European Journal of Plastic Surgery

Published by Springer Nature
Online ISSN: 1435-0130
Print ISSN: 0930-343X
Learn more about this page
Recent publications
The principles of nasal reconstruction include the need to reconstruct three tissue layers, the need to restore entire skin aesthetical units, and, possibly, the replacement with like tissues. Computer-aided design (CAD) and computer-aided manufacturing (CAM) technologies were applied to two total nasal reconstructions in male patients who underwent rhinectomy for cancer. Three-dimensional (3D) data were obtained from computerized tomography (CT) scan-derived DICOM files (Digital Imaging and Communications in Medicine), this allowed us to design the shape of the reconstructive nose in order to mimic the native nose and to plan dimensions and angles. A custom-made titanium plate was manufactured for the structure and a bi-dimensional template for the forehead flap was printed. The patients underwent a total nasal reconstruction in three layers: local flaps for the lining, custom-made titanium plate for the structure, and expanded forehead flap for the skin. Forehead flap pedicle was divided 3 weeks postoperatively under local anesthesia in an outpatient clinic, as well as further minor refinements. The patients underwent a 6-month post-operative CT scan in order to compare the result to the planned nose. No complications were reported. The superimposition demonstrated a 92% match in case 1 and 95% match in case 2 between the reconstructed nose and the planned one. Forehead flap is still the most favorable option for nasal reconstruction, CAD technology allows to implement the planning and makes the procedure easier; moreover, the use of a CAM plate for the structure allows to reconstruct a nose with the desired naso-frontal angle. Level of evidence: level V, therapeutic study.
Background Due to its unpredictable retention rate, using autologous fat alone for the enhancement of breast volume is often unsatisfactory. To overcome this limitation, fat transfer has been proposed as an immediate adjuvant procedure to aesthetic breast surgery, creating the concept of hybrid mammoplasty.Fat transfer has already been shown to correct minor defects with good clinical outcome, but the amount of fat that can be safely transferred has not yet been identified. Our hypothesis is that contour improvement with small-volume fat transfer as a primary adjuvant treatment can lead to a better patient outcome.MethodsA retrospective single-centre uncontrolled case series study was conducted on 70 patients who underwent hybrid mammoplasties for aesthetic purposes only. Primary and secondary cases were included and divided into corresponding groups. An ad-hoc outcome scale based on clinical parameters was created to standardise results; results were analysed after a follow-up period of at least 12 months.ResultsThe overall results were reported as good in 48.7% of cases, moderate in 32.8%, and sufficient in 18.5%. Primary cases with small deformities showed a better outcome on our scale compared to revisional ones (57.4% good compared to 29%; p = 0.038). A transferred volume of fat up to 100 ml was associated with a higher retention rate (OR = 2.3; p = 0.032).Conclusions Small breast contour deformities or prosthesis coverage can be easily corrected with fat transfer. Based on our score system, this technique is indicated for volume enhancement up to 100 ml; beyond that the outcome quality decreases, and further corrections would be needed.Level of evidence: Level IV, Therapeutic.
Schematic overview of the key steps of targeted muscle reinnervation (TMR). The muscle segment is innervated by a single motor nerve. The motor nerve innervating the target muscle segment is divided, creating a denervated muscle segment, and the nerves are coapted. After TMR, the major mixed nerve reinnervates the target muscle segment preventing neuroma formation
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 flow diagram detailing the screening process and number of articles at each stage
Forest plots demonstrating Numerical Rating Scale (NRS) scores for residual limb pain (2a) and for phantom limb pain (2b). SD standard deviation, CI confidence interval, IV inverse variance
Forest plot demonstrating Patient-Reported Outcomes Measurement Information System (PROMIS) scores for residual limb pain by intensity (3a), behavioral (3b), and interference (3c). SD standard deviation, CI confidence interval, IV inverse variance
Forest plot demonstrating Patient-Reported Outcomes Measurement Information System (PROMIS) scores for phantom limb pain by intensity (4a), behavioral (4b), and interference (4c). SD standard deviation, CI confidence interval, IV inverse variance
Background Targeted muscle reinnervation (TMR) has been shown to reduce phantom limb pain (PLP) and residual limb pain (RLP) in amputee patients, improving the quality of life. This systematic review aimed to evaluate the quality of data and determine the efficacy of TMR on pain reduction and functional outcomes in amputees. Methods The protocol was registered and published a priori on PROSPERO (CRD42021285083). Medline, Embase, CENTRAL, Science Citation Index, and PsycINFO databases were searched until June 2022, retrieving 10 studies (n = 943). Selected outcomes were pain scores, improvement in limb function, complication rates, pain medication, and resubmission rates. Results Ten studies (1 RCT and 9 observational studies) were included (n = 1099 limbs). The mean follow-up was 17.9 months (range 9.6–24.0). For NRS, the pooled mean difference was − 2.68 (95% CI: − 3.21, − 2.14; p < 0.0001) for RLP and − 2.17 (95% CI: − 2.70, − 1.63; p < 0.0001) for PLP, in favor of the TMR group, respectively. Pooled mean differences were significantly lower for all domains (all p < 0.0001) of the PROMIS score, in favor of the TMR group. Complication rates ranged from 0 to 16%. All studies showed a reduction in PLP and RLP following TMR. Three studies, assessing functional outcomes, showed an increase following TMR. The RCT was graded high quality and observational studies were moderate to very low quality. Conclusions Despite varying study quality, pooled analysis shows a significant reduction in RLP and PLP across all PROMIS domains and significant reduction in NRS scores in the TMR group. Additionally, TMR demonstrated improved functional outcomes for amputees. Systematic review registration. PROSPERO CRD42021285083. Level of evidence: Not gradable
Common harvesting technique of hemi-hamate arthroplasty. Points A and B in the left images are the distal aspects of the hamate bone in a coronal and sagittal plane, respectively. These are then represented in their final location in the right-hand images once the osteochondral graft has been transferred to the proximal interphalangeal joint. The distal dorsal articular surface of the hamate is harvested through a longitudinal incision over the 4th and 5th carpometacarpal joints (CMCJ). Dorsal veins, the dorsal sensory branch of ulnar nerve and the extensor tendons are protected and retracted to expose the joint capsule. Capsulotomy of the 4th and 5th CMCJs is performed to expose the dorsal surface of the hamate. The templated defect from the finger middle phalanx base is transcribed to the hamate. An oscillating sore is used to make the one transverse and two vertical osteotomies of the hamate. Over sizing the graft by ~ 1 mm in all dimensions is suggested to allow subsequent tailoring of the graft. An osteotome is used in a retrograde or anterograde fashion to complete the final osteotomy, assisted by traction and volar displacement of the metacarpal bases. The joint capsule and skin are closed with the surgeon’s preferred suture
PRISMA protocol flow chart outlining the screening of articles
Background The hemi-hamate arthroplasty is utilised for the management of complex fracture-dislocations for injuries of the proximal interphalangeal joints (PIPJ) of the fingers. PIPJ outcomes are well described, including the post-operative range of motion, grip strength and osteochondral graft union. However, there is a paucity of evidence analysing the rate of donor site morbidity and complications. This systematic review aims to present the published morbidity of the donor site for the hemi-hamate arthroplasty. Methods A search was conducted in MEDLINE, Embase, Emcare, CINAHL and ProQuest Nursing and Allied Health databases from their inception which yielded 384 articles to be screened. Pertinent anatomy, harvesting techniques and post-operative donor site care of the hemi-hamate arthroplasty is reviewed. Results One hundred three cases of hemi-hamate arthroplasty were included in this review with seven (6.8%) complications presented, one of which required operative intervention. Conclusion Donor site morbidity resulting from harvesting an osteochondral graft for a hemi-hamate arthroplasty is low. The overall quality of evidence from the studies in this review is low, highlighting the need for further robust prospective trials. Level of evidence Not gradable.
Study selections
Layers of the scalp.
Source: author’s work using Adobe Illustrator™, based on the literature review
Irrigation and innervation of the scalp.
Source: author’s work using Adobe Illustrator™, based on the literature review
Case of a patient with a history of radiotherapy who had wound dehiscence in scalp closure (1). A scalp flap was designed in a secondary intervention (2), but it reappeared due to peripheral vasculature damage (4). Another scalp flap was made in a third intervention, adding a pericranium flap, highlighting the importance of preserving the pericranium (5)
Background Scalp complications in craniofacial surgeries can increase morbidity and mortality. Given the inelastic characteristics of the scalp, these surgeries can be challenging, and multiple complications can arise. The literature on craniofacial surgery is extensive. However, few articles address scalp complications, associated factors, and prevention. This study aims to identify and classify scalp complications in craniofacial surgery and describe associated risk factors, general preventive measures, and an initial therapeutic approach. Methods We conducted a literature search in PubMed, Scopus, Cochrane Library, and LILACS to review the scalp complications in craniofacial surgery. The studies selected included retrospective case series, narrative reviews, systematic reviews, and cadaveric anatomic studies. We completed the search with book chapters and specific topic reviews. Results We screened a total of 124 sources and selected 35 items for inclusion in this review. Based on the updated review, we categorized scalp complications into wound defects, soft tissue contour irregularities, neurovascular defects, and infection. We discuss the main characteristics, risk factors, preventive measures, and initial management of these complications. Conclusions For craniofacial surgery, understanding the surgical anatomy, identifying risk factors, adequate surgical planning, and interdisciplinary cooperation between neurosurgeons, plastic surgeons, and the interdisciplinary team are essential to prevent and treat scalp complications. Level of evidence: Not ratable
Background Over 30% of breast cancers in the UK are diagnosed in elderly women (age ≥ 70). Women in this age group are less likely to undergo primary surgery for breast cancer, and those who are treated with surgery are more likely to receive a mastectomy. Compared to simple wide local excision, oncoplastic breast surgery (OBS) can reduce re-operation rates, including in larger cancers, and yet maintain/improve breast aesthetics. Despite these advantages, older women are largely underrepresented in the available literature.Methods To explore the utility of OBS in women aged ≥ 70 years in a well-established surgical practice, a retrospective review of patients undergoing breast-conserving surgery was performed. Tumour characteristics, operative variables and adjuvant treatment details of elderly patients were compared with the younger cohort.ResultsA total of 325 patients underwent breast-conserving surgery during the study period including 60 who underwent OBS (22.64%). In fit/operable elderly women, despite greater cancer size, OBS was minimal (n = 1/52, 1.96%), likely due to multi-factorial reasons such as the multidisciplinary team’s subconscious age bias or assumptions against qualitatively escalated surgery. In contrast, more patients (n = 6/52, 11.76%) were deemed fit for cytotoxic chemotherapy.Conclusions Whilst OBS-related benefits certainly should be weighed against the increased risks of a longer operative time and recovery, balanced considerations should be made when considering the escalation of systemic adjuvant treatments and related side-effects vis-à-vis de-escalation of surgery and relation to physical and psychological considerations.Level of Evidence: Level IV, Risk / Prognostic Study.
