Search Results (207)

Background/Objectives: Postoperative infection is the leading cause of limb loss after microsurgical reconstruction of diabetic foot ulcers (DFUs), and povidone-iodine alone neither disrupts wound-bed biofilm nor penetrates hyperkeratotic debris. We assessed the feasibility of whole-field preoperative antisepsis with a pH-optimized sodium hypochlorite (NaOCl) cleanser applied before povidone-iodine draping. Methods: Consecutive patients undergoing microsurgical DFU reconstruction (January 2023–May 2024) were grouped by date of protocol introduction into pre-protocol (n = 9) and post-protocol (n = 6) cohorts. Primary outcome: technical feasibility, assessed by protocol completion, operative time, flap survival, limb salvage, and flap revision. Secondary, descriptive: postoperative infection, early (≤30 days) or late (>30 days). Results: The protocol was delivered as specified in all six post-protocol patients, without procedural modification or attributable adverse event. Operative time did not differ (388 vs. 430 min; p = 0.596); flap survival and limb salvage were 100% in both groups, with one flap revision per group. Baseline characteristics were comparable. Early infection was similar (16.7% vs. 11.1%; p = 1.000); late infection was absent post-protocol versus 33.3% pre-protocol (OR 0.14, 95% CI 0.01–3.4); and total infection was 16.7% versus 44.4% (OR 0.33, 95% CI 0.04–3.0). Follow-up was asymmetric (4.5 vs. 24.5 months); a 6-month landmark analysis showed 0 of 3 versus 3 of 6 (p = 0.464). Conclusions: Whole-field preoperative NaOCl antisepsis was technically feasible, with no adverse effect on flap survival or limb salvage. No statistically significant differences in the parameters were detected, though the sample is too small to establish comparability. An adequately powered trial is required. Full article

Background/Objectives: Frailty is increasingly recognized as a clinically relevant marker of reduced physiological reserve in surgical oncology. The modified 5-item frailty index (mFI-5) is simple and practical, but its clinical significance in oral squamous cell carcinoma (OSCC) remains incompletely defined. This study evaluated the association between mFI-5-defined frailty and postoperative complications, especially postoperative delirium, as well as survival outcomes in patients undergoing surgery for OSCC. Methods: We retrospectively analyzed 127 patients who underwent surgical resection for OSCC with postoperative high care unit (HCU) management between 2013 and 2021. Frailty was defined as an mFI-5 score of ≥2. Clinical characteristics, postoperative outcomes, HCU stay, length of hospital stay, overall survival (OS), and disease-free survival (DFS) were compared between frail and non-frail groups. Univariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for postoperative complications. An exploratory multivariable logistic regression analysis for postoperative delirium was performed using age ≥65 years and sex as covariates. Delirium was retrospectively assessed from clinical documentation considered consistent with DSM-5 criteria. Results: Twenty-one patients (16.5%) were classified as frail. Postoperative delirium occurred more frequently in frail patients than in non-frail patients (42.9% vs. 19.8%; p = 0.023). In a multivariable logistic regression model adjusted for age ≥65 years and sex, mFI-5-defined frailty was significantly associated with postoperative delirium (adjusted OR, 3.07; 95% CI, 1.08–8.60; p = 0.035). No significant association was observed for pneumonia, surgical site infection, or free-flap reoperation. Frailty was not significantly associated with HCU stay, length of hospital stay, OS, or DFS. Conclusions: mFI-5-defined frailty was associated with postoperative delirium but not with survival outcomes in this OSCC cohort. Because this retrospective study was limited by sample size, comorbidity-driven mFI-5 scoring, non-standardized delirium screening, and potential residual confounding, mFI-5 should be interpreted as a convenient screening marker rather than a stand-alone predictor. Comprehensive perioperative assessment incorporating frailty, nutrition, sarcopenia, cognition, tumor burden, and treatment-related factors may better identify patients at risk. Full article

Background/Objectives: Robotic-assisted breast reconstruction with deep inferior epigastric perforator (DIEP) flap has been developed as a minimally invasive alternative to conventional open DIEP harvest, having the primary goal of reducing donor-site morbidity while preserving flap reliability. Methods: A targeted literature search was performed in PubMed using the keywords “robotic” AND “DIEP”. Following title, abstract and reference screening, 10 studies were included in the final analysis. The current narrative review summarizes the existing literature regarding robotic versus conventional DIEP flap reconstruction, concentrating on abdominal wall preservation, postoperative pain and recovery, operative time, flap survival, and complication rates, with respect to learning curve and feasibility. Results: The included studies demonstrate significantly shorter fascial incisions, together with reduced abdominal wall disruption in robotic DIEP harvest compared with conventional techniques. However, current evidence has not demonstrated that this anatomical difference translates into clinically significant reductions in donor-site morbidity. Some comparative studies also report lower postoperative pain scores and shorter hospital stay in robotic cohorts. Flap survival and overall complication rates appear comparable between robotic and conventional DIEP reconstruction. However, robotic surgery remains linked to longer operative times and higher infrastructural requirements. Conclusions: Robotic DIEP reconstruction represents a feasible and potentially advantageous evolution in autologous breast reconstruction, but larger prospective multicenter studies with long-term follow-up are necessary to establish definitive superiority over conventional techniques. Full article

