Experimental investigation of tension-reducing effectiveness of keystone perforator island flap.

Background and aim: Nowadays, the reconstruction of large and complex defects with keystone perforator island flaps (KPIF) has gained popularity in plastic and reconstructive surgery. The keystone perforator island flap was described as a curvilinear shaped trapezoidal design flap, with two V-Y advancement flaps end-to-side. It is a multiperforator advancement flap, based on multiple fasciocutaneous or musculocutaneous perforators, described by Behan in 2003. These flaps have a simple harvest technique, an easy-to-implement design, and they are time and cost-saving. Their blood supply lends a versatile and robust character, with less complications. Nonetheless, their biomechanical properties and effectiveness are unclear, the wound-closure tension-reducing effect is not well documented in existing literature. The present study aims to investigate the wound closure tension-reducing effect of type I, type IIA, type Sidney Melanoma Unit I (SMU) and type SMU II KPIFs. The main purpose of this study was to clarify the tension-reducing effect of the KPIF technique, which can contribute to the understanding of the biomechanical benefits of the KPIF. Methods: This is an experimental, in vivo study, based on twelve white race porcine models (PIC-FII-377), as their anatomy and wound healing process is very similar to that of humans. In this study, 42 wounds that could not be closed by primary wound closure, known as 'unclosable' elliptical defects, were created in six different anatomical regions. The criteria used for not achieving primary wound closure were the breaking of 0 nylon suture or the edges of the wound. Each defect was closed with different types of keystone perforator island flap: type I, type IIA, type Sydney Melanoma Unit I and type Sydney Melanoma Unit II. Keystone perforator island flaps were used in 42 cases. Intraoperative tissue tension was measured by an AXIS FB50, 50 N force gauge tensiometer. In all cases a wide elliptical excision was performed for the primary defect. Before reconstruction, tissue tension was measured across the widest point of the elliptical primary defect. Skin incision was performed for the first flap, without division of deep fascia. After preparing first flap, tension was measured at the widest point of the wound. Furthermore, deep fascia for the second flap was divided, tissue tension across the widest point of the primary defect was measured. Finally, tension was measurement across the widest point of the donor-site after closure of the defect-side flap and V-Y closure of either end of keystone perforator island flap. Results: In this study were included 12 porcine model (PIC-FII-377). A number of 42 keystone perforator island flaps were performed in this study, in six different anatomical regions, ranging between 3.3 x 12 cm and 16 x 30 cm. All elliptical defects were unclosable, with varying sizes ranging between 2 x 4 cm and 8 x 20 cm. The mean tension that was required to close all wounds with primary closure initially was 24.51 N 10.73 N. After using a type I KPIF a tension decrease of -7.04 N ± 4.93 N was seen, in the case of type IIA KPIF the tension decreased to -12.43 N± 5.63 N. Furthermore, after reconstruction with type SMU I KPIF the tension decreased to -7.38N ± 5.21N. After using a type SMU II KPIF a tension decrease of -10.52 N± 5.74 N was seen. Conclusions: The main purpose of this study was to clarify the tension-reducing effect of the KPIF technique, which can contribute to the understanding of the biomechanical benefits of the KPIF. The outcomes of the present study suggest that type I, type IIA, type SMU I, and SMU II of keystone perforator island flaps have a significant tension-reducing effects, especially the technique that involves the division of the deep fascia. The results of this experimental research thoroughly explain the benefits of these flaps. The effectiveness of the flap and doubts on biomechanical properties have not been answered so far. It will encourage more plastic surgeons to use the flap, especially given its proven benefits.

ESPRAS Survey: National and European Societies for Plastic Surgeons.