Schematic drawing of the incisions of the double wing transposition flaps in a fingertip injury
(Above, left) A transverse injury, index finger, distal fingertip amputation, and flap design. (Above, right) The flap is fully elevated. (Below, left) Intraoperative view after the flap inset. (Below, right) Volar view at 15 months postoperatively
(Above) A volar oblique, middle finger, distal fingertip amputation, and flap design. (Below, left) Intraoperative view after the flap inset. (Below, right) Volar view at 18 months postoperatively
(Above, left) A volar oblique, thump tip amputation. (Above, right, and below, left) Intraoperative view after the flap inset. (Below, right) Volar view at 16 months postoperatively
Background Fingertip amputations are common injuries of the hand and their surgical treatment can be challenging due to their unique structure, composite content, and scarcity of available tissue. We describe the double wing transposition flap, a new technique for fingertip reconstruction, and report 1-year outcomes.Methods This is a retrospective study of patients who underwent a double wing transposition flap for fingertip reconstruction following amputation. Data with regards to the injured digit, size of the defect, level of amputation (Ishikawa), and plane of amputation was recorded. Any early complications of surgery were documented. The outcomes measured included time to return to work/ normal activities, the arc of motion at the distal interphalangeal joint (DIPJ), two-point discrimination (2-PD), and late complications like cold intolerance, pain, and nail deformity.ResultsA total of 46 patients (mean age: 28 years; 38 men and 8 women) with 46 fingertip amputations were reconstructed with a double wing transposition flap. The mean defect size was 2.2 × 1.9 cm. There were no partial or total flap losses. The mean arc of motion at the DIPJ was 73°, and the mean 2-PD was 4.8 mm. A total of 8 patients had a hook nail deformity. No patient complained of pain or cold intolerance.Conclusions The double wing transposition flap is a simple procedure for fingertip reconstruction. It can be done relatively fast, which does not need dissection of the neurovascular pedicles, and can be used in the reconstruction of transverse, volar oblique, and dorsal oblique fingertip amputations.Level of evidence: Level IV, Therapeutic study.
Background Liposuction is one of the most common procedures in the practice of plastic surgery. Since it evolved, continuous modifications have been to decrease blood loss so that patients are hemodynamically stable intra- and postoperatively. Tranexamic acid (TXA) has long been used for its antifibrinolytic properties that were beneficial in reducing blood loss, rate of transfusion, and hemoglobin drop in major trauma and surgeries. Its use in plastic surgery, however, is still limited. In this study, we aim to illustrate the effect of intravenous (IV) and local infiltration of TXA on blood loss in liposuction surgery. Methods Between April 2019 and April 2021, 90 patients who requested liposuction for various body parts were randomly allocated into 3 equal groups: control group, IV TXA, and local infiltration of TXA. A sample was taken from infranatant and sent for hematocrit calculation. Volume of blood in lipoaspirate was then calculated. Patients were assessed for blood loss and postoperative bruising. Results Volume of blood loss in lipoaspirate was considerably lower in the TXA groups, with 60% decrease in blood loss for the local TXA group in comparison with the control group. TXA has also been shown to markedly decrease bruising tendency in postoperative liposuction patients. Conclusions TXA can be used to decrease blood loss in large-volume liposuction, modify the need for blood transfusion intra- and postoperative, and improve the results of liposuction procedure without the need for multiple sessions. Level of evidence Level II, Risk/Prognostic Study.
Background Patient satisfaction following rhinoplasty is a growing area of research; and researchers have developed various validated tools to evaluate postoperative outcomes. It remains a key measure of surgical success with functional and aesthetic outcomes. The current study aims to assess patient satisfaction with cosmetic and functional surgical outcomes following rhinoplasty in the Saudi population via the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS). Methods This study was conducted in a cross-sectional design with an electronic survey among adult patients 6 to 12 months after rhinoplasty in a private center in Riyadh, Saudi Arabia. The SCHNOS assessment tool was used in this study, a simple, valid, and reliable method for evaluating the success of cosmetic rhinoplasty. Results A total of 205 patients participated in the current study. Results showed significant differences in the SCHNOS-O subscale in those aged > 35 years (median = 10.0, IQR = 0.0–27.5) being significantly lower than those of the other age categories. Furthermore, divorced participants scored higher than those married (median = 47.5, IQR = 45.0–60.0). Finally, participants with the highest household income scored lower nasal obstruction scores (median = 30.0, IQR = 10.0–40.0) than those in the lowest income category. Conclusions Saudi patients above the age of 35 reported higher satisfaction levels with the surgical outcome following rhinoplasty. Divorced patients were more likely to be dissatisfied with the surgical outcome. Compared to patients in other parts of the Kingdom, patients in the Central region had fewer nasal obstruction symptoms and better cosmetic results. Level of evidence: Not ratable
The treatment of benign forehead lesions is traditionally performed with an open excision technique. This causes a notorious scar with incomplete cosmetic results. The objective of this study is to assess the results obtained after single-port video endoscopic surgery in patients with benign forehead tumors. An observational, retrospective case study was done. All single-port endoscopic frontal resection procedures were registered from 2016 to 2019. Intraoperative and postoperative data were identified. Sixteen patients were recruited. The median age was 48 (range 18–62). The follow-up period was of 12 months (range 7–15). Out of 20 tumors, histological analysis found out 10 lipomas (50%), 8 Osteomas (40%), and 2 cysts (10%). The endoscopic method through a single scalp incision allowed the complete removal of the lesions. Postoperative complications and the patient´s cosmetic satisfaction were registered; only one case of hematoma was recorded (6.25%) that required drainage at the doctor´s office; one patient with a cyst recurred after 12 months follow-up, and required new surgery. There were no nervous lesions. Single-port endoscopic approach to treat benign forehead lesions represents an effective and safe treatment, and provides excellent cosmetic and satisfaction results and low complication rate. Level of Evidence: Level IV, therapeutic study.
A Medical student survey respondent’s year of study. B Source of exposure to plastic surgery
Survey results before and after respectively for respondents who identified a significant global need for reconstructive surgeons were able to correctly identify a route in plastic and reconstructive surgery training and reported interest in learning more about plastic and reconstructive surgery
Student reported chief complaints that would warrant a plastic and reconstructive surgery consultation before and after the module
Student reported fields that commonly collaborate with plastic surgeons, before and after the module
IntroductionMedical schools do not routinely provide exposure to plastic and reconstructive surgery, and perceptions have been distorted by mainstream media’s display of a cosmetically centered field. This study aimed to determine if an informative video by a plastic surgeon could impact preclinical medical students’ perception, knowledge, and interest in plastic and reconstructive surgery.MethodsA survey with a 6-min module was provided to medical students across North America. Questions included exposure to plastic and reconstructive surgery, interest, knowledge, common consultations, and chief complaints that would require plastic surgery involvement. In addition, their perception of the worldwide need for plastic and reconstructive surgery and the percentage of the field that is cosmetic-centered were surveyed.ResultsOne-hundred sixty-eight students responded to the survey; 91.1% of respondents indicated that they have received little to no formal curricular exposure. After the module, more students identified the large unmet need for plastic and reconstructive surgeons worldwide, a correct route in training, more specialities that plastic surgeons collaborate with, and more chief complaints that would require a plastic surgery consult and were interested in learning more about plastic surgery.ConclusionsA short 6-min module provides increased awareness about the global unmet need for plastic and reconstructive surgeons, the role of these surgeons in a hospital setting, and increased interest in the field from medical students. Implementing early educational plastic and reconstructive surgery opportunities in medical school curriculums may help garner interest from students, correct misconceptions, and foster more accurate future consults and collaborative efforts from future physicians.Level of evidence: Not ratable.
PRISMA 2020 flow diagram
Background Nail bed injuries are a major cause of presentation in the emergency department, accounting for 15 to 24% of all fingertip injuries, but management lacks consensus. Different methods have been published for the treatment of subungual hematoma, which leads to an important controversy among hand surgeons. The objective of this study was to conduct a systematic review to compare nail trepanation with nail avulsion and matrix repair, deciding which is the most appropriate according to each injury pattern. Methods We carried out a systematic review of the literature using MEDLINE via PubMed, Virtual Health Library, Embase, and Cochrane Library through September 2021. Inclusion criteria were journal articles published in the last 11 years (2010–2021) in English, French, Portuguese, and Spanish and conducted in humans. Case reports, case series studies, and pre-clinical studies were excluded, in addition to those which are still in progress, did not report primary outcome or full-text was not available. Results The search resulted in the screening of 599 records. Of these articles, 16 were eligible for the review. As shown in some literature reviews, the traditional approach to subungual hematoma is to remove the nail, analyze the sterile matrix, and repair the injury. According to many authors, this can depend on the size of subungual hematoma and if there is any fracture associated. On the other side, subungual hematomas also can be relieved by simple trephination, yielding good pain relief and satisfactory nail plate regeneration. Conclusions With our review, we can determine more accurate recommendations regarding the possible treatment for ungual complex injuries with subungual hematomas. In this sense, nail trephination alone is recommended whenever possible and nail removal with matrix repair is better when there is fracture or hematoma covers greater than 50%. In addition, small non-painful bruises do not require intervention, as knowing that it is incorporated into the nail and progressively migrates to the free edge of the nail plate. Level of evidence: Not ratable.
Background Distal tip necrosis of random pattern skin flaps is the most occurring complication in skin flap surgery. Delay phenomenon augments flap vascularity and increases survival of skin flaps. In this study, hyaluronic acid dermal filler was used in the rat dorsal skin via subcutaneous injection to reveal its role in the flap viability and the delay phenomenon. Methods Eighteen rats were randomized in 3 groups. Group 1 rats were the control group. Group 2 rats underwent surgical delay procedure. Group 3 was pretreated with 1 mL of hyaluronic acid dermal filler injection. Seven days after, a caudally based dorsal skin flap was elevated. Flap necrosis area, intensity of the newly formed vessels, subdermal vascular architecture, and inflammation severity in the flaps were evaluated. Results Flap necrosis areas were found statistically significant among the groups. The mean number of subdermal capillaries increased significantly in group 3. The mean values of vessel diametres were statistically significant among the groups. Inflammation scores of groups 2 and 3 were low or moderate levels. Conclusions HA injection increases the survival of rat dorsal flaps; however, it is not superior or equivalent to surgical delay at least with this volume, concentration, and delay time. Level of evidence: Not ratable.
