Search Results (96)

Bronchopleural fistula is a rare but severe complication of lung resection, associated with significant morbidity and mortality, especially when an open-window thoracostomy is required. The clinical and surgical management is complex and becomes even more challenging in the presence of underlying conditions such as recurrent infections or malignancy. Postoperative management is equally demanding, as local compression may help prevent fistula recurrence but can compromise flap perfusion. A 65-year-old male with a history of right upper lobectomy and subsequent sublobar resection for lung adenocarcinoma presented with an 8 × 4 cm open-window thoracostomy complicated by chronic bronchopleural fistula and empyema. Extensive fibrosis of the surrounding tissues, including the ipsilateral latissimus dorsi muscle, limited the available reconstructive locoregional options. Reconstruction was performed using primary fistula closure reinforced with a contralateral free latissimus dorsi musculocutaneous flap and a fascia patch graft secured with cyanoacrylate-based bioadhesive. Postoperatively, continuous near-infrared spectroscopy monitoring enabled safe application of compressive bandage while minimizing the risk of flap perfusion compromise. Complete fistula closure was achieved. Apart from a surgical site abscess requiring debridement on postoperative day 7, no further complications occurred. At the 2-year follow-up, the patient remains free of fistula recurrence, wound dehiscence, or oncological relapse. We describe a novel approach for open-window thoracostomy closure combining a free musculocutaneous flap with a fascia patch graft reinforced by bioadhesive, together with postoperative perfusion monitoring using near-infrared spectroscopy. This strategy may help address both the reconstructive and postoperative challenges associated with complex bronchopleural fistulas. Full article

Background/Objectives: Behçet’s disease is a chronic relapsing multisystem inflammatory disorder characterized by recurrent mucocutaneous ulceration, vasculitis, and exaggerated inflammatory responses to minor trauma. These features may adversely affect wound healing after major head and neck oncologic reconstruction. This case report describes repeated wound breakdown after oral cavity reconstruction in a patient with Behçet’s disease and advanced floor-of-mouth squamous cell carcinoma. Methods: A 51-year-old woman with Behçet’s disease and T4N2bM0 squamous cell carcinoma involving the floor of the mouth and tongue underwent tumor resection followed by reconstruction of the oral cavity defect using a right anterolateral thigh perforator free flap. Subsequent surgical procedures included debridement of necrotic tissue, negative-pressure wound therapy, split-thickness skin grafting of the thigh donor site, and salvage tumor resection with pectoralis major myocutaneous flap reconstruction after tumor recurrence. Results: After the initial anterolateral thigh free flap reconstruction, flap perfusion was satisfactory in the immediate postoperative period; however, delayed marginal necrosis developed from the distal tongue-side flap margin, whereas the floor-of-mouth portion remained relatively stable. The right thigh donor site also developed progressive suture-line necrosis and wound dehiscence, requiring operative debridement, negative-pressure wound therapy, and split-thickness skin grafting. Although skin grafting achieved eventual donor-site coverage, partial graft necrosis and delayed secondary healing occurred. Persistent fistula and wound instability delayed postoperative radiotherapy, and recurrent floor-of-mouth squamous cell carcinoma subsequently developed approximately 6 months after the initial surgery. After salvage resection and pectoralis major myocutaneous flap reconstruction, the flap appeared viable at inset, but marginal ecchymosis, partial necrosis, and wound dehiscence again developed, requiring additional debridement, quilting sutures, and negative-pressure wound therapy. The wound gradually stabilized with staged wound management. Conclusions: This case illustrates a multifactorial pattern of repeated marginal wound breakdown after technically successful flap reconstruction in a patient with Behçet’s disease. Behçet-related pathergy-like inflammation, vasculitis, and microcirculatory dysfunction may represent possible contributing mechanisms, but they were not directly proven in this patient. In oral cavity reconstruction, such wound instability may delay adjuvant therapy and adversely affect oncologic outcomes. Careful perioperative planning, close multidisciplinary coordination, meticulous tension-free closure, early recognition of wound compromise, and readiness for staged wound management are essential in patients with Behçet’s disease undergoing major head and neck oncologic reconstruction. Full article