BACKGROUND: The European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) comprises 40 national societies across Europe. In addition to ESPRAS, there are 8 different European Plastic Surgery societies representing Plastic Surgeons in Europe. The 4th European Leadership Forum (ELF) of ESPRAS, held under the motto "Stronger together in Europe" in Munich in 2023, aimed to collect and disseminate information regarding the national member societies of ESPRAS and European societies for Plastic Surgeons. The purpose was to identify synergies and redundancies and promote improved cooperation and exchange to enhance coordinated decision-making at the European level. MATERIAL AND METHODS: An online survey was conducted regarding the organisational structures, objectives and challenges of national and European societies for Plastic Surgeons in Europe. This survey was distributed to official representatives (Presidents, Vice Presidents and General Secretaries) and delegates of national and European societies at the ELF meeting. Missing information was completed using data obtained from the official websites of the respective European societies. Preliminary results were discussed during the 4th ELF meeting in Munich in March 2023. RESULTS: The ESPRAS survey included 22 national and 9 European Plastic Surgery societies representing more than 7000 Plastic Surgeons in Europe. Most national societies consist of less than 500 full members (median 182 members (interquartile range (IQR) 54-400); n=22). European societies, which covered the full spectrum or subspecialities, differed in membership types and congress cycles, with some requiring applications by individuals and others including national societies. The main purposes of the societies include research, representation against other disciplines, specialisation and education as well as more individual goals like patient care and policy regulation. CONCLUSION: This ESPRAS survey offers key insights into the structures, requirements and challenges of national and European societies for Plastic Surgeons, highlighting the relevance of ongoing close exchange between the societies to foster professional advancement and reduce redundancies. Future efforts of the ELF will continue to further explore strategies for enhancing collaboration and harmonisation within the European Plastic Surgery landscape.

Metal-insulator transition in composition-tuned nickel oxide films.

Thin films of the solid solution Nd1-xLaxNiO3are grown in order to study the expected 0 K phase transitions at a specific composition. We experimentally map out the structural, electronic and magnetic properties as a function ofxand a discontinuous, possibly first order, insulator-metal transition is observed at low temperature whenx= 0.2. Raman spectroscopy and scanning transmission electron microscopy show that this is not associated with a correspondingly discontinuous global structural change. On the other hand, results from density functional theory (DFT) and combined DFT and dynamical mean field theory calculations produce a 0 K first order transition at around this composition. We further estimate the temperature-dependence of the transition from thermodynamic considerations and find that a discontinuous insulator-metal transition can be reproduced theoretically and implies a narrow insulator-metal phase coexistence withx. Finally, muon spin rotation (µSR) measurements suggest that there are non-static magnetic moments in the system that may be understood in the context of the first order nature of the 0 K transition and its associated phase coexistence regime.

Minimising donor-site morbidity following limbs' injuries with keystone perforator island flap reconstruction.

Plastic surgeons strive to choose better techniques to reconstruct the defects of the limbs, minimising the wound healing problems, improving the aesthetic and functional outcome with less complications. This study refers to the use of keystone perforator island flap (KPIF) in limbs' reconstruction, their harvesting technique to minimise donor-site morbidity, maximise the functional and cosmetic outcome, and will point on the most important indications and advantages. Between January 2014 and June 2020, a number of 28 cases were treated in our department, with simple or complex defects of the limbs. The database included patients' demographics, comorbidities, aetiology, characteristics of the flap, surgical factors, follow-up period and flap outcomes. We performed 28 KPIFs, 14 of type I, 12 of type IIA, 1 of type III, and 1 of type IV, with an average size of 69 cm2 (ranged from 1.25 cm2 to 318 cm2 ). Trauma was the major cause of the defects. One flap exhibited approximately 4% partial superficial necrosis. All donor sites healed without any adverse events. All patients were satisfied with the functional and aesthetic results. The KPIFs provide a simple and effective method of wound closure by using tissues of similar texture, thickness and colour. Preserving the main artery and the underlying muscle, this flap reduces the donor site morbidity. The use of KPIFs seems to be one of the most suitable choices whenever possible.

Mangled upper extremity: Our strategy of reconstruction and clinical results.

The management of mangled upper extremity is very challenging because the anatomical complexity of the region, the large number of possible involved anatomical elements, and the necessity of obtaining a good functionality. The impressive development of microsurgical techniques in the last decades contributed a lot to the salvage of several extreme injuries with mangled extremities considered untreatable in the past. Such injuries can nowadays be successfully managed by means of replantation/revascularization or complex reconstruction by using simple or complex microsurgical flaps. The more important steps in managing a mangled upper extremity are the decision making, the moment of reconstruction, the debridement, and the reconstruction by using customized methods. The decision regarding extremity salvage or amputation has to be individualized taking into account general and local factors. These factors influence the absolute or relative indication, but the final decision is up to the experience of every single surgical team. The timing of reconstruction is still a large debated subject, but it seems that the reconstruction as soon as possible is in the advantage of obtaining a much better functional recovery. The debridement should be very carefully performed in the attempt to preserve all the essential anatomical elements able to allow the obtaining of enough functionality. Most of these lesions are accompanied by simple or complex tissue defects. The coverage of these defects needs customized simple or composite flaps used both as free and local/regional microsurgical flaps. Based on the experience regarding the strategy and management of the mangled upper extremity in two European hand trauma centers, we conclude that the keystone in savaging this kind of lesions is represented by a very carefully assessment of the patient and lesion, an enough aggressive debridement, and an as soon as possible reconstruction.

