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Background: People with diabetic foot ulcers (DFUs) are at risk of major amputation, which is associated with a high mortality rate (exceeding 50% at 5 years) and reduced quality of life. The authors hypothesized that flap reconstruction of DFUs improves patient outcomes in comparison with standard treatment modalities, including major amputation., Methods: MEDLINE, Embase, the Cochrane Library, and gray literature were searched on February 9, 2022. Comparative and single-arm studies reporting outcomes of DFUs treated with local, regional, or free flaps that included function, limb loss, mortality rates, and flap failure rates were included. Risk of bias was assessed, and meta-analysis of proportions was performed., Results: A total of 3878 records were retrieved, of which 45 met the inclusion criteria, including the records of 1681 patients who underwent flap reconstruction of DFUs. Free flaps were most commonly performed ( n = 1257 [72%]). Only one study used a verified functional outcome measure. At 12 months, the mortality rate was 6.35% (95% CI, 3.89% to 10.20%), the limb loss rate was 11.39% (95% CI, 7.02% to 17.96%), and the free flap failure rate was 9.95% (95% CI, 8.19% to 12.05%). All studies were at high risk of bias. A comparative meta-analysis of interventions was not performed because of study method and outcome heterogeneity., Conclusions: There is short-term evidence that flap reconstruction (including microsurgical transfer) has low mortality, limb loss, and flap failure rates. However, there are limited high-quality comparative studies, and uncertainty remains regarding the outcome of DFU flap reconstruction in comparison to other treatments., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Purpose: Immediate postmastectomy breast reconstruction plays an integral role in patient care because of its psychosocial benefits. New York State (NYS) passed the 2010 Breast Cancer Provider Discussion Law with the aim of increasing patient awareness of reconstructive options through mandating plastic surgery referral at the time of cancer diagnosis. Short-term analysis of the years surrounding implementation suggests the law increased access to reconstruction, especially for certain minority groups. However, given the continued presence of disparities in access to autologous reconstruction, we aimed to investigate the longitudinal effects of the bill on access to autologous reconstruction along various sociodemographic cohorts., Methods: Retrospective review identified demographic, socioeconomic, and clinical data for patients undergoing mastectomy with immediate reconstruction at Weill Cornell Medicine and Columbia University Irving Medical Center from 2002 to 2019. Primary outcome was receiving implant or autologous-based reconstruction. Subgroup analysis was based on sociodemographic factors. Multivariate logistic regression identified predictors of autologous reconstruction. Interrupted time series modeling analyzed differences in reconstructive trends for subgroups before and after the 2011 implementation of the NYS law., Results: We included 3178 patients; 2418 (76.1%) and 760 (23.9%) patients underwent implant and autologous-based reconstruction, respectively. Multivariate analysis indicated that race, Hispanic status, and income were not predictors of autologous reconstruction. Interrupted time series showed that with each year leading up to 2011 implementation, patients were 19% less likely to receive autologous-based reconstruction. Following implementation, there was a 34% increase in the odds of receiving autologous-based reconstruction with each passing year. Following implementation, Asian American and Pacific Islander patients experienced a 55% greater increase in the rate of flap reconstruction than White patients. Following implementation, the highest-income quartile experienced a 26% greater increase in the rate of autologous-based reconstruction compared with the lowest-income quartile. After implementation, Hispanic patients experienced a 30% greater decrease in the rate of autologous-based reconstruction compared with non-Hispanic patients., Conclusions: Our data indicate the long-term efficacy of the NYS Breast Cancer Provider Discussion Law in increasing access to autologous-based reconstruction, especially for certain minority groups. These findings underscore the importance of this bill and encourage its adoption into other states., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Practice variation has been well documented across the US health care system but has not been explored in reconstructive surgical choice after keratinocyte carcinoma (KC) extirpation., Objective: Assess practice variation in utilization of complex (flap or graft) reconstruction after excision of KC on the nose among a multidisciplinary group of reconstructive surgeons (Mohs micrographic and plastic surgery)., Materials and Methods: A randomly selected subset of surgically treated, routine, primary, invasive KCs on the nose between 2000 to 2012 at the Veterans Affairs (VA)-Boston Healthcare System were assessed. Patient factors, tumor factors, and individual surgeons with sufficient case volume were fit to a multivariate logistic regression model to assess between-surgeon differences in the odds of performing a complex reconstruction., Results: Ten surgeons met the case volume threshold for analysis, encompassing 338 KC on the nose excised and reconstructed from 2000 to 2012. After adjusting for patient age, tumor diameter, and location, 6 surgeons performed significantly more complex reconstructions than the reference surgeon, and the case-adjusted predicted probability of complex reconstruction ranged from 7% to 99% (p ≤ .0001)., Conclusion: Marked practice variation in reconstruction choice exists among surgeons after extirpation of KC on the nose at one VA health care system. High-quality comparative studies regarding optimal nasal reconstruction after extirpation of KC are needed., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: This study aims to describe our surgery technique and discuss patients treated through the dorsoulnar artery (DUA)-based technique of osseous and osteo-fascio-cutaneous vascularized ulnar bone grafting., Patients and Methods: Between January 2011 and January 2015, six male patients (median age: 22.5 years; range, 20 to 24 years) who underwent surgery during which the technique of DUA ulnar bone graft was utilized. One patient with scaphoid nonunion, three patients with Kienböck's disease, and two patients with a traumatic metacarpal defect were retrospectively evaluated. The joint range of motion (ROM), grip strength, Disabilities of the arm, shoulder and Hand (DASH) questionnaire score and Visual Analog Scale (VAS) score, and radiographies before and after surgery were examined. Scintigraphy was performed at 12 weeks postoperatively to monitor the viability of the bone graft., Results: All patients showed improvements in the ROM, grip strength, VAS, and DASH scores. According to the radiographic examination, bone union was achieved in all patients and the scintigraphy revealed that vascularization was detected in the bone tissue., Conclusion: The advantages of DUA-based vascularized bone graft are good bone quality and quantity and versatility due to its long pedicle. The osteo-fasio-cutaneous DUA flap seems to be effective in the treatment of traumatic metacarpal bone defects accompanied by skin loss. The DUA-based vascularized ulnar bone may be a source for scaphoid and lunate biological bone reconstruction.