Background: Large segmental bone defects remain a major challenge in reconstructive surgery, particularly in the presence of impaired vascularization. Despite advances in scaffold design and biomaterials, insufficient vascular supply continues to represent the primary limitation in bone tissue engineering, often leading to impaired osteogenesis and graft failure. Objective: This review aims to analyze the role of vascularized flaps as “living bioreactors” in bone tissue engineering, focusing on their capacity to enhance scaffold vascularization, support osteogenesis, and facilitate clinical translation. Methods: A narrative review was conducted through a structured search of PubMed, Scopus, and Web of Science using combinations of the following keywords: “bone tissue engineering”, “vascularized flaps”, “arteriovenous loop”, and “in vivo bioreactor”. Relevant preclinical and clinical studies were selected based on their contribution to vascularization strategies in scaffold-based bone regeneration, with the aim of illustrating the evolution and integration of these approaches. Results: Vascularized flaps provide an established vascular network and a biologically active microenvironment that promote scaffold integration and tissue regeneration. Periosteal flaps demonstrate strong osteogenic potential, whereas muscle and omental flaps primarily act as vascular carriers and adaptable regenerative environments. AV loop-based strategies enable intrinsic axial vascularization, ensuring rapid and homogeneous perfusion of large constructs. Hybrid approaches, including regenerative matching axial vascularization (RMAV), integrate vascularized tissues with advanced biomaterials and show promising translational outcomes. Conclusions: Vascularization-driven strategies represent a paradigm shift in bone tissue engineering, moving from passive scaffold implantation to actively engineered, vascularized constructs. The integration of microsurgical techniques with advanced biomaterials offers significant potential for the development of personalized and clinically applicable bone regeneration strategies. Full article

Background/Objectives: Occipital defects with dural exposure represent a complex reconstructive challenge requiring reliable vascularized coverage to prevent severe complications. This study aims to describe a salvage reconstructive approach using a transverse cervical artery (TCA)-based inferior trapezius flap and to highlight a technical modification intended to increase flap reach. Methods: We report the case of a 61-year-old male presenting with a chronic occipital defect associated with infection following cerebellar abscess evacuation. After failure of primary closure, skin grafting, and local flap reconstruction, a regional pedicled inferior trapezius musculocutaneous flap was performed. Intraoperatively, the dorsal scapular artery (DSA) was selectively sacrificed after confirmation of dominant TCA perfusion to increase the arc of rotation. Flap perfusion was assessed clinically. Results: The flap provided adequate coverage of the defect with stable perfusion. The postoperative course was favorable, with resolution of a minor donor-site seroma. At 1- and 3-month follow-up, stable coverage, preserved cervical mobility, and satisfactory aesthetic outcomes were observed. These results were maintained at 1-year follow-up, with no functional limitation or late complications. Conclusions: This single case report suggests that a TCA-based inferior trapezius flap may represent a feasible salvage option in selected occipital defects. The intentional sacrifice of the DSA appeared to increase flap reach in this case; however, its safety and reproducibility remain uncertain. Further studies are required before this approach can be routinely recommended. Full article

Background: Acute type A aortic dissection (ATAAD) is a life-threatening condition that may be complicated by malperfusion, particularly in patients with prior aortic interventions such as Thoracic Endovascular Aortic Repair (TEVAR). Management becomes increasingly complex when the dissection involves supra-aortic branches and compromises previously placed stents. Methods: We report the case of a 58-year-old male presenting with ATAAD and left lower limb paralysis, with a history of prior TEVAR. Imaging demonstrated an entry tear in the ascending aorta with extension into the distal left main and supra-aortic branches, resulting in a dissection flap obstructing the proximal end of the TEVAR stent. The patient underwent emergency surgical intervention including a Bentall procedure, coronary artery bypass grafting (CABG), and deployment of a small Ascyrus Medical Dissection Stent (AMDS) distally within the TEVAR stent. Pre-operatively, the patient had severe lower limb ischemia due to near-complete obstruction of distal flow. Results: Following surgical intervention, there was restoration of true lumen perfusion with resolution of malperfusion. The patient was successfully weaned from cardiopulmonary bypass, extubated on post-operative day 4, and discharged on day 7 with stable hemodynamics and intact bilateral lower limb perfusion. Post-operative computed tomography (CT) demonstrated a well-seated AMDS with no evidence of ongoing false lumen perfusion. At 30-day follow-up, there was no clinical or biochemical evidence of organ malperfusion. Conclusions: The use of an AMDS deployed within a pre-existing TEVAR stent may represent an effective strategy for managing complex ATAAD with malperfusion, particularly in cases requiring combined surgical interventions. Full article