Algorithm outlining reconstructive options following BCT
Background Abdominal flaps and latissimus dorsi flaps can be used to provide soft tissue coverage and recreate the breast mound following breast conservation therapy (BCT), which consists of lumpectomy and radiation. This study compares complication rates and the need for revision surgery between the two flap groups. Methods This study retrospectively reviewed charts for all patients who underwent BCT and presented for delayed partial breast reconstruction with either a free abdominal flap (MS-TRAM, DIEP, SIEA) or pedicled latissimus dorsi flap at our institution between January 2005 and August 2017. Charts were reviewed for basic demographics, comorbidities, oncologic data, postoperative complication incidence, and whether patients underwent revisionary surgery. Results A total of 21 patients met inclusion criteria, which included 12 latissimus (LD) and 9 abdominal (Abd) flap-based reconstructions. Demographics and comorbidities were similar between cohorts. Overall complication rates were similar between groups for both recipient site (LD: 16.7%, Abd: 22.2%; p = 0.748) and donor site (LD: 8.3%, Abd: 0.0%; p = 0.375). Overall rates of revisionary surgery were also similar in both groups (p = 0.445). Mean follow-up time was similar between the two cohorts (p = 0.227). Conclusions The flap choice in partial reconstruction is multi-factorial and is based largely upon surgeon experience, surgeon and patient preference, and body habitus. Our study shows that both abdominal flaps and the latissimus dorsi flap are able to reconstruct partial mastectomy defects with relatively low and comparable complication rates. Revision rates are similar between the autologous flap options as well. Level of evidence: Level IV, Therapeutic.
Case 1, 63-year-old male, sustained a snake bite injury with cytotoxic venom effect to left non-dominant hand. As a direct result, the patient suffered deep and superficial venous thrombosis in that limb and tissue necrosis of the skin over the dorsum of the hand. a shows loss of soft tissues overlying the common extensor tendons to the middle and ring fingers and the dorsal extensor expansion overlying the proximal interphalangeal joint and the proximal phalanx of the little finger before commencing PRP injections, at 2 weeks after two debridements. The patient received injections twice a week. A polyurethane semi-occlusive dressing covered the wound. The hand underwent splinting in a functional position, and a mobilization program included both passive and active movements between periods of rest. b shows a shrinking wound and granulating tendon 2 weeks after commencing injections. c shows granulated and epithelialized tendons, with further wound shrinkage, at 5 weeks after commencing injections. d shows a healed hand at 80 days after therapy commencement, having taken 44 days for granulation tissue to cover the bare tendons. The hand demonstrated minimal area of scarring relative to the original size of the wound defect
Case 2, a 78-year male, using an anterior approach for a partial ankle joint replacement, developed skin necrosis and wound breakdown, exposing the tibialis anterior tendon. On presentation 3 weeks after the primary surgery, pulses of the anterior tibial artery were not palpable. a shows the wound before minor debridement and commencement of PRP injections. The patient received injections twice a week for the first 2 weeks and then weekly for 6 weeks. A polyurethane semi-occlusive dressing covered the wound. With a splinted foot, the patient ambulated under controlled conditions. b shows granulation of the wound bed and tendon, which progressed further as new islands of granulation appeared in the wound. c shows an increase in granulation tissue growth in the wound compared to b and some reduction in the size of the wound. By the end of 8 weeks, the wound was fully granulated. d shows a spontaneously epithelialized wound at 8-month follow-up, after therapy. Complete healing took 190 days. e shows the skin overlying the tibialis anterior tendon pinched off the underlying tendon, which was an unexpected feature because the wound healed by secondary intention
Case 3, a 68-year-old female with diabetes mellitus, after developing necrotizing fasciitis of the foot and lower leg, the patient required surgical removal of most of the skin and subcutaneous below the knee. After surgery, topical PRP application to the wound and PRP injection into the exposed tibialis anterior and Achilles tendon followed. The leg and foot were skin grafted once the wound bed granulated. a shows a residual Achilles tendon that had lagged the wound itself in granulating. Tendon PRP injecting continued once weekly, and Granuflex® dressed the residual wound. b shows islands of granulation developing by the second week in the exposed Achilles tendon. c shows the surface area of islands of granulation to be increasing by the fourth week. By the fifth week, granulation tissue entirely covered the tendon. The wound was then skin grafted. d shows a well-healed leg and Achilles tendon with durable skin cover at 1-year follow-up
Case 4, a 60-year-old female sustained a mutilating dog-bite injury to both ankle regions. The injury to the left foot and ankle resulted in skin loss over the anteromedial part of the ankle, exposing a large portion of the tibialis anterior tendon and a small section of the talus of the ankle joint. The extent of injury to the right foot and ankle was much more severe, resulting in a comminuted fracture-dislocation of the ankle, exposed ankle joint, distal tibia, and Achilles tendon. The right foot and ankle management included skeletal stabilization, multiple debridements, and a delayed primary muscle free flap. The left foot and ankle had a splint applied, and PRP injected twice a week into the tendon. The entire wound and tendon by 68 days after the commencement of the PRP therapy, granulated. The wound was skin grafted at this stage. a shows the left foot and ankle with exposed tibialis anterior tendon and open joint of the ankle. b shows the left foot and ankle wound fully granulated. c shows the left foot and ankle with a healed ankle at 1-year follow-up after skin grafting. d shows the open fracture-dislocation of the right ankle with a significant soft tissue loss stabilized with a ring fixator. Viewed side-on, the exposed Achilles measured 10 cm. e shows a healed right leg and ankle at 1-year follow-up after free flap reconstruction
Case 5, a 62-year-old female, required treatment for an ulcerated wound on the distal aspect of the right lower leg. The ulcer followed the excision of a soft tissue sarcoma, split skin grafting of the defect, and adjuvant radiotherapy. The first treatment of the ulcer with negative pressure wound therapy failed to improve the wound. On presentation, the exposed lower leg tendons were necrotic on the surface, and the wound’s base appeared devitalized. After a minor, conservative debridement of the exposed surface of the tendons in the rooms, PRP injections into the remaining viable portions commenced, applying a hydrocolloid dressing. a to c show progressive proliferation of granulation tissue originating from the tendon over time. d shows avascular, dry tibialis anterior and peroneal tendons of the lower leg before commencing PRP injections. e shows an increase in vascularity of the tendon and new blood vessel formation in the surrounding skin. These blood vessels were absent in the skin at the exact location before commencing treatment. f granulation tissue biopsy microscopy with hematoxylin and eosin stain shows the density of vessel formation synonymous with that of a biopsy of a hemangioma. g to i show the progression of the spontaneous epithelialization from the wound edges as the granulation tissue developed and coalesced. The wound healed in 220 days from the commencement of treatment
Background Platelets are rich in cytokines and growth factors. Exposed tendons in wounds do not naturally heal by granulation and epithelization. The study aimed to explore the effects of PRP injection therapy on exposed tendons in open wounds and determine if the tendon could support wound healing. Methods A retrospective observational clinical study was undertaken from 2012 to 2018 to assess wound healing from exposed tendons in wounds in patients treated with PRP injections and occlusive dressings. Parameters studied included patient and management factors, wound and functional outcomes, wound healing progression, and the direct effects of PRP therapy on tissues. Results Twenty-three patients with several comorbidities received treatment. The average age of patients was 56 years, with an age range of 25 to 79 years. Twenty of the 23 patients (87%) reached complete healing. Eighteen of the 20 (90%) had good tendon excursion and associated joint movement for the limb’s function. The complication rate was low. PRP injection therapy produced a response of increased vascularity, the proliferation of granulation tissue from the tendon, and epithelialization from the surrounding skin. Conclusions Intra-tendinous PRP injections used with occlusive dressings can heal the exposed tendon and open wound by process of granulation and epithelization, restoring adequate limb function. Level of evidence: Level IV, Therapeutic study.