Methylene Blue and Proflavine as Intraarterial Marker for Functional Perforazome-Comparative Study.

Methylene blue (MB) is both a dye and a medicine known and used for a long time including as lymphatic tracer in melanoma and breast cancer for revealing sentinel lymph nodes. Proflavine (PRO) is an acriflavine dye, used as bacteriostatic disinfectant against many gram-positive bacteria that was also successfully applied to evaluate morphopathological changes in tissues. This study was performed on a group of twenty-eight Wistar rats and had as its main objective the in vivo evaluation of the use of MB and PRO as perforator tracers. The two dyes proved to be effective functional perforasome tracers with medium inflammatory infiltrate in the skin of the island perforator flap which heals perfectly at 14 days with complete absence of the inflammatory reaction. At the same injected amount, PRO seems to determine a greater inflammatory reaction compared with MB, but in smaller concentration, the inflammatory response is absent in the case of PRO. In conclusion, both substances tested within this in vivo study are good functional perforasome tracers, but PRO has the advantage of the absence of inflammatory reaction when using lower concentrations, while preserving unalerted its efficiency as tracer.

ESPRAS Survey on Breast Reconstruction in Europe.

BACKGROUND: The European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) previously identified the need for harmonisation of breast reconstruction standards in Europe, in order to strengthen the role of plastic surgeons. This study aims to survey the status, current trends and potential regional differences in the practice of breast reconstruction in Europe, with emphasis on equity and access. MATERIALS AND METHODS: A largescale web-based questionnaire was sent to consultant plastic and reconstructive surgeons, who are experienced in breast reconstruction and with understanding of the national situation in their country. Suitable participants were identified via the Executive Committee (ExCo) of ESPRAS and national delegates of ESPRAS. The results were evaluated and related to evidence-based literature. RESULTS: A total of 33 participants from 29 European countries participated in this study. Overall, the incidence of breast reconstruction was reported to be relatively low across Europe, comparable to other large geographic regions, such as North America. Equity of provision and access to breast reconstruction was distributed evenly within Europe, with geographic regions potentially affecting the type of reconstruction offered. Standard practices with regard to radiotherapy differed between countries and a clear demand for European guidelines on breast reconstruction was reported. CONCLUSION: This study identified distinct lack of consistency in international practice patterns across European countries and a strong demand for consistent European guidance. Large-scale and multi-centre European clinical trials are required to further elucidate the presented areas of interest and to define European standard operating procedures.

Our Definition of Propeller Flaps and Their Classification.

The term propeller flap was introduced for the first time by Hyakusoku to define an island flap, based on a subcutaneous pedicle hub, that was rotated 90 degrees to correct scar contractures due to burns. With the popularization of perforator flaps, the propeller movement was applied for the first time to a skin island vascularized only by an isolated perforator, and the terms propeller and perforator flap were used together. Thereafter, the surgical technique of propeller flaps evolved and new applications developed. With the "Tokyo consensus," we proposed a definition and a classification schema for propeller flaps. A propeller flap was defined as an "island flap that reaches the recipient site through an axial rotation." The classification included the SPP (SPP) flap, the perforator pedicled propeller (PPP) flap, and the supercharged PPP (SCP) flap. A recent update added a new category, the axial pedicled propeller (APP) flap. Here we propose our updated and comprehensive classification of propeller flaps, taking into account the previous classification and subsequent publications. Based on their vascular pedicle, we consider the following five types of propellers: (1) SPP flap, 2.PPP flap, its subtype (2a) SCP flap, (3) APP flap, (4) muscle propeller flap, and (5) chimeric propeller flap. The variables that can be taken into account in the classification are as follows: type of nourishing pedicle, degrees of skin island rotation, position of the nourishing pedicle, artery of origin of the pedicle, and flap shape.

Propeller Flaps for Hand and Digit Reconstruction.

