Pyoderma Gangrenosum Post-Breast Surgery: A Case Report and Comprehensive Review of Management Strategies.

Background/Objectives: Pyoderma gangrenosum (PG) is a rare, autoimmune skin condition characterized by painful, rapidly progressing ulcers, often associated with autoimmune dysregulation. Managing PG following breast surgery presents unique challenges due to its pathergy phenomenon, which complicates surgical interventions. This article outlines the case of PG in a 48-year-old female post-breast surgery and reviews management strategies through a systematic analysis of the literature. Methods: A systematic literature review from 2018 to 2023 identified 24 relevant articles on PG management post-breast surgery. The studies were analyzed to compare the efficacy and complications of conservative versus combined (conservative and surgical) treatment strategies. Results: Results indicate that while conservative management, primarily with corticosteroids, remains preferred, combined strategies, including systemic therapies, vacuum-assisted closure, and surgery, offer significant benefits in select cases. Conclusions: Our findings suggest that a personalized, multifaceted treatment plan is crucial for managing PG effectively, emphasizing the need for early detection, meticulous planning, and comprehensive care to optimize patient outcomes.

The Expression of Forkhead Box P3 T Regulatory Lymphocytes as a Prognostic Factor in Malignant Melanomas.

Since transcription factor Forkhead Box P3 (FoxP3) was identified as a specific regulatory T cell (Treg) marker, researchers have scrutinized its value as a potential novel therapeutic target or a prognostic factor in various types of cancer with inconsistent results. The present analysis was performed to assess the influence of Treg FoxP3 expression on the prognosis of primary melanoma and to evaluate the correlations with various clinicopathological prognostic factors. We analyzed all eligible patients with stage pT3 primary malignant melanomas treated in a tertiary cancer center. Immunohistochemical staining for Treg FoxP3 expression was performed on retrospectively identified paraffin blocks and subsequently correlated with the outcomes of the patients. A total of 81% of the patients presented a positive Treg FoxP3 expression, being correlated with a higher risk of lymph node metastasis, tumor relapse, and death. Moreover, positive expression was statistically associated with a shorter OS. The tumor relapse rate was estimated at 36.7%. A positive expression of Treg FoxP3 and lymph node metastasis were associated with a higher risk of death based on multivariate analysis. Treg FoxP3 expression may be used as an independent prognostic factor in patients with malignant melanoma to evaluate tumor progression and survival.

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.

The effects of the COVID-19 pandemic on the diagnosis and prognosis of melanoma 2 years after the pandemic in two Romanian counties.

Background: The COVID-19 pandemic disrupted the healthcare system and negatively affected the diagnosis and management of melanoma worldwide. The purpose of this study is to investigate the long-term effects of the COVID-19 pandemic on the diagnosis and prognosis of melanoma. Materials and methods: This retrospective cohort study included histopathologically confirmed melanoma cases from March 2019 to February 2023 in Cluj and Bihor counties. Data from the post-COVID-19 period (March 2021 to February 2023) were compared to the pre-COVID-19 period (March 2019 to February 2020) and the COVID-19 period (March 2020 to February 2021). Patient characteristics, monthly diagnostics, histological subtypes, and key histological features were analyzed using statistical tests. Results: The number of melanoma cases diagnosed annually decreased by 31.37 and 23.75% in the first and second post-pandemic years, respectively, compared to pre-pandemic numbers. Diagnostic rates also decreased by 14.9 and 5.4% in the first and second post-pandemic years, respectively, compared to the pandemic period. Prognostic factors worsened in the post-pandemic period, with higher Breslow index and mitotic rate, and increased ulceration and thick melanomas compared to the pre-pandemic period. Conclusion: The COVID-19 pandemic had a long-lasting impact on the diagnosis of melanoma in Romania, resulting in advanced stages and unfavorable prognostic factors. Larger global studies are needed to comprehensively understand the pandemic's long-term effects on the diagnosis of melanoma.

Hereditary Breast Cancer in Romania-Molecular Particularities and Genetic Counseling Challenges in an Eastern European Country.