Background: Implant-based breast reconstruction is commonly avoided in the setting of radiation therapy, mainly because of risks of capsular contracture. Nevertheless, as breast reconstruction is becoming more available, more patients undergo both implant-based breast reconstruction and radiotherapy. The dilemma is how to manage capsular contracture if it does occur. The goal of this study was to examine the outcome of patients with implant-based breast reconstruction who developed postirradiation capsular contracture and were treated with capsulotomy or capsulectomy, with or without fat grafting., Methods: The authors reviewed charts of patients who developed capsular contracture following alloplastic breast reconstruction followed by radiation therapy, between 2008 and 2018. The surgical treatment methods for capsular contracture were evaluated along with their outcomes. A follow-up of at least 1 year was required., Results: Forty-eight breasts with postirradiation capsular contracture underwent surgical implant exchange with capsular release, of which 15 had combined fat grafting and 33 did not. Overall, 35 breasts (72.9 percent) showed long-term resolution of capsular contracture; 24 underwent a single procedure and 11 required an additional fat grafting procedure. Some patients [six breasts (12.5 percent)] were offered a consecutive round of fat grafting, and some [seven breasts (14.5 percent)] were offered autologous reconstruction because of lack of improvement. Fat grafting increased the success rate by more than 30 percent when it was initially and consecutively used., Conclusions: Postirradiation capsular contracture may be treated successfully by secondary procedures, sustaining implant-based breast reconstruction in over 70 percent of breasts. Fat grafting may elevate resolution rates even further, to 86 percent. Larger prospective studies are required to validate these findings., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Background: Autologous reconstruction after mastectomy became more and more popular, so this study aimed to obtain up-to-date and comprehensive data on autologous reconstruction in China., Methods: An electronic questionnaire was sent to 110 hospitals, which were chosen depending on geographical distribution and hospital types. The questionnaire investigated the demographics, characteristics, breast cancer treatment and reconstruction situation of these hospitals through different modules. We only focused on the autologous breast reconstruction module data., Results: 96 hospitals have performed breast reconstruction surgery. The proportion of the hospital performing latissimus dorsi flap (LDF, N = 91), pedicle transverse rectus abdominis myocutaneous flap (pTRAM, N = 62), free abdominal flap (N = 43) and other kinds of flap decreased in sequence. Of the overall reconstruction cases, only 34.3% were autologous reconstruction and LDF was still the most popular option for autologous reconstruction. Related factors of hospital performing different procedures included years of performing breast reconstruction, breast surgical volume, and establishment of an independent plastic surgery department. Compared with LDF, abdominal breast reconstruction was associated with a higher flap necrosis rate., Conclusions: This cross-sectional survey offers real-life autologous reconstruction information on a large population and covers the national surgical landscape in China. Autologous reconstruction is still an important part of breast reconstruction. Nevertheless, its low proportion and lower proportion of abdominal flap reconstruction in each institution, demonstrates that special training should be developed for breast surgeons and multidisciplinary cooperation would be promoted in the future., Competing Interests: Declaration of competing interest The authors declared that they have no conflicts of interest to this work. We declare that we do not have any commercial or associative interest that represents a conflict of interest in connection with the work submitted., (Copyright © 2020. Published by Elsevier Ltd.)

Objective: The objective of this report was to demonstrate the clinical application of free flow-through anterolateral thigh flaps for the treatment of high-tension electrical wrist burns., Methods: We collected the data of 8 patients with high-tension electrical wrist burns admitted to Beijing Jishuitan Hospital from January 2014 to December 2018. The clinical and pathological data were extracted from electronic hospital medical records. We obtained follow-up information through clinic visits., Results: The injury sites for all 8 patients were the wrists, specifically 5 right and 3 left wrists, all of which were on the flexor side. Five patients had ulnar artery embolism necrosis and patency, with injury to the radial artery. Two patients had ulnar and radial arterial embolization and necrosis. The last patient had ulnar arterial embolization and necrosis with a normal radial artery. After debridement, the wound area ranged from 12 cm × 9 cm to 25 cm × 16 cm. The diagnoses for the eight patients were type II to type III high-tension electrical wrist burns. Free flow-through anterolateral thigh flaps (combined with great saphenous vein transplantation if necessary) were used to repair the wounds. The prognosis for all patients was good after six months to one year of follow-up., Conclusion: Treating wrist types II and III high-tension electrical burns is still challenging in clinical practice. The use of free flow-through anterolateral thigh flaps (combined with great saphenous vein transplantation if necessary) to repair the wound and to restore the blood supply for the hand at the same time is a good choice for treating severe wrist electrical burns., (Copyright © 2020 The Editorial Board of Biomedical and Environmental Sciences. Published by China CDC. All rights reserved.)

Background: Technical advances have been made in reconstructive diabetic limb salvage modalities. It is unknown whether these techniques are widely used. This study seeks to determine the role of patient- and hospital-level characteristics that affect use., Methods: Admissions for diabetic lower extremity complications were identified in the 2012 to 2014 National Inpatient Sample using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The study cohort consisted of admitted patients receiving amputations, limb salvage without flap techniques, or advanced limb salvage with flap techniques. Multinomial regression analysis accounting for the complex survey design of the National Inpatient Sample was used to determine the independent contributions of factors expressed as marginal effects., Results: The authors' study cohort represented 155,025 admissions nationally. White non-Hispanic patients had the highest proportion of reconstruction without and with flaps, whereas black patients had the lowest. Multinomial regression models revealed that controlling for nongas gangrene and critical limb ischemia, both of which have a much greater incidence in minorities, the effect of race against receipt of reconstructive modalities was attenuated. Access to urban teaching hospitals was the strongest protective factor against amputation (9 percent reduction; p < 0.01) and predictor of receiving limb salvage without flaps (5 percent increase; p < 0.01) and with flaps (3 percent increase; p < 0.01)., Conclusions: This study identified multiple patient- and hospital-level factors associated with decreased access to the gamut of reconstructive limb salvage techniques. Disparity reduction will likely require a multifaceted strategy that addresses the severity of disease presentation seen in minorities and delivery system capabilities affecting access and use of reconstructive limb salvage procedures., Clinical Question/level of Evidence: Risk, III.

To analyze patient satisfaction and the predictive factors characterizing three types of one-stage immediate breast reconstruction (IBR) after mastectomy, including prosthesis, latissimus dorsi myocutaneous flap (LDMF), transverse rectus abdominis myocutaneous (TRAM) flap techniques.Data were collected via face-to-face or telephone interviews from eight breast centers in China from January 2012 to December 2016. A standardized questionnaire that evaluated the general satisfaction and aesthetic satisfaction was sent to patients who had undergone IBR. Logistic regression analysis was performed to identify risk factors associated with patient satisfaction among the three types of breast reconstruction.A total of 412 questionnaires were sent out, and 309 copies were collected including 226 prosthesis, 46 LDMF, and 37 pedicle TRAM reconstruction. Logistic regression analysis showed that general satisfaction and aesthetic satisfaction were significantly correlated with radiotherapy (P < .001, P = .018), respectively. Besides, the aesthetic satisfaction was also associated with nipple-areola complex (NAC) preservation (P < .001).Our multi-center study identified factors of higher patient satisfaction, like NAC preservation and absence of radiotherapy, in order to help breast surgeons make better decisions about individualized reconstruction plan.

There are few studies comparing methods for pilonidal cyst closure. This study was conducted to compare simple surgical closure, secondary healing, and closure using a Limberg flap in the treatment of patients affected with pilonidal cysts. In total, 150 patients with pilonidal cysts were selected and randomized into 3 groups, with 50 participants in each group. Group A underwent primary closure, Group B underwent secondary closure, and Group C underwent closure with a Limberg flap. Operating time, amount of pain after surgery, time to mobilization, time until return to work, time for complete healing, time until being able to sit on the toilet without pain, postoperative complications including infection and recurrence, and seroma and edema after surgery were compared among the 3 groups. Duration of surgery in the Limberg flap group was significantly longer than the duration of surgery in Group A or Group B (p < .001). The time to patient mobilization, the time when the patient returned to work, the time to complete healing, and the time to being able to sit on the toilet without pain were significantly shorter in Group C than in Group A or Group B (p < .001). Although the procedure takes longer when using a Limberg flap, it appears to be a more effective method in the surgical treatment of patients with pilonidal cyst because of the reduced healing time and improved functional status after the procedure.