Flow diagram of patients undergoing autologous breast reconstruction with an abdominally based free or pedicled flap, with or without a TAP block, screened for conversion to POU in the Clinformatics.® database. Patients were identified through CPT and HCPCS codes (Appendix Table 5)
Background The transversus abdominus plane (TAP) block reduces postoperative donor site pain in patients undergoing autologous breast reconstruction with an abdominally based flap. This study aimed to determine the effect of TAP blocks on rates of conversion to chronic opioid use. Methods The Clinformatics Data Mart was queried from 2003 to 2019, extracting adult encounters for abdominally based free and pedicled flaps based on common procedural terminology (CPT) codes. Patients were excluded if they had filled a narcotic prescription 1 year to 30 days prior to surgery. The exposure variable—TAP block—was identified by CPT codes. Outcomes were evaluated using morphine milligram equivalents (MME) from prescriptions filled between 30 days prior to and 30 days after surgery. Chronic opioid use (COU) was defined as receiving 4 unique prescriptions or a 60-day supply between 30 and 180 days after surgery. Results Of the 4091 patients, (mean age 51.2 ± 9.0 years), 181 (4.4%) had a TAP block placed. Perioperative MMEs/day, postoperative COU, and length of stay did not differ in patients who received a TAP block (p = 0.142; p = 0.271). Significant predictors of risk of conversion to COU included younger age, pedicled abdominal flap, Elixhauser comorbidity index score > 3, filling a psychiatric medication prescription, and filling a benzodiazepine prescription. Conclusions In patients undergoing autologous breast reconstruction with abdominally based flap reconstruction, TAP blocks do not decrease perioperative MME/day, conversion to chronic opioid use, or length of stay. These data suggest that intraoperative TAP block placement may be a low-yield opioid-reduction strategy. Level of evidence: Level III, risk/prognostic study
Background A rising incidence of cutaneous melanoma causes a high prevalence of patients eligible for clinical follow-up, which increases the burden on the resources in the health care system. The objectives of this study are to investigate the effect of the current surveillance program in terms of detecting recurrence or development of de novo cutaneous melanomas and evaluate the efficacy of the different detection modalities including self-skin examination, physical examination, and routine imaging. Methods The study is designed as a retrospective cohort study. Patients with ≥ 1 follow-up visit(s) in the first 2 years after diagnosis of stage IB–IIIC disease in the melanoma surveillance program at Aarhus University Hospital in 2019 are included. Detection of recurrence rate by either physician-based examination, self-skin examination or routine imaging is compared. Results Two-hundred and ninety-one patients were included and 26 recurrences/de novo cutaneous melanomas were identified. Physician-based exams detected 39.5%, self-skin examination detected 34.9%, and imaging detected 27.8% of the recurrences. Conclusions Physician-based examination and self-skin examination are the most effective modalities to detect recurrences. Imaging modalities detected most recurrences when performed due to suspicion. The number needed to treat for stage IB was relatively high, which is why a prolonged interval between follow-up visits for this stage is advisable. The risk of recurrence is associated with disease stage which is why it is reasonable to base the follow-up program for melanoma patients on this parameter. Level of evidence: Level II, Risk/Prognostic
Background Bromelain-based enzymatic debridement is gaining increased interest from burn specialists in the last few years. The objective of this manuscript is to update the previous, first Spanish consensus document from 2017 (Martínez-Méndez et al. 43:193–202, 2017), on the use of enzymatic debridement with NexoBrid® in burn injuries, adding the clinical experience of a larger panel of experts, integrating plastic surgeons, intensivists, and anesthesiologists. Methods A consensus guideline was established by following a modified Delphi methodology of a 38-topic survey in two rounds of participation. Items were grouped in six domains: general indication, indication in critical patients, pain management, conditions for NexoBrid® application, NexoBrid® application technique, and post-debridement wound care. Results In the first round, experts established consensus (strongly agree or agree) on 13 of the 38 statements. After the second round, a consensus was reached on 24 of the 25 remaining statements (97.2%). Conclusions The present updated consensus document provides recommendations on the use of bromelain-based enzymatic debridement NexoBrid®, integrating the extensive clinical experience of plastic surgeons, intensivists, and anesthesiologists in Spain. Further clinical trials and studies are required to corroborate, modify, or fine tune the current statements. Level of evidence: Not ratable
PRISMA flow diagram
Overall risk of bias assessment as per the criteria from the National Institute of Health quality assessment tool for observational cohort and cross-sectional studies
Background The extensor digitorum brevis muscle (EDB) has been transferred as a pedicled or free flap for various indications, including those requiring functional muscle transfers. It can be used as a muscle flap or as a compound flap (either a composite or a chimeric flap) including skin, fat and/or nerves. This PRISMA-compliant systematic review reports on the use of EDB flaps to provide an evidence-based report of its indications, complications and outcomes and thereby clarify its utility to reconstructive surgeons. Methods PubMed, Embase, and Medline databases were searched for English-language clinical studies (1990 to 2020) of all evidence levels. Cadaveric and studies relating to orthopaedic foot and ankle procedures were excluded. The main outcomes were flap survival, reoperation, revisions and functional outcomes depending on the aim of the reconstruction. Results 33 papers were eligible (248 flaps). Procedures were classified according to the recipient site of EDB flaps: face (13%), hand (9%) and lower limb (78%). EDB was used as a free flap in 22.6% of cases. EDB flaps were used as a pure muscle flap, or as a compound flap (composite or chimera). In lower limb reconstruction cases, flap blood flow was either anterograde (n = 150) or retrograde (n = 43). EDB flap dimensions ranged 3–4.5 × 6–6.7 cm. There was a 5.2% total and 4% partial flap failure, all limited to anterograde lower limb pedicled applications. Donor site complications included delayed wound healing (7.3%), wound dehiscence (5.4%), reduced ankle mobility (3.9%), hypertrophic scars (3.4%) and paraesthesia over the dorsum of the foot or first webspace (3.4%), amongst others. Conclusions EDB flaps have been successfully used in facial, hand and lower limb reconstruction both as soft tissue cover and as a functional transfer. This versatile flap has reasonable low donor site morbidity, reliable anatomy with options for proximal pedicle lengthening and can be used as a pedicled or a free flap. Level of Evidence: Not ratable.
Operation site
Indications. “Other” summarizes rare indications (reported less than 50 times in this cohort)
Operation techniques
Causative factors for revision surgery in patients with major complications
Minor complications
Background Reduction mammaplasty and mastopexy are an ideal teaching opportunity for residents. While residents benefit from teaching operations, it is essential to evaluate whether this poses risks for the patient. The purpose of this study is to determine the impact of hands-on training for residents as primary surgeons in reduction mammaplasties and mastopexies.Methods The data of 1103 patients who underwent surgery between January 2000 and December 2010 at Innsbruck Medical University were extracted and analyzed by training status of the primary surgeon.ResultsA total of 833 patients were included in the study. The overall complication rate was 4.9%. For surgeries conducted by specialists, the rate was 4.8% and for those performed by residents 5.1% (p = 0.85). No significant difference in complication rates between senior residents and junior residents was found (p = 0.58). Analysis for major and minor complications demonstrated no statistically significant difference between specialists or residents (p = 0.054). A three-way comparison between specialists, senior and junior residents showed significantly more major complications occurring in the junior resident cohort (p = 0.018).Conclusions This study demonstrates that having a resident under supervision as a primary surgeon does not increase the complication rate, establishing hands-on residents’ training in plastic surgery as a safe training method.Level of evidence: Level III, Risk/Prognostic.
Plastic surgery knowledge in the Middle Ages is known to have progressed via the Sushruta Samhita and Pragmateia of Paul of Aegina. Both texts influenced numerous medical authors of the Middle Ages, particularly those from the Islamic Golden Age. Little is known of how this information was transferred to these great writers. This article examines how the Sushruta Samhita and the Pragmateia crossed international borders and contributed to the practice of plastic surgery in the early Middle Ages. A comprehensive review of medical, medical humanities and history databases (PubMed; MEDLINE; Web of Knowledge; Anthropology; JSTOR, Encyclopedia of ancient history), non-digital printed texts and digitised manuscripts (Biblioteca Medicea Laurenziana and BnF Gallica) was conducted using multiple search terms and filters including Middle Ages Surgery; Paul of Aegina; Sushruta; Branca Family; Reconstruction; Plastic Surgery; Islamic Medicine; Nasal reconstruction and Rhinoplasty. The search was restricted to publications which focused on the period between 476 and 1453 AD. A seventh century translator, Hunain ibn Ishaq; a thirteenth century manuscript Par. gr. 2293; the Arab conquest of Sicily; and an eleventh century translator, Constantine the African were identified. From Sushruta and Paul, our speciality proliferated in the Middle Ages due to the Great Translation Movement and the prosperity of the Islamic Golden Age. It influenced several medical authors like Albucasis, resulting in Paul and Sushruta’s techniques crossing international borders. Level of evidence: Not ratable.
PRISMA diagram of the study selection process
Background Reduction mammoplasty is a commonly performed cosmetic procedure in the UK. Wound breakdown and infection are damaging complications both for patient experience and for cosmetic outcome. The questions we as investigators wanted to answer were: according to the best available scientific data, firstly which patients are at greatest risk of developing complications following reduction mammaplasty, and secondly what strategies are being employed by surgeons to reduce the incidence of these complications? Methods A review was carried out according to PRISMA guidelines across multiple electronic databases The key words used were a combination of “reduction”, “mammaplasty”, “mammoplasty” or “infection”. The inclusion criteria for the searches related to studies published in English, and no time-frame limit was set. Studies which specifically compared outcomes between cancer and non-cancer resections were excluded. Following review of the literature, key risk factors for the development of wound breakdown or infection following reduction mammaplasty were identified, and the available evidence for each appraised. Subsequently, methods employed by surgeons to reduce the incidence of such complications were collated, and again the evidence behind each was summarised Results Smoking status, BMI and steroid use appear to be the patient risk factors with the greatest evidence to suggest they pose an increased risk of wound complication following RM. In terms of strategies to reduce wound complications, a single dose of preoperative antibiotics appears to have a beneficial effect on wound complications and infections notably. Conclusions Reduction mammoplasty is an important plastic surgery procedure, and further research is required to understand how to minimise expensive, and cosmetically detrimental wound complications. Patient selection, counselling and risk stratification are key. Future research focussing on methods or techniques to reduce complication rates such as novel ways to protect the T junction and the utilisation of newer skin closure devices may prove valuable. Level of evidence: Not ratable
This 67-year-old female patient presented with a 7 × 10-cm anterior knee defect after multiple arthroplasty revisions. She had an antibiotic spacer in place. After debridement and irrigation, knee fusion was performed by the arthroplasty surgeon (a). For soft tissue cover, we performed a keystone advancement-rotation flap from the lateral thigh (b, c). Closure was easily attained in a V–Y fashion both cranially and caudally thereby avoiding skin grafting (d, e). The wounds were closed and stable at the 1-year follow-up (f)
This 62-year-old male patient presented with a 4 × 5-cm anterior knee defect after quadriceps tendon reconstruction (a). The soft tissue defect was reconstructed with a rotation-advancement keystone flap from the lateral thigh (b). Anterior closure was performed in an omega fashion (c). Wounds were well healed at 2 weeks (d)
The anterior midline incision is the most popular approach to the knee among orthopedic surgeons, including in total knee arthroplasty (TKA). Wound breakdown in the anterior knee can rapidly lead to an exposed joint and hardware because of the scarcity of soft tissue padding. Should it happen, expedite reconstitution of the skin envelope is essential to avoid jeopardizing the surgical result. We propose the use of modified advancement-rotation keystone flaps for the effective closure of these defects. The records of patients reconstructed with this technique at our institution between January and July 2021 were reviewed. Four cases were identified and are described, three of which resulted from complications of TKA and one of quadricipital tendon reconstruction. Mean follow-up was 8 months (range 6–12 months). All flaps survived completely. Localized wound dehiscence in one patient was treated successfully with flap readvancement. Other patients recovered uneventfully. Knee flexion was fully regained in two patients and limited only by the underlying osteoarticular condition in the remaining two. Patients with arthroplasty hardware in place could retain it. All patients had remarkably good tactile and pain sensation at the 6-month follow-up. Esthetic results were satisfactory in terms of color, texture, and contour. Orthopedic surgeons continue to struggle to treat and prevent wound dehiscence after knee surgery, especially in peripheral hospitals without plastic surgery consultation. This technique of local tissue redistribution can easily be learned by both plastic and knee surgeons allowing them to solve and potentially prevent this common problem. Level of evidence: Level V, Therapeutic
Distribution of the videos along continent (A) and source (B)
JAMA score histogram (A). Percentages of JAMA criteria (B). FH-SS histogram (C). Percentages of FH-SS Criteria (D). JAMA, Journal of American Medical Association; FH-SS, flaps for hand reconstruction-specific scoring system
Background Hand injuries might present with exposed tendons, bones, and neurovascular structures, requiring flap reconstruction. Comprehending various flap options for hand injuries requires detailed knowledge, surgical skills, and considerable practice. Surgery residents commonly use web-based learning; one is YouTube for surgical education. We aim to evaluate the reliability and quality of the videos on YouTube for hand surgery training.Methods Video extraction from YouTube were done by keywords on 24 August 2021. JAMA scores and flap reconstruction of the hand-specific scoring system (FH-SS) were used to evaluate the selected videos. ResultsThe mean JAMA score and FH-SS were 1.72 and 8.54, respectively. JAMA scores and FH-SS of the videos from Europe were significantly lower than from America and Asia (p = 0.0001 and p = 0.0063, respectively). The JAMA scores of physicians were significantly higher than that of medical sources (p < 0.0001).Conclusions The low JAMA score and the average FH-SS suggest that YouTube videos are unreliable and poorly qualified for hand surgery residents. The high JAMA score of the physician’s videos emphasizes the reliability of YouTube videos depending on the sources. Surgery residents should be skeptical of the information of YouTube videos on surgical education.Level of Evidence: Not ratable
Firework types vs depth of burn injury
Background Fireworks are often used to celebrate holidays and events. With novel designs and availability, there is potential for blast and burn injuries that can impact livelihood and function. This study aims to describe and analyse firework-related burns in adults across New South Wales and the Australian Capital Territory. Methods A retrospective statewide review was performed from January 2010 to December 2020 at the adult burns units. All firework-related burn injuries older than 18 years that attended or were referred to the burns unit were included. Results There were 203 patients with a firework-related burn injury. The male to female ratio was 4:1 with an average age of 32.2 years. Men were 5.2 years younger than women (31.2 vs 36.4, p = 0.010). Men were more likely to have firework-related injuries on non-holidays, whereas women were more likely on holidays (p = 0.050). Men were more likely to operate fireworks after consuming alcohol resulting in burns than women (34.4% vs 12.5%, p = 0.007). Sparklers were more common amongst women, whereas fireworks had higher proportions amongst men (p = 0.009). The most common site of injury was the hands. The most frequent type of injury was a mid-dermal burn (61.6%), followed by superficial (25.2%), and full thickness (13.2%) respectively. The operative rate was 17.7% with a mean total length of stay of 2.2 days (range: 1–12). Conclusions Firework-related burns have distinct patterns of use and injuries amongst men and women. Alongside legislation, awareness of the potential hazards for shopgood fireworks such as sparklers is critical for future prevention campaigns. Level of evidence: Level III, Risk/Prognostic.