In Romania, breast cancer (BC) is the most common malignancy in women. However, there is limited data on the prevalence of predisposing germline mutations in the population in the era of precision medicine, where molecular testing has become an indispensable tool in cancer diagnosis, prognosis, and therapeutics. Therefore, we conducted a retrospective study to determine the prevalence, mutational spectrum, and histopathological prediction factors for hereditary breast cancer (HBC) in Romania. A cohort of 411 women diagnosed with BC selected upon NCCN v.1.2020 guidelines underwent an 84-gene NGS-based panel testing for breast cancer risk assessment during 2018-2022 in the Department of Oncogenetics of the Oncological Institute of Cluj-Napoca, Romania. A total of 135 (33%) patients presented pathogenic mutations in 19 genes. The prevalence of genetic variants was determined, and demographic and clinicopathological characteristics were analyzed. We observed differences among BRCA and non-BRCA carriers regarding family history of cancer, age of onset, and histopathological subtypes. Triple-negative (TN) tumors were more often BRCA1 positive, unlike BRCA2 positive tumors, which were more often the Luminal B subtype. The most frequent non-BRCA mutations were found in CHEK2, ATM, and PALB2, and several recurrent variants were identified for each gene. Unlike other European countries, germline testing for HBC is still limited due to the high costs and is not covered by the National Health System (NSH), thus leading to significant discrepancies related to the screening and prophylaxis of cancer.

Hidradenitis suppurativa. A case report.

Hidradenitis suppurativa is a disease with underestimated incidence, consequences and treatment difficulty. Regarded as a minor illness, for the patient it is disabling physically and socially, and for the doctor it is a challenge in choosing the appropriate treatment. We present the case of a 28-year-old man who presented with an advanced and persistent form of hidradenitis treated in a general surgery department. Solving the case combined conservative and surgical treatment (wide excisions, plasties with fasciocutaneous superior gluteal artery perforator flap, thoracodorsal artery perforator flap, free anterolateral thigh flap). This case illustrates the problems raised by a seemingly trivial disease. KEY WORDS: Fasciocutaneous Superior Gluteal Artery Perforator Flap, Follicular Occlusion, Free Anterolateral Thigh Flap, Hidradenitis Suppurativa, Skin Ulcer, Skin Fold, Thoracodorsal Artery Perforator Flap.

Reduction of Anastomotic Time Through the Use of Cyanoacrylate in Microvascular Procedures.

Background: Ever since the description of the first microvascular anastomosis, numerous alternative methods have been described to the classical approach. Tissue adhesive has shown promising result in previous studies and can be a fast and efficient alternative which still requires more studies to allow its clinical implementation. Methods: A randomized comparative experimental study was conducted on rats' femoral arteries and an end-to-end anastomosis was performed in order to compare 2 anastomosis techniques. In one group, a simple interrupted suture was utilized, whereas in the second group a combination between fewer sutures and tissue adhesive was used. The anastomotic time, total operative time, blood flow velocity before, immediately after and 48 hours after the procedure, as well as an independent grading of the anastomosis immediately after the procedure were performed. Magnetic resonance imaging (MRI) was performed in order to assess the degree of stenosis. After euthanasia, histology and scanning electron microscopy (SEM) were performed on the vessels in order to assess possible complications. Results: A total of 24 anastomoses were performed, of which 12 with a classic technique and 12 with an adhesive technique. All the anastomoses were patent with a significant reduction of anastomotic and total operative time. The grading of the anastomoses showed better results in the classic suture group. The blood flow velocities were not statistically significant between the 2 groups. On MRI there was one stenotic anastomosis, whereas histology and SEM showed more complications on the adhesive group. Conclusion: Anastomotic times were significantly lower with a non-significant trend toward more thrombotic complications in the adhesive group. Further improvement of the glue properties and refinement of the technique will likely make it a viable alternative to interrupted suturing in the future.

Historique: Depuis que la première anastomose microvasculaire a été décrite, de nombreuses méthodes ont été utilisées en plus de la méthode classique. L'adhésif tissulaire a donné des résultats prometteurs dans des études antérieures et peut représenter une solution rapide et efficace qui devra faire l'objet de plus d'études avant d'être adoptée en clinique. Méthodologie: Les chercheurs ont mené une étude expérimentale aléatoire et comparative sur des artères fémorales de rat. Ils ont effectué une anastomose de bout en bout pour comparer deux techniques d'anastomose. Dans un groupe, une seule suture interrompue a été utilisée, et dans le second, une combinaison d'un moins grand nombre de sutures et d'adhésif tissulaire a été privilégiée. La durée de l'anastomose, la durée totale de l'intervention, la vélocité du débit sanguin avant, immédiatement après et 48 heures après l'intervention, de même que le classement indépendant de l'anastomose immédiatement après l'intervention. L'imagerie par résonance magnétique a permis d'évaluer le degré de sténose. Après l'euthanasie, les chercheurs ont effectué l'histologie et la microscopie électronique sur les vaisseaux pour évaluer les complications possibles. Résultats: Au total, 24 anastomoses ont été exécutées, soit 12 avec la technique classique et 12 avec la technique d'adhésion. Toutes les anastomoses étaient perméables et s'associaient à une réduction importante de la durée de l'anastomose et de l'opération totale. Le classement de l'anastomose a révélé de meilleurs résultats dans le groupe de suture classique. La vélocité du débit sanguin n'était pas statistiquement significative entre les deux groupes. On a constaté une anastomose sténosée à l'imagerie par résonance magnétique, tandis que l'histologie et la microscopie électronique ont révélé plus de complications dans le groupe d'adhésion. Conclusion: La durée de l'anastomose était beaucoup plus courte et présentait une tendance non significative vers un plus grand nombre de complications thrombotiques dans le groupe d'adhésion. Des améliorations des propriétés de la coller et le raffinement des techniques en feront probablement une solution viable pour remplacer les sutures.

