Unconventional Perfusion Flaps in the Experimental Setting: A Systematic Review and Meta-Analysis.

BACKGROUND: Unconventional perfusion flaps offer multiple potential advantages compared with traditional flaps. Although there are numerous experimental articles on unconventional perfusion flaps, the multiple animal species involved, the myriad vascular constructions used, and the frequently conflicting data reported make synthesis of this information challenging. The main aim of this study was to perform a systematic review and meta-analysis of the literature on the experimental use of unconventional perfusion flaps, to identify the best experimental models proposed and to estimate their global survival rate. METHODS: The authors performed a systematic review and meta-analysis of all articles written in English, French, Italian, Spanish, and Portuguese on the experimental use of unconventional perfusion flaps and indexed to PubMed from 1981 until February 1, 2017. RESULTS: A total of 68 studies were found, corresponding to 86 optimized experimental models and 1073 unconventional perfusion flaps. The overall unconventional perfusion flap survival rate was 90.8 percent (95 percent CI, 86.9 to 93.6 percent; p < 0.001). The estimated proportion of experimental unconventional perfusion flaps presenting complete survival or nearly complete survival was 74.4 percent (95 percent CI, 62.1 to 83.7 percent; p < 0.001). The most commonly reported animal species in the literature were the rabbit (57.1 percent), the rat (26.4 percent), and the dog (14.3 percent). No significant differences were found in survival rates among these species, or among the diverse vascular patterns used. CONCLUSION: These data do not differ significantly from those reported regarding the use of unconventional perfusion flaps in human medicine, suggesting that rabbit, rat, and canine experimental unconventional perfusion flap models may adequately mimic the clinical application of unconventional perfusion flaps.

Stab injury to the preauricular region with laceration of the external carotid artery without involvement of the facial nerve: a case report.

BACKGROUND: Open injuries to the face involving the external carotid artery are uncommon. These injuries are normally associated with laceration of the facial nerve because this nerve is more superficial than the external carotid artery. Hence, external carotid artery lesions are usually associated with facial nerve dysfunction. We present an unusual case report in which the patient had an injury to this artery with no facial nerve compromise. CASE PRESENTATION: A 25-year-old Portuguese man sustained a stab wound injury to his right preauricular region with a broken glass. Immediate profuse bleeding ensued. Provisory tamponade of the wound was achieved at the place of aggression by two off-duty doctors. He was initially transferred to a district hospital, where a large arterial bleeding was observed and a temporary compressive dressing was applied. Subsequently, the patient was transferred to a tertiary hospital. At admission in the emergency room, he presented a pulsating lesion in the right preauricular region and slight weakness in the territory of the inferior buccal branch of the facial nerve. The physical examination suggested an arterial lesion superficial to the facial nerve. However, in the operating theater, a section of the posterior and lateral flanks of the external carotid artery inside the parotid gland was identified. No lesion of the facial nerve was observed, and the external carotid artery was repaired. To better understand the anatomical rationale of this uncommon clinical case, we dissected the preauricular region of six cadavers previously injected with colored latex solutions in the vascular system. A small triangular space between the two main branches of division of the facial nerve in which the external carotid artery was not covered by the facial nerve was observed bilaterally in all cases. CONCLUSIONS: This clinical case illustrates that, in a preauricular wound, the external carotid artery can be injured without facial nerve damage. However, no similar description was found in the reviewed literature, which suggests that this must be a very rare occurrence. According to the dissection study performed, this is due to the existence of a triangular space between the cervicofacial and temporofacial nerve trunks in which the external carotid artery is not covered by the facial nerve or its branches.

A stab wound to the axilla illustrating the importance of brachial plexus anatomy in an emergency context: a case report.

BACKGROUND: Although open injuries involving the brachial plexus are relatively uncommon, they can lead to permanent disability and even be life threatening if accompanied by vascular damage. We present a case report of a brachial plexus injury in which the urgency of the situation precluded the use of any ancillary diagnostic examinations and forced a rapid clinical assessment. CASE PRESENTATION: We report a case of a Portuguese man who had a stabbing injury at the base of his left axilla. On observation in our emergency room an acute venous type of bleeding was present at the wound site and, as a result of refractory hypotension after initial management with fluids administered intravenously, he was immediately carried to our operating room. During the course of transportation, we observed that he presented hypoesthesia of the medial aspect of his arm and forearm, as well as of the ulnar side of his hand and of the palmar aspect of the last three digits and of the dorsal aspect of the last two digits. Moreover, he was not able to actively flex the joints of his middle, ring, and small fingers or to adduct or abduct all fingers. Exclusively relying on our anatomical knowledge of the axillary region, the site of the stabbing wound, and the physical neurologic examination, we were able to unequivocally pinpoint the place of the injury between the anterior division of the lower trunk of his brachial plexus and the proximal portion of the following nerves: ulnar, medial cutaneous of his arm and forearm, and the medial aspect of his median nerve. Surgery revealed a longitudinal laceration of the posterior aspect of his axillary vein, and confirmed a complete section of his ulnar nerve, his medial brachial and antebrachial cutaneous nerves, and an incomplete section of the ulnar aspect of his median nerve. All structures were repaired microsurgically. Three years after the surgery he showed a good functional outcome. CONCLUSIONS: We believe that this case report illustrates the relevance of a sound anatomical knowledge of the brachial plexus in an emergency setting.

The self-inflicted burns-Typology and its prognostic relevance in a 14-year review of self-inflicted burns in a tertiary referral centre.

Self-inflicted burns (SIB) are responsible for 2-6% of admissions to Burn Units in Europe and North America, and for as many as 25% of admissions in developing nations. Recently, a promising new tool was proposed to stratify SIB patients in the following subgroups: "typical", "delirious", and "reactive". However, as far as the authors know, the clinical usefulness of this instrument has not yet been validated by others. We retrospectively reviewed the clinical records of 56 patients admitted to our Burn Unit with the diagnosis of SIB injury in the past 14 years. The following parameters were evaluated: demographic features; psychiatric illness; substance abuse; mechanism of injury; burn depth, total body surface area (TBSA) involved, Abbreviated Burn Severity Index (ABSI); length of hospital stay, and mortality. All patients were followed up by a psychologist and a psychiatrist, and were classified according to the SIB-Typology Tool, into three classes: "typical", "delirious" and "reactive". There was a slight predominance of the "typical" type (44.6%), followed by the "delirious" type (30.4%), and, finally the "reactive" type (25.0%). Mortality was significantly higher in the "typical" subgroup. In conclusion, the SIB-Typology Tool appears to be a valuable instrument in the clinical management of SIB patients.