Background/Objectives: Nipple-sparing mastectomy with immediate reconstruction is a preferred option for selected patients undergoing prophylactic or therapeutic mastectomy. Optimizing postoperative wound care is essential to support healing, preserve the nipple–areola complex, and prevent delays in oncologic treatments. This retrospective observational study aimed to evaluate the clinical outcomes associated with the use of the NovoX^® Cup medical device in post-NSM surgical wound management, assessing clinical–surgical outcomes and quality of life (QoL). Methods: We conducted a retrospective observational study on 54 patients who underwent NSM with immediate reconstruction at AOUI Verona between January 2025 and January 2026; Novox^® Cup was applied intraoperatively and changed every 48 h according to protocol. Surgeon-reported outcomes were assessed by the skin flap viability scale and the complications by Clavien–Dindo classification. Patient-reported outcomes were assessed via the Wound-QoL17 questionnaire at 7, 30, and 90 days. Clinical outcomes were supported by photographic documentation. Results: Mean age was 51.5 years; BMI averaged 23.9 kg/m². Local complications occurred in 30.4% of cases (infections 12%, dehiscence 10%, seromas 4%). Mean healing time was 15 days, with 87.4% of patients having drains removed by day 14. One patient required surgical revision, and one (1.8%) experienced delayed adjuvant therapy. Wound-QoL17 responses showed minimal discomfort and high satisfaction. Clinical evaluation revealed favorable wound appearance and preserved NAC perfusion within 48 h. Conclusions: Novox^® Cup appears effective in supporting wound healing and NAC preservation after NSM, with high patient satisfaction and minimal treatment delays. Its integration into postoperative care may enhance outcomes and maintain oncologic timelines. Full article

Background: The optimal timing of cranioplasty (CP) after decompressive craniectomy (DC) remains debated. Early reconstruction may enhance neurological recovery through restoration of cerebral perfusion and cerebrospinal fluid dynamics, yet concerns persist regarding postoperative complications. Objective: To evaluate the impact of early versus delayed cranioplasty on neurological outcomes and postoperative complications in adults following decompressive craniectomy. Methods: A systematic review was conducted in accordance with PRISMA guidelines (PROSPERO ID: CRD420251123808). PubMed, OVID, and Web of Science were searched for studies published between January 2017 and December 2025. Eligible studies compared early and delayed CP in adults and reported neurological outcomes and/or complications. Results: Twenty-one retrospective cohort studies including 8462 patients were analyzed. Neurological improvement was observed in both groups across multiple validated scales (GOSE, GOS, GCS, mRS, BI, FIM, NIHSS, MMSE). Early CP was consistently associated with superior recovery, including higher one-year Barthel Index improvement (74.1% vs. 54.8%), greater FIM gains (7.31% vs. 4.66%), and higher composite recovery rates (95.6% vs. 80.0%). No study demonstrated superior recovery with delayed CP. Infection, hydrocephalus, and seizure rates were comparable between groups. However, hematoma (21% vs. 10.4%) and hygroma (7.49% vs. 4.73%) were more frequent after early CP, although hematoma rates were influenced by a large database study. Bone flap resorption was less frequent with early CP (1.44% vs. 6.26%). Conclusions: Early cranioplasty is associated with improved neurological recovery but carries an increased risk of select complications, particularly hematoma and hygroma, representing a clinically relevant trade-off. Delayed CP does not demonstrate overall superior safety due to higher bone flap resorption. Timing should be individualized, and prospective multicenter studies with standardized definitions are needed. Full article