Background: Within the multidisciplinary management of breast cancer, variations exist in the reconstructive options offered and care provided. The authors evaluated plastic surgeon perspectives on important issues related to breast cancer management and reconstruction and provide some insight into factors that influence these perspectives., Methods: Women diagnosed with early-stage breast cancer (stages 0 to II) between July of 2013 and September of 2014 were identified through the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries. These women were surveyed and identified their treating plastic surgeons. Surveys were sent to the identified plastic surgeons to collect data on specific reconstruction practices., Results: Responses from 134 plastic surgeons (74.4 percent response rate) were received. Immediate reconstruction (79.7 percent) was the most common approach to timing, and expander/implant reconstruction (72.6 percent) was the most common technique reported. Nearly one-third of respondents (32.1 percent) reported that reimbursement influenced the proportion of autologous reconstructions performed. Most (82.8 percent) reported that discussions about contralateral prophylactic mastectomy were initiated by patients. Most surgeons (81.3 to 84.3 percent) felt that good symmetry is achieved with unilateral autologous reconstruction with contralateral symmetry procedures in patients with small or large breasts; a less pronounced majority (62.7 percent) favored unilateral implant reconstructions in patients with large breasts. In patients requiring postmastectomy radiation therapy, one-fourth of the surgeons (27.6 percent) reported that they seldom recommend delayed reconstruction, and 64.9 percent reported recommending immediate expander/implant reconstruction., Conclusions: Reconstructive practices in a modern cohort of plastic surgeons suggest that immediate and implant reconstructions are performed preferentially. Respondents perceived a number of factors, including surgeon training, time spent in the operating room, and insurance reimbursement, to negatively influence the performance of autologous reconstruction.

Background and Objectives: The purpose of this study is to present our experience using free fillet flaps to reconstruct massive oncologic defects of the upper and lower extremity., Methods: A retrospective chart review was performed to include patients who underwent oncologic resection followed by reconstruction using free fillet flaps from July 2001 to October 2018. Patient demographics, clinical and surgical characteristics, and postoperative complications were reviewed., Results: In total, 12 patients were identified and included in this study. Mean age was 48.9 years old. Five patients had extended forequarter amputations and seven patients had external hemipelvectomies, all for locally advanced tumors. Mean tumor size was 15 ± SD 6.4 cm, and negative tumor margins were achieved in all the patients. Mean flap size was 1028 ± SD 869 cm 2 . The mean follow-up was 13 months. There were no partial or total flap losses in the postoperative period. Two patients had flap-related postoperative complications, including flap bleeding and wound dehiscence. Median survival was 18 months., Conclusion: The free fillet flap is a safe, reliable, and valuable approach for reconstructing oncological defects. It offers the advantage of avoiding donor site morbidity, while providing extensive soft-tissue coverage as a one-step solution for massive oncologic defects., (© 2019 Wiley Periodicals, Inc.)

Objectives: To describe American Head and Neck Society (AHNS) surgeon submental flap (SMF) practice patterns and to evaluate variables associated with SMF complications., Methods: The design is a cross-sectional study. An online survey was distributed to 782 AHNS surgeons between 11/11/16 and 12/31/16. Surgeon demographics, training, practice patterns and techniques were characterized and evaluated for associations with frequency of SMF complications., Results: Among 212 AHNS surgeons, 108 (50.9%) reported performing SMFs, of whom 86 provided complete responses. Most surgeons who performed the SMF routinely reconstructed oral cavity defects with the flap (86.1%, n = 74). Thirty-seven surgeons (43.0%) experienced "very few" complications with the SMF. Surgeons who practiced in the United States versus internationally (p = 0.003), performed more total career SMFs (p = 0.02), and routinely reconstructed parotid and oropharyngeal defects (p = 0.04 and p < 0.001) with SMFs were more frequently perceived to have "very few" complications. SMF surgeons reported more perceived complications with the SMF compared to pectoralis major (p = 0.001) and radial forearm free flaps (p = 0.01). However, similar perceived complications were reported between all three flaps when surgeons performed >30 SMF. Among 94 surgeons not performing SMFs, 71.3% had interest in a SMF training course., Conclusions: Practice patterns of surgeons performing SMFs are diverse, although most use the flap for oral cavity reconstruction. While 43% of surgeons performing the SMF reported "very few" complications, overall complication rates with the SMF were higher compared to other flaps, potentially due to limited experience with the SMF. Increased training opportunities in SMF harvest and inset are indicated., (Published by Elsevier Inc.)

Background: Rates of breast reconstruction following mastectomy continue to increase. The objective of this study was to determine the frequency of elective revision surgery and the number of procedures required to achieve a stable breast reconstruction 2 years after mastectomy., Methods: Women undergoing first-time breast reconstruction after mastectomy were enrolled and followed for 2 years, with completion of reconstruction occurring in 1996. Patients were classified based on the absence or presence of complications. Comparisons within cohorts were performed to determine factors associated with revisions and total procedures. Mixed-effects regression modeling identified factors associated with elective revisions and total operations., Results: Overall, 1534 patients (76.9 percent) had no complications, among whom 40.2 percent underwent elective revisions. The average number of elective revisions differed by modality (p < 0.001), with abdominally based free autologous reconstruction patients undergoing the greatest number of elective revisions (mean, 0.7). The mean total number of procedures also differed (p < 0.001), with tissue expander/implant reconstruction patients undergoing the greatest total number of procedures (mean, 2.4). Complications occurred in 462 patients (23.1 percent), with 67.1 percent of these patients undergoing elective revisions, which was significantly higher than among patients without complications (p < 0.001). The mean number of procedures again differed by modality (p < 0.001) and followed similar trends, but with an increased mean number of revisions and procedures overall. Mixed-effects regression modeling demonstrated that patients experiencing complications had increased odds of undergoing elective revision procedures (OR, 3.2; p < 0.001)., Conclusions: Breast reconstruction patients without complications undergo over two procedures on average to achieve satisfactory reconstruction, with 40 percent electing revisions. If a complication occurs, the number of procedures increases., Clinical Question/level of Evidence: Risk, II.

