Prophylactic Venous Supercharging in Deep Inferior Epigastric Artery Perforator Flap Surgery: A Retrospective Dual-Center Study.

BACKGROUND: Deep inferior epigastric artery perforator (DIEP) flap is nowadays considered the gold standard in breast reconstruction. However, venous congestion is still a leading cause of free flap failure. Despite the conspicuous articles regarding the use of a secondary venous anastomosis, there is a lack in the literature regarding the prophylactic use of a secondary venous route to reduce the incidence of complications during breast reconstruction. METHODS: A double-center retrospective study based on women undergoing DIEP breast reconstruction was conducted, dividing patients into case group (DIEP flaps with double venous anastomosis) and control group (DIEP flaps with single venous anastomosis). Demographic and surgical data and complications were compared and statistically analyzed, and a reconstructive algorithm was proposed to improve the flap insetting. RESULTS: In total, 154 patients were included in the study, divided into case group (74 patients) and control group (80 patients). The median age at the time of surgery was 49.09 years (range: 29-68 years), slightly lower in group 1 when compared with group 2. The mean body mass index (BMI) was 25.52 kg/m2 (range: 21.09-29.37 kg/m2), in particular 25.47 kg/m2 (range: 23.44-28.63 kg/m2) in group 1 and 25.58 kg/m2 (range: 21.09-29.37 kg/m2) in group 2. No statistical differences were found between groups in terms of BMI and smoking and comorbidities history. The average operative times were 272.16 minutes (range: 221-328 minutes) in group 1 and 272.34 minutes (range: 221-327 minutes) in group 2, with no significant difference between groups, as well as ischemia time (44.4 minutes in group 1 [range: 38-56 minutes] and 49.12 minutes in group 2 [range: 41-67 minutes]). Statistical analysis showed a reduction in short-term complications and a statistically significant reduction for take-backs in the two groups. CONCLUSIONS: Our study suggests that venous supercharging of DIEP flap by performing dual venous anastomosis can be routinely and safely done prophylactically, and thus not only after intraoperative assessment of venous congestion, to avoid flap venous congestion and decrease the rates of re-exploration.

The medial sural artery perforator flap for retromolar trigone reconstruction: A multicenter case series.

BACKGROUND: Retromolar trigone (RMT) cancer is a rare malignancy, which develops in a narrow area of the oral cavity. Surgical intervention requires wide excision and appropriate reconstruction usually with a free tissue transfer. Little has been published regarding the ideal microvascular reconstruction, mainly focusing on radial forearm and anterolateral thigh free flap. The medial sural artery perforator flap (MSAP) is not new for head and neck reconstruction but its use for RMT reconstruction has not been previously explored. The purpose of the study is to present a multicentric case series investigating the reliability of MSAP flap for RMT reconstruction. METHODS: The study is designed as a retrospective case series. All patients diagnosed with RMT cancer and undergone surgical resection and immediate reconstruction with a MSAP flap between February 2016 and March 2020 were identified. Patients' demographics and surgical details were collected. Functional results were evaluated using the Head and Neck Module of the European Organization for Research and Treatment of Cancer at 12 months of follow-up. A total of 34 patients with a mean age of 58 years were included in the study. An average defect size of 31.5 cm2 was observed after RMT tumor resection. RESULTS: The MSAP flaps' average dimensions were 11 ± 3.1 cm in length and 4.7 ± 1.6 cm in width with a mean thickness of 1.4 ± 0.8 cm. No flap complications were observed in 28 cases; four patients developed an orocutaneous fistula. One patient needed surgical revision for venous congestion while only one case of flap failure was observed. At 12 months of follow-up, 87% of the patient cohort had normal, understandable speech. No patient experienced complete loss of swallowing. Results of the H&N35 module showed a significative postoperative improvement in mouth soreness, mouth opening and social (p < .05*). No patient complained difficulty in motility at the donor site. CONCLUSIONS: The MSAP flap appears to be appropriate for RMT reconstruction and could be considered the workhorse for small to medium size defect of RTM region. It has a long pedicle of matching caliber and provides adequate tissue volume with minimal donor site morbidity.