Ultrasound (US) technology produces noninvasive high-resolution imaging and is considered a valuable energy source in shaping and sculpting tissues. The plastic and reconstructive surgery specialty has the unique ability to customize and apply ultrasound in a range of clinical applications, including replacing the use of chemoprophylaxis for deep venous thromboses, in addition to monitoring ruptures of breast implants, masses, and cystic lesions. Ultrasound is even an excellent tool to identify and assess vessels and perform postoperative free-flap monitoring following microsurgical anastomosis. Since abdominal penetration is a disastrous complication of liposuction, ultrasound-assisted liposculpting has been linked with low surgical effort and high patient satisfaction and comfort. Moreover, ultrasound-guided transverse abdominal plane (TAP) blocks have helped reduce postoperative pain and the need for narcotic medication usage in abdominoplasty surgeries. Hand and wrist tendon ruptures, neoplasia, and cystic or solid lesions are diagnosed by ultrasound. In addition, ultrasound may help distinguish between pathological and structural abnormalities in the median nerve of carpal tunnel syndrome (CTS) patients. In burns, the role of ultrasound is limited; however, laser Doppler imaging (LDI) can help assess different aspects of the wound healing process and support objective decision-making regarding either grafting or excising the burned areas. Other critical clinical roles of ultrasound include minimizing the risk of postoperative edema and bruising and detecting the location of the affected nerves and arteries in patients with migraine headaches. In this review, the use of ultrasound in plastic and reconstructive surgery is elaborated and discussed. Level of evidence: Not ratable
Comparison of the change in vessel diameter due to the application of both drugs
Comparison of the change in vessel diameter after the anastomosis
Comparison of the percentage change in vessel diameter before and after the application of the drugs in both groups
Comparison of the percentage of change in vessel diameter post anastomosis
Background Use of topical vasodilators in microsurgery to ameliorate intraoperative vasospasm after dissection of vessels is widely used. It not only facilitates the anastomosis but also enhances the flap survival outcome. Finding safe and effective agent is important in vitro. Studying it primarily in vivo will facilitate finding this agent before proceeding to in vitro application. This study aims to experimentally compare the efficacy of two vasodilators in relieving vasospasms. Methods In this in vivo study, the effect of topical application of verapamil was compared to lidocaine in relieving the vasospasm of femoral vessel of 21 Sprague–Dawley rats. Results Verapamil provided dilatation exceeding that of the lidocaine, as the mean of dilation after application of the verapamil was 0.28 mm and the maximum dilation was 0.6 mm. While after lidocaine application, the mean of dilation was 0.17 and the maximum dilation was 0.45 mm. The percentage of change in vessel diameter after application of drugs was 63.85% in the verapamil group and 33.57% in lidocaine group. Conclusions In the current study, it was proven that both verapamil and lidocaine have statistically significant vasodilator effects. However, verapamil is superior to lidocaine in its topical vasodilator effect. It has also longer duration of vasodilator effect. Level of evidence: Not ratable
A Open sternal wound; B wound debridement and medial pectoralis undermining; C vertical cut; D lateral undermining; E releasing lateral border of pectoralis; F undermining adjacent to the rib cage and the upper anterior sheath of the rectus abdominis muscle; G pulling the flaps medially and excising tissue excess from them; H final result
Blood supply of flaps
1, before debridement; 2, after debridement; 3, marking the vertical lines; 4, undermining towards the axilla after undermining of the pectoralis; 5, releasing lateral edge of the pectoralis; 6, the released lateral edge of the pectoralis; 7, suturing the flaps in the midline; 8, suturing the vertical cuts and final result at the operation; 9, 3 weeks after the operation
1, before operation; 2, after debridement; 3, the result at the end of the operation; 4, 4 months after the operation
Background Closure of the deep sternal wound is a well-known challenge for chest and plastic surgeons. Various techniques have been described. However, there remains a need for a better one—a simple, safe procedure with minimal complications for patients, who usually present with underlying serious comorbidities. We present our technique for medium-size sternal wound closure in men. Methods Nineteen male patients, aged 52 to 85 years (average 71.7 years), with severe risk factors and underlining diseases underwent sternal wound closure with modified bipedicle pectoralis major myocutaneous flaps. The flaps have a rich blood supply from perforators of the pectoralis major muscles and branches of the thoracoacromial and superior epigastric arteries. This technique was performed as a single procedure for 12 patients (63%), as a second procedure for six patients (32%), and as a third one for one patient (5%). There was no need for humeral detachment of the muscle, and the skin deficit was solved by mobilizing skin medial to the axilla. Results No ischemic changes or dehiscence was shown in any of the flaps. Three patients (16%) had a second procedure, two because of bleeding in POD1 and POD14, and one due to infection. One patient (5%) had pulmonary emboli. Another patient (5%) had severe pulmonary effusion. Four patients (21%; average age 76y) died perioperatively (sepsis in 3 and cardiac arrest in 1). Conclusions The modified bipedicle pectoralis myocutaneous flaps technique is safe and simple. It should be considered in medium-size sternal wound closure in men. Level of evidence: Level IV, therapeutic study.
a Forty-six-year-old patient with left breast carcinoma b Final result 8 months after expander removal and implant positioning
a Forty-four-year-old patient with bilateral breast carcinoma b Final result at 6 months after prepectoral breast reconstruction with ADM through bilateral hemiperiareolar access
Box plots for patients’ BREAST-Q results
Background The aim of this retrospective study is to analyze and compare the cost of two-step breast reconstruction with expander/implant versus total prepectoral breast reconstruction (BR) with acellular dermal matrix (ADM). Patients’ satisfaction was also evaluated. Methods A retrospective investigation was performed on the patients who underwent breast reconstruction between December 2017 and October 2019 by Plastic and Reconstructive Microsurgery at Careggi University Hospital in Florence and divided into group A (prepectoral BR with breast implants and ADM) and group B (BR with breast expander and implant). Complications, patients’ satisfaction with BREAST-Q questionnaire, and complete cost analysis for each type of reconstruction have been analyzed and compared. Results Seventy-two patients were recruited for the study, divided into group A (32 patients) and group B (40 patients). The total number of complications is 8 cases out of 36 (22.22%) in the group of cases and 10 out of 42 (23.80%). For patients’ satisfaction, the statistical analysis does not show significant differences both with a parametric and with non-parametric tests. Total overall cost of expander/prosthesis with BR is 7308.83 €, while the cost of immediate prepectoral reconstruction is around 8062.76 € showing an increase in expenditure compared to the control group of 753.93 €. This difference corresponds to 9.35% of the price of prepectoral BR. Conclusions Our results showed no major differences among the two techniques. The minor difference in costs for prepectoral technique is justified with main advantages of a reduce number of hospitalizations and, consequently, waiting list for breast reconstruction. Level of evidence: Not gradable.
Background Regional lymph node metastases (RLNM) in cases of soft tissue sarcoma (STS) are relatively rare, with limited data available on optimal patient management and prognosis. To help address this, we present our own experiences of patients with STS RLNMs. Methods We performed a retrospective review of all patients with STS RLNM managed at our regional sarcoma treatment centre over a 28-year period (1987–2015). Datasets collected include patient demographics, disease characteristics, management and outcomes. Results Thirty-five patients were included for analysis (21:14 male:female, median age 65 years, range 18–89). The commonest subtypes identified were undifferentiated pleomorphic sarcoma, leiomyosarcoma, liposarcoma, and rhabdomyosarcoma. Thirteen patients had RLNM at presentation. Median time for RLNM development in the remaining 22 patients was 1.9 years (range 0.4–22.7). During follow-up (median 5.8 years), 29 patients (83%) died of their disease at a median of 3 years from time of RLNM diagnosis. This gave the cohort an estimated 5-year survival of 29%. There was no difference in the survival of patients that presented with RLNM and those that developed RLNM during follow-up (p = 0.506). Five-year survival was better in patients with isolated RLNM compared with those with RLNM and visceral metastases (p < 0.001). Lymph node resections had no effect on survival (p = 0.832). Conclusions The prognosis of patients with STS RLNM is poor, albeit better than that of patients with visceral metastases. Considering the absence of a clear survival benefit identified by our analysis, we recommend that non-operative treatment is strongly considered as first-line RLNM management. Level of evidence: Level IV, Prognostic study.