Background and Objectives: The effects of nicotine on wound healing and flap survival remain controversial. While smoking is associated with increased flap complications, emerging evidence suggests that nicotine may exert dose- and duration-dependent effects. This study aimed to investigate how short-term, low-dose nicotine affects flap survival and to evaluate its potential role in oxidative stress and ferroptosis. Materials and Methods: Twelve adult male BALB/c mice were randomly assigned to either a control group or a nicotine-treated group, with six mice in each group. Nicotine, at a dose of 2 mg/kg, was given subcutaneously for fourteen days before flap surgery. This treatment continued for seven days after the surgery. A dorsal random-pattern skin flap model was established in all animals. The flap necrosis area was assessed on postoperative day 7 using planimetric analysis. Serum and tissue glutathione peroxidase 4 (GPX4) levels and serum malondialdehyde (MDA) levels were measured. Histopathological evaluation included epithelialization, microvascular density, neovascularization, fibroblast density, and inflammatory cell infiltration. Results: Nicotine treatment significantly reduced flap necrosis compared with the control group. Histopathological analysis demonstrated significantly increased epithelialization and microvascular density in the nicotine-treated group, whereas no significant differences were observed in neovascularization, fibroblast density, or inflammatory cell infiltration. Biochemical analyses revealed no significant differences in serum or tissue GPX4 levels or serum MDA levels between the groups. Conclusions: Short-term nicotine administration enhanced flap survival, correlating with increased epithelialization and microvascular density, while not significantly affecting markers of oxidative stress or ferroptosis. These results imply that the positive impact of nicotine on flap viability might be largely attributable to vascular processes rather than pathways involving oxidative stress. Full article

The study presents a numerical analysis of a wave energy converter in the form of a rigid flap located adjacent to a vertical breakwater wall, intended for operation under the moderate wave climate conditions of the Baltic Sea. A simplified first-order dynamic model (1 DOF) was employed, enabling parametric evaluation of energy yield and structural loads. The analysis was divided into two regimes: regular waves, treated as the operational (power production) mode, and breaking waves, interpreted as the loading condition. For regular waves, mean and peak power outputs were determined, and energy consistency was verified with respect to the available wave power flux. In the impulsive regime, the energy within a specified time window was evaluated, and a parametric load intensity index was introduced to define the transition to survival mode. Artificial intelligence tools were used for parameter space exploration, iterative tuning of PTO damping, and validation of results. The obtained results indicate a significant trade-off between maximizing energy yield and limiting dynamic loads. The results are therefore interpreted as trend-oriented, order-of-magnitude estimates for a conceptual device, not as a final design basis or a quantitative prediction of annual energy production. The role of AI in this work is limited to workflow support: generation of simulation variants, iterative PTO-damping selection under explicit constraints, consistency checks, and aggregation of outputs; no machine-learning hydrodynamic surrogate or data-driven validation model is claimed. Clarification: the numerical results are presented as screening-level estimates from a simplified 1 DOF model. They are not claimed to replace wave-tank, field, or high-fidelity CFD validation, and the quantitative values should be interpreted as preliminary design indicators rather than direct device-performance predictions. Full article

Background/Objectives: Reconstruction of complex soft-tissue defects in the lower extremity remains a significant challenge in reconstructive surgery, necessitating reliable vascularized tissue coverage when local options are exhausted. Since 1984, the free ALT flap has been recognized for its versatility, consistent vascular anatomy and low donor-site morbidity. Methods: A two-pronged approach was used, consisting of a systematic review of 18 clinical studies (published 2015–2025, n > 3400) and a retrospective analysis of 20 patients treated for high-energy traumatic defects at a single center (2017–2021). Primary endpoints included flap survival, complication rates, and functional outcomes. Results: The retrospective cohort demonstrated a 90% flap survival rate, which was not significantly different from the figure of 92.4% reported in the literature (p = 0.661). The overall complication rate was 40%, significantly higher than the 7.4% literature average (p < 0.001). Most complications were localized wound-healing disorders, such as partial necrosis, associated with the zone of injury in trauma. Despite these complications, a 100% limb salvage rate was achieved. Good functional outcomes, defined as regaining weight-bearing capacity, were observed in 80% of patients, consistent with the literature benchmarks (84.8%, p = 0.532). Conclusions: Within the limitations of this retrospective cohort and systematic review, the findings suggest that the free ALT flap is a reliable option for lower-extremity reconstruction, providing high flap survival and favorable functional outcomes despite a relatively high rate of localized wound complications in complex trauma cases. Full article

