenting the perfusion of the abdominal wall in cases where the single pedicle DIEP flap is limited. The anatomical basis of the flap can be planned preoperatively with CTA, facilitating faster operating times and good outcomes. [ABSTRACT FROM AUTHOR]

Background: While autologous breast reconstruction is frequently sought, donor sites providing versatility in volume with low donor site morbidity other than the abdominal wall are limited. Gluteal artery perforator flaps have been described in this role, however variations in individual vascular anatomy have resulted in the difficult planning of flaps, and particularly selection of whether superior or inferior gluteal artery perforators should be utilized. Methods: Five consecutive patients underwent a gluteal artery perforator flap for breast reconstruction. Preoperative imaging of the gluteal artery vasculature was undertaken with computed tomographic angiography (CTA). Both superior and inferior gluteal artery perforators were mapped on imaging, and the dominant system selected preoperatively. The anatomical basis, operative technique and outcomes are discussed. Results: In all cases, CTA was able to demonstrate individual vascular anatomy, and select the optimal perforators supplying the gluteal integument. Either a superior gluteal artery perforator (SGAP) or inferior gluteal artery perforator (IGAP) flap was planned, and undertaken successfully in each case. There was a 100% flap survival, with low donor site morbidity. Conclusion: With the use of preoperative planning, selection of either an SGAP or IGAP flap can be reliably made based on individual vascular anatomy. With low donor site morbidity and good aesthetic outcomes, gluteal artery perforator flaps are a good option in cases where the abdominal wall is not appropriate. [ABSTRACT FROM AUTHOR]

Purpose: The nerve to masseter has long been used as a recipient to innervate free muscle flaps for facial nerve reconstruction in adults and children alike. This presentation demonstrates the effectiveness and utility of the masseter nerve to directly re-innervate the native muscles forming a natural smile in an elderly population. Methodology: Twelve patients aged 40 to 92 years underwent facial nerve resection for malignant disease. There were 11 immediate and one delayed reconstructions utilising the masseter nerve for reconstruction of the smile. The nerve to masseter was dissected and transposed to achieve a direct neurorrhaphy to the nerve to zygomaticus major without the necessity of a nerve graft. Results: The earliest movement of the commissure of the mouth was detected at 10 weeks postoperatively. All patients reviewed at 6 months showed dynamic movement and were graded cosmetically as either good or excellent. Conclusion: This is a fast, simple and reliable technique which achieves good cosmetic outcomes for facial reanimation in an elderly population and dispels the myth that dynamic reanimation of the smile is not achievable in patients over 50 years old. [ABSTRACT FROM AUTHOR]

Purpose: Free muscle microvascular transfer has been the preferred procedure for reanimation of the face in young patients with facial palsy. Historically, the use of the contralateral facial nerve via a cross facial nerve graft has been the chosen method for innervation. However, this usually involves a two-stage procedure, precludes treatment of patients with bilateral facial paralysis and has had variable results with symmetry, tone and strength of voluntary movements. The unreliability of result has been greater in older patients. The nerve to masseter has been successfully shown to provide a reliable alternative for use in facial reanimation with both free muscle transfer and direct nerve transfer to the facial nerve. We present the results of cases using the nerve to masseter in both middle-aged adult and paediatric free gracilis transfer and also with direct innervation with the facial nerve in the elderly. Methodology: Nine patients with facial nerve paralysis underwent reanimation surgery utilising the nerve to masseter. Three adult and three paediatric patients received free gracilis muscle transfer. Three other elderly patients underwent transfer of the ipsilateral masseteric nerve to facial nerve through direct coaptation. Results: All patients have been able to good movement post-operatively with the earliest contractions noted at one month post surgery. All patients had significant movement by three months post surgery. A number of patients have also been able to achieve some amount of spontaneous movement. Conclusions: The nerve to masseter provides a highly reliable source of innervation for free muscle transfers and direct nerve transfer in older adults and children. [ABSTRACT FROM AUTHOR]