Treatment of a Case of Toe Hair-Thread Tourniquet Syndrome With Hirasè Technique.

ABSTRACT: Hair-thread tourniquet syndrome (HTTS) is an uncommon condition that affects mostly babies, usually a few months old. It happens when a strand of hair or cloth fiber encircles an appendage causing a condition of total or subtotal ischemia (West J Med 1976;125:335-336). This condition has been described several times in the recent literature. Appendages involved include toes, fingers, genitalia, uvula, and neck (N Engl J Med 1965;273:866-867). The mechanism of injury usually involves the fiber cutting the skin deeply through soft tissues, veins, and arteries. As HTTS occurs in small babies and hidden parts of the body, sometimes this event can be very difficult to detect and irritability may be the only symptom. The treatment consists of releasing the circumferential constriction and restoring the arteriovenous flow also with microsurgical techniques if vessel interruption is present. Unfortunately, the fiber or the thread often penetrates so deep that, once an HTTS is recognized, it may be very challenging to identify and trim. The authors present a case of HTTS of the second toe of the right foot in a 2-month-old baby treated with surgical release and Hirasè technique. After the thread was successfully cut and removed, the forefoot was covered with aluminum foil, and a bag with ice was immediately put all around. After 3 days, we observed a complete survival of the toe without any sign of necrosis. Later control at 6 months showed complete restitutio ad integrum of the affected digit with a normal perfusion and absence of any onychopathy. Hirasè technique represents a simple, safe, and low-cost option of treatment for HTTS.

Dual-Plane Retro-pectoral Versus Pre-pectoral DTI Breast Reconstruction: An Italian Multicenter Experience.

BACKGROUND: The use of conservative mastectomies has risen significantly during the last few years. The reconstructive choice of direct-to-implant reconstruction has become more practicable with modern mastectomy techniques. The initial trend in Italian centers was to use dual-plane hybrid reconstruction. However, a high level of complications has been registered. From 2015 onward, in our centers, a pre-pectoral approach has been adopted. The authors sought to describe the Italian trend to gradually discard the sub-pectoral technique with lower lateral pole coverage of the prosthesis using ADMs comparing it with the pre-pectoral approach with ADMs, without any muscle dissection, in terms of complication rates. MATERIALS AND METHODS: A multicenter retrospective clinical study was performed from January 2010 to June 2018. The enrolled patients were divided into two groups: Cases with an ADM-only coverage pre-pectoral reconstruction made up the first group (Group 1). Those with the retro-pectoral muscular position + ADM implant coverage comprised the second one (Group 2). Complications such as seroma, hematoma, wound dehiscence, surgical site infection, reconstruction failure, animation deformity and capsular contracture were recorded. RESULTS: We performed 716 direct-to-implant reconstructions: 509 were partially sub-pectoral and 207 were pre-pectoral. Minimum follow-up was 1 year. Incidence of complications was higher in dual-plane reconstructions. There were statistical significant differences in the rates of seroma and hematoma. CONCLUSION: Using the pre-pectoral approach, the authors have experienced favorable aesthetics and superior clinical and functional outcomes. Retro-pectoral muscular ADM implant coverage has to be considered only in specific complicated second-stage surgeries. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Anatomical Study and Clinical Application of Ulnar Artery Proximal Perforator Flaps.