Types of CSD. A Type 1; CSD extends to less than 50% of the nares, mild. B Type 2; CSD extends between the nasal vestibular skin and 50% of the nares. C Severe: type 3; CSD extends beyond the nasal vestibular skin
Change graph of average NOSE and ROE scores according to CSD types in preoperative, postoperative 1st and 6th months (repeated measure ANOVA statistics)
Background Caudal septum deviation (CSD) causes functional and aesthetical problems, and surgical management of CSD is difficult. CSD has been included as a subcategory in the previous septum deviation classifications. However, a classification has not yet been made for CSD. This study aimed to design a useful classification for CSD. Methods Patients who underwent septoplasty (SP) or septorhinoplasty (SRP) with the diagnosis of CSD were included in the study consecutively. CSD was divided into three groups according to the relation of the anterior edge of the septum with nares from the caudal aspect. CSD is classified as simple: type 1; CSD extends to less than 50% of the nares, mild: type 2; CSD extends between the nasal vestibular skin and 50% of the nares, severe: type 3; and CSD extends beyond the nasal vestibular skin. Preoperative and postoperative first- and sixth-month Nasal Obstruction Symptom Evaluation (NOSE) and the Rhinoplasty Outcome Evaluation (ROE) questionnaire scores, duration of surgery, revision rates within, and complication rates were identified. Results During the study, 568 patients underwent septum surgery and 70 (12.3%) patients with CSD were included in the study. Forty-two (60%) of the patients were female and 28 (40%) were male. The mean age was 24.4 ± 6.8 in all patients. Type 1 CSD was detected in 41(58.6%) patients, and it was the most common type. The duration of the operation was not affected by the type of CSD (p = 0.068, one-way ANOVA). However, preoperative and postoperative NOSE and ROE scores at 1 and 6 months showed a significant difference according to CSD types. According to post-HOC analysis, there was no significant difference between type 2 and type 3 CSD for the postoperative 1st and 6th month ROE scores (p = 0.760 and p = 0.905, respectively, Tamhane test). The difference between NOSE and ROE scores in the preoperative period and in the postoperative 1st month was significantly affected by the type of CSD according to the repeated-measure ANOVA test. A simple residual deviation was detected in 8 patients (11.4%) 6 months after the surgery and 5 of them (62.5%) were in the CSD type 3 group (p = 0.001, Pearson chi-square test). Conclusions This proposed new CSD classification can be used objectively both in the evaluation of symptoms and in the prediction of surgical outcomes. Level of evidence: Level III, Diagnostic study.
Drawing of possible flap designs and positions. The flap is so dynamic so that it may be superiorly, inferiorly, medially, laterally, or even obliquely based. Figure legends: case (1), (a) post-burn hypertrophic scarring and contractures of the left wrist and finger. b Excision of scarred skin and release of contractures were done. c Post-operative view showing flap inset. d Side view of the left hand after 6 years post-operative visit. e Antero-posterior view showing flap as thick as the surrounding skin. f Donor site showing complete take (hidden donor site area). Case (2), (a) dorsum of the right hand after debridement with exposed bones and tendons. b Wound debridement showing exposed extensor tendons and metacarpal bones. c Elevation of ultra-thin abdominal flap. d Dorsum of the right hand 2 days post-operative and flap inset. e Dorsum of the hand after flap separation and grafting of the partial flap loss. Case (3), (a) post-burn extensive keloid formation of the right whole upper limb. b Post-burn extensive keloid formation of the left upper limb. c Excision of the keloid of the right hand, wrist and distal forearm. d Both hands 6 months after separation of the second flap. Case (4), (a) post-traumatic soft tissue loss of the left hand and fingers. b Wound debridement showing exposed vital structures and phalanges. c After complete separation of the flap. d After release of syndactyly
Background The reconstruction of soft tissue defects of the hand, wrist, and forearm with exposed tendons, joints, bones, and neurovascular bundles represents a great challenge for plastic surgeons. Such defects require early and effective quality coverage to protect the underlying vital structures, preserve hand functions, and allow for early rehabilitation. This study aimed to evaluate the versatility of ultra-thin abdominal flap for the coverage of hand and forearm soft tissue loss with no or minimal morbidity or further debulking procedures. Methods From January 2013 to April 2019, all patients in whom ultra-thin abdominal flaps were used to resurface soft tissue defects of the hand and forearm were retrospectively reviewed and included in this study. Patient satisfaction was also investigated and categorized into three groups: satisfaction with reconstructed defects, flap donor sites, and the graft donor site. Results Thirty flaps were used to resurface 30 upper limb defects with minimal complications and good esthetic outcome with no need for further flap debulking. Twenty patients were very satisfied with the defect coverage, nine were satisfied, and one patient was not satisfied. Regarding the flap donor site, 11 patients were very satisfied, 17 were satisfied, while two patients were not satisfied. Conclusions Soft tissue defects of the upper limb can be reconstructed effectively with the ultra-thin abdominal flap resulting in minor or no complications. This flap gives good results with minimal donor site morbidity if it is well designed and meticulously dissected. Level of evidence: Level IV, Therapeutic study
FTSG. Drawing at the donor site including both the flap and the skin graft whose triangular shape shares the basis with the proximal border of the flap and whose height is double the length of the basis (a). The flap has been harvested and the graft has been distally shifted and stretched to cover the donor site; incisions are opened to prevent fluid collection (b). The final reconstructive result of the forearm donor site with a split-thickness skin graft can be appreciated 6 months after surgery (c)
STSG. Split-thickness skin graft harvested from the patient’s thigh, with the use of a dermatome. The desired length has been achieved and only the distal portion of the graft is still attached to the donor site (a). The graft has been placed on the radial wound bed with the dermal side below and it has been fixed in place with a suture on the edges and on the central part of the graft to facilitate the adhesion to the wound bed (b). The final reconstructive result of the forearm donor site with a split-thickness skin graft can be appreciated 6 months after surgery (c)
Patient and Observer Scar Assessment Scale and Liu questionnaire about donor site functionality
Background The radial forearm free flap (RFFF) is one of the most common reconstructive choices for head and neck soft tissue defects worldwide. One of the techniques to cover up the donor site defect is based on the use of split-thickness (STSG) or full-thickness skin grafts (FTSG). Methods Ours is a retrospective study including 36 RFFF reconstructive surgery patients at the University Hospitals of Verona and Parma treated between 2016 and 2020, with more than 6 months’ follow-up. Nineteen patients received a FTSG, locally harvested from the forearm, while 17 a STSG from the thigh. We used two already validated scales for the evaluation of the surgical scars. The first one is the Patient and Observer Scar Assessment Scale that rates vascularity, pigmentation, thickness, relief, pliability, and the surface area, and it incorporates the patient’s assessments of pain, itching, colour, stiffness, thickness, and relief. The second questionnaire was developed by Liu in 2011 to assess the functionality of the donor site from a patient’s perspective. Results Pigmentation, thickness, relief, and surface area were statistically better in the FTSG than in the STSG group, while, according to the patients, the functional results turned out to be similar. Conclusions From our experience, the locally harvested FTSG is to be considered the best alternative, with a better aesthetic outcome than the STSG harvested from the thigh and with a higher degree of protection provided to the forearm flexor tendons, without the need for an additional donor site. Level of evidence: Level III, therapeutic study.
Background Management of complex trauma of the upper and lower limbs represents a constant challenge for orthopedic surgeons and plastic surgeons, especially due to the difficulty encountered in the decision-making process of trying to save the affected limb and reducing the risk of poor prognosis. Score and classification systems have been developed to guide the surgical indication based on the objectivity of the clinical picture and the potential results that can be obtained. The aim of this paper is to evaluate and compare the different score and classification systems used to choose the most effective indications and surgical strategy in complex limb trauma. Methods The authors carried out a systematic review of the literature comparing the classifications of exposed limb fractures and scoring systems on the most suitable surgical indication, evaluating their reliability and impact on the preoperative decision-making process. Results From the PubMed search, the authors extracted and reviewed 53 studies published between 1976 and 2018. The following were compared: Gustilo-Anderson classification, Tscherne-Oestern classification, Orthopedic Trauma Association classification, Mangled Extremity System Score, Ganga Hospital Open Injury Severity Score, NISSSA (Nerve injury, Ischemia, Soft-tissue injury, Shock, and Age of Patient Score), and others. Pros and cons have been highlighted for each of them, particularly in terms of sensitivity and specificity. Conclusions The results of literature review showed that to date, there is no ideal classification for complex limb injuries and that even the most recently published recommendations use classifications that present important drawbacks. For complex trauma of the upper limb, the available classifications are even more incomplete. A multidisciplinary judgment, of both orthopedic and plastic surgeons on used score and classification systems, may give the patient an accurate reconstructive surgical treatment. As for amputative and sub-amputative trauma of the lower limb, the authors exhort to include the possibility of restoring plantar sensitivity in the factors to be used for decision-making. For the upper limb, they recommend to always check for the presence of a double level nerve injury; if the patient has suffered a preganglionic lesion of the brachial plexus, this may represent a contraindication to reimplant. Level of Evidence: Not gradable.
Neurobiological theories in assessing the human face
Mirror versus true image. A mirror image is the image of people ‘in the mirror’, which is the image most people identify themselves with (left picture). In true image, for example created by using a camera, shows the opposite, namely the left side is projected on the right and vice versa (right picture)
The human face is crucial in social interaction and demonstrates cues of health, trustworthiness, emotions, and much more. A peripheral facial palsy (PFP) refers to a lower motor neuron lesion of the facial nerve and, due to its anatomy, could have many etiologies, such as traumatic, idiopathic, infectious, and oncological. Approximately 30% are left with long-term sequelae and 4% with severe dysfunction. For facial plastic surgeons, a PFP represents a great reconstructive challenge. It is a debilitating condition with functional (corneal exposure, epiphora, oral incompetence, and nasal obstruction, among others) and aesthetic sequelae that often result in physical, psychosocial, communicative, and quality-of-life losses. It remains the question how we measure the effects of the treatment of patients with a facial palsy, since there are many variety in cosmetic appreciation, surgical goals, patients’ needs, and measuring tools. The aims of this narrative review are: 1) to give an overview of conservative measuring and classification tools, 2) clinician-graded instruments versus patient-graded instruments, and 3) which domains should be considered when assessing effects of our treatment. Level of evidence: Not gradable.