Background and Objectives: Extramammary Paget’s Disease (EMPD) of the perineal region is a rare intraepidermal adenocarcinoma requiring wide excision, resulting in extensive defects that are challenging to reconstruct while preserving contour and function. This descriptive case series evaluated a reconstructive selection strategy using pedicled superficial circumflex iliac artery perforator (SCIP) flaps and pedicled anterolateral thigh (ALT) flaps for perineal defects following wide excision of EMPD. Materials and Methods: This retrospective case series reviewed patients with perineal EMPD who underwent wide excision followed by reconstruction using pedicled SCIP flaps or pedicled ALT flaps. Patient demographic and lesion characteristics, operative and flap characteristics, post-reconstruction complications, oncologic outcomes, and satisfaction were analyzed. Results: 15 patients (mean age 63 years, SD 7.3) were included in this case series. Ten patients underwent reconstruction using pedicled SCIP flaps (mean 106 cm², SD 23.3), and five patients with pedicled ALT flaps (mean 245.2 cm², SD 41.2). All flaps survived, but one patient developed limited partial necrosis managed with secondary healing. During a mean follow-up of 17.7 months (SD 1.3), one patient (6.7%) developed recurrence and eventually distant metastasis resulting in death. Among the 14 surviving patients, 13 (92.9%) reported overall satisfaction with cosmetic and functional outcomes assessed using a non-validated ordinal scale. Conclusions: Pedicled SCIP and ALT flap reconstruction provides reliable, well-vascularized tissue coverage for perineal EMPD defects and achieves generally favorable short-term outcomes. The choice between flap types should be tailored to the defect size, location, and patient characteristics. Full article

Background: Foot degloving injuries are associated with extensive soft-tissue disruption, compromised perfusion, and a high risk of flap necrosis. Hyperbaric oxygen therapy (HBOT) is known to enhance tissue oxygenation and support flap survival; however, its application in pediatric patients may be limited due to poor cooperation, intolerance to chamber-based treatment, and limited accessibility. Case Presentation: A 7-year-old girl presented with a crush injury to the left foot after being run over by a vehicle, resulting in severe soft-tissue damage. Evaluation revealed a dorsal foot degloving injury, a proximal phalanx fracture of the great toe, and dislocations of the fourth proximal interphalangeal and fifth distal interphalangeal joints. Emergency surgery included open reduction, K-wire fixation, debridement, and artificial dermal grafting using Pelnac. On postoperative day 1, the flap showed signs of compromised perfusion. As HBOT was not feasible, topical oxygen therapy using Natrox was applied continuously for 17 days. Serial wound assessments demonstrated gradual improvement in flap viability. Although ischemic changes developed in the toes, necrosis remained superficial and was successfully managed with local debridement and dressings. Residual skin defects with partial necrosis were treated with split-thickness skin grafting, which healed without major complications. The patient resumed ambulation after splint removal. Conclusions: In pediatric patients with compromised flaps in whom HBOT is not feasible, topical oxygen therapy may serve as a practical adjunctive treatment option. Although its independent effect cannot be established in a single case, this report suggests its potential role in flap salvage and in limiting tissue necrosis. Full article

Background/Objectives: Reconstruction of full-thickness soft-tissue defects of the heel can be challenging due to the specific structural and functional demands of this region. Local flaps are often used due to their ability to provide durable and sensate coverage. This case series and systematic review aim to assess their surgical efficacy and reported outcomes, particularly in the context of the rhomboid flap. Methods: A systematic review was conducted in accordance with PRISMA guidelines, using PubMed, Cochrane and EBSCO. Studies published up to March 2026 evaluating local flaps were included, whereas distant pedicled and microvascular flaps were excluded. Defect size, flap types and surgical outcome were extracted and synthesized in a comparative table. In addition, we present four clinical cases of full-thickness soft-tissue heel defects reconstructed with a local rhomboid flap. This retrospective, single-center case series includes patients treated at our institution between January 2023 and March 2026, with initial debridement followed by flap coverage. Results: The four patients had a mean defect size of 4.1 cm². All defects ultimately healed, though one case demonstrated delayed wound healing. Eventually, neither donor-site morbidity, nor recurrence were observed during a mean follow-up of 7.4 months (range 1 to 17 months). Nine studies were included in the review, encompassing 56 patients. Despite the variety of the studies regarding design and flaps used, all focused on outcomes, including flap survival, complication rate, and functional recovery. Local flaps appear to be a feasible option for this type of soft-tissue defect; however, they seem to be limited to small defects. Conclusions: Local flaps may represent a valuable option for small full-thickness heel defects up to 6 cm² according to the “like-with-like” principle. They are associated with low surgical morbidity and do not compromise subsequent reconstructive options, making them a reasonable first-line approach. Limitations include the small sample size, retrospective design, the unequal follow-up time, as well as the absence of standardized functional outcome assessment. Full article