The reconstruction of soft tissue defects of the hand, as seen often after trauma or tumor excision, is a challenge due to the great differentiation of tissues depending on the hand area involved. The classical intrinsic "workhorse flaps" of the hand are associated with a significant donor-site morbidity. Capturing perforator vessels in discrete donor areas can reduce the amount of soft tissue that has to be dissected and included in what now would be a perforator flap, while also insuring robust vascularization of those transferred tissues. Moreover, the presence of perforator vessels both on the dorsal and volar sides of the hand allows harvest of perforator flaps that will respect the like-with-like principle by maintaining the main characteristics of volar and dorsal skin as desired. However, the dissection of these flaps, especially those based on volar palmar and digital perforators, still requires microsurgical skills to preserve the fine vascularization of these flaps. These small flaps are also amenable for application of the propeller flap concept. This is an especially valuable means for preserving the length of an amputated finger where bone is exposed by using more proximal uninjured tissues. Although in general only a short dissection is required to raise a propeller flap in this region, most often the donor site will have to be closed by a skin graft.

The effects of optimizing blood inflow in the pedicle on perforator flap survival: A pilot study in a rat model.

BACKGROUND: Perforator flaps have led to a revolution in reconstructive surgery by reducing donor site morbidity. However, many surgeons have witnessed partial flap necrosis. Experimental methods to increase inflow have relied on adding a separate pedicle to the flap. The aim of our study was to experimentally determine whether increasing blood flow in the perforator pedicle itself could benefit flap survival. METHODS: In 30 male Lewis rats, an extended posterior thigh perforator flap was elevated and the pedicle was dissected to its origin from the femoral vessels. The rats were assigned to three groups: control (group I), acute inflow (group II) and arterial preconditioning (group III) depending on the timing of ligation of the femoral artery distal to the site of pedicle emergence. Digital planimetry was performed on postoperative day (POD) 7 and all flaps were monitored using laser Doppler flowmetry perioperatively and postoperatively in three regions (P1-proximal flap, P2-middle of the flap, P3-distal flap). RESULTS: Digital planimetry showed the highest area of survival in group II (78.12%±8.38%), followed by groups III and I. The laser Doppler results showed statistically significant higher values in group II on POD 7 for P2 and P3. At P3, only group II recorded an increase in the flow on POD 7 in comparison to POD 1. CONCLUSIONS: Optimization of arterial inflow, regardless if performed acutely or as preconditioning, led to increased flap survival in a rat perforator flap model.

Reconstructive microsurgery in upper limb reconstruction: 30 years' experience of a single surgeon.

The reconstruction of compound tissue defects in upper extremity injuries often represents a challenge. The goal of reconstruction is to obtain not only a good cosmetic result, but also the best possible function. Microsurgery highly contributes to the management of upper limb simple or complex defects by offering a large number of surgical possibilities. Due to advances in understanding of blood supply to tissues and microsurgical techniques in the last 50 years, microsurgeons have renounced more and more to the use of traditional flaps in favour of the more reliable perforator flaps. This article presents the experience of a single surgeon performing post-traumatic upper limb reconstructive microsurgery over the last 30 years.

Comparative Study Regarding the Properties of Methylene Blue and Proflavine and Their Optimal Concentrations for In Vitro and In Vivo Applications.

Methylene blue and proflavine are fluorescent dyes used to stain nucleic acid from the molecular level to the tissue level. Already clinically used for sentinel node mapping, detection of neuroendocrine tumors, methemoglobinemia, septic shock, ifosfamide-induced encephalopathy, and photodynamic inactivation of RNA viruses, the antimicrobial, anti-inflammatory, and antioxidant effect of methylene blue has been demonstrated in different in vitro and in vivo studies. Proflavine was used as a disinfectant and bacteriostatic agent against many gram-positive bacteria, as well as a urinary antiseptic involved in highlighting cell nuclei. At the tissue level, the anti-inflammatory effects of methylene blue protect against pulmonary, renal, cardiac, pancreatic, ischemic-reperfusion lesions, and fevers. First used for their antiseptic and antiviral activity, respectively, methylene blue and proflavine turned out to be excellent dyes for diagnostic and treatment purposes. In vitro and in vivo studies demonstrated that both dyes are efficient as perfusion and tissue tracers and permitted to evaluate the minimal efficient concentration in different species, as well as their pharmacokinetics and toxicity. This review aims to identify the optimal concentrations of methylene blue and proflavine that can be used for in vivo experiments to highlight the vascularization of the skin in the case of a perforasome (both as a tissue tracer and in vascular mapping), as well as their effects on tissues. This review is intended to be a comparative and critical presentation of the possible applications of methylene blue (MB) and proflavine (PRO) in the surgical field, and the relevant biomedical findings from specialized literature to date are discussed as well.

