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.

Large Exchange Coupling Between Localized Spins and Topological Bands in MnBi2 Te4.

Magnetism in topological materials creates phases exhibiting quantized transport phenomena with potential technological applications. The emergence of such phases relies on strong interaction between localized spins and the topological bands, and the consequent formation of an exchange gap. However, this remains experimentally unquantified in intrinsic magnetic topological materials. Here, this interaction is quantified in MnBi2 Te4 , a topological insulator with intrinsic antiferromagnetism. This is achieved by optically exciting Bi-Te p states comprising the bulk topological bands and interrogating the consequent Mn 3d spin dynamics, using a multimodal ultrafast approach. Ultrafast electron scattering and magneto-optic measurements show that the p states demagnetize via electron-phonon scattering at picosecond timescales. Despite being energetically decoupled from the optical excitation, the Mn 3d spins, probed by resonant X-ray scattering, are observed to disorder concurrently with the p spins. Together with atomistic simulations, this reveals that the exchange coupling between localized spins and the topological bands is at least 100 times larger than the superexchange interaction, implying an optimal exchange gap of at least 25 meV in the surface states. By quantifying this exchange coupling, this study validates the materials-by-design strategy of utilizing localized magnetic order to manipulate topological phases, spanning static to ultrafast timescales.

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.

Interfacial charge transfer and persistent metallicity of ultrathin SrIrO3/SrRuO3 heterostructures.

Interface quantum materials have yielded a plethora of previously unknown phenomena, including unconventional superconductivity, topological phases, and possible Majorana fermions. Typically, such states are detected at the interface between two insulating constituents by electrical transport, but whether either material is conducting, transport techniques become insensitive to interfacial properties. To overcome these limitations, we use angle-resolved photoemission spectroscopy and molecular beam epitaxy to reveal the electronic structure, charge transfer, doping profile, and carrier effective masses in a layer-by-layer fashion for the interface between the Dirac nodal-line semimetal SrIrO3 and the correlated metallic Weyl ferromagnet SrRuO3. We find that electrons are transferred from the SrIrO3 to SrRuO3, with an estimated screening length of λ = 3.2 ± 0.1 Å. In addition, we find that metallicity is preserved even down to a single SrIrO3 layer, where the dimensionality-driven metal-insulator transition typically observed in SrIrO3 is avoided because of strong hybridization of the Ir and Ru t2g states.

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.

Intraoperative study of the functional perforasome - an experimental model.

Background and aims: The aim of this study is to find the most suitable protocol based on an animal experimental model, through the use of a fluorescent dye, determining also its minimal concentration needed to stain the skin after arterial injection, in order to evidence the functional perforasome by visual examination. Methods: Methylene blue solution was used in order to determine the territory vascularized by one perforator on fresh cadavers in many studies which introduced, as a final result, the concept of perforasome. One of the most frequent complications of perforator flaps is partial flap necrosis which could be avoided by correctly assessing pre-operatively the functional perforasome surface.Two groups of seven rats were used in order to establish a proper surgical protocol to evaluate the functional perforasome in vivo by injecting the dye. Also, the minimal concentration for methylene blue was experimentally determined. Results: The direct injection into the femoral artery of the proper concentration of dye, 1mM for methylene blue and the clamping of all the branches except the medial branch of the superficial epigastric artery is a reliable model to study the functional perforasome. Conclusions: Our study demonstrates that the intraoperative assessment with fluorescent dye of the functional perforasome by intra-arterial injection of methylene blue is an easy, affordable and very efficient method to reduce the number of partial necrosis of the perforator flaps.

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.

Length scales of interfacial coupling between metal and insulator phases in oxides.

Controlling phase transitions in transition metal oxides remains a central feature of both technological and fundamental scientific relevance. A well-known example is the metal-insulator transition, which has been shown to be highly controllable. However, the length scale over which these phases can be established is not yet well understood. To gain insight into this issue, we atomically engineered an artificially phase-separated system through fabricating epitaxial superlattices that consist of SmNiO3 and NdNiO3, two materials that undergo a metal-to-insulator transition at different temperatures. We demonstrate that the length scale of the interfacial coupling between metal and insulator phases is determined by balancing the energy cost of the boundary between a metal and an insulator and the bulk phase energies. Notably, we show that the length scale of this effect exceeds that of the physical coupling of structural motifs, which introduces a new framework for interface-engineering properties at temperatures against the bulk energetics.

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.

Composite rib and serratus anterior pedicle transfer for reconstruction of an osteomyelitis of the humerus.

We report the case of a 40 year-old male with Staphylococcus aureus osteomyelitis of the proximal humerus after open reduction and internal fixation of a fracture from motor vehicle accident. Removal of the osteosynthesis, extensive debridement and intravenous antibiotics administration was done followed by external fixation stabilization and reconstruction with a combined pedicled flap using the serratus anterior reversed flap and the 6th rib. At the last follow-up, healing of the bone flap was observed; the patient experienced useful motion of his upper extremity without any evidence of recurrent infection.

High Division of the Median Nerve with Unusually High Origin of the 3rd Space Common Digital Nerve.

BACKGROUND: Median nerve (MN) variation in the carpal tunnel has been well documented by Lanz. Encountering rarely documented variants, that do not fit into existing classifications, increases the risk of iatrogenic injury. METHODS: The random occurrence of two unclassifiable anatomical variants of the MN in the carpal tunnel gives motivation to search the literature for similar and identical cases. CASE REPORTS: This article presents two cases of very rare anatomical variants of high division of the MN. First case is a pure high branching of the 3rd space common digital nerve (CDN). The second case is a high division of the MN to a thicker lateral component and a thinner medial component. The lateral component of the MN gives off the palmar cutaneous branch (PCB), the thenar motor branch (TMB), the 1st and 2nd space CDN's and contributes medially with a branch to the 3rd space CDN. The medial component of the MN bifurcates distally into a medial and lateral branch. The lateral branch from the medial component of the MN distally unites with the medial branch of the lateral component of the MN to form the 3rd space CDN. The medial branch from the medial component of the MN has a major contribution to the 4th space CDN from the ulnar nerve. In both cases, the medial component of the MN has a transmuscular course through the flexor digitorum superficialis (FDS) muscle. DISCUSSION: Finding similar case reports from worldwide suggests the need to improve current classification of the MN variants in the carpal tunnel. CONCLUSIONS: One cannot rely entirely on the existing anatomical classifications of the MN in the carpal tunnel. There is an underappreciated risk of iatrogenic injury, especially in endoscopic carpal tunnel release, and a chance of missing out on repair of important anatomical structures in trauma cases. There is a possibility of augmenting group 3 of Lanz's classification by adding subgroup "3D High division of the MN with the medial component having a transmuscular course through the FDS muscle", stating the different distal branching patterns.

Lower limb replantation: 27 years follow up.

Replantation of lower extremity is a very complex and difficult procedure. There are still a lot of controversies about indications, even numerous scoring systems are now available that can facilitate the surgeon's decision. We present the functional results of a replanted below-knee amputation in an elderly patient, 27 years after the injury and discuss the indication for replantation.