Background/purpose: Prosthetic patch (patch) and muscle flap (flap) techniques are utilized for severe congenital diaphragmatic hernia (CDH) repair; however, when performed on extracorporeal membrane oxygenation (ECMO), the risk of hemorrhage increases. We sought to compare bleeding complications between repair types., Methods: We retrospectively reviewed 2010-2016 on-ECMO CDH repairs., Results: Twenty-nine patients met criteria: 13 patch (44.8%) and 16 flap (55.2%). Eight patch (61.5%) and 13 flap (81.2%) patients had left-sided defects (p = 0.223). All defects were Type C or D (Type C: patch 53.8%, flap 56.2%, p = 0.596). There was no difference in gestational age at delivery (patch 37.5 ± 0.9 weeks, flap 37.2 ± 1.3 weeks, p = 0.390) or age at repair (patch 7.46 ± 6.6 days, flap 6.00 ± 4.3 days, p = 0.476). Seven patch (53.8%) and 9 flap (56.2%) patients survived to discharge (p = 0.596). Estimated intraoperative blood loss was equivalent (patch 35.3 ± 53.9 mL, flap 24.2 ± 18.4 mL, p = 0.443). One patch patient (7.6%) and two (12.5%) flap patients required reoperation in the first 48 h for bleeding (p = 0.580). 48-h postoperative transfusions were the same for those that required reoperation (patch 282.0 mL/kg, flap 208.5 ± 21.9 mL/kg, p = 0.054) and those that did not (patch 120.7 ± 111.7 mL/kg, flap 118.4 ± 89.9 mL/kg, p = 0.561)., Conclusions: On-ECMO bleeding complications are equivalent for both flap and patch CDH repair., Level of Evidence: Type III (retrospective comparative study)., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Women with small- to moderate-sized breasts present a specific challenge to performing oncoplastic volume-displacement techniques for reconstructing breast defects after breast-conserving surgery (BCS). In such cases, the lateral thoracic wall region serves as a versatile reconstruction donor site. Therefore, in the present study, we aimed to investigate the effectiveness and feasibility of employing lateral thoracic adipofascial (LTA) flaps to reconstruct breast defects following BCS., Patients and Methods: A total of 58 female patients who underwent BCS between February 2016 and April 2017 were analyzed. Of these, 33 patients were reconstructed with LTA flaps, and the other 25 patients received BCS only and were assigned as the control group. All patients were followed up, and we assessed surgery-related complications, breast appearance, and disease recurrence., Results: The mean weight of the resected breast tissue was 65.9 g (range, 35-100 g). The mean volume of LTA flaps was 309.5 cm 3 (range, 112.6-588 cm 3 ). This oncoplastic technique was performed with minimal complications in all patients. Two patients exhibited partial adipose liquefaction (6.1%), and 2 patients manifested wound infections., Conclusions: The LTA flaps were reliable and useful for reconstructing breast defects after BCS when the resected volume was confined to between 50 and 100 g, particularly in patients with small- to moderate-sized breasts. This is optimal for patients with lesions located in the upper-outer quadrant., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To describe American Head and Neck Society (AHNS) surgeon supraclavicular flap (SCF) practice patterns and to identify variables associated with SCF complications., Methods: The design is a cross-sectional study. An online survey was distributed to 782 AHNS surgeons between November 11, 2016, and December 31, 2016. The primary outcome was frequency of SCF complications. Independent variables included demographics, training, practice patterns, and SCF techniques., Results: Adequate survey responses were obtained from 221 AHNS surgeons. Among these, 54.3% (n = 120) performed supraclavicular flaps (SCFs). Most surgeons used the SCF for cutaneous (n = 85; 78.7%) or parotid-temporal bone (n = 59; 54.6%) defects. Nearly one-third (n = 31; 29.8%) of surgeons experienced more than a "few" SCF complications. Surgeons experienced fewer pectoralis major flap (P < 0.001) and radial forearm free flap (P < 0.001) complications compared to SCF complications. Univariate analysis demonstrated no association between surgeons with "few" SCF complications and Doppler use in SCF design (P = 0.90), harvest location (P = 0.51), and pedicle skeletonization (P = 0.25). Multivariable logistic regression revealed that surgeons performing more than 30 SCFs compared to less than or equal to 30 SCFs had a greater odds of having "few" SCF complications (odds ratio 7.1, 95% confidence interval [1.1-43.9], P = 0.04)., Conclusion: A majority of surgeons performing SCFs use the flap to reconstruct cutaneous and parotid-temporal bone defects. The significance of relatively higher SCF complications compared to other routine flaps should be explored further. Surgeon experience with the SCF appears to be significantly associated with SCF success, whereas training characteristics, practice patterns, and technical variations may not be associated with SCF outcomes., Level of Evidence: NA Laryngoscope, 129:2012-2019, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Aim: To compare the rate of failure of radiofrequency thermocoagulation for anal fistula with that of rectal advancement flap in a case-matched study., Method: Patients who underwent radiofrequency treatment were compared with age- and sex-matched patients with Crohn's disease (CD) who underwent a rectal flap procedure. Fistula features, general characteristics and the main clinical events were recorded in a prospective database. Failure was defined by at least one of following: abscess, purulent discharge, visible external opening or further drainage procedure., Results: A total of 62 patients [median age 45 (range 36.8-57.5) years; 22 women, 40 men; 22 with CD] were analysed. The failure rate of radiofrequency treatment was higher than that of rectal flap treatment (74.2% vs 32.2%; P = 0.004). The cumulative probabilities of failure of the radiofrequency treatment were 53.8% (38.8-68.3), 71.8% (55.3-84.0) and 87.4% (70.6-95.3) at 3, 6 and 12 months, respectively. Three patients in the radiofrequency group required drainage for an abscess and one had severe thermal ulceration. The Cox proportional hazards regression model (surgical procedure, obesity, CD) showed rectal flap treatment [3.48 (1.60-8.07); P = 0.001] and CD [2.60 (1.16-6.41); P = 0.02] to be the main independent predictors of healing., Conclusion: Radiofrequency thermocoagulation is a less satisfactory sphincter-sparing treatment for the management of anal fistula than a rectal flap procedure., (Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.)

Background: The treatment sequence involving a mastectomy and immediate breast reconstruction (IBR) via the latissimus dorsi flap technique after chemotherapy and radiotherapy is not common. Our experience of this alternative to the standard treatment at our institute is reported herein., Patients and Methods: This was a single-center, retrospective study. We enrolled patients who received this so-called "inverse" sequence for invasive, nonmetastatic breast cancer between 2009 and 2016., Results: Fifty-two patients, aged between 24 and 65 years, with a mean body mass index of 24.5 underwent this treatment. Most involved T2 (59.6%, n = 32), multifocal (55.8%, n = 29) tumors, and 57.7% (n = 30) of the patients presented with axillary lymph node involvement. All patients had received sequential chemotherapy and 50 Gy of radiation. Pathological complete response (pCR) was found in 51.3% (n = 20), of cases in the traditional inverse sequence group, using Chevalier and Sataloff classifications (T and N pCR). Postoperatively, 1 patient required surgical revision because of a hematoma, 42 (80.8%) presented with lymphocele, 3 had impaired would healing, and 2 had more than 5 cm of skin necrosis on the front flap. Median follow-up was 61.9 months and the median time between diagnosis and surgery was 9.7 months. Three patients presented with metastases, 2 with local recurrence, and 1 patient died of cancer. No contralateral or lymph node recurrence was discovered., Conclusion: This treatment sequence, the feasibility of which was shown in this study, is an alternative for patients who want an IBR to avoid the time spent without one breast. This practice requires upstream multidisciplinary cooperation for optimal patient screening., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The increasing trend of women with unilateral breast cancer to electively undergo contralateral prophylactic mastectomy in addition to treatment of the index breast has been controversial. The authors set out to better frame the risks and benefits of contralateral prophylactic mastectomy in the treatment of unilateral breast cancer by evaluating outcomes of a large, consecutive cohort of patients., Methods: An institutional review board-approved review of a single-surgeon (N.T.) experience (2013 to 2018) was conducted of all consecutive patients with unilateral breast cancer treated with mastectomy and immediate reconstruction. Patient characteristics, surgical pathologic results, and 30-day complications were assessed. Outcomes of patients with unilateral cancer who underwent unilateral mastectomy versus bilateral mastectomy (with one breast being contralateral prophylactic mastectomy) were compared. Logistic regression models evaluated various risk factors for potential associations with positive pathologic findings in the contralateral prophylactic mastectomy specimen and/or postoperative complications., Results: Of 244 patients, 68 (27.9 percent) underwent unilateral mastectomy and 176 (72.1 percent) underwent contralateral prophylactic mastectomy. Surgical pathologic results of the prophylactic breast revealed occult ductal carcinoma in situ or invasive cancer in 13 patients (7.3 percent) and lobular carcinoma in situ in eight patients (4.6 percent). Incidence of complications was similar between groups [unilateral mastectomy, 19.12 percent (n = 13); contralateral prophylactic mastectomy, 13.07 percent (n = 23); p = 0.234]., Conclusions: Immediate reconstruction for unilateral mastectomy and contralateral prophylactic mastectomy have similar complication risk profiles, among patients as a whole and between individual breasts. These findings contribute to our understanding of the clinical impact prophylactic mastectomy and reconstruction may have on optimizing the counseling among extirpative surgeons, reconstructive surgeons, and patients., Clinical Question/level of Evidence: Therapeutic, III.