Background/Objectives: Chronic wounds are a major source of morbidity in patients with paraplegia, often resulting in repeated treatment, prolonged hospitalization, and reduced quality of life. Reconstruction becomes particularly challenging when a wound arises in a scarred trunk region and is further complicated by deep infection, osteomyelitis, or enteric fistula. We describe the staged management of a complex left flank wound in a paraplegic patient, initially reconstructed with a quadrilateral pinwheel flap and later requiring multidisciplinary salvage for recurrence associated with rib osteomyelitis and a colocutaneous fistula. Methods: A paraplegic man in his 50s presented with a chronic left flank wound after repeated full-thickness skin graft failure and persistent Pseudomonas aeruginosa infection. After wide debridement, the approximately 7 × 7 cm defect was reconstructed with a quadrilateral pinwheel flap composed of four Limberg-style rhomboid fasciocutaneous flaps positioned at the 12, 3, 6, and 9 o’clock orientations, elevated at the level of the deep fascia, and transposed into the central defect, with adjunctive negative-pressure wound therapy (NPWT). Approximately 1 year later, recurrence with rib osteomyelitis required rib resection. During NPWT, feculent drainage led to the diagnosis of a colocutaneous fistula. Subsequent multidisciplinary treatment included fistula tract resection, colonic repair with omental patching, transposition of vascularized omentum into the chest wall cavity to obliterate dead space, continued NPWT, and delayed primary closure. Results: Initial local flap reconstruction achieved wound coverage, and immediate postoperative clinical assessment, including pinprick and refill testing, confirmed satisfactory flap perfusion; however, delayed recurrence developed in association with rib osteomyelitis. After definitive fistula surgery, dead-space management with vascularized omentum, wound conditioning with staged NPWT, and delayed primary closure, the wound healed completely. At 6 months after delayed closure, no recurrence of fistula, osteomyelitis, wound dehiscence, or soft-tissue breakdown was observed, and the patient’s daily comfort and functional independence were improved compared with the preoperative condition. Conclusions: A quadrilateral pinwheel flap may provide an effective tension-dispersing local fasciocutaneous option for selected scarred trunk defects in high-risk patients. However, when chronic wounds are compounded by deep infection and enteric fistula, durable healing depends not on flap design alone but on staged multidisciplinary management incorporating definitive source control, vascularized tissue transfer for dead-space elimination, NPWT, and appropriately timed closure. Full article

Flap reconstruction remains a cornerstone after oncologic resection, trauma, and complex wounds, yet partial necrosis, venous congestion, and delayed healing continue to drive morbidity and unplanned re-exploration. Even when macroscopic inflow and outflow are re-established, distal and border-zone tissue may remain constrained by microcirculatory dysfunction. This review frames flap compromise as a biomimetics-relevant failure of a hierarchical transport network and summarizes the vascular repair mechanisms that regenerative interventions aim to replicate. We outline key concepts governing flap perfusion, including angiosomes, choke vessels, endothelial barrier failure, mural cell support, and immune regulation within the angiogenic niche, and relate these to no-reflow, thrombo-inflammation, and impaired vascular regeneration. We then synthesize regenerative strategies aimed at durable reperfusion, spanning recombinant factors, gene and nucleic acid delivery, cell-based therapies, cell-free biologics, including extracellular vesicles and platelet-derived products, pharmacologic modulators, and biomaterial platforms that localize and sustain bioactivity. Translation will require functional perfusion endpoints, standardized reporting of delivery parameters, and safety-conscious designs that minimize aberrant angiogenesis and vector-related risks in post-resection settings. Full article

Introduction: Implant-based breast reconstruction is associated with an increased risk of ischemic complications, which may result in implant loss, suboptimal aesthetic outcomes, and delays in adjuvant oncological treatment. Additionally, axillary surgery carries a risk of upper-limb lymphedema. Indocyanine green (ICG) angiography enables more accurate real-time assessment of tissue perfusion than clinical evaluation alone, while axillary reverse mapping (ARM) facilitates the preservation of upper-limb lymphatics. The integration of these techniques reduces complications and improves both functional and aesthetic outcomes. Materials and methods: A total of 208 breast cancer patients who underwent mastectomy followed by immediate implant-based breast reconstruction were enrolled in this case–control study. The prospective intervention group received intraoperative ICG angiography at three time points and underwent ARM with ICG. Conventional surgical techniques were applied in the retrospective control group. Results: ICG angiography showed excellent diagnostic accuracy for predicting postoperative ischemic complications (AUC = 0.93, 95% CI 0.82–0.99, p < 0.001). Compared with the control group, patients in the ICG group had significantly lower rates of mastectomy skin flap necrosis (11.5% vs. 30.8%, p = 0.001), seroma (4.8% vs. 14.4%, p = 0.032), hematoma (1.9% vs. 9.6%, p = 0.033), and lymphedema (2.9% vs. 17.3%, p < 0.001). They also experienced shorter hospitalization (6.2 ± 1.9 vs. 8.0 ± 2.8 days, p < 0.001), fewer delays in adjuvant treatment initiation (16.3% vs. 32.7%, p = 0.010), and higher aesthetic satisfaction scores (81.41 ± 10.12 vs. 76.03 ± 9.74, p <0.001). Conclusions: Intraoperative indocyanine green angiography is a valuable tool for predicting ischemic complications in alloplastic breast reconstruction and is associated with reduced morbidity, fewer delays in adjuvant treatment, and improved aesthetic outcomes. Preliminary evidence suggests that axillary reverse mapping is associated with lower rates of upper-limb lymphedema. Full article