Background: The macrovascular arteriovenous shunt (MAS) connecting the deep inferior epigastric artery (DIEA) and superficial inferior epigastric vein (SIEV) in the abdominal wall has already been identified as an important structure, and further study has been deemed necessary to establish its role and function., Methods: Review of CT angiograms (CTA) of 38 female patients was undertaken, by means of analysis of fine-cut axial images and three-dimensional image reconstructions of the cutaneous vasculature of the deep and superficial vasculature. In vivo dissection of the structure was also performed to establish its communications. Lastly, a histopathological analysis was carried out to investigate its intrinsic structure and function., Results: The MAS was identified in both sides of the abdomen in all subjects and the diameter ranges from 0.72 to 2.81 mm with a median diameter of 1.28 mm. In vivo dissection revealed it as a distinct structure connecting the DIEA and SIEV. Pathological analysis showed that it has characteristics of both elastic and muscular arteries, which constitutes a new vessel., Conclusion: These further investigations have yielded a better understanding of the MAS shunt, its position, structure and function. This can be of crucial importance to reconstructive surgeons when raising the DIEP flap., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Rectus abdominis is a muscle that is commonly used clinically as a muscle flap, especially in reconstructive surgery. Its intramuscular innervation, however, has rarely been examined in detail or accurately mapped. The purpose of this study was to use biopsied, histological specimens complemented with a staining technique to investigate intramuscular nerve connections and distribution of the rectus abdominis., Methods: Four fresh human cadavers were included in the study and rectus abdominis was dissected bilaterally. Nerve sections innervating the rectus abdominis were biopsied and histologically processed. Sections were viewed under the microscope, and axons within each fascicle were counted using imaging software. All specimens were stained with a modified Sihler's staining technique. Intramuscular innervation was observed and the number as well as distribution was recorded., Results: Macroscopically stained specimens showed that the eighth, ninth, 10th and 12th intercostal nerves innervated the eight muscle bellies of rectus abdominis. The greatest number of minor nerve branching as well as intramuscular nerve communications originated from nerve roots T9 and T10. Minor nerve branches crossed tendinous intersections to communicate with adjacent nerves and innervate adjacent muscle bellies. Nerves originating from T9 had the greatest number of nerve fascicles and the highest axon count in each cadaver., Conclusion: The rectus abdominis is divided into four compartments with each receiving its own independent nerve supply. Minor nerve branches crossed tendinous intersections to communicate with adjacent muscle bellies and nerves suggesting that rectus abdominis can be used as a whole in innervated free flap transfer procedures., (© 2020 Royal Australasian College of Surgeons.)

Background: Limb salvage surgery in conjunction with adjuvant radiotherapy is the preferred treatment for soft tissue sarcoma. This study aims to determine if ipsilateral pedicled anterolateral thigh (ALT) flap reconstruction of groin defects post soft tissue sarcoma resection results in acceptable rates of lymphoedema, while also providing good soft tissue cover and minimal donor site morbidity., Methods: A retrospective chart audit was conducted with ethics approval, obtaining a case series of 16 patients operated on at a single institution by the senior surgeon. Patients who underwent ipsilateral pedicled ALT flap coverage of irradiated groin defects following soft tissue sarcoma resection were included. Comparative six-point limb circumference measurements were utilized to diagnose lymphoedema, with a difference of 10% when compared to the non-operative side being deemed significant., Results: Lymphoedema was noted in three patients (18.8%) with an average follow-up period of 40.9 (range 8-59) months., Conclusion: Previously published lymphoedema rates in sarcoma limb salvage surgery of 15.5-30% are comparable to the rates obtained in this cohort. Lymphoedema rates do not appear to be higher in patients undergoing ipsilateral pedicled ALT flap reconstruction, thus making it a useful soft tissue coverage technique in this cohort., (© 2019 Royal Australasian College of Surgeons.)

Background: Treatment of head and neck cancer may result in disfiguring and debilitating anatomical changes. Osseointegrated implants may be used in these patients to facilitate attachment of implant-retained dentures or cosmetic prostheses., Methods: A retrospective audit was performed, reviewing the treatment of patients who received dental or craniofacial osseointegrated implants during treatment of head and neck cancer., Results: One hundred sixty implants were inserted in 54 patients with oral, nasal, orbital, or auricular defects. Overall, 85% of implants were successful after mean follow-up of 25.7 months. The brand of implant used was shown to impart a statistically significant implant survival difference, and orbital implants had poorer survival compared to nonorbital implants. There was a statistical insignificant implant survival advantage in both nonsmokers and patients who did not undergo radiotherapy., Conclusions: Dental and craniofacial osseointegrated implants may be reliably used in patients with head and neck cancer. However, further research is required to clarify the role of smoking in osseointegrated implant failure., (© 2019 Wiley Periodicals, Inc.)

Background: Bony free flaps are used to reconstruct head and neck cancer defects. The most commonly used flaps are the free fibula flap and the deep circumflex iliac artery (DCIA) flap. Radiotherapy may be given post-operatively to prevent cancer recurrence. This radiotherapy can, however, destroy the bone; a complication termed osteoradionecrosis (ORN). Although there have been studies comparing free fibula and DCIA flaps in terms of success rates and complications, few have assessed the incidence of ORN in both groups., Methods: A retrospective cohort study was conducted involving patients from Royal Melbourne Hospital and St Vincent's Hospital Melbourne who had either a free fibula or DCIA flap for head and neck cancer reconstruction in the past 10 years. Data collected included demographic, operative, and postoperative data. Analysis was performed using Statistical Package for Social Sciences and Microsoft Excel, utilising t-tests, chi-square tests and logistic regression analyses., Results: A total of 154 patients were identified. Of these patients, 127 had free fibula flaps and 27 had free DCIA flaps. Twelve patients had ORN post-op, 10 had free fibula flaps, and 2 had free DCIA flaps. No statistically significant difference was found between the ORN rates in free fibula flaps and free DCIA flaps., Conclusion: Rates of ORN incidence should not be a major consideration in preoperative planning of free flaps for mandibular reconstruction as both fibula and DCIA free flaps are comparable., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Background: Reconstruction of lip defects following neoplasia and trauma is a common procedure in plastic surgery. Reconstruction of large lip defects is a difficult undertaking and some degree of residual functional impairment and disability are likely to occur. Microsurgical reconstruction is the recommended technique for large lip defects; however, limitations exist regarding optimal aesthetic and functional outcomes with current free flap options., Method: We propose a new composite flap design based on the innervated pronator quadratus with the radial forearm free flap for a more dynamic reconstruction of total or near total lip defects. Results of our series of four patients have been reviewed., Results: The radial forearm flap - innervated pronator quadratus flap has been used in four patients thus far for lip reconstruction. This flap, in our limited series has shown excellent results in achieving oral competence, good motor function and acceptable cosmetic appearance., Conclusion: The composite radial forearm-pronator quadratus flap is a promising new lip reconstruction technique that has potential to provide a higher level of oral competence, sphincteric function and symmetrical lip movement, than current microsurgical options in dynamic lip reconstruction. This method warrants further investigation in plastic surgery literature., (© 2019 Royal Australasian College of Surgeons.)

Background: The vertical rectus abdominis myocutaneous (VRAM) and transverse rectus abdominis myocutaneous (TRAM) flaps have traditionally been excluded from consideration of reconstructions with functional potential, because of their segmental innervation. We present a case series that aimed to demonstrate that segmental innervation does not preclude successful neural anastomoses and can deliver a functional reconstruction of a total compartment in the anterior thigh., Methods: This review included all patients who required total anterior thigh compartmentectomy and reconstruction between December 2009 and February 2016 were included from the first author's prospective database., Results: Eleven cases were identified, with innervated rectus abdominis flaps used for anterior thigh reconstruction. During the median follow up period of 12 months, all patients had reinnervation of the rectus with six reaching M5, one M4+, one M4, two M3 and one M2, according to Medical Research Council power grades., Conclusion: All patients had successful functional reconstruction in the thigh using the rectus abdominis myocutaneous flap., (Copyright © 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Mastectomies closed with a linear scar can distort the resulting shape of the breast. We present our novel Y-peg-in-a-round-hole closure method of the mastectomy scar, which improves the shape of the reconstructed breast while maintaining reliable healing, implant coverage, and minimum scar size for covering by tattoo., Materials and Methods: A retrospective review of all breast reconstruction cases performed by the senior surgeon during the period from January 2010 to January 2017 was undertaken. Data were analyzed for wound healing problems, infection rates and mastectomy skin flap necrosis., Results: Data were extracted for 126 consecutive patients with 154 breast reconstructions. Twelve breasts (7.7%) experienced wound healing problems, for which 7 (4.5%) required revisionary surgery. Eighteen breasts (11.7%) developed an infection requiring antibiotics, of which 8 (5.2%) needed a further operation. Four breasts (2.6%) needed removal of the implant. No patients were lost to follow-up., Conclusion: After nipple resecting mastectomy, the Y-peg-in-a-round-hole scar minimizes radial size and contour deformity but allows for reliable wound healing.

Introduction: The treatment for soft tissue sarcomas has evolved to include radiotherapy, wide local excision and plastic surgical reconstruction. Goals for the reconstruction of these irradiated defects are the introduction of non-irradiated healthy tissue, tension-free closure and obliteration of potential dead space. Although many defects once required free tissue transfer for reconstruction, greater knowledge of anatomical vascular pattern has led to the increasing use of propeller perforator flaps, islanded and transposed into the defect. Propeller flap outcomes for the reconstruction of irradiated skin defects have only been reported in case reports. We evaluated the use of propeller perforator flaps at St Vincent's Hospital Melbourne in a series of patients for the reconstruction of irradiated sarcoma defects., Methods: All patients who underwent sarcoma resection with plastic surgical reconstruction at St Vincent's Hospital from January 2009 to February 2017 were identified from unit audits and medical record data and compared depending on the type of reconstruction. Propeller perforator flaps were evaluated compared to other methods of reconstruction., Results: Thirty-nine cases involved single perforator propeller flaps for reconstruction. The frequency of propeller flap reconstruction has greatly increased from 3 in their first year of use in 2013 to 12 in 2015. Most propeller flaps were used to reconstruct thigh defects (43.6%) followed by shoulder defects (17.9%). Generally the defects were smaller (138.7 cm 2 ) than free flaps (214.2 cm 2 ), and the usual composition of the defect was skin and subcutaneous tissue only. Patients who underwent propeller flap reconstruction had a significantly short length of inpatient stay (p < 0.01), and there were no total failures., Conclusion: Propeller perforator flaps are useful for the reconstruction of irradiated defects in sarcoma reconstruction surgery, particularly small- to moderate-sized fasciocutaneous defects. They offer less morbidity, faster recovery and better aesthetic results than free or standard pedicle flaps. The success of propeller flaps has changed the algorithm for how we approach towards the reconstruction of irradiated sarcoma defects to consider their use as the first reconstructive option for superficial sarcoma defects., (Copyright © 2018 Elsevier Ltd. All rights reserved.)