BACKGROUND: The purpose of this study is to document the vascular anatomy of the free ulnar artery proximal perforator flap and to highlight the possibility of harvesting it based on the perforators originating from the posterior ulnar recurrent artery (PURA), to spare both the main axis of vascular supply to the hand. In addition, we present a case series of five patients treated for soft tissue defects of the hand with free ulnar artery proximal perforator flaps. METHODS: Ten specimens of anterior forearm were dissected in this study to register number and characteristics of ulnar perforators. The dissection was focused on the perforators originating from the larger branch of the ulnar artery, the PURA, at the proximal third of anteromedial forearm. The anatomical dissections were evaluated in relationship with clinical dissections performed during flap harvesting in five patients. RESULTS: In three of the specimens dissected, the proximal perforator originated from the PURA, and in the other seven specimens, it originated directly from the ulnar artery. Five cases of reconstruction of the hand were performed with success using the free ulnar artery proximal perforator flap, and in two cases, the perforator from the PURA was found and it was possible to raise the flap based on this branch of the ulnar artery. CONCLUSION: The free ulnar artery proximal perforator flap can be harvested in two different manners for the same skin island of the forearm. When possible, harvesting it form the PURA allows lengthening of the pedicle. In our experience, this flap presents many advantages such as thinness and hairlessness; it allows preservation of the ulnar neurovascular bundle with an acceptable donor site morbidity. LEVEL OF EVIDENCE: IV.

Medial femoral condyle free flap in combination with paramedian forehead flap for total/subtotal nasal reconstruction: Level of evidence: IV (therapeutic studies): Level of evidence: IV (therapeutic studies).

BACKGROUND: The nose is a functionally complex organ with also a critical role in aesthetics. For reconstruction of full thickness nasal defects, multiple stages are needed and there is risk for resorption resulting in residual deformity. The aim of this report was to develop and evaluate a new method for full thickness total/subtotal nose reconstruction using the medial femoral condyle free flap (MFCFF) in combination with a paramedian forehead flap. METHODS: Between November 2015 and January 2018, eight patients (four males, four females) mean age 52 years (range 40-73 years) undergoing a total/subtotal nasal excision and subsequential reconstruction with MFCFF plus paramedian forehead flap were enrolled. Six cases were squamous cell carcinomas while two were basal cell carcinomas. The MFCFF was stabilized, with the periosteum as inner layer, with plates and a paramedian forehead flap was used as external skin coverage. All patients were evaluated for with postoperative nasal endoscopy and CT scan. A postoperative questionnaire was given 6 months after surgery. RESULTS: The mean MFCFF size was 2-3.8 cm × 2.25-2.5 cm with a mean pedicle length of 6.3 cm (range 4.1-9.4 cm). The postoperative period was uneventful. The mean follow-up was 16 months, no bone displacement or resorption was observed at the CT scan, no evidence of nasal stenosis occurred. All patients had a satisfying aesthetic evaluation and a good subjective nasal function. CONCLUSIONS: In this series, the MFCFF in combination with the paramedian forehead flap appeared to provide a valid subtotal nose reconstruction, allowing for the recreation of all the three nasal layers and maintaining the nose projection and airway patency in the long term.

Comparisons of fascio-cutaneous anterolateral thigh and sandwich fascial ALT free flap in the distal extremity reconstruction.

INTRODUCTION: The anterolateral thigh (ALT) flap is considered a workhorse reconstructive option; however, it is encumbered by its bulkiness that can result in poor final outcome and need for revision surgery. The aim of the present study was to compare the standard cutaneous ALT free flap and sandwich fascial ALT (SALT) free flap, raised harvesting between the Scarpa's fascia and the crural fascia, for distal extremity soft tissue reconstruction, including pre- intra- and post-operative considerations and outcomes. PATIENTS AND METHODS: A retrospective review of medical records from 2013 to 2018 of 24 patients who underwent distal extremity reconstruction with standard fascio-cutaneous ALT flap (13 patients) and SALT flap (11 patients) was performed. The mean defect dimensions were 12 × 6.5 cm in group 1 and 12 × 6 in group 2. Surgical outcomes and quality of life were assessed (through the upper extremity functional scale and the lower extremity functional scale questionnaires. RESULTS: The mean flap dimensions were 13.1 × 7.1 in group 1 and 14.1 × 7.8 in group 2, the overall flap success rate was 100% (one microvascular venous thrombosis occurred in group 1), no statistically significant difference was recorded regarding microvascular thrombosis (one patient in group p = .369) and infections (one patient in group 1, p = .36) while a statistically significant difference was presence regarding the number of secondary/debulking procedures (6 patients vs. 0) (p = .0076) and the quality of life perception showed an overall better perception in group 2 with statistical significant difference (p = .03). CONCLUSION: The SALT flap represents a valid option, as showed through our preliminary data, when a thin and robust reconstruction is required when dealing with distal extremities soft tissue reconstruction.