Results from the SESQ. Percentage of patients who experienced excess skin and their rating of this excess skin in the upper panel and patient rating of their discomfort caused by the excess skin (VAS score, 0–10) in the lower panel. Women in the left column, men in the right column, before (B) and after (A) bariatric surgery. Dots represent means, lines represent medians, and boxes represent quartiles. The Sign test was used to compare the percentage of patients who experienced excess skin, and the Wilcoxon signed-rank test was used to evaluate significance for discomfort
Top section: probability of discomfort score ≥ 6 (VAS score 0–10) related to excess skin on the arms (A) and thighs (B) 18 months after bariatric surgery from ptosis of the skin of the arms and thighs (cm) before bariatric surgery with 95% CI (shaded area), using logistic regression. Bottom section: relationship (Spearman’s correlation) between ptosis of the arms (C) and thighs (D) in cm and discomfort (VAS 0–10) after surgery
Background Bariatric surgery is an effective weight loss method for patients with obesity. One side effect of bariatric surgery is uncomfortable excess skin. Much remains to be learned about physical measurements and patients’ subjective perceptions of it. Here, we investigated the pre- to post-bariatric changes in patients’ perception and physical measurements of the skin on the arms and thighs, in order to find possible subgroups especially affected by post-operative excess skin and to identify predicting factors. Methods One hundred forty-seven patients eligible for bariatric surgery completed the Sahlgrenska Excess Skin Questionnaire (SESQ) and underwent measurements of their skin before and 18 months after the procedure. Results Although most physical measurements decreased post-operatively, many patients reported increased discomfort. We identified one subgroup particularly prone to report excess skin on the arms post-operatively: women with high discomfort from excess skin on the arms and high body mass index (BMI), pre-operatively. Ptosis of the excess skin seems to be a feasible measurement for predicting post-operative discomfort. For every centimetre of ptosis pre-operatively, patients had 1.37- and 1.31-fold higher odds of achieving a score for post-operative discomfort from excess skin on the upper arms and thighs, respectively, of ≥ 6 (on a 0–10 scale). Conclusions We identified a subgroup especially affected by discomforting excess skin on arms and thighs after weight loss. Furthermore, we suggest a pre-operative pro-operative ptosis measuring to predict post-operative discomfort level. The result of this study further increases the knowledge of excess skin and should be useful in further improving patient education. Level of Evidence: Level III, risk / prognostic study.
A Cross-section of soft tissue layers overlying the nasal osseocartilaginous framework. B The fibromuscular layer (FM) is a continuous sheet of muscle and aponeuroses that lies over the osseocartilaginous framework, sandwiched between the subcutaneous areolar layer (SAL) and the deep areolar layer. The FM is reflected in the midline showing that no major vessels lie beneath it. C The major vessels of the nose lie on the FM just under the SAL. These vessels comprise the paired alar and columellar arteries (derived from the external carotid system) and the paired dorsal nasal arteries (internal carotid system) and the plexus of anastomoses between them. DAL, deep areolar layer; FM, fibromuscular layer; P, perichondrium; S, skin; SAL, subcutaneous areolar layer. (Figure reproduced from Commentary on: Microautologous fat transplantation for primary augmentation rhinoplasty: long-term monitoring of 198 Asian patients by Wu W., Aesthetic Surg J 36(6):657–659 [2] published with open access, which permits use, distribution, and reproduction in any medium)
Landmarks used for measurements on a nasal CT scan of a patient with a noticeable nasal hump. G, glabella; F, nasofrontal suture; S, sellion; P, pronasale; H’, beginning of superficial nasal hump; H, apex of nasal hump; H’’, ending of superficial nasal hump; E, ethmoidal-point; R, rhinion
Background The soft tissue envelope (STE) of the nose contributes, along with the osteocartilaginous framework, to the nasal shape and contour. Its manipulation may pose challenges during reduction rhinoplasty, influencing aesthetic outcomes.MethodsA retrospective study was performed in patients who underwent nasal computer tomography (CT) in our medical institution, from 2015 to 2018. On sagittal CT scans, at midline, nose length, hump height, hump length, nasofrontal angle, STE thickness, and average thickness were measured. Patients seeking primary rhinoplasty for dorsal hump reduction were compared to a control group.ResultsThe study population included 136 Caucasian Mediterranean patients (42 males; 94 females) with a mean age at nasal CT of 32.9 years. Patients seeking rhinoplasty presented a longer nose (p < 0.001) and a wider nasofrontal angle (p < 0.001). Nose length presented a significant positive correlation with both nasal hump length (r = 0.465, p < 0.001) and height nose length (r = 0.479, p = 0.002) as well as with the average STE thickness (r = 0.25, p = 0.02). Male patients presented a higher STE average thickness (4.8 ± 0.5 mm vs 3.9 ± 0.6 mm, p < 0.001). Age did not present a statistically significant correlation with any of the STE measurements. The nasal STE was thickest at the nasofrontal suture in both groups. The thinnest point of the STE was found in the rhinion in control patients, whereas in patients seeking rhinoplasty, this corresponded to the nasal hump’s apex. STE thickness over the ethmoidal point was thinner in patients seeking rhinoplasty (p < 0.001).Conclusions Through the imagiological analysis of anatomical landmarks in patients seeking rhinoplasty, our study contributes to a more objective characterization of the nasal soft tissue envelope, whose evaluation in clinical practice is usually dependent solely on the eyes and hand of the surgeon with no clear reproducible measurements. In our study, nose length correlated with the STE thickness, and the hump apex was the thinnest point of the STE in patients seeking rhinoplasty. This statement is supported by previous studies in cadaveric specimens and backs up the surgical concept that preservation rhinoplasty should encompass the preservation of important soft tissue envelope structures and not only the osteocartilaginous vault.Level of evidence: Level IV, Diagnostic.
The canonical and non-canonical Wnt signaling pathways. In canonical Wnt signaling, in the inactive state, Wnt ligands are absent, and β-catenin is phosphorylated by the destruction complex (comprised of the scaffold protein Axin, APC, GSK3β, casein kinase (CK1α)). Phosphorylated β-catenin then becomes ubiquitinated by β-TrCP200 and targeted for proteasomal degradation. The absence of β-catenin within the nucleus allows the TCF (lymphoid enhancer factor)/LEF (lymphoid enhancer factor) and transducing-like enhancer (TLE/Groucho) proteins to promote histone deacetylases (HDACs), resulting in repression of target genes. In the active state, secreted Wnt ligands bind Frizzled (Fzd) receptors and LRP co-receptors leading to LRP phosphorylation by CK1α and GSK3β, and recruitment of dishevelled (Dvl) proteins. At the plasma membrane, Dvl proteins polymerize, become activated, and inactivate the destruction complex. The cytoplasmic β-catenin is free to accumulate and translocate to the nucleus, where it associates with LEF and TCF by displacing TLE/Groucho complexes. The nuclear β-catenin complex recruits histone-modifying co-activators that promote gene expression and activation of numerous cellular processes. In the non-canonical Wnt/PCP pathway, Wnt ligands bind the ROR-Fzd receptor resulting in recruitment and activation of Dvl. Active Dvl binds GTPase Rho by de-inhibiting the cytoplasmic protein Dvl-associated activator of morphogenesis 1 (DAAM1). Rho and the GTPase Rac1 bind and activate Rho kinase (ROCK) and c-Jun N-terminal Kinase (JNK), causing cytoskeletal rearrangement and/or transcriptional responses. Non-canonical Wnt/Ca²⁺ signaling involves G-protein-stimulated phospholipase C activity resulting in an influx of intracellular calcium and activation of downstream calcium-dependent cytoskeletal and/or transcriptional responses
Cross-talk between Wnt and Hh signaling pathways
Basal cell carcinoma (BCC) is the most common skin cancer worldwide, and its incidence is increasing due to the aging population and the cumulative effects of widespread sun exposure. The Wnt gene family is involved in cell growth regulation, differentiation, and organogenesis, and not surprisingly, Wnt genes have been linked to oncogenesis. Specifically, β-catenin, a key signaling regulator of the Wnt pathway, is involved in the genesis of numerous human cancers including BCCs. Dysregulation of the patched/hedgehog intracellular signaling pathway, other important pathways regulating cell growth and regulation, has also been linked to BCCs. In this review, we outline the key mechanisms of the Wnt and patched/hedgehog intracellular signaling pathways and their involvement in the development, homeostasis, and progression of BCCs. Level of Evidence: Not gradable.
Background Duration and take of gluteal lipografting are unpredictable. More importantly, unsafety of intramuscular lipofilling has been recently proven. Stromal Enriched Lipograft (SEL) is likely to enhance survival of injected fat. The purpose of this study is to describe the use of SEL for gluteal augmentation through injection into the subcutaneous layer.MethodsA retrospective study was performed to assess outcomes and patient satisfaction with subcutaneous gluteal augmentation through SEL in 194 patients between 2015 and 2017. A control group (non-SEL) in which fat injection was performed through a traditional Coleman’s technique between 2010 and 2013 was compared with the SEL group.Demographics and the amount of injected tissue were sought in patients’ charts. Complications and aesthetic outcomes were taken into account. The mean surgical gain of hip circumference was determined. Comprehensive improvement after gluteal fat augmentation was rated on a scale of 1 to 5, in which 1 is “worse,” 2 is “no change,” 3 is “improved,” 4 is “much improved,” and 5 is “very much improved.” The evaluation was made at 12 months by an independent assessor.ResultsAt 12 months postoperatively, the mean gain in terms of hip circumference was 3.3 cm in the SEL group and 0.9 in the non-SEL group and this outcome was statistically significant. No cases of infection or liponecrosis of the grafted area occurred. At 12 months, 75% of cases were rated as much improved or more and 16% were classified as improved.Conclusions More research is needed, but when SEL is utilized, the increased and prolonged duration of the grafted fat is such that repeat procedures are rare, which allows to target the subcutaneous layer as the recipient site, instead of the muscular plane, with increased safety.Level of evidence: Level IV, Therapeutic study.