Background: In head and neck reconstructive surgery, flap loss remains a major complication and continues to represent a significant challenge in perioperative management. Although free tissue transfer is widely used, unsatisfactory outcomes are still reported across different flap procedures. Anaesthetic management plays an important role in influencing flap perfusion through its effects on systemic haemodynamics, regional blood flow, and microcirculation. However, there is currently no consensus on universally acceptable haemodynamic targets, and the impact of intraoperative strategies appears to be highly application-specific. Materials and Methods: This narrative review was conducted in accordance with the 2019 SANRA guidelines. PubMed^® was used as the primary database for literature selection. Relevant studies addressing anaesthetic management in head and neck free flap surgery were reviewed, with a particular focus on intraoperative haemodynamic control, ischemia–reperfusion injury, fluid and transfusion management, vasoactive agents, and advanced monitoring techniques. Results: Ischemia–reperfusion injury represents a major mechanism of vascular compromise in free flap surgery and has a significant impact on microcirculatory perfusion. The literature suggests that several anaesthetic strategies—including goal-directed fluid therapy, cautious use of vasopressors, and advanced haemodynamic monitoring—may support intraoperative haemodynamic stability and improve flap perfusion. Nevertheless, the magnitude of haemodynamic improvement achievable with these strategies and their effect on graft survival vary according to patient characteristics, surgical factors, and flap type. Conclusions: Current evidence indicates that anaesthetic management has the potential to contribute to improved intraoperative haemodynamic control in head and neck free flap reconstruction, thereby supporting graft viability. However, haemodynamic targets and management strategies cannot be generalised and should be interpreted within specific clinical contexts. Rather than aiming for optimisation, future research should focus on defining acceptable clinical outcomes for individual applications and on evaluating whether achievable haemodynamic improvements are sufficient to reduce flap-related complications to clinically acceptable levels. Full article

Early recognition of vascular compromise is essential for reconstructive flap survival. In human surgery, local glucose monitoring is widely used as an objective indicator of perfusion, but its application in veterinary patients is still limited. This report describes postoperative glucose measurement as a simple and minimally invasive method for evaluating flap viability in two dogs. This report describes two prospectively observed clinical cases in which local glucose measurement was applied as an adjunctive monitoring tool during postoperative flap management. Local glucose values were measured with a handheld glucometer at predefined flap and control sites. Serial readings were compared with daily assessments of flap color, temperature, turgor, and wound integrity. A previously suggested threshold of 60–62 mg/dL was used as a reference for potential perfusion compromise. In Case 1, a phalangeal fillet flap showed a brief glucose decline on postoperative days 2–3, followed by normalization and uneventful healing. In Case 2, which underwent advancement flap reconstruction after wound dehiscence, glucose values remained persistently below 60 mg/dL and preceded visible ischemia and distal necrosis. Local glucose monitoring provided rapid and clinically meaningful information about flap perfusion. Transient decreases reflected reversible postoperative congestion, whereas persistent hypoglycemia indicated progressive ischemia. These findings support the use of glucose monitoring as an adjunct in small-animal reconstructive surgery. Full article

Vascularised composite allotransplantation (VCA) has an evolving role in the reconstruction of complex functional and aesthetic deficits non-amenable to autologous or implant-based reconstructive modalities. International applications of VCA span upper extremity, face, abdominal wall, uterus, and penile transplantation, with more than 300 procedures performed worldwide. Among these, abdominal wall transplantation has uniquely contributed to the development of the sentinel skin flap (SSF) concept, in which solid organ transplant patients undergo simultaneous transplantation of a solid organ and a donor-derived vascularised skin flap, with the skin component of the SSF being trialled internationally as a means of monitoring for rejection within the solid organ allograft. Despite growing clinical success, VCA continues to face substantial barriers to wider adoption. Acute rejection remains highly prevalent, affecting up to 89% of recipients, with significant morbidity linked to intensive systemic immunosuppression. Challenges are further amplified by the unique immunological heterogeneity of composite grafts, ethical concerns surrounding identity-linked tissues, and the lack of standardised outcomes reporting across VCA subtypes. Advances in machine perfusion technologies and emerging cellular and biomaterial-based immunomodulation strategies show promise in reducing immunosuppression burden and improving graft longevity. This review outlines the current state of VCA, including clinical applications, outcomes, and mechanistic insights from pre-clinical studies, while highlighting key ethical considerations and evolving regulatory frameworks. Future progress will depend on standardised reporting systems, improved donor–recipient matching, better understanding of ischemia–reperfusion injury, and the development of next-generation immunosuppressive/immuno-modulatory therapies. Collectively, these innovations position VCA as a rapidly advancing field with significant potential to redefine reconstructive and transplant surgery. Full article

Background: Microsurgery and free tissue transfer with microanastomoses are common practices that are reliable for restoring anatomical function and/or morphology. Maintaining adequate blood flow to transferred tissue and preventing thrombosis are key challenges in improving the success of surgery. We conducted a systematic review to investigate the use, effects, and efficacy of lipo-prostaglandin E1 (lipo-PGE1) and PGE1, which have vasodilatory and anticoagulation effects, in microsurgery. Methods: Studies were reviewed for information about the administration of lipo-PGE1/PGE1, including the purpose, effectiveness, administered doses, and duration of use. This review included articles published up to 2024. Databases: PubMed, MEDLINE, and Embase were searched using the keywords: “flap” AND “prostaglandin E1” and “microsurgery” AND “prostaglandin E1.” Results: The initial database search yielded 359 citations; 14 were included in our study with qualitative analysis. These 14 original articles reported PGE1/lipo-PGE1 use in microsurgery for the reconstruction of different anatomical sites, with the most common being the head and neck. Twenty-one different flaps were used; the most common flaps used in head, neck, and lower limb reconstructions were anterolateral thigh flaps. Most studies reported using PGE1/lipo-PGE1 as an antithrombotic, an anticoagulant, a vasodilator, and a strategy to examine blood flow post administration. Only one study compared its effectiveness between two groups and showed significantly lower perfusion-related complications in the prostaglandin group than in the control group. Conclusions: Lipo-PGE1/PGE1 has potential vasodilator effects that increase blood flow through free flaps and potential anticoagulant properties that help prevent thrombosis in microanastomoses. However, multicenter, randomized controlled studies are needed to fully elucidate its benefits. Full article

Background/Objectives: The goal of reconstructive hand surgery is to achieve both functional and aesthetic restoration. The primary aim of this study is to perform a detailed, practice-oriented evaluation of perforator-based and local flaps for soft-tissue reconstruction of the hand and digits, focusing specifically on their functional reliability, anatomical consistency, complication profile, and aesthetic integration in a real-world, high-complexity referral population. Methods: This retrospective single-center study included 37 patients with soft tissue defects of the hand that required flap coverage between September 2021 and September 2024. The study assessed patient demographics, defect characteristics, flap selection, surgical techniques, and outcomes including satisfactory soft tissue coverage, functional results and occurrence of complications. Various perforator flaps were analyzed, including the dorsal metacarpal artery flap, reverse radial forearm flap, reverse posterior interosseous artery flap, reverse homodigital and heterodigital island flaps, and the thenar flap. Results: Satisfactory soft tissue coverage was achieved in 35 out of 37 patients. One case involved partial distal flap necrosis, and another presented with Foucher flap failure. The remaining flaps demonstrated stable integration, preserved perfusion, and durable soft-tissue coverage with satisfactory contour and pliability. Functional outcomes were favorable, with restoration of joint mobility and absence of secondary deformities. Conclusions: This study supports the continued use of perforator and local flaps in upper extremity reconstruction, emphasizing the need for individualized planning to optimize the outcomes. Full article