A novel technique for the safe transfer of the pedicle of a free flap in head and neck reconstruction using a nasopharyngeal airway connected to a negative pressure suction Abstract Microsurgical free flaps are the accepted standard of care for head and neck reconstruction after tumor resection. In many cases, the pedicle of the free flap needs to be tunneled under bone and/or soft tissues to reach the recipient vessels in the site of anastomosis, most often located in the neck. Passing the pedicle through the dissected tunnel is always a blind procedure that increases the risk of shearing, turning, twisting, or kinking and in the worst case disconnection. We hereby demonstrate a novel and simple technique for a safe delivery of the pedicle to the anastomosis site in the neck using a nasopharyngeal airway (nasal airway) connected to negative pressure suction. In all of our cases, no complications were noted during the pedicle delivery to the neck while using this method. Level of Evidence: Level IV, therapeutic study.

Radiation-associated angiosarcoma after autologous breast reconstruction: report of two cases in a plastic surgery unit Abstract Radiation-associated breast angiosarcoma is a rare diagnosis but is commonly reported. Angiosarcoma occurring in non-breast tissue in breasts that have been reconstructed with autologous tissue following mastectomy is extremely rare. In our unit, we have managed two patients with angiosarcoma arising in non-breast tissue autologous reconstructions. Our report emphasises that any tissue treated with radiotherapy—that is, the residual mastectomy skin flaps or non-breast tissue autologous reconstructions—are at a risk of secondary angiosarcoma. We also discuss recommended surgical management, surveillance and genetic testing. Level of Evidence is V, risk study.

Replantation and revascularization of the upper extremity: clinical experience of a microsurgical department in Portugal Abstract Background Since the pioneering works of Malt and Komatsu and Tamai in the 1960s, thousands of replantations and revascularizations of the upper extremity have been performed worldwide. The advent of microsurgery allowed surgeons to replant or revascularize essentially any amputated part. However, the mechanism of injury or patient comorbidities are important factors that can affect the outcomes. Methods Patients submitted to upper extremity replantation or revascularization between 2014 and June 2018 were retrospectively analyzed. Demographic features, type of accident, mechanism of injury, amputation level, and success rate were examined. Results Over the 4.5-year period, 45 replantations and 20 revascularizations were performed. The vast majority of patients were male. The mean age was 45.7 years old in the replantation group and 49.2 years old in the revascularization group. In both groups, the crush/avulsion injury was the most common mechanism. The overall success rate was 57.8% in replantation and 75% in revascularization. The failure in the replantation group was mainly due to arterial insufficiency. Conclusions The success of revascularization is higher than replantation; however, the mechanism of injury seems to be a critical determinant of the outcome. Level of Evidence: Level IV, therapeutic study.

Liposuction fat emboli resulting in myocardial infarction: a case report and review of the literature Abstract Liposuction is a well-tolerated and safe procedure performed by plastic surgeons. Rare, major complications include infection, perforation of abdominal wall/viscus, and fat emboli. Fat emboli, seen more often after long bone fractures, are rarely associated with liposuction. We report the only known case of myocardial infarction (MI) secondary to fat embolism in the setting of post-procedural liposuction. A review of the literature was undertaken to elucidate the pathophysiology of liposuction-associated fat embolism, identify patient and procedural risk factors, discuss diagnostic criterion, and identify management of this rare but potentially fatal complication. Level of Evidence: V Type of study: Risk study

The use of a Gore-Tex prosthesis to stabilise venous drainage in an amputated distal forearm replantation Abstract Venous drainage disorders are one of the common complications after peripheral limb replantation. We report a middle-aged male patient who underwent a macro-amputation of the distal forearm at the wrist as part of an occupational accident. After successful replantation, a postoperative venous drainage disorder develops, which despite multiple revisions and the installation of a wide venous grafts could not be permanently repaired and endangered the preservation of the hand. The use of a Gore-Tex prosthesis allows a sufficient venous drainage and was the last option to preserve the limb. As far as we know, the available sources give no information about the use of Gore-Tex prostheses in venous drainage restoration in a case of hand replantation. The resulting limb drainage was sufficient, exhibiting both stability and minimal complications in healing. Despite significant advances in surgical technique, replanting the amputated hand in the forearm remains a challenge for the reconstructive surgeons’ community.

“TRANS”-questionnaire (TRANS-Q): a novel, validated pre- and postoperative satisfaction tool in 145 patients undergoing gender confirming mastectomies

Total breast reconstruction with fat graft after serial expander deflation: a case series Abstract Fat graft popularity has increased over the last few decades, finding a widespread pattern of application in oncological reconstruction, wound therapy and cosmetic surgery. Recently, the fat graft has been used for breast volume replacement after skin modelling by conventional tissue expanders positioned during mastectomy or after forced removal of prostheses due to complications. Our purpose was to assess fat grafting feasibility and safety, indicating its low rate of complications. We retrospectively analysed 7 patients treated with autologous fat grafts after oncological surgery for breast cancer. Patients not eligible for implant reconstruction and patients who refused implants were included. We analysed age, BMI (Body Mass Index), expansion rate and grafting data (session numbers, injected volume in each session and complication rates). Clinical examinations were performed every 6 months for 1 year after complete reconstruction to evaluate adipose tissue reabsorption and, eventually, further required fat grafting sessions. The aesthetic outcomes were excellent in all of the patients in our series. According to patient surveys, the satisfaction rate was very high. The filled expanders’ final volumes varied from 270 to 630 mL (average: 420 mL). The number of fat grafting sessions ranged between 2 and 3 (average 2.43), and the injected grafting volume during each session varied from 35 to 300 ml (average 175.43 ml). Expander deflation during each surgery session varied from 50 to 270 ml (average 100.63). No complications were reported. Our technique is useful and innovative and leads to good aesthetic results with shorter hospital recovery and low complications rates, compared to major reconstructive surgery. Moreover, the oncological safety appears to be uncompromised. Therapeutic, IV.