Prognostic factors for in-transit metastasis in patients with malignant melanoma.

Background and aims: Malignant melanoma represents an aggressive and unpredictable malignancy, with high locoregional recurrence rates, regardless of tumor stage and therapeutic management. This study aims to identify the main histopathological prognostic factors involved in the development of in-transit metastasis in patients with malignant melanoma. Methods: The study includes only patients that were diagnosed with malignant melanoma and with histologically confirmed in-transit metastasis who were treated in a comprehensive cancer center between 2010-2021. Histopathological parameters were investigated, univariate and multivariate analysis was performed. Results: A total of 26 patients were included in the analysis. On univariate and multivariate analysis, only primary cutaneous melanomas located on the thorax correlated with the risk of developing in-transit metastasis, whereas clinicopathological factors such as an increased Breslow thickness and Clark level, the presence of ulceration, positive lymph nodes, a non-brisk TIL density, a high mitotic rate, a nodular subtype, and age >50 years may represent risk factors, even though we could not find any correlations. Conclusions: Primary cutaneous melanomas that arise on the thorax present a high risk for the occurrence of locoregional disease, whereas other clinicopathological characteristics could not be used to predict local recurrence. However, prospective and more extensive cohort studies are needed in order to validate these important prognostic factors.

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.

Treatment and Prevention of Periprosthetic Capsular Contracture in Breast Surgery With Prosthesis Using Leukotriene Receptor Antagonists: A Meta-Analysis.

BACKGROUND: Capsular contracture (CC) is the most common long-term complication of breast surgery with prosthesis. Leukotriene receptor antagonists (LRAs) have been tested as a potential treatment; however, mixed results have been observed. OBJECTIVES: The aim of this study was to undertake a meta-analysis to clarify the treatment and prophylactic capabilities of LRAs in the management of CC. METHODS: A systematic literature search of the most popular English-language databases was performed to identify relevant primary publications. We included all studies that used the Baker scale to evaluate the treatment and preventive capabilities of LRAs. RESULTS: Six eligible studies were included based on predefined inclusion and exclusion criteria, totalling 2276 breasts, of which 775 did not receive LRAs and 1501 did. Final pooled results showed that LRAs could help manage CC with a risk difference (RD) of -0.38 with a corresponding 95% CI of -0.69 to -0.08, showing statistical significance at a Z value of 2.48, P = 0.01. Subgroup analysis based on the type of drug showed that only montelukast yielded statistical significance (RD = -0.27, 95% CI = -0.51 to -0.03, Z = 2.20, P = 0.03). Zafirlukast did not seem to influence CC. Further subgroup analysis based on treatment timing showed that prophylaxis was ineffective and only treatment for ongoing CC yielded statistically significant improvements. CONCLUSIONS: The current meta-analysis proved that LRAs could be used in the management of CC. Only treatment for ongoing CC showed statistically significant improvements. Montelukast seemed to be more efficient with a safer profile for adverse effects, whereas zafirlukast yielded no statistically significant results.

Immediate Breast Reconstruction in Large Ptotic Breasts Using the Inferior Based Dermal Flap. Indications and Technique.

Introduction: Achieving good aesthetic outcomes during immediate reconstruction in women with large ptotic breast presents a unique challenge for the reconstructive surgeon. We present our paradigm regarding immediate reconstruction in patients with large ptotic breasts, using the inferiorly based dermal flap. Materials and Methods: Ten patients with large ptotic breasts underwent mastectomy and immediate implant reconstruction at the "Prof. Dr. I. Chiricuta" Institute of Oncology. The mastectomy was carried out using a Wise pattern skin resection with preservation of a dermal flap at the lower pole of the breast. The flap was sutured to the pectoralis major muscle and completed the subpectoral pocket created for the implant. Results: The reconstruction was done bilaterally in three cases with a total number of 13 reconstructed breasts. Of these 11 required dermal flaps. All reconstructions were completed successfully and there were no implant losses. Four breasts (36%) developed superficial necrosis of the tip of the mastectomy flaps at the T junction. Conclusion: The dermal flap technique is safe, versatile and reliable. It is used in a wide array of reconstructive scenarios as it provides the surgeon with an excellent alternative to more costly and unreliable methods.

The Use of Negative Pressure Wound Therapy in the Management of Parotid Sialocele: A Case Report.

Parotid sialocele is an accumulation of saliva inside a subcutaneous cavity, usually as a result of trauma or iatrogenic injury of the parotid gland or duct, which can progress to other complications if left untreated. Numerous treatment options have been described before, but there is currently no evidence based consensus. We present a case of a patient treated for sialocele with the use of negative pressure wound therapy. Laryngoscope, 131:E1094-E1095, 2021.

The value of tumor infiltrating lymphocytes as prognostic factor for lymph node status and survival amongst patients with cutaneous malignant melanoma.

PURPOSE: Tumor infiltrating lymphocytes (TILs) in cutaneous malignant melanoma are classified as brisk, non-brisk or absent. Numerous studies suggest the presence of TILs, especially brisk, are associated with a lower rate of lymph node metastasis and with an improved overall survival (OS). Our purpose was to assess the value of TILs as a prognostic factor for the lymph node metastasis and survival in completely resected pT3 stage malignant melanoma patients. METHODS: We included a number of 114 patients with pathological pT3 cutaneous malignant melanoma, treated exclusively in our institution, between 2000-2015. Correlations of clinical and pathological factors with lymph node status and OS were analyzed. RESULTS: A brisk infiltrate was present in 60% of the patients, whereas 40% presented a non-brisk infiltrate or absent TILs. In univariate analysis, the presence of ulceration was correlated with a non-brisk infiltrate, whereas in multivariate analysis, lymph node invasion and a non-brisk infiltrate were associated with a higher risk of death. CONCLUSIONS: TILs density grade represents an independent prognostic factor for the OS. Therefore, we conclude that an accurate prognosis may be provided by TILs status in patients with pT3 malignant melanoma.

Free-flap breast reconstruction on experimental porcine model.

INTRODUCTION: Free flaps require mastering microsurgical technique. In addition, breast reconstruction implies accuracy not only in flap survival, but also satisfying aesthetic outcome. Thus, such complex abilities can be acquired by creating experimental models for surgical training. MATERIALS AND METHODS: In accordance with relevant anatomy data found in literature, we chose a porcine model and performed a flap similar to the human deep inferior epigastric perforator (DIEP). Furthermore we developed a surgical protocol for a free flap transfer similar to a double-pedicle DIEP flap. The adipo-cutaneous flap was harvested as a free flap based on the superior abdominal vascularization and microsurgical anastomoses were performed to both the internal thoracic and thoracodorsal vessels. RESULTS: We were able to harvest a superior epigastric double-perforator free flap with increased similarity to the human DIEP flap. Microsurgical anastomoses were possible to both to the internal thoracic vessels and thoracodorsal vessels, which both proved to have optimal caliber for termino-terminal anastomosis. CONCLUSION: Although there are several differences when comparing a swine experimental model with human anatomy, our protocol enhances the possibilities for training in breast reconstruction.

Molecular Links between Central Obesity and Breast Cancer.

: Worldwide, breast cancer (BC) is the most common malignancy in women, in regard to incidence and mortality. In recent years, the negative role of obesity during BC development and progression has been made abundantly clear in several studies. However, the distribution of body fat may be more important to analyze than the overall body weight. In our review of literature, we reported some key findings regarding the role of obesity in BC development, but focused more on central adiposity. Firstly, the adipose microenvironment in obese people bears many similarities with the tumor microenvironment, in respect to associated cellular composition, chronic low-grade inflammation, and high ratio of reactive oxygen species to antioxidants. Secondly, the adipose tissue functions as an endocrine organ, which in obese people produces a high level of tumor-promoting hormones, such as leptin and estrogen, and a low level of the tumor suppressor hormone, adiponectin. As follows, in BC this leads to the activation of oncogenic signaling pathways: NFκB, JAK, STAT3, AKT. Moreover, overall obesity, but especially central obesity, promotes a systemic and local low grade chronic inflammation that further stimulates the increase of tumor-promoting oxidative stress. Lastly, there is a constant exchange of information between BC cells and adipocytes, mediated especially by extracellular vesicles, and which changes the transcription profile of both cell types to an oncogenic one with the help of regulatory non-coding RNAs.

Improvement of recovery parameters using patient-controlled epidural analgesia after oncological surgery. A prospective, randomized single center study.

PURPOSE: The aim of this study was to compare patient-controlled epidural analgesia (PCEA) versus conventional opioid intravenous (IV) infusion after gastrointestinal cancer surgery regarding several post-surgery parameters of recovery. METHODS: One hundred and one patients were prospectively randomized to receive either thoracic/lumbar PCEA (PCEA group) or the standard analgesia technique used in our hospital, conventional IV infusion of morphine (IVMO group) after gastrointestinal cancer surgery. Pain intensity, time of mobilization and bowel function recovery were analyzed post-surgery. We also evaluated postoperative complications and length of Postoperative-Intermediate Intensive Care Unit (PI-ICU) stay and hospital stay. RESULTS: Pain intensity was significantly less in the PCEA group in comparison with the IVMO Group at awakening 2, 8, 24, 30 and 48 hours after surgery (p <0.001, p <0.001, p <0.001, p = 0.043, p = 0.036, and p = 0.029, respectively). The latency to bedside mobilization, walking, first postoperative flatus and apparition of first stool were significantly faster (1.74 versus 2.26 days, 3.06 versus 3.78 days, 2.1 versus 3.14 days and 3.73 versus 5.28 days, respectively) in the PCEA group than in the IVMO group (p <0.001, p <0.001, p <0.001, and p <0.001, respectively). The incidence of nausea/vomiting was significantly lower in the PCEA group in comparison with the IVMO group (p = 0.001). Surgical-associated complications were significantly lower in the IVMO Group than in the PCEA group (p = 0.023). Length of PI-ICU stay was similar in the two groups but length of hospital stay was significantly shorter in PCEA group (4 versus 5 days p = 0.2849, 9 versus 12 days; p <0.001). CONCLUSIONS: PCEA provides better postoperative pain control, improves postoperative recovery after gastrointestinal cancer surgery compared with conventional intravenous morphine infusion. Therefore, it is more acceptable than conventional pain management.

Using dynamic infrared thermography to optimize color Doppler ultrasound mapping of cutaneous perforators.

AIMS: The high technical demands associated with perforator flaps demand a precise preoperative identification and evaluation of perforator vessels. Color Doppler Ultrasonography (CDU) and Dynamic Infrared Thermography (DIRT) are currently used for preoperative perforator mapping. Each individual technique has advantages and disadvantages. The purpose of this paper is to analyze the value of combining the two methods in order to optimize the process of preoperative perforator mapping. MATERIAL AND METHODS: CDU and DIRT were used for preoperative perforator mapping in 10 pigs. The results were compared to intraoperative findings. Total number of perforators, localization, and identification of the dominant perforator was analyzed for each method. The examination time was recorded for each procedure. RESULTS: Both methods had a high sensitivity in determining the number and localization of perforators when compared to those identified during surgery. DIRT produced a higher number of false positive results. CDU accurately identified the emergence of the perforators in the fascia in all cases. Both methods correctly identified the dominant perforator. The sensitivity, positive predictive value, and accuracy of CDU were 93.56%, 97%, and 91.30% respectively and for DIRT 95.05%, 80.67%, and 77.41% respectively. The average examination was 39.76 minutes for CDU and 10.24 minutes for DIRT. The average time taken into account for the analysis of a single perforator in order to confirm DIRT findings was 1.83 minutes. CONCLUSIONS: Preoperative perforator mapping has become a compulsory step in nearly all reconstructive procedures. In our study, both CDU and DIRT correctly identified the dominant perforator in all cases. By combining the two examinations overall mapping time can be reduced significantly. A reduced examination time translates into increased patient compliance and a lower procedure cost. The combined mapping technique facilitates the selection of the ideal perforator in all cases. Correctly identifying the dominant perforator preoperatively reduces operative time, lowers complication rates and ensures an overall better result.

Dynamic perfusion assessment during perforator flap surgery: an up-to-date.

Flap monitoring technology has progressed alongside flap design. The highly variable vascular anatomy and the complexity associated with modern perforator flaps demands dynamic, real-time, intraoperative information about the vessel location, perfusion patterns and flap physiology. Although most surgeons still assess flap perfusion and viability based solely on clinical experience, studies have shown that results may be highly variable and often misleading. Poor judgment of intraoperative perfusion leads to major complications. Employing dynamic perfusion imaging during flap reconstruction has led to a reduced complication rate, lower morbidity, shorter hospital stay, and an overall better result. With the emergence of multiple systems capable of intraoperative flap evaluation, the purpose of this article is to review the two systems that have been widely accepted and are currently used by plastic surgeons: Indocyanine green angiography (ICGA) and dynamic infrared thermography (DIRT).