The surgical management of extremity bone defects, particularly post-traumatic nonunion wounds, remains a challenge. Vascularized bone flaps (VBFs), widely used for mandibular reconstruction in head and neck oncologic surgery, are less established in extremity reconstruction and are typically performed freehand, which has several limitations. In the past decade, virtual surgical planning (VSP) and computer-aided design and modeling (CAD-CAM) technology have enabled patient-specific 3D-printed models to guide reconstruction. While this technology has been used extensively in head and neck reconstructive surgery, its application to extremity reconstruction is less well-documented. This case series evaluates the feasibility, safety, and surgical utility of VSP and in-house CAD-CAM manufacture of 3D-printed models and cutting guides for post-traumatic non-healing extremity reconstructions using VBFs. Eight patients at a single tertiary academic center underwent VBF reconstruction guided by patient-specific models and cutting guides, with cases grouped into categories (humerus, femur, and tibia). The multi-disciplinary workflow supported preoperative visualization, osteotomy planning, and intraoperative execution. All vascularized flaps survived, and radiographic union was documented in patients with adequate follow-up. These findings suggest that integrating VSP and CAD-CAM into trauma-associated VBF extremity reconstruction is feasible and safe and may improve reconstructive accuracy and enhance multi-disciplinary team workflow, potentially contributing to improved clinical outcomes. Full article

Background: Recovery after major head-and-neck reconstruction extends beyond flap survival and wound closure, involving swallowing, psychological adaptation, body image, and overall quality of life. Integrated multidimensional assessments remain limited in routine reconstructive outcomes research. Aim: The aim of this study was to characterize and compare six-month multidimensional recovery—clinical, functional, nutritional, psychological, and body-image outcomes—between microvascular free-flap and regional pedicled-flap reconstruction and to identify factors that stratify risk for persistent functional and psychosocial impairment. Methods: We conducted a single-center prospective cohort study at the “Victor Babeș” University of Medicine and Pharmacy, Timișoara, Romania, enrolling 87 adults undergoing major reconstructive surgery after ablative treatment of head-and-neck defects (52 microvascular free flaps; 35 regional pedicled flaps). Patients were assessed at baseline and 6 months using the SF-36, WHOQOL-BREF, Body Image Scale (BIS), HADS, PHQ-9, GAD-7, Functional Oral Intake Scale (FOIS), speech intelligibility, and PEG/tracheostomy dependence. Results: At 6 months, most SF-36 and WHOQOL-BREF domains improved with moderate effect sizes (d = 0.3–0.7; all p ≤ 0.009), and body image distress decreased significantly (ΔBIS −2.9 ± 4.6; p < 0.001), whereas social functioning showed no robust gain (p = 0.098; not surviving false-discovery-rate correction). Pedicled reconstruction was associated with higher PEG dependence (37.1% vs. 9.6%; p = 0.005) and worse FOIS (4.7 ± 1.4 vs. 5.6 ± 1.2; p = 0.003). Major complications were linked to blunted or worsening psychological trajectories and a threefold higher rate of clinically significant depression (HADS-D ≥ 11: 66.7% vs. 18.7%; p = 0.001). In a reduced four-predictor multivariable model, pedicled flap (aOR 4.6), adjuvant radiotherapy (aOR 2.8), major complication (aOR 3.3), and lower baseline FOIS (aOR 0.5 per point) were independently associated with PEG dependence (optimism-corrected AUC 0.79). Clustering identified three recovery phenotypes—functional/emotional responders, psychological/body-image responders, and global slow recovery—with significantly different PEG rates (5.9%, 21.4%, 40.0%; p = 0.006). Exploratory mediation analysis suggested that the association between reconstruction technique and mental quality-of-life recovery was partly statistically accounted for by swallowing and body-image improvement. Conclusions: Recovery after major head-and-neck reconstruction is multidimensional and heterogeneous. Baseline swallowing function, reconstruction technique, radiotherapy, and major complications jointly stratify risk for persistent functional and psychosocial impairment, supporting risk-adapted multidisciplinary rehabilitation and early psycho-oncologic screening. Full article