Background: The management of skin cancers has evolved with the development of Mohs micrographic surgery and a greater emphasis on surgical training within dermatology. It is unclear whether these changes have translated into innovations and contributions to the reconstructive literature., Objective: To assess contributions from each medical specialty to the cutaneous head and neck oncologic reconstructive literature., Methods: The authors conducted a systematic review of the head and neck reconstructive literature from 2000 through 2015 based on a priori search terms relating to suture technique, linear closure, advancement, rotation, transposition and interpolation flaps, and identified the specialty of the senior authors., Results: The authors identified 74,871 articles, of which 1,319 were relevant. Under suture technique articles, the senior authors were primarily dermatologists (58.2%) and plastic surgeons (20.3%). Under linear closure, the authors were dermatologists (48.1%), plastic surgeons (22.2%), and otolaryngologists (20.4%). Under advancement and rotation flaps, the senior authors were plastic surgeons (40.5%, 38.9%), dermatologists (38.1%, 34.2%), and otolaryngologists (14.4%, 21.6%). Under transposition and interpolation flaps, the senior authors were plastic surgeons (47.3%, 39.4%), dermatologists (32.3%, 27.0%), and otolaryngologists (15.3%, 23.4%)., Conclusion: The primary specialties contributing to the cutaneous head and neck reconstructive literature are plastic surgery, dermatology, and otolaryngology.

One benefit of Mohs micrographic surgery (MMS) is maximal tissue sparing compared to standard excisional surgery techniques. It also has the highest statistical cure rate for appropriately selected nonmelanoma skin cancers (NMSCs) in cosmetically sensitive areas, making it a preferred choice for many self-referred patients or their referring physicians. Patients and nondermatologist physicians may be unaware of how frequently Mohs surgeons perform complex surgical repairs compared to other specialists. Our objective was to compare the quantity and characteristics of flap or graft repairs on the nose or ears following skin cancer extirpation performed by either a fellowship-trained Mohs surgeon or plastic surgeons at 1 academic institution. A retrospective chart review of all skin cancer surgeries was performed to collect data on all flap or graft repairs on the nose or ears at Baylor Scott and White Health (Temple, Texas) from October 1, 2016, to October 1, 2017. We collected secondary data on final defect size prior to the repair, skin tumor type, referring specialty for the procedure, and patient demographics. We found that Mohs surgeons performed a larger number of complex repairs on cosmetically sensitive areas compared to plastic surgeons following skin cancer removal, which may be unrecognized in several specialties that refer patients for management of skin cancers, creating a possible practice gap. More data may aid referring providers in optimally advising and managing patients with cutaneous malignancies.

Background: Free tissue transfer is a routine practice in adults with good success rates. Further advances in techniques and microsurgical skills have proved that free tissue transfer in paediatric population is feasible, reliable and safe., Methods: This study is conducted to compare anastomosis duration, total general anaesthesia duration, hospital stay and outcomes of flaps (survival, partial loss, complete loss, complications) in paediatric group (age <15 years) and adult group (15-70 years age). All patients with large soft tissue defects, congenital defects, traumatic defects and post tumour extirpation were included in this study from December 1st 2017 to May 30th 2018. These patients underwent different microsurgical procedures, the reconstructive armamentarium included use of Latissimus dorsi flap, Anterolateral thigh flap, Fibula flap, Radial forearm flap, functioning Gracillis muscle, iliac crest flap, deep inferior epigastric artery perforator flap and Rectus abdominis muscle flap. Post-traumatic defects were the commonest indication of free tissue transfer in Paediatric population while post tumour extirpation defects were commonest defects encountered in adult population.., Results: On average the total anaesthesia duration is slightly shorter in paediatric group than in adult patients while anastomosis duration is slightly shorter in adults then in paediatric patients. The overall complication rate is comparable in both groups and all the flaps survived well., Conclusions: Microsurgical free tissue transfer can be confidently attempted in children and their results are comparable with those of adult group.

The authors sought to compare hospital utilization and complications in patients undergoing pharyngeal flap (PF) or sphincter pharyngoplasty (SP) for velopharyngeal insufficiency (VPI). A retrospective analysis of the 2014 and 2015 American College of Surgeons National Surgical Quality Improvement Project-Pediatrics (ACS NSQIP-P) was performed. Current procedural terminology codes were used to identify children undergoing PF (42225, 42226) and SP (42950) for VPI (International Classification of Diseases version 9: 478.29, 528.9, or 750.29). Four hundred forty-six patients were treated for VPI with either PF (n = 250) or SP (n = 196). The groups were demographically similar in age, gender, race, and preoperative comorbidity. Pharyngeal flap was performed less often as an outpatient procedure than SP (96/250 [38.4%] vs 130/196 [66.3%], P < 0.0001) and had a longer total length of hospital stay (mean 1.76 ± 1.29 vs 0.98 ± 0.91 days, P < 0.0001). No difference in total complications (10/250 [4.0%] vs 3/196 [1.5%], P = 0.124) was identified. The reduction in hospital resource utilization (fewer admissions, shorter length of stay) is notable. No difference in complications was identified between the 2 procedures.

Background: Seroma formation is a common complication after mastectomy. Flap fixation has the potential to prevent seroma formation, but identifying patients that are at risk of developing seroma, remains challenging. The aim of this study was to assess the association between pro-inflammatory cytokines in seroma fluid one day after surgery and seroma formation and it sequelae., Methods: Patients undergoing mastectomy were randomized into one of three groups: no flap fixation, flap fixation using sutures or flap fixation using tissue glue. Seroma samples from 40 consecutive patients undergoing mastectomy were collected on the first postoperative day for analysis of interleukin-6 and tumor necrosis factor-α. Seroma formation and its sequelae were assessed in the outpatient clinic ten days, six weeks and three months after surgery., Results: TNF-α concentrations were not detectable in the seroma samples of any of the 40 patients. BMI (p = 0.001) and weight of the resected surgical specimen (p = 0.003) were associated with higher IL-6 levels in seroma on the first postoperative day after mastectomy. A higher seroma concentration of IL-6 was associated with significantly fewer patients with clinical seroma formation three months after surgery (p = 0.027)., Conclusion: IL-6 is associated with clinical seroma formation three months after surgery. There is however no evident association between IL-6 and complications related to seroma formation. Higher IL-6 levels are predictive of less long-term seroma formation. Application of flap fixation does not seem to influence the level of IL-6., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: Noma is a devastating and destructive disease of the face for which there is a dearth of information regarding surgical options. Herein, we describe the facial deformities and patient characteristics in a patient population affected by noma and the surgical approaches used in treatment., Methods: Retrospective case series of a Doctors Without Borders (Médecins Sans Frontières) intervention at Sokoto Children's Noma Hospital in northern Nigeria, the highest-volume noma hospital in the world., Results: Twenty-two procedures were performed on 18 patients with noma, 44% of whom were children. The majority of patients (n = 10, 55.5%) were made aware of surgical care through a Doctors Without Borders outreach program. Patients' reasons for seeking care included functional (61.1%, n = 11), appearance (61.1%, n = 11), and social stigma (66.7%, n = 12). The majority (83.3%, n = 15) had lip involvement. Four patients (22.2%) underwent staged flap procedures including prelamination, flap delay, or pedicle division. The mean duration of surgical procedure was 87 minutes (range 5-306 minutes). The minor complication rate was 16%. There were no major complications or deaths., Conclusion: Noma is a mutilating disease of the face that occurs in settings of extreme malnutrition. A total of 55.5% of noma patients were made aware of surgical care through outreach programs. The majority of noma patients seek care to improve function (61.1%) and appearance (61.1%), and to address social stigma (66.7%). A total of 83.3% of noma patients had lip involvement. Facial reconstructive surgeons must rely on principles of congenital, traumatic, and oncologic deformity repair while focusing on safe, reliable procedures for low-resource settings., Level of Evidence: 4 Laryngoscope, 129:96-99, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: The decompressive hemicraniectomy operation is highly effective in relieving refractory intracranial hypertension. However, one limitation of this treatment strategy is the requirement to perform a subsequent cranioplasty operation to reconstruct the skull defect-an expensive procedure with high complication rates. An implant that is capable of accommodated post-hemicraniectomy brain swelling, but also provides acceptable skull defect coverage after brain swelling abates, would theoretically eliminate the need for the cranioplasty operation. In an earlier report, the concept of using a thin, moveable plate implant for this purpose was introduced., Methods: Measurements were obtained in a series of stroke patients to determine whether a plate offset from the skull by 5 mm would accommodate the observed post-hemicraniectomy brain swelling. The volume of brain swelling measured in all patients in the stroke series would be accommodated by a 5-mm offset plate. In the current report, we expanded our analysis to study brain swelling patterns in a different population of patients requiring a hemicraniectomy operation: those with traumatic brain injuries (TBI)., Results: We identified 56 patients with TBI and measured their postoperative brain herniation volumes. A moveable plate offset by 5 mm would create sufficient additional volume to accommodate the brain swelling measured in all but one patient. That patient had malignant intraoperative brain swelling and died the following day., Conclusions: These data suggest that a 5 mm offset plate will provide sufficient volume for brain expansion for almost all hemicraniectomy operations., (Copyright © 2018. Published by Elsevier Inc.)