Free Bipedicled Radial Forearm and Posterior Interosseous Artery Perforator Flap Phalloplasty.

INTRODUCTION: The free radial forearm (FRFA) flap is universally still considered as the gold standard technique in penile reconstruction. Typically, a considerably large flap is required, often involving almost the entire circumference of the forearm. Partial necrosis may occur at the distal-most (dorsoradial) part of the flap as a result of insufficient perfusion. AIM: To describe a new technique using the posterior interosseous artery (PIOA) to supercharge FRFA phalloplasty. METHODS: In a 12-month period, all patients having FRFA flap phalloplasty were enrolled. Perioperative, after complete flap dissection, an indocyanine green perfusion scan was performed. In case of insufficient perfusion at the distalmost part of the flap, a supramicrosurgical anastomosis was performed between the FRFA pedicle and the PIOA (artery only). MAIN OUTCOME MEASURES: Studied outcomes included the rate of marginal necrosis, surgical time, postoperative posterior interosseous nerve damage and urethral complications (fistula, stenosis or necrosis). RESULTS: A total of 27 FRFA flap phalloplasties was performed. Anastomosis of the PIOA was needed in 15 cases. No marginal necrosis was observed in these cases. There were no cases of postoperative posterior interosseous nerve damage. There were no significant differences in urethral complications (fistula, stenosis or necrosis) between the 2 groups. CLINICAL IMPLICATIONS: In selected cases where insufficient perfusion of the dorsoradial part of the flap is present, patients may benefit from arterial supercharging to prevent postoperative marginal necrosis. STRENGTH & LIMITATIONS: Strengths include a single surgeon, thus lending continuity of skill and technique, a consecutive series, and 100% short-term follow-up. Limitations include single institution series and a limited number of patients. CONCLUSION: Arterial supercharging is effective in improving perfusion of large FRFA flaps used in phalloplasty when dorsoradial hypoperfusion is detected on an indocyanine green perfusion scan. It is a technically challenging addition to the standard technique because of the small size of the vessels, the close relationship between the PIOA and the posterior interosseous nerve, and the vulnerability of the newly constructed intra-flap anastomosis. De Wolf E, Claes K, Sommeling CE, et al. Free Bipedicled Radial Forearm and Posterior Interosseous Artery Perforator Flap Phalloplasty. J Sex Med 2019;16:1111-1117.

Reconstruction of complex soft tissue defects including tendons with anterolateral thigh flap extended to fascia lata: Long term recovery and functional outcomes.