Surgical management of hidradenitis suppurativa with keystone perforator island flap.

INTRODUCTION: Hidradenitis suppurativa is a chronic, relapsing disease of the skin, characterized by apocrine gland and pilosebaceous complex infections, causing recurrent superficial nodules and abscesses, fistula formation, scarring and fibrosis. It is accepted that wide local excision and local coverage is the crucial treatment to prevent recurrence of the disease. MATERIALS AND METHODS: All patients presenting for surgical treatment of hidradenitis suppurativa between 2014 and 2019 were identified from the hospital database. Only patients with hidradenitis suppurativa confined to the axillary, inguinal or sacrococcygeal regions in Hurley grade II and III were included. A total of 21 patients (11 male, 10 female) aged between 21 and 76 years were evaluated retrospectively. All of the 22 defects were reconstructed with keystone perforator island flap following wide local excision. We performed descriptive analysis of demographic data, comorbidities, topographic distribution of lesions, Hurley scoring, size of defect, specific type of reconstruction, complications, follow-up period, recurrences. RESULTS: 21 patients with localized axillary, inguinal or sacrococcygeal hidradenitis suppurativa were identified, and 22 keystone perforator island flaps were performed. All keystone perforator island flaps survived giving a durable cover to the affected regions. There were no complications. Functional and aesthetic results were satisfactory and there were no recurrences. CONCLUSION: These findings confirm that the keystone perforator island flap procedure can be effective for immediate defect reconstruction after wide local excision of advanced hidradenitis suppurativa of the axillary, inguinal and sacrococcygeal regions and provides excellent aesthetic results.

A sequence of flaps and dissection exercises in the living model to improve the learning curve for perforator flap surgery.

INTRODUCTION: The training to learn how to perform perforator flaps requires practice on a living model to optimize dissection and to evaluate outcome. The purpose of this study was to describe a training model that optimizes the use of animals in order to perform the maximum number of exercises per animal. MATERIAL AND METHODS: The sequence has been planned and practiced by the first and last author, recorded perfected and implemented in a two-day surgical course. The sequence was then evaluated by the trainers and the trainees by means of a questionnaire. RESULTS: All students were able to complete the sequence of exercises before the end of the second day except two (8/10) who could not complete one exercise each. The students considered the Deep Superior Epigastric Artery Perforator flap the most difficult to perform, being the most technically demanding. The sequence of exercises was judged either easily reproducible or reproducible by all the students. Two students suggested to postpone the DSEAP flap to the second day, after some training, to optimize the experience with the most challenging and rewarding flap. CONCLUSIONS: The training sequence proposed offers a wide range of exercises and allows four trainees, divided in two teams, to work and learn on the same animal. They can perform a wide range of flaps and also harvest the internal mammary vessels. The living model allows for evaluation of the quality of the surgical performance, judged by the difficulties and complications encountered during dissection, and finally through the feedback of flap perfusion.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

The Propeller Flap for Traumatic Distal Lower-Limb Reconstruction: Risk Factors, Pitfalls, and Recommendations.

BACKGROUND: Defects in the distal third of the leg are difficult to cover and often require free tissue transfer, even for defects of limited sizes. Propeller flaps have been designed specifically as an alternative to free tissue transfer but at times have been associated with unacceptably high complication rates. We therefore aimed to prospectively assess our own institutional experience with this technique and to define its role in lower-limb reconstruction. METHODS: All patients who had been managed with reconstruction of the distal part of the leg with a propeller flap between 2014 and 2017 were included in the study. Demographic, clinical, and follow-up data on the patients and surgical procedures were recorded with special focus on the complication profile. RESULTS: Twenty-six patients underwent propeller flap reconstruction of the distal part of the leg: 12 flaps were based on the posterior tibial artery, and 14 were based on the peroneal artery. Postoperative complications developed in association with 1 of the 12 flaps based on the posterior tibial artery, compared with 8 of the 14 flaps based on the peroneal artery (p = 0.015). Moreover, the presence of a higher Charlson comorbidity index (≥2) was strongly associated with the development of postoperative complications (p < 0.001). CONCLUSIONS: Propeller flaps are a reliable option for traumatic reconstruction in carefully selected patients with lower-limb defects. In our experience, the rate of complications was higher for propeller flaps based on the peroneal artery and for patients with a Charlson comorbidity index of ≥2, whereas posterior tibial artery-based propeller flap reconstruction was a reliable surgical option for patients with a small defect in the distal third of the lower limb. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Giant keystone type III perforator flaps for dermatofibrosarcoma protuberans defect reconstruction.