Background: Replantation is the gold standard procedure for traumatic amputation of fingertips. Reposition flap procedure is performed using nail-bone complex as a free graft and covering graft site with a flap to preserve original finger length, nail complex, and sensory functions of fingertip in pateints where microsurgical methods cannot be applied. In our study, we aimed to compare the long-term outcomes of patients with amputated fingertips who underwent replantation or reposition flap procedures., Methods: Thirty-five patients of replantation and 28 patients of reposition flap procedures only for 2nd, 3rd, and 4th fingertip amputations were included in the study. Complete fingertip amputations involved Foucher zones 2 and 3. The patients were followed up postoperatively for a median period of 13 months (9-23 months). All patients were assessed with static and dynamic 2-point discrimination tests, Semmes-Weinstein monofilament test, and cold intolerance test for the development of neuroma on the donor site., Results: In 5 patients, replantation procedure failed. In such failed patients, after the removal of necrotic tissues, the stump was either repaired or reconstruction with a flap was applied. Wound dehiscence was observed at the lateral sides of the flaps in 2 patients who underwent reposition procedures., Conclusion: Reposition flap repair can be a good cost-effective alternative to other fingertip repair procedures in appropriately selected patients who are not amenable to microsurgery. It preserves the length and sensory functions of fingertips and enables patients to return to their daily life as soon as possible.

Background The necessity of silicone stenting in endoscopic dacryocystorhinostomy (DCR) procedures is a controversial subject in the literature. Objective The purpose of the present study is to assess the long-term anatomical and functional outcomes of endoscopic-powered DCR (EP-DCR) without stenting or mucosal flaps. Methods One hundred twenty EP-DCR procedures were performed in 107 patients. Anatomical success was defined as a patent ostium on irrigation and functional success as free flow of dye from the ostium and resolution of epiphora. Results The mean follow-up was 46.5 months (range: 24-87). Of the 120 procedures, 13 were bilateral and 94 were unilateral. Anatomical and functional success rates of 92.5% were obtained. Conclusion EP-DCR without stenting is a safe and economic technique that provides satisfactory long-term results and could be considered as the treatment of choice for patients with postsaccal nasolacrimal duct obstruction.

The reconstruction of soft tissue defects with a similar type of tissue and minimizing morbidities are important. Herein, we describe our surgical experience using customized reconstruction with a series of modified keystone flaps. We retrospectively reviewed data of 48 consecutive soft tissue reconstructions using modified keystone flaps between March and December 2017. Soft tissue reconstruction was performed and there was no major complication in the follow-up period. The dimensions of the wound defect ranged from 1 × 1 cm 2 to 20 × 18 cm 2 with a mean size of 4.7 × 3.5 cm 2 , while the dimensions of the customized keystone design flap ranged from 2 × 1 cm 2 to 23 × 19 cm 2 with a mean size of 7.9 × 5.4 cm 2 . Minor dehiscence in three cases (6%) and partial flap loss in one case (2%) were noticed. Two cases healed spontaneously and other two cases were surgically recovered. Due to its simplicity, reliability, versatility and minimal morbidity, our modified keystone flaps could be excellent surgical options in various soft tissue reconstructions., (© 2018 Japanese Dermatological Association.)

The paper summarizes 32 months (January 2014 - August 2016) of activity of the Replantation Service for hand amputation in Poland. Over this period a total of 568 cases of total and subtotal amputations as well as other complex injuries to the hand were referred. Of these, 354 referrals (62%) were accepted and 214 (38%) rejected. Among accepted, there were 167 total (47%) and 142 subtotal (40%) amputations; 45 patients (13%) had other severe hand injuries. Vast majority of the patients constituted males aged a mean of 39 years. The most common injury was amputation of several digits in one patient, and thumb amputation - a total of 229 cases (65%), followed by transmetacarpal and wrist amputations - 92 (30%) and forearm/arm amputations - 33 cases (9%). Replantation of amputated extremity was performed in 141 patients (40%), revascularization in 145 (41%) and in 29 (8%) primary repair of the complex injuries. In 27 cases (8%), a coverage of the tissue defects, and in 12 (3%) primary terminalization was performed. Survival rate was of 78% for replantation and revascularization. Comparing to the period 2010-2012, an increase in number of treated patients (of n=64 cases), in number of amputations (of 96 cases) and in number of amputated digits (of 88 cases) were noted. The activity report shows importance of Replantation Service, an informal structure, in saving limbs of severely mutilated patients.

Aims: Presenting our clinical experience with the postauricular island flap (pif) and estimation of the results following partial external auditory canal (eac) and/or auricular conchal bowl reconstructions with the pif in patients after carcinoma resections., Methods: We have analyzed postoperative results of 19 patients after auricular conchal bowl (11), or auricular conchal bowl and eac (8) reconstructions with pif, following malignant tumor resections, between 2000-2015. The patients were followed-up and evaluated in respect of early and long-term results after surgical treatment considering plastic surgeon's and patient's opinion., Results: The cancers were completely excised in all patients, and there were no recurrences within at least 2 years of follow-up. The observed complications after reconstructions comprised venous congestion in five cases (26.3 %), pinning of the operated ear in four patients (21 %), prominent earlobe in three (15.8 %), and eac constriction in three cases (15.8 %). Postoperative result was very good in all cases (both in the opinion of plastic surgeon and patients), except patients with pinning of the operated ear, prominent earlobe (moderately satisfied). Conclusions 1. Combined operations involving postauricular island flap reconstructions after partial (external auditory meatus and/or auricular conchal bowl) resections allowed for complete removal of malignant tumors with no evidence of recurrence, and also preservation of proper conchal shape in the reconstructed ear. 2. Retroauricular approach in cases with cancer involvement of the external auditory meatus allowed for proper visualization and estimation of lesions extent, as well as adequate surgical access.

Background: Implant-based immediate breast reconstruction after skin-sparing mastectomy has shown a significant improvement in patients' quality of life, making the procedure steadily more popular year after year. However, this technique has a high morbidity rate, including skin necrosis and implant exposure., Methods: A retrospective review of a prospectively held database for autologous breast reconstruction in our institution of the last 5 years found eight cases with exposed implants after nipple-sparing mastectomy and immediate reconstruction. A single-stage procedure consisting on implant removal and immediate replacement with a deepithelialized DIEP flap was performed in all cases (10 DIEP flaps)., Results: All flaps were successful. Patients' mean age was 45 years old. Three patients developed seroma (5, 7, and 14 days after surgery, respectively). No infections were detected in up to 24 months of follow-up., Conclusions: Nipple-sparing mastectomy with immediate implant-based reconstruction is considered oncologically safe. However, it has a high rate of complications that could require implant removal. Immediate free flap reconstruction is a feasible and safe option to replace the missing volume with low risk of complications that result in a soft and natural-shaped breast.