BACKGROUND: We evaluated composite anterolateral thigh (ALT) flaps including vascularized fascia lata (FL), for stable soft tissue coverage and tendons restoration at various joint levels in a one-stage procedure. METHODS: We performed a retrospective investigation including 21 "functional" ALT flaps between November 2006 and December 2016. In all patients included, FL was shaped to anatomical reproduce a tendon structure. Functional analysis included range of motion and force assessment. Functional scores were established according to Chen classification, DASH, and LEFS score. Defects resulted from tumor excision, trauma, burn, or infection-debridement and were distributed in four main anatomical districts: knee (seven cases), ankle (six cases), forearm-elbow (four cases), and hand-wrist level (three cases). RESULTS: Nineteen flaps were raised as free flaps, while two as distally-based propeller flaps. Average follow-up was 38 months. Major complication requiring the harvest of a second flap was seen in two patients, whereas three flaps presented superficial necrosis and was treated in an outpatient regimen. We observed 81% of total ROM recovery compared to contralateral sides with 89% recovered articular stability. Best articulation outcomes were present in elbow reconstruction, while ankle reconstructions showed less articularity. Hospital stay was significantly reduced in hand and wrist functional reconstruction when compared with reconstruction at the ankle level (P < 0.05). CONCLUSION: The ALT flap extended to vascularized FL provides a particularly effective and resistant tissue that can be folded to reconstruct and support tendinous structures. This can restore functional and structural integrity after complex defects in a single stage procedure.

Induced membrane technique for the treatment of severe acute tibial bone loss: preliminary experience at medium-term follow-up.

PURPOSE: Management of acute open tibial fractures with critical bone defect remains a challenge in trauma surgery. Few and heterogeneous cases have been reported about the treatment with the induced membrane technique. METHODS: We prospectively evaluated three patients treated with the induced membrane technique for acute Gustilo IIIB tibial fractures with critical bone defect. Success treatment was defined by bone union with patient pain free. Clinical and radiological evaluations were performed regularly until healing, then annually and with a minimum follow-up of five years. RESULTS: In all patients but one, a success was recorded, respectively, at four and six months. These two patients were pain free until the final follow-up, and no graft resorption or secondary complications related to the index surgery were observed. The third case was managed successfully with a bone transport technique. CONCLUSION: The induced membrane technique is an alternative good option for the treatment of these severe lesions.

Thumb Reconstruction With Thin Proximal Ulnar Perforator Free Flap.

Soft tissue defects of the thumb with exposure of tendons, periosteum, or neurovascular bundles require a complex reconstruction aimed at restoring both skin coverage and the essential function of pinching and manipulation. When large defects are involved, a free tissue transfer is indicated. The proximal ulnar perforator flap represents an interesting solution without the drawbacks of other more widespread free flaps. This report describes the case of a patient with a squamous cell carcinoma of the thumb that required circumferential resection of the soft tissue of the distal phalanx and the interphalangeal joint. The exposed structures were covered with pliable and texture-matching skin harvested from the proximal volar forearm and based on the proximal ulnar perforator. After 12-month follow-up, the patient was satisfied with the aesthetic outcome. Donor-site morbidity was minimal and no functional impairment in daily-life activities was reported. Even though a skilled microsurgical technique is required for the dissection of the perforator, its constant vascular anatomy and the low risk of damage to the main neurovascular bundle should make this flap reliable for the majority of hand surgeons.

Role of Negative Pressure Therapy as Damage Control in Soft Tissue Reconstruction for Open Tibial Fractures.

The concept of damage control orthopaedics (DCO) is a strategy that focuses on managing orthopaedic injuries in polytrauma patients who are in an unstable physiological state. The concept of DCO is an extension of damage control surgery or damage limitation surgery (DCS/DLS). Recently, it has become clear that certain patients, following extensive soft tissue trauma, could benefit from the idea of DCS. In the management of severe lower extremity trauma with exposed fracture sites, aggressive early wound excision debridement, early internal fixation, and vascularized wound coverage within a few days after trauma were proposed. A negative-pressure dressing can be easily and rapidly applied to obtain a temporary closure between surgical stages. While negative pressure wound therapy (NPWT) has clear indications in the management of chronic wounds, its applications in the acute setting in victims of polytrauma are uneven. We conducted a review of the current clinical literature to evaluate the role of NPWT in this field, which points out that the negative pressure, applied immediately after the first debridement, seems to be an optimal bridge to the final reconstruction up to 7 days.

Efficacy of anti-adhesion gel of carboxymethylcellulose with polyethylene oxide on peripheral nerve: Experimental results on a mouse model.