Skin wound healing properties of Hypericum perforatum , Liquidambar orientalis , and propolis mixtures Abstract Traditional formulation therapies based on natural origin compounds offer new alternatives for treatment of skin wounds. Hypericum perforatum (HP), Liquidambar orientalis (LO), and propolis have been proved to promote skin wound healing. Extracts of these compounds are traditionally used as folk remedies. They all have different effects on each phases of wound healing. Wound healing effects of the mixtures of these compounds were investigated. HP, LO, and propolis were prepared as combinations of mixtures at an equal rate. Fifty Spraque-Dawley rats were included in this study. They were divided into the following 5 groups: group 1 (control), group 2 (HP-propolis, 1:1), group 3 (HP-LO, 1:1), group 4 (LO-propolis, 1:1), and group 5 (HP-LO-propolis, 1:1:1). Two incisional wounds were made and primarily closed on the interscapular region of every rat. Formulations were applied daily on the wounds. Biopsies were taken on days 3, 7, and 21 postoperatively from every rat. Histopathological and tensile strength parameters were analyzed. Angiogenesis and epithelialization rates were significantly higher in treatment groups compared with control (p < 0.05). Inflammation was significantly lower (p < 0.05) in treatment groups compared with control. There was no significance in tensile strength between groups. There was no difference between treatment groups. Hypericum perforatum, Liquidambar orientalis, and propolis have all improved wound healing in incisional wounds. Although they produced different effects on various parameters, mixtures of these compounds ensure a more stable response to wounds. As a result, we can mention about a positive synergy between the compounds. Level of Evidence: Level III, Experimental study.

Outcomes of prepectoral implant-based breast reconstruction with Braxon® acellular dermal matrix—a single-centre experience Abstract Background Single-stage direct-to-implant reconstruction is the most common method of reconstruction in the UK after a mastectomy. Prepectoral implant placement with full implant coverage using acellular dermal matrix (ADM) is a relatively new technique. We report on long-term outcomes of prepectoral immediate breast reconstruction (IBR) using Braxon® ADM from a single institution. Methods All patients operated for a mastectomy with IBR using Braxon® from January 2016 to March 2018 were included in the study. The demographic details, treatment details and short- and long-term outcomes were evaluated. Factors affecting complication rates were analysed. Patient-reported outcome measures were studied using BREAST-Q questionnaires. Results One hundred and sixteen reconstructions performed in 98 patients were included in the study. The median age was 50 years with a mean body mass index of 27.33 kg/m2. The median follow-up period was 440 days. The implant-related major complication rate was 17%, with an unplanned readmission rate of 22.4% and a return to theatre rate of 21.4%. Early complications were significantly higher in patients with node-positive disease. Delayed complications were seen in nine patients. The implant loss rate was 4.3%. The mean BREAST-Q scores were 78 for satisfaction with treatment and 64 for satisfaction with breast domains. The outcomes were comparable to reported national data. Conclusions Prepectoral implant-based reconstruction with Braxon has comparable complication rates with good long-term aesthetic and patient-reported outcomes. Further studies with larger cohort and longer follow-up are needed. Level of Evidence—Level III, therapeutic study.

Antibiotic prophylaxis: current recommendations in plastic surgery Abstract Background Guidelines for prophylactic antibiotics in surgery have long been established; however, few have focused on recommendations in plastic surgery. Surgical site infection rates remain low, yet the use of prophylactic antibiotics has surged in the past 30 years. This article summarizes current recommendations of prophylactic antibiotic use to produce consensus guidelines in plastic surgery. Methods A literature review was conducted in the PubMed, Cochrane, and Ovid databases and studies were included if randomized controlled trials indicated a statistically significant decrease in surgical site infections. Surveys conducted by the American Society of Plastic Surgeons regarding prophylactic antibiotic use from 1975, 1985, 2000, and 2010 were compiled and analyzed. Results Of 143 articles found, nine randomized controlled trials showed a reduction in surgical site infections after antibiotic prophylaxis for specific plastic surgery procedures. There are evidence-based recommendations for prophylactic antibiotics in breast surgery, abdominoplasty, contaminated hand or face surgery, prosthetic surgery, rhinoplasty, microsurgery, and acute and burn reconstruction cases. The proportion of plastic surgeons using prophylactic antibiotics has steadily increased from 1975 to 2010 with a significant increase from 2000 to 2010. Conclusions Systemic antibiotic prophylaxis is recommended for use in breast surgery, abdominoplasty, contaminated hand or face surgery, prosthetic surgery, rhinoplasty, microsurgery, and acute and burn reconstruction cases. Recent surveys indicate that the majority of plastic surgeons continue to use prophylactic antibiotics in clean cases of the hand, face, and body despite recommendations. Additional procedure-specific randomized controlled trials are necessary to provide evidence-based recommendations for antibiotic prophylaxis in plastic surgery. Level of Evidence: Level IV, risk / prognostic study