Objectives: To compare the outcomes of endoscopic repair of bilateral congenital choanal atresia using a flap technique without stenting versus endoscopic repair using stenting without a flap., Methods: A prospective randomised controlled study was conducted, comprising 72 patients with bilateral congenital choanal atresia. The patients were randomised into two groups. Group A (42 patients) underwent endoscopic repair using a mirrored L-shaped flap without stenting, and group B (30 patients) underwent endoscopic repair using stenting without a flap., Results: At a mean follow-up period of 18.2 months, endoscopic assessment revealed a patent posterior choana in 81 per cent and 83.33 per cent of patients in group A and group B respectively. Choanal stenosis occurred in 21.40 per cent and 33.33 per cent of patients in group A and group B respectively. Granulation tissue was observed in 28.6 per cent and 53.3 per cent of patients in group A and group B respectively., Conclusion: The endoscopic approach utilising a flap without stenting is safe and effective, with a high success rate.

Background: Radionecrosis is a complication of nasopharyngeal carcinoma (NPC) that is difficult to treat. Endoscopic debridement is the first-line treatment for radionecrosis. After debridement, however, either bone or the internal carotid artery is exposed and requires mucosal coverage., Objectives: This study sought to demonstrate the effectiveness of a nasoseptal flap (NSF) after endoscopic debridement of radionecrosis in the reconstruction of nasopharyngeal or skull base defects., Methods: Nine patients with NPC who underwent navigation-guided endoscopic debridement, followed by NSF reconstruction between April 2013 and July 2016, were included. The patients' clinical features and outcomes were evaluated., Results: All nine patients had headaches, and eight had a foul odor associated with their radionecrosis. One patient underwent three radiotherapy treatments, four had two treatments, and the remaining four had just one treatment. The foul odor disappeared after treatment in all the patients who had been affected. The headache was significantly reduced after treatment in all patients. The NSF detached in two patients. In one patient, NSF failed, and the patient experienced postoperative rupture of the internal carotid artery. In the seven other patients, the NSF successfully covered the resultant defects, despite one intraoperative internal carotid artery rupture. Only two patients required further debridement, whereas the others experienced complete healing after just one surgical procedure. The nasopharyngeal surface was healthy-appearing in eight patients (median follow-up, median 11 months)., Conclusion: Reconstruction by using NSF after endoscopic debridement for radionecrosis of NPC allowed for faster healing and reduced the need for further debridement.

Oncoplastic and reconstructive techniques are essential tools in the armamentarium of contemporary breast surgeons. The aim of the study was to identify oncoplastic reconstructive patterns in breast cancer centers across Poland. A questionnaire of 18 questions was sent by email to the members of the Polish Society of Surgical Oncology and the Polish Society of Plastic, Reconstructive and Esthetic Surgery via their dedicated websites. The numbers of breast cancer patients operated on in each center ranged from 120 to 904 per year. Breast-conserving surgery (BCS) predominated in all but one center (range 50-70%). Immediate breast reconstructions (IBR) accounted for 6-42% of procedures, The most frequent type of IBR was either a two-stage expander followed by a permanent implant or one-stage implant- based with or without synthetic mesh. The most frequent type of delayed breast reconstruction (DBR) was a two-stage expander followed by implant-based reconstruction. None of the surveyed cancer centers performed free flap reconstruction. Deep inferior epigastric perforator (DIEP) flaps were performed in the plastic surgery department. Reconstructions based on pedicled flaps were performed in cancer centers. Acellular dermal matrices (ADM) and fat transfer were used in selected centers. In the clinical scenario of adjuvant radiotherapy, delayed breast reconstruction was favored. The full range of oncoplastic BCS was performed. Patient-reported outcome measures (PROM) and complications were assessed. Our findings can act as a platform for further improvement in skills, certification, data collection and audit, including patient reported expectation measures. There is also an urgent need to address pan-European inconsistencies in procedural reimbursement.

Background: The authors report a new nipple-areolar complex (NAC) reconstruction technique using an autograft of the ipsilateral areola for breast cancer with nipple invasion., Methods: A total of 43 patients with breast cancer involving nipple invasion underwent oncoplastic surgery with NAC reconstruction. The nipple was reconstructed with a C-V flap, and the areola was autografted onto the new areola bed after the ipsilateral areola was confirmed to be tumour-free. The cosmetic results were self-evaluated by the patients after chemotherapy or radiotherapy according to a 4-point scoring system., Results: Overall satisfaction with the cosmetic result was assessed as follows: excellent (n = 14), good (n = 19), fair (n = 7) or poor (n = 3). Oncological evaluation revealed no cases of local recurrence and five cases of distant metastasis., Conclusion: The immediate NAC reconstruction technique involving a C-V flap and autografting of the ipsilateral areola is a feasible method for obtaining realistic areolar reconstruction., (© 2016 Royal Australasian College of Surgeons.)

Background: Sphincter-sparing repairs are commonly used to treat anal fistulas with significant muscle involvement., Objective: The current study evaluates the trends and efficacy of sphincter-sparing repairs and determines risk factors for fistula recurrence., Design and Settings: A retrospective review was performed at 3 university-affiliated teaching hospitals., Patients: All 462 patients with cryptoglandular anal fistulas who underwent 573 sphincter-sparing repairs between 2005 and 2015 were included. Patients with Crohn's disease were excluded., Main Outcome Measures: The primary outcome was the rate of fistula healing defined as cessation of drainage with closure of the external opening. Risk factors for nonhealing were also analyzed., Results: Five hundred three sphincter-sparing repairs were analyzed, whereas 70 were lost to follow-up. Two hundred twenty sphincter-sparing repairs (44%) resulted in healing, 283 (56%) resulted in nonhealing with a median follow-up of 9 (range, 1-125) months. The median time to fistula recurrence was 3 (range, 0-75) months with 79% and 91% of recurrences noted within 6 and 12 months. Patients treated with a dermal advancement flap, rectal advancement flap, or ligation of the intersphincteric tract procedure were less likely to have a recurrence than patients treated with a fistula plug or fibrin glue (p < 0.001). Over time, there was a significantly increased use of the ligation of the intersphincteric tract procedure (p < 0.001) and a significantly decreased use of fistula plugs and fibrin glue (p < 0.001); healing rates improved accordingly. There were no significant differences in healing rates with respect to patient demographics, comorbidities, or fistula characteristics., Limitations: This study was limited by its retrospective design., Conclusions: Healing rates following sphincter-sparing repairs of cryptoglandular anal fistulas are modest, but have improved over time with the use of better surgical techniques. In this study, ligation of the intersphincteric fistula tract and flaps were superior to fistula plugs and fibrin glue; the former procedures are therefore favored. See Video Abstract at http://links.lww.com/DCR/A391.