INTRODUCTION: Perineural scar formation is responsible for pain and loss of function after surgical procedures. Neurolysis and application of anti-adhesion gels are required to restore a gliding surface. We tested a carboxymethylcellulose (CMC) and polyethylene oxide (PEO) gel on mouse sciatic nerve to describe its safety and efficacy. METHODS: Adult mice underwent a surgical procedure in which we burned the muscular bed of the sciatic nerve bilaterally (Burned group) and applied anti-adhesion gel to 1 of the nerves (Burned+gel group). After 3 weeks, we studied scar tissue by biomechanical and histological evaluation. RESULTS: Both histological and biomechanical analysis showed that the gel reduced perineural scarring. The difference between the Burned and Burned+gel groups was statistically significant. CONCLUSIONS: CMC-PEO gel can reduce perineural scar tissue. In histological section, scar tissue was present in both groups, but in the Burned+gel group a gliding surface was identified between scar and nerve.

Free gracilis flap for chest wall reconstruction in male patient with Poland syndrome after implant failure.

Poland's syndrome (PS) is a congenital monolateral deformity that may involve breast, chest wall, and upper limb with different degrees of clinical expressions. In some cases, the problem is mainly cosmetic, and the reconstruction should be performed to achieve minimal scarring and donor site morbidity. The authors describe a case report of a male patient with PS who developed a severe capsular contraction after 25 years implant reconstruction, who was treated after explantation using free gracilis flap (FGF). In this patient, only the pectoralis major muscle was missing. An FGF was performed to reconstruct the anterior axillary fold and the soft tissue defect. There was no flap loss, the patient had a clearly improved appearance of the chest wall, and the pain syndrome was solved. In this case report, we demonstrate our experience with the use of an FGF for chest wall reconstruction in male patients with PS after prosthesis explantation.

Evaluation of lymphangiogenesis in acellular dermal matrix.

INTRODUCTION: Much attention has been directed towards understanding the phenomena of angiogenesis and lymphangiogenesis in wound healing. Thanks to the manifold dermal substitute available nowadays, wound treatment has improved greatly. Many studies have been published about angiogenesis and cell invasion in INTEGRA(®). On the other hand, the development of the lymphatic network in acellular dermal matrix (ADM) is a more obscure matter. In this article, we aim to characterize the different phases of host cell invasion in ADM. Special attention was given to lymphangiogenic aspects. MATERIALS AND METHODS: Among 57 rats selected to analyse the role of ADM in lymphangiogenesis, we created four groups. We performed an excision procedure on both thighs of these rats: On the left one we did not perform any action except repairing the borders of the wound; while on the right one we used INTEGRA(®) implant. The excision biopsy was performed at four different times: First group after 7 days, second after 14 days, third after 21 days and fourth after 28 days. For our microscopic evaluation, we used the classical staining technique of haematoxylin and eosin and a semi-quantitative method in order to evaluate cellularity counts. To assess angiogenesis and lymphangiogenesis development we employed PROX-1 Ab and CD31/PECAM for immunohistochemical analysis. RESULTS: We found remarkable wound contraction in defects that healed by secondary intention while minor wound contraction was observed in defects treated with ADM. At day 7, optical microscopy revealed a more plentiful cellularity in the granulation tissue compared with the dermal regeneration matrix. The immunohistochemical process highlighted vascular and lymphatic cells in both groups. After 14 days a high grade of fibrosis was noticeable in the non-treated group. At day 21, both lymphatic and vascular endothelial cells were better developed in the group with a dermal matrix application. At day 28, lymphatic endothelial cells had organized themselves, engineering the pseudocylindrical structure better disposed in the ADM group than in the control group, and the lymphatic cells were detectable inside the vessels' lumen in this group. CONCLUSION: This study has made it possible to demonstrate the absolute importance of an ADM in proper wound healing and has shown better definition of both the qualitative and quantitative aspects of lymphangiogenesis compared to the second intention healing. A major grade of organization of the extracellular matrix and a minor grade of fibrosclerosis in ADM allowed a well-structured morphologic and functional development of the endothelial and lymphatic vascular structures. This study hopes to represent a clinical basis for a wider use of ADM in lesions where lymphatic complications are common.