INTRODUCTION: Dermatofibrosarcoma protuberans (DFSP) is a relatively rare malignant tumor, with important local aggressiveness. CASE REPORT: We present a case of a 59-years-old man with a history of Psoriasis and viral hepatitis C presented in our department with a giant lesion on the posterior trunk, of 24/36 cm, with pus and local bleeding, causing important anemia. The tumor was excised, creating an elliptical defect of around 34 × 42 cm down to fascial level, which was covered by two lateral flaps - modified Keystone type III. RESULTS: The flaps were completely viable and integrated with small dehiscence, which were assisted to heal secondarily. CONCLUSION: Our paper presents a reliable alternative to skin grafting for a very large defect on the posterior trunk, the modified type III keystone flap, to our knowledge, for the first time presented for such a wide defect and on adult.

Emergency toe-to-hand transfer for post-traumatic finger reconstruction: A multicenter case series.

BACKGROUND: The aim of this paper was to evaluate the outcomes of a homogenous series of emergency with a toe-to-hand transfer reconstructions with a different timing: immediate (same surgical step with the debridement), primary (in the first 24 h), early (24-72 h after the debridement) or delayed (72 h-7 days). MATERIALS AND METHODS: Between 2001 and 2011, 31 patients received an immediate reconstruction with a toe-to-hand transfer. Data on indications, timing, type of surgery, complications and outcomes (sensory and motor recovery, patient satisfaction) were extrapolated and recorded. RESULTS: Most of the procedures in our series (71%) were performed in the first 24 h. Survival rate was 100%. The only complications were 3 venous thrombosis (10%), solved with surgical re-exploration. Only 1 patient required secondary surgery for web deepening. No functional problems were recorded at the donor site. Sensibility recovery was acceptable in all patients; toe mobility was higher for the reconstructed thumb (85%) than for other digits (77%). Patient satisfaction was high with regard to functional results and lower but acceptable with regard to the aesthetic outcome. There was no difference in satisfaction rate of patients treated within 24 h or within 7 days. CONCLUSION: No conclusive evidence exists in favor of an immediate versus a primary, early or delayed emergency reconstruction. Emergency toe transfer for finger reconstruction is a safe procedure and its outcomes are comparable to those reported in the literature for secondary reconstruction. Immediate reconstruction has the advantage of an easier dissection, but early or delayed reconstruction gives more time to discuss with the patient and to plan surgery.

Why, when and how propeller perforator flaps in reconstructive surgery.

PURPOSE: The aim of this paper was to evaluate the outcomes of propeller perforator flaps used all over the body, and to appreciate their advantages and/or disadvantages over the free perforator flaps. METHOD: Patients that required propeller perforator flaps used all over the body were eligible to participate in this study. A preoperative Doppler examination was performed for all the flaps in the trunk and thigh, but not regularly in the face, lower leg, foot, forearm and hand. We evaluated the most important technical aspects of harvesting the flaps, the main indications and advantages of using propeller perforator flaps, their disadvantages and complications. For post-excisional face and trunk defects after cancer or decubitus ulcers were performed approximately 25% of flaps. RESULTS: We had very good results in approximately 70% of cases. In the remaining cases, excepting 3 cases in which the flaps were completely lost, we registered only minor complications due to venous congestion, which were solved spontaneously or by skin grafting. CONCLUSION: The main advantages of propeller perforator flaps, i.e. no need of microvascular anastomoses, replacing like-with-like, faster functional rehabilitation, can reduce in well selected cases the indication for free flaps. The rate of complications is not higher than by using other methods. The single real disadvantage of propeller perforator flaps is the location of the perforator close to the defect, what can be an impediment in trauma cases.