Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases.

PURPOSE: The aim of this report is to compare free perforator flaps and propeller flaps in the coverage of lower limb soft tissue defects. PATIENTS AND METHODS: 179 patients (age between 5 and 92 years old), underwent soft tissue reconstruction of the lower limb between January 2009 and January 2015, either by free flap or propeller flap. The two groups were retrospectively evaluated in order to assess the outcome, complications and potential risk factors. Correlations between risk factors and presence/absence of failure or complications have been evaluated with descriptive statistical analysis and a set of logistic regression models. Finally, an economic analysis was conducted to evaluate the different tecniques. RESULTS: In a simple descriptive statistical analysis, the overall failure rate is 6% for free flaps and 3.7% for propeller flaps; the complication rates are 14% vs 21.5% and it increases as dimension increases. The logistic models relating failure and complications with potential risk factors do not show significant differences, whereas the economic analysis show that the average expense of free flaps is 5077.5€ per patient, 1595.6€ per patient for propeller flaps. CONCLUSIONS: Our results do not demonstrate significant differences between the two groups about correlation of risk factors or flap size with complication or failure. The surgical option choice should be taken only after accurate evaluation of the soft tissue surrounding the defect. Propeller flaps should be preferred in case of small/medium size defects in otherwise healthy extremities. Free perforator flaps should be the choice in large defects due to trauma or vascular diseases. The economic analysis suggests that propeller flap should be considered when possible.

Perforator-based Reverse Radial Teno-Adipo-Fascial Flap: Surgical Technique and Case-report for the Functional Reconstruction of the Dorsum of the Hand.

BACKGROUND: Dorsal complex cutaneotendinous lesions of the hand represent a reconstructive challenge. The use of composite microvascular flaps and vascularized tendon grafts represent the gold-standard. The radial anti-brachial region can still represent an excellent donor site, to the detriment of the possible sacrifice of the radial artery. The reverse radial anti-brachial flap can be either perforator-based, thus saving the radial artery or raised as an adipo-fascial flap, to spare the skin. PATIENTS AND METHODS: A case of post-traumatic highly contaminated dorsal cutaneotendinous defect of the second ray of the hand was reported. An original surgical reconstructive technique with a Revers Radial Teno-Adipo-Fascial Flap (RRTAFF) plus vascularized Palmaris Longus was described, preserving the radial artery. A simple partial thickness skin graft was performed a second time to complete dorsal cutaneous coverage. A subsequent infection was managed by trusting the complete vascularization of the tissues used for the reconstruction. RESULTS: The hand healed well with containment of the infection. The dorsal healed skin appeared elastic and pliable enough. Passive and active motion of interphalangeal and metacarpofalangeal joints were very satisfying. The donor site was well healed, with almost no morbidity. CONCLUSIONS: This reconstructive strategy provides a quick and straightforward single-stage option for the reconstruction of complex cutaneotendinous defects of the dorsum of the hand. Such a reconstruction, with a completely vascularized procedure, is particularly indicated in cases of high contamination or infection of the recipient site.

Refinements in Tear Trough Deformity Correction: Intraoral Release of Tear Trough Ligaments: Anatomical Consideration and Clinical Approach.

BACKGROUND: Correction of tear trough (TT) deformity is a crucial aspect of facial rejuvenation. Because the anatomical origins of TT deformity lie in the TT ligaments, which firmly attach the dermis to the periosteum, the release of TT ligaments should be considered when performing an etiological correction. The aim of this paper is to propose an alternative method for TT deformity correction, comprising use of filler together with the release of TT ligaments. This technique was compared to the procedure of only percutaneous filler. METHODS: From January 2014 to December 2015, 10 patients were enrolled in the study for recurrence of TT deformity. All the patients underwent TT ligament release and filler injections; all had been previously treated with percutaneous hyaluronic acid injection without ligament release. Under local anesthesia, the TT ligaments were detached using a blunt cannula introduced directly in the supra periosteal plane through an intraoral access. Once the ligament was released, the TT depression was evenly recontoured with a very small amount of filler. The clinical data, digital images, evaluations of outcomes, including patient satisfaction rates were collected and compared. RESULTS: Adding the procedure of TT ligament release to filler injections showed satisfactory results, avoiding an unnatural puffy appearance. The comparison between the two different methods showed improved outcomes and increased patient satisfaction with minor patient discomfort among those who underwent TT ligament release. CONCLUSION: Because TT ligaments are among the etiologic factors of TT deformity, they have a strong impact on procedures that are designed to improve TT deformity; therefore, TT ligament release should always be considered to obtain satisfactory, natural results. LEVEL OF EVIDENCE IV: 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 .