Synthetic Simulators for Microsurgery Training: A Systematic Review.

Background: Microsurgery has a steep learning curve. Synthetic simulators have proven to be useful training tools for the initial learning stages, as well as being ethically sound, viable, safe, and cost-effective. The objective of this review was to determine the quality, effectiveness, and validity of these simulators as well as to assess their ability to evaluate microsurgical skills. Methods: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. We searched databases (Web of Science, Scopus, and PubMed) to identify original articles describing synthetic training models for microsurgery. Three reviewers evaluated articles for inclusion following predefined selection criteria. Data were extracted from full-texts of included articles. Results: Thirty-nine studies met the inclusion criteria. A total of 38 different devices have been recorded. Microsurgical training devices offer a low-cost, fast, and consistent method to concretely quantify and assess the initial microsurgical skills of trainees using standardized exercises that can be scored by the examiner. According to the authors, the outcomes were satisfactory, with a tangible improvement in microsurgical abilities, despite the lack of a common comparison scale. Conclusions: Thanks to their availability, cost, and effectiveness, synthetic models are the recommended option to train basic, intermediate and advanced procedures before executing them on in vivo models.

The Nasolabial Flap in Nose Reconstruction: Tips and Tricks Towards Expanded Usage and Optimized Cosmesis.

Background: The nose is the most critical aesthetic element of the face and even the smallest loss of substance can create a deformity of concern. The forehead flap has been the workhorse for nasal reconstruction for centuries but requires multiple surgical steps and leads to prominent donor-site scarring. The nasolabial flap allows a single-step reconstruction with a donor-site scar concealed in the nasolabial crease but is conventionally designated for small defects involving the ala. Methods: The authors analysed all surgical records of patients undergone nasal reconstruction by nasolabial flap between May 2005 and December 2021 by the Plastic Surgery Unit of a major regional hospital in Lombardy. Defects were classified according to Burget's subunit principle and the 3-component approach. Reconstruction features and finesses were reported and analysed. Results: In the 16-year period under analysis, 378 patients with nasal defects of various aetiologies received nose reconstruction by nasolabial flap. All nasal subunits were involved; 20 patients had multisubunit defects. In all the cases the reconstruction with nasolabial flap, alone or combined with other solutions, was intended to be one-stage. Conclusions: The authors present several tips and tricks about preoperative planning and design, choice of the pedicle, flap harvesting and sculpting with preservation/restoration of grooves and convexities, conjoining multiple flaps, downsizing extensive defects by a rhinoplasty-like framework reduction. With a careful planning and refined technique, the range of application of the nasolabial flap can include defects involving any nasal subunit and larger and/or multisubunit defects.

Historique: Le nez est l'élément esthétique primordial du visage, et même la plus petite perte de substance peut créer une malformation préoccupante. Le lambeau du front est utilisé pour la reconstruction nasale depuis des siècles, mais il est associé à de multiples étapes chirurgicales et entraîne des cicatrices importantes au foyer du donneur. Le lambeau nasolabial (ou nasogénien) favorise une reconstruction en une seule étape dissimulée dans le pli nasolabial, mais est habituellement conçu pour corriger de petites malformations de l'aile du nez. Méthodologie: Les auteurs ont analysé tous les dossiers chirurgicaux des patients qui avaient subi une reconstruction nasale par lambeau nasolabial entre mai 2005 et décembre 2021 à l'unité de chirurgie plastique d'un important hôpital régional de la Lombardie. Ils ont classé les malformations d'après le principe des sous-unités de Burget et l'approche en trois éléments. Ils ont également rendu compte des caractéristiques et des subtilités de la reconstruction et les ont analysées. Résultats: Au cours des 16 années analysées, 378 patients ayant des malformations nasales de diverses étiologies ont subi une reconstruction nasale par lambeau nasolabial. Toutes les sous-unités nasales étaient touchées. Ainsi, 20 patients présentaient de multiples malformations sous-unitaires. Dans tous les cas, la reconstruction à l'aide d'un lambeau nasolabial, seule ou combinée à d'autres solutions, était prévue en une étape. Conclusions: Les auteurs proposent plusieurs trucs et conseils au sujet de la planification et de la méthodologie préopératoires, du choix du pédicule, du prélèvement du lambeau et de la sculpture pour préserver ou restaurer les plis et les convexités, de la combinaison de multiples lambeaux, afin d'atténuer les malformations importantes par une réduction selon une structure similaire à celle de la rhinoplastie. Grâce à une planification attentive et une technique raffinée, l'éventail d'applications du lambeau nasolabial peut inclure les malformations touchant toutes les sous-unités nasales et les malformations sous-unitaires plus importantes ou multiples.

Surgical management of advanced sinonasal cancer: a 10-year mono-institutional experience.

Objective: Endoscopic endonasal surgery is effective in the treatment of sinonasal cancers. However, in cases of well-differentiated locally advanced neoplasms as well as recurrences, the most appropriate treatment is debated. The purpose of this study is to report a mono-institutional experience on craniofacial surgery performed in a tertiary-care referral centre. Methods: This was a retrospective analysis of 90 patients treated with transcranial and/or transfacial resection for sinonasal cancer between 2010 and 2020. Outcome measures included overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and recurrence-free survival (RFS). Results: The 5-year OS, DSS and DFS were 48.2%, 60.6% and 28.7%, respectively. Factors correlated with prognosis were pT-classification (p = 0.002), histotype (p = 0.012) and dural involvement (p = 0.004). Independent prognostic factors were orbital apex infiltration (p = 0.03), age (p = 0.002) and adjuvant therapy (p = 0.03). Conclusions: When endoscopic endonasal surgery is contraindicated and chemoradiotherapy is not appropriate, craniofacial and transfacial approaches still represent an option to consider, despite the non-negligible morbidity.

Diastasis Recti with Concomitant Ventral Hernia Repair: An Initial Experience in the United Arab Emirates Population.

Introduction: Diastasis recti (DR) is characterized by an abnormal separation between the rectus abdominis muscles. Traditional repair includes only plication; however, complications may arise in the presence of concurrent ventral hernias (VH). This study aims to evaluate the safety and feasibility of diastasis repair in a United Arab Emirates (UAE) population. Methods and Procedures: This retrospective cohort study was conducted with IRB approval. All patients who underwent a DR repair (DRR) with concomitant ventral hernia repair between October 2022 and February 2024 were included. Results: A total of 20 patients were included in the study. The cohort was 80% female, with a mean overall age of 44.05 years. The mean body mass index was 27.4 kg/m2. All patients (100%) presented with DR associated with an abdominal wall defect; 17 patients (85%) with umbilical hernia, 2 patients (10%) with umbilical and incisional hernia, and 1 patient (5%) with umbilical with epigastric hernia. A total of 12 (60%) patients underwent laparoscopic DRR concomitant with VH repair, 5 (25%) patients underwent open DRR with VH repair and abdominoplasty, and 1 patient (5%) underwent DRR with VH repair and liposuction. All cases were successful without complications or conversions. Complications within 30 days included only seromas in 6 patients (30%), one requiring drainage. Conclusion: Our initial experience suggests that DR repair with concomitant VH repair and/or abdominoplasty is feasible and safe in the UAE population. Our experience demonstrated surgical outcomes compared to other regions in the world.