Background/Objectives: Postoperative monitoring of microvascular free flaps is critical for early detection of vascular complications and flap survival. Nurses play a central role in this process; however, qualitative evidence on their experiences and challenges remains limited. This study explored nurses’ experiences in free tissue flap care to identify clinical practices, challenges, and improvement needs. Methods: A phenomenological qualitative design was used. Data were collected through semi-structured interviews with nine nurses experienced in free tissue flap care, recruited via purposive and snowball sampling. Interviews were conducted online and lasted 30–45 min. Data were analyzed using content analysis with MAXQDA 2025. Inter-researcher reliability was 97%. Results: The findings were categorized into four main themes and seventeen subthemes: (1) clinical monitoring and evaluation in the care process, (2) challenges and difficulties, (3) emotional and professional reflections, and (4) suggestions for improving care. Nurses reported that flap care requires intensive monitoring, rapid decision-making, and close collaboration with physicians, especially within the first 24–48 h. Monitoring was largely based on observation and experience due to the lack of standardized protocols. Major challenges included high workload, frequent assessments, and donor site management. Emotional burden, stress, and responsibility were also prominent. Conclusions: Free flap care is a complex and demanding process for nurses. The lack of standardized monitoring tools and protocols is a key gap. Developing structured tools, improving training, and strengthening multidisciplinary collaboration may enhance patient safety and care quality. Full article

The deep inferior epigastric perforator (DIEP) flap holds its place as the gold standard approach for autologous tissue breast reconstruction given the strong durability, favorable donor site morbidity, and high patient satisfaction overall. With the reliability and safety of microsurgical reconstruction of the breasts being well-established over these last decades, the goals of DIEP flap reconstruction have expanded beyond flap survival toward optimization of aesthetic, patient-reported, and quality-of-life outcomes. Achieving ideal cosmesis requires thoughtful decision-making across the reconstructive continuum, including of radiation timing, mastectomy incision design, nipple–areolar complex management, reconstructive sequencing, flap shaping and inset, abdominal closure, neurotization, and the potential role of any revision or adjunctive procedures. Modern techniques including delayed-immediate reconstruction, nipple delay, free nipple grafting, fat grafting, and abdominal wall reinforcement have expanded the availability of personalized care in breast reconstruction. This narrative review integrates a targeted literature search with consensus-driven expert opinion informed by our senior authors’ extensive cumulative experience performing DIEP flap breast reconstruction. It discusses principles, technical strategies, and evolving evidence for optimizing aesthetic outcomes in DIEP flap breast reconstruction while preserving safety and minimizing morbidity. Full article

Background/Objectives: Computer-aided surgical planning (CASP) technologies, including virtual surgical planning (VSP), 3D printed cutting guides, and patient-specific implants, have been increasingly applied to deep circumflex iliac artery (DCIA) free flap reconstruction of maxillofacial defects. Despite growing adoption, no systematic review has specifically evaluated their accuracy and clinical outcomes. This study aimed to comprehensively assess the impact of CASP on reconstruction accuracy, operative efficiency, flap survival, and implant rehabilitation in DCIA flap surgery. Methods: A systematic search of PubMed, Web of Science, and Google Scholar was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Studies reporting CASP-assisted DCIA free flap reconstruction with three or more patients were included. Methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) checklist and the Cochrane Risk of Bias 2.0 tool for the randomized controlled trial (RCT). Results: Thirty studies (1 RCT, 13 comparative, and 16 non-comparative) involving 844 patients were included. VSP with 3D-printed cutting guides was the most frequently used technology (n = 22). Mean linear deviations between planned and actual outcomes ranged from 0.40 to 4.4 mm, with most studies reporting 0.7–2.7 mm. The sole RCT demonstrated significantly better accuracy (1.3 vs. 5.5 mm, p < 0.001) and shorter reconstruction time (16 vs. 39 min, p < 0.001) with CASP. Flap survival ranged from 90% to 100%. Conclusions: CASP technologies, particularly VSP with 3D-printed cutting guides, appear to improve the accuracy and predictability of DCIA flap reconstruction. However, the evidence base is predominantly retrospective and heterogeneous; prospective multicenter studies with standardized outcome measures are needed before definitive clinical guidelines can be established. Full article

Background/Objectives: Reconstruction of defects in the ankle, