"DO ONE, GET TWO": dual venous drainage of the radial forearm free flap by a single venous anastomosis.

PURPOSE: The radial forearm free flap (RFFF) remains a workhorse in microsurgical reconstruction. Its failure is primarily due to problems with venous drainage; for this reason, controversy on venous anastomosis patterns still exists. This manuscript describes our experience in using a communicating vein to overcome the complications of venous drainage of the RFFF. METHODS: Following a review of the vascular anatomy of the RFFF, we retrospectively review the use of the communicating vein and report our results, with the aim of overcoming the dichotomy "superficial versus deep venous system" and "single versus double anastomosis" and discussing the evidence of advantages in using a single microanastomosis with a communicating vein. RESULTS: Our retrospective review included a total of 123 patients in which a RFFF was performed to reconstruct intraoral defects, performed with a single venous anastomosis using the communicating vein. Four patients (3.25%) required a return to theatre for revision of the venous anastomosis and one case resulted in flap failure due to arterial insufficiency (0.81%). CONCLUSIONS: Our series highlights the constant presence of the communicating vein, although with variations of origin and course that did not preclude the possibility to correctly perform the anastomosis. Advantages of a single microanastomosis with the communicating vein include ease, speed, reliability and versatility in planning the anastomosis. Based on our results, the use of the communicating vein showed comparable and, in some cases, more favourable results when compared to venous anastomotic complications reported in the literature.

Outcomes of a Mini External Fixator System for the Treatment of Unstable Periphyseal Hand Fractures.

Background: Most unstable hand fractures in children are treated by closed methods. If osteosynthesis is required, Kirschner (K)-wires are commonly used, though they carry a risk of injury to the physis. We have been using a mini external fixator system (MEFS) for the treatment of unstable periphyseal fractures of the hand. The aim of this study is to describe the application and report the outcomes of MEFS for the treatment of periphyseal fractures of the hand. Methods: We retrospectively reviewed all the patients with periphyseal fracture of the hand treated with MEFS from March 2010 to December 2019. Data with regard to age, sex, hand dominance, digit and bone injured, mechanism of injury, medical records and related radiographs were collected. Salter-Harris classification was used to classify epiphyseal fractures and the Al-Qattan classification for categorising neck fractures. Range of motion and residual deformity of the affected fingers were evaluated during follow-up and at 3 months postoperatively. Results: Fourteen periphyseal unstable fractures were treated using closed reduction and MEFS. Only one patient with a fracture of the neck of the proximal phalanx of the little finger required revision surgery. No patient had pin site infection or pin loosening and the device was well tolerated by all patients. All fractures united and all the patients recovered a full range of motion at final follow-up. Conclusions: The MEFS is a reasonable alternative for unstable periphyseal fractures with good outcomes and avoids the risk of iatrogenic physeal injury from K-wire fixation. Level of Evidence: Level IV (Therapeutic).

Bone regeneration after pedicled periosteal dorsal metacarpal flap. Reconstructive technique.

The dorsal metacarpal artery (DMCA) flap is considered as one of the working horses to cover exposed extensor tendon or bone of dorsal digits. The periosteal composite DMCA reverse flap (pcDMCAr flap) is described as a fast and safe solution to manage this kind of trauma. A 35-year-old male had a trauma to his left hand from a circular saw. The resultant injury was localized to the proximal middle finger with a dorsal bone loss. A vascularized composite flap, including 3th metacarpal periosteum, was elected as the most appropriate option. Postoperative follow-up at 6 months confirmed bony regeneration. There are no documented cases to the best of our knowledge demonstrating the use of pcDMCAr flap to treat fractures with bone loss in the proximal digits. This report suggests that technique may be employed as regenerative bone flap in reconstructive surgery for proximal fingers trauma with bone loss and open fracture. KEY WORDS: Bone regeneration, Dorsal metacarpal flap, Periosteum.

Inveterated Facial Palsy Correction with Endoscopically Assisted Multiple Muscle Transposition and Lifts: The EMTL Procedure.

Introduction The aim of the present analysis was to study the safety and efficacy associated with reanimation in facial nerve palsy by the endoscopically assisted multiple muscle transposition and lifts (EMTL). Patients and Methods The study sample included all patients who had undergone a facial reanimation by EMTL procedure from September 2015 to May 2019. The patients were analyzed retrospectively, with more than 1 year of follow-up, and were evaluated in terms of functional-aesthetic results and postoperative complications. The outcome was evaluated with the Sunnybrook scale. Results Fourteen patients were included in the present study. They were all inveterate palsies with minimum 4 years from the initial injury. The preoperative Sunnybrook score ranged from 0 to 5 and the postoperative ranged from 30 to 65. Spontaneous smile achievement was obtained in 10 patients and only mild restoration in one patient. The scar and static correction were satisfactory in all patients. Eye protection was improved in all cases with some form of active blinking in six cases. Conclusion This study showed that facial palsy correction with EMTL procedure offers a promising alternative treatment for patients with facial palsy not suitable for microsurgical muscle transposition.

An unusual case of neurothekeoma of the arm in an adult.

Neurothekeomas are uncommon benign neoplasms with a peripheral nerve sheath origin. This tumor usually involves dermis and is described as a small, solitary, slow growing and reddish to flesh-colored nodule or papule. Neurothekeoma preferentially affects the central aspect of the face, the arms or shoulders of women in the second and third decades of life. This is the first case report of neurothekeoma involving the wrist developing from synovial tissue and with uncertain clinical behavior in an adult female. The tumor was completely excised under brachial plexus block. Histopathologically, the examination of the microscopic slides revealed the presence of a 20-mm diameter, well-circumscribed and multilobulated tumor composed of abundant myxoid stroma with cellular elements; with immunohistochemistry there was positivity to vimentin but S100-protein, epithelial membrane antigen, cytokeratin AE1-3, CD99 and CD34 were all negative. This pattern suggested a myxoid tumor form of neurothekeoma, mixed subtype. The patient had an atypical local recurrence and was re-operated after 3 months. After 12 months there was no evidence of clinical recurrences confirmed by magnetic resonance evaluation. Basically, our case report adds an important element in the correct clinical management of neurotecheomas: faced with a histological diagnosis with an unusual localization and mixed or hypercellular type, clinicians must consider the possibility of an early local recurrence, suggesting a close clinical and radiological follow-up.

Actualities in big segments replantation surgery.

Replantation of an amputation is no longer a difficult technical problem. Indeed, the experience gathered over the last few decades, right from the first concepts posed by the pioneers up to the present era and the improved technical aids, all go to suggest that the majority of amputated segments may now be reconstructed. However, what we really want from a replant is not just survival but function. Indications for replantations must follow careful and objective patient selection together with the evaluation of type and site of lesion and possible complications. Furthermore, the important role of emergency organization in this type of surgery is to be emphasized. Nowadays, clean cut injuries are rarer and are being substituted by high energy trauma which may produce extensive tissue lesions that increase complications and lead to poor functional results. Consequently, some authors were induced to describe evaluation systems for decision making which still present problems which are in part due to the large number of parameters to be taken into consideration as well as to the complex functionality of the upper limb. This led us to evaluate our case series of 52 major replantations of the upper limb over the last 10 years and to compare it with other published series. The best form of reconstruction following total amputation of a major limb segment is still its replantation. The highly significant increase in the quality of life is able to justify the higher social costs and the number of operations required.

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS): experience with high-dose intravenous immunoglobulins and topical conservative approach. A retrospective analysis.

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are rare, drug-induced, severe acute exfoliative skin and mucosal disorders. Several treatments previously proposed have produced contradictory results in small series; in 1998 the use of intravenous immunoglobulins (IVIG) was introduced with excellent clinical findings. Our experience (1999-2005) using IVIG in the therapy of TEN/SJS, together with a local conservative approach, is reported and related to our previous treatments (1993-1998). The SCORTEN and the standardized mortality ratio (SMR) was used to evaluate the efficacy of our therapeutic modalities. Eight patients were treated before IVIG era and 23 patients have been treated with IVIG. There was no significant difference in SCORTEN between the two groups. Concerning the local approach, a conservative wound management in IVIG series replaced an extensive epidermal debridment and coverage with artificial skin substitutes of the pre-IVIG series. Overall mortality in patients treated before IVIG was 75% (6/8), in the IVIG group it decreased to 26% (6/23) with a cessation of further epidermal detachment after an average of 5 days (3-10 days) from the onset of the therapy. The SMR showed a trend to lower actual mortality (not significative) with IVIG treatment than the predicted mortality (SMR=0.728; 95% CI: 0.327-1.620).