Pre-operative shark attack-related injuries to the A forehead, B left elbow, C anterior torso, and D breasts
Shark attack-related injuries to the breasts reconstructed with DIEP flaps (A, B)
Shark attack-related injuries (SARIs) are rare but may result in highly complex wounds requiring reconstruction by plastic surgeons. Here, we present an unusual case of SARI of the breast and briefly review literature on reconstructive management of (1) breast injuries from other large animals and (2) SARIs to other parts of the body. Our patient was a 39-year-old woman who experienced massive bilateral breast tissue loss from a shark attack. After primary surgical wound management, including debridement and washout, the patient underwent completion mastectomy with bilateral deep inferior epigastric perforator flap breast reconstruction. Literature review revealed that reports of animal-related injuries to the breast are rare, with ours being the first on SARI to the breast and the only describing major reconstruction of animal-related breast injury. Literature on reconstruction of non-breast SARI wounds is limited to two case reports describing severe tissue damage akin to that seen in our patient, both necessitating extensive debridement followed by reconstruction. Overall, our findings demonstrate the uniquely devastating damage resulting from SARIs and the value of primary wound management and abdominally based free flaps in successfully reconstructing these wounds. Level of evidence: Level V, therapeutic study.
Background To better quantify the impact that breast cancer-related arm lymphedema (BCRL) has on health-related quality of life (HR-QOL), a disease-specific patient-reported outcome measure (PROM) is needed. The LYMPH-Q Upper Extremity Module was recently developed for patients with BCRL. The aim of this study was to perform an advanced translation and culturally adapt the LYMPH-Q Upper Extremity Module for use in Denmark. Methods The LYMPH-Q Upper Extremity Module was translated into Danish according to the guidelines of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and the World Health Organization (WHO). The process included two forward and one back translation, an expert panel meeting, and cognitive debriefing interviews with patients. The focus of the translation was to develop a Danish version that used appropriate patient-friendly language while maintaining the meaning of the items, instructions and response options. Results The two forward translations resulted in minor differences in terminology. These discrepancies were discussed among the translators and a harmonized Danish version 1 was achieved. Comparison of the back translation to the original English version identified 14 items/instructions/response options that required re-translation. Subsequently, experts helped to identify and resolve the language for 10 items/instructions/response options that did not maintain the same meaning as the English version. Participants in the cognitive debriefing interviews did not report any difficulties with understanding the items/instructions/response options. Conclusions The translation and cultural adaption process led to the development of a conceptually equivalent Danish version of the LYMPH-Q Upper Extremity Module. Level of Evidence: Not gradable
Resection of EMPD in the scrotal area reconstructed with a pedicled transposition flap. Gallery showing the surgical progress described in case II. A The weakly defined borders of the EMPD lesion are sought marked. B The primary defect after resection. C Reconstruction with a pedicled transposition flap from the anterior medial part of the upper thigh
Extramammary Paget’s disease (EMPD) is a rarely described skin neoplasm primarily affecting the anogenital region. The diagnosis of EMPD is often delayed due to misdiagnosis which results in delayed treatment. Surgical excision is the mainstay of treatment in patients diagnosed with EMPD. However, cancerous remains are relatively often found due to difficulties with defining the tumor margins during surgery. This results in multiple re-excisions and potential dissemination. We here present two cases of primary EMPD in males and challenges associated with EMPD treatment. Mapping biopsies can provide valuable knowledge and prohibit multiple unsuccessful re-excisions, in patients where the tumor border is difficult to define. A mapping strategy can also contribute to a reduced skin excision, which is crucial in the genital region. Furthermore, we find that PET-CT is an important tool in the disease staging and, hence, selection of adequate treatment strategies. Level of evidence: Level V, therapeutic study.
Pyoderma gangrenosum is a rare skin condition which is difficult to diagnose as it often presents similarly to common complications such as wound infection, tissue ischemia and necrotizing fasciitis. We present a patient who underwent immediate DIEP free flap breast reconstruction and developed post-surgical pyoderma gangrenosum (PSPG), initially with non-characteristic signs and symptoms. Our patient first developed severe headache, fever and erythema surrounding her wound. The classical signs of painful ulcers with undermined bluish borders and surrounding violaceous rash were not seen for nearly 4 weeks. This, in combination with positive wound culture, made for a challenging diagnosis in an elective breast reconstruction patient. Diagnosis of PSPG relies on clinical signs first and is supported by wound swab culture and sensitivity and tissue biopsy for histopathology. The treatment of choice for PSPG is high-dose systemic steroids followed by an oral prednisolone taper over a period of 4–6 weeks. Early diagnosis of PSPG can optimize outcomes and reduce morbidity. We should consider PSPG as a differential diagnosis when post-operative wound infection is suspected, particularly if a non-classical pattern is seen. We could also consider discussion of PSPG as a rare, yet serious complication during the consent process. Level of evidence: Level V, diagnostic study.
The green arrow shows the lateral thigh perforator, superficial to the thigh muscles. SAR, sartorius muscle; RF, rectus femoris muscle; IMS, intermuscular septum
The arrows show the anatomy of the perforators, with green showing the lateral thigh perforator, yellow showing the medial thigh perforator, and blue showing the common vascular pedicle arising from the superficial femoral artery
Two skin paddles marked over the thigh
The white arrow shows the skin paddle for lining, and the black arrow shows the de-epithelialized skin paddle for volume replacement of the cheek
a Defects over the thigh at two different levels; instead of making defect of 10-cm width, two flaps of 5-cm width taken. b The donor thigh closed primarily following the principle of “Z” plasty
The anterolateral thigh (ALT) flap is a workhorse soft tissue flap. Anteromedial thigh (AMT) flap has been used as a savior flap when lateral thigh perforators are absent. ALT and AMT flaps are based on cutaneous perforators arising from the descending branch of the lateral circumflex femoral artery (LCFA), a branch of the profunda femoris artery (PFA). Here, we present a case report of a chimeric ALT and AMT flap where the perforators were directly arising from the superficial femoral artery (SFA). This case highlights an unusual origin of the vascular pedicle in the ALT and AMT flaps and promotes the freestyle perforator flap harvest theory. Level of evidence: Level V, therapeutic study.
Steps in the Dutch translation and cultural adaptation of the LYMPH-Q
Background The LYMPH-Q Upper Extremity module is a new patient-reported outcome measure (PROM) developed to assess patient outcomes of breast cancer-related arm lymphedema (BCRL). Content for the LYMPH-Q Upper Extremity Module was developed from the extensive input of patients and experts in the field of breast surgery and breast cancer-related lymphedema. Rasch Measurement Theory analysis was used to assess psychometric properties. The aim of this study was to perform a Dutch translation and cultural adaptation of the LYMPH-Q Upper Extremity Module. Methods The translation process was performed in accordance with the guidelines of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR).The process included two forward translations, two back translations, and cognitive debriefing interviews with patients with BCRL. Results Comparison of the two forward translations showed that the translations for most items (n = 60; 88.2%) were conceptually consistent between the two translators. Translations of the remaining items were reviewed and discussed until consensus was reached. Three items in the back translation had a different meaning when compared to the original English version and required re-translation. The resultant Dutch version of the LYMPH-Q was tested in a series of cognitive debriefing interviews with seven patients and showed good content validity. Conclusions The translation and cultural adaptation process resulted in a conceptually equivalent Dutch version of the LYMPH-Q Upper Extremity Module. This new PROM can now be used in clinical practice and research settings to evaluate outcomes in patients with BCRL. Level of evidence: Not gradable
Pre-operative marking
Post operative results 6 months
Postoperative outcomes of single stage augmentation mastopexy: Case 1 (augmentation mastopexy PERLE.™ MR340)
Postoperative outcomes of single stage augmentation mastopexy: Case 2 (augmentation mastopexy PERLE.™ SOR-HR-360)
Surgical method for typical augmentation mastopexy (see figure for photo description)
Background Single-stage augmentation mastopexy is popular approach in managing patients with ptosis and volume loss. Despite its growing popularity, there is still on-going debate about performing this procedure as a one-stage operation as opposed to two-stage procedure due to possible increase of significant complications when the single stage approach is used. Our study aims to analyse the safety of the approach by assessing the complication rate and subsequently investigate how these unfavourable outcomes were managed. Methods Retrospective analysis included 85 patients who underwent single stage augmentation mastopexy by a single consultant surgeon. Complications were divided into major (admission < 30 days, non-cosmetic surgery under general anaesthesia (GA) > 30 days) and minor (not requiring admission < 30 days) and those with an unfavourable cosmetic outcome. Results Sixty two percent (N = 53) underwent the single stage mastopexy and augmentation without experiencing any complications. 8% (N = 7) of the patients experienced major complication, requiring operation under GA; 18% (N = 15) experienced minor complications, all managed non-operatively. 14% (N = 12) patients were classified as having an unfavourable cosmetic result. 15% (N = 13) patients required a second operation under GA, and 6% (N = 7) required revision under local anaesthesia. Mean follow-up was 34 months. Higher complication rate was noted to be in higher ASA group (P = 0.04) and demonstrated tendency in higher rate with the use of greater volume implants (P = 0.06). Conclusions Single-stage augmentation mastopexy remains a safe approach in selected patients, with the additional benefits of convenience and cost. Complication rates are comparable to the overall complication rates in 2-stage approach technique. Level of evidence: Level IV, Risk / Prognostic study.
Breakdown of materials used for wound closure
Number of hypersensitivity patients using the varying suture materials
Percentage of patients developing hypersensitivity relative to suture usage
Introduction Hypersensitivity is an unfortunate potential outcome in patients undergoing surgery following traumatic injuries to their hands. In our practice, we noted that certain suture types may increase the risk of the patient developing hypersensitivity. Methodology We conducted a retrospective observational study to investigate if certain suture materials increase the risk of hypersensitivity when used to repair surgical wounds in hand trauma. Patients undergoing hand trauma surgery over a period of five consecutive months were included in the study. Ethics committee approval was obtained from Peninsula Health’s research office. Results 184 patients were included in the study. Hypersensitivity was observed in 30 (16.3%) patients post-operatively. Chromic gut suture was used in 53.3% of the patients who experienced hypersensitivity. Patients who had chromic catgut used in their surgery were 2.82 times more likely to develop hypersensitivity than patients who did not have chromic gut used ( p = 0.0015). If a patient had a nerve repaired and chromic gut sutured used, they were 6.50 times more likely to develop hypersensitivity ( p < 0.0001). Conclusion Surgeons should be aware that this data indicates that suture choice in hand trauma patients can greatly impact the risk of the patient developing hypersensitivity. Level of evidence: Level IV, risk/prognostic study.
Top-cited authors
Rene van der hulst
  • Maastricht University
Rutger M. Schols
  • Maastricht University
Moris Topaz
  • Hillel Yaffe Medical Center
Narin Nard Carmel Neiderman
  • Tel Aviv Sourasky Medical Center
Ming Sen Li
  • Shenzhen Second People's Hospital