Background: Microvascular decompression (MVD) for neurovascular compression syndromes, such as trigeminal neuralgia and hemifacial spasm, has been traditionally described as an interposing technique using Teflon. Some alternative interposing materials have been proposed. In addition, transposing techniques have been increasingly reported as an alternative with a potentially lower recurrence rate and fewer complications., Objective: To describe our experience with a technique consisting of transposition of the superior cerebellar artery using a fenestrated clip and a tentorial flap in patients with trigeminal neuralgia., Methods: We describe a novel transposing technique using a fenestrated clip and a tentorial flap in patients with neurovascular compression. An illustrative case is provided of an 83-year-old female patient who complained of a 4-year history of left trigeminal neuralgia caused by compression by the superior cerebellar artery who was treated with this technique. Furthermore, a thorough review of the literature is presented., Results: The patient underwent the procedure with the proposed technique without complication. Both the surgery and the postoperative course were uneventful. The patient remains asymptomatic 1 year after the procedure., Conclusion: We propose a novel technique for the treatment of trigeminal neuralgia, eliminating the need for padding the vessel with a foreign body. This technique can be applied successfully in selected cases of neurovascular compression syndromes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: In oncoplastic breast surgery, the size and location of the defect are two of the major factors affecting the post-operative cosmetic outcome after partial mastectomy. We introduce a modified superior-based dermoglandular rotation flap technique, which can be applied for relatively large tumours and in cases of inner quadrant defects of the breast without surgery of the contralateral breast., Methods: Between January 2007 and December 2012, a total of 34 female patients with breast cancer underwent breast-conserving surgery using the 'fish-hook incision rotational flap'. A fish-hook-shaped skin incision line was designed from an axillary site to the tumour, about 2-3 cm below the skin crease of the inframammary fold. After partial mastectomy, a superior-based dermoglandular tissue flap was mobilized off the pectoralis major muscle and the lower abdominal flap was dissected downward. The dermoglandular flap was then rotated and the lower dissected lower abdominal flap was advanced in the upward direction to fill the defect and restore the breast shape. The cosmetic results were self-estimated 12 months after surgery., Results: Mean excised volume of the breast was 23.2 ± 6.1%. The location of the tumours was as follows: upper inner (n = 13, 38.2%) and lower inner quadrant (n = 21, 61.8%). The overall cosmetic satisfaction was self-estimated as follows: excellent (n = 19, 55.9%); good (n = 10, 29.4%); fair (n = 4, 11.8%); poor (n = 1, 2.9%)., Conclusions: The 'fish-hook incision rotation flap' is a feasible, effective oncoplastic technique that can be applicable to a relatively large defect located in the inner quadrant of the breast., (© 2015 Royal Australasian College of Surgeons.)

Introduction: The effect of vasopressors on flaps remains controversial in the literature. Often, surgeons avoid vasopressors with the thought that vasoconstriction reduces flap perfusion resulting in flap loss., Methods: A retrospective review was performed on patients who required chest wall reconstruction from 1998 to 2013. Patients were identified through the use of Current Procedural Terminology codes. The data collected included demographics, indications for surgery, prior debridement, preoperative albumin levels, and perioperative vasopressor use. Outcomes measures included flap survival, flap complications, reoperation rates, intensive care unit length of stay, and mortality., Results: Of the 1220 patient records reviewed, 88 had chest reconstruction by a plastic surgeon. Twenty-one patient records were excluded due to incomplete data. One patient experienced complete flap loss; these data were excluded from statistical analysis. Fifty patients received perioperative vasopressors whereas 15 did not. There was no significant difference in flap survival or loss between groups who received perioperative vasopressors and those who did not receive vasopressors. Age, intensive care unit length of stay, flap complications, and reoperation rates were significantly higher in those with partial flap survival., Conclusions: Perioperative vasopressor use does not adversely affect the outcome of pedicled flaps for chest wall reconstruction. Further research is warranted to review the effects of vasopressor dose and type on pedicled flaps.

Background: Many surgical techniques have been described for the treatment of pilonidal sinus, yet rates of recurrence and prolonged wound healing remain high and consensus on the optimal technique is lacking. This retrospective study evaluates outcomes of the use of the house advancement flap in the treatment of pilonidal sinus including time to wound healing, sinus recurrence, wound infection and flap necrosis., Method: Thirty-three consecutive patients who underwent excision and house advancement flap for pilonidal sinus, of whom seven patients (21%) had recurrent pilonidal sinus disease following previous surgical intervention, were reviewed retrospectively. Follow-up ranged from 4 to 59 months (mean 28 months)., Results: All 33 patients completed a follow-up survey. Age at time of operation ranged from 14 to 44 years with a mean of 25 years. No patients developed wound infection or flap necrosis. Four patients (12%) failed to achieve primary wound healing; mean time to wound healing for the remaining 29 patients was 62 days. Recurrence of pilonidal sinus occurred in eight patients (24%), at a mean time of 22 months post-operatively., Conclusion: The house advancement flap achieves primary wound closure in almost 90% of cases with few acute post-operative complications. However delayed wound healing and sinus recurrence remain issues with this technique and it appears to have little advantage over other primary closure techniques., (© 2015 Royal Australasian College of Surgeons.)

Background: Up to 90% of patients undergoing breast cancer surgery suffer from seroma formation, which can cause discomfort and various complications after mastectomy. This retrospective observational cohort study aimed to elucidate whether flap fixation with fibrin sealant (ARTISS) tissue glue reduces seroma formation and seroma aspiration after mastectomy when compared with flap fixation using Vicryl sutures and when compared with a conventional wound closure technique., Methods: All patients undergoing mastectomy due to invasive breast cancer or ductal carcinoma in situ were eligible for inclusion. From May 2012 to March 2013, all patients undergoing mastectomy in 2 large breast cancer centers were treated using flap fixation with Vicryl sutures. From September 2013 to March 2014, all patients undergoing mastectomy were treated with flap fixation using ARTISS tissue glue. The data were retrospectively analyzed and compared with a "drain-only" group that was not treated with flap fixation (May 2011-March 2012)., Results: A total of 230 women who underwent mastectomy were retrospectively analyzed in this trial; 88 patients were included in the drain-only group (DO), 92 patients were included in the flap fixation group using Vicryl sutures (FF-1), and 50 patients were included in the flap fixation group using ARTISS tissue glue (FF-2). There was significantly less seroma formation in the group after flap fixation using sutures (P = .006). There were significantly fewer patients who required seroma aspiration in the FF-1 group (P = .001) and the FF-2 group (P = .001) after undergoing mastectomy and sentinel node biopsy or modified radical mastectomy., Conclusion: This study suggests that flap fixation after mastectomy using ARTISS tissue glue or sutures reduces postoperative seroma aspiration. As a result, flap fixation might lead to less patient discomfort. A randomized, prospective trial should be performed to verify these results., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Reconstruction of extensive defects of the lower abdomen, penoscrotum, trochanter, groin and knee without using complex microsurgery is a reconstructive challenge. Pedicled anterolateral thigh (ALT) flaps offer many advantages over other regional flaps for this purpose, such as the large skin area and soft-tissue availability, a remarkable pedicle length, and possessing multiple components and reliability. We present our experience of using pedicled ALT flaps for repairing various defects., Methods: From September 2006 to December 2013, 42 pedicled ALT flaps were used in 41 patients for defects of the lower abdomen (three patients), trochanter (26 patients), penoscrotum (10 patients), groin (one patient) and knee (one patient). Twenty-eight were men and 13 were women, and their mean age was 70.5 years (range, 22-103 years). The characteristics of the patients' age, sex, cause, flap size, flap component, follow-up and donor sites were recorded., Results: The flap size ranged from 8 × 5 cm (40 cm 2 ) to 11 × 18 cm (198 cm 2 ). The length of the pedicle ranged from 9 to 16 cm, which was enough to reach the defect without tension. No surgery-related mortality occurred. In 34 flaps, donor sites were closed primarily and eight underwent split-skin grafting. Satisfactory coverage was achieved in all patients., Conclusion: Our experience has shown the wide arc of rotation, large skin replacement potential, multiple components and reliability of pedicled ALT flaps. They are technically simple to apply as myocutaneous/fasciocutaneous flaps with minimal donor site morbidity., (© 2015 Royal Australasian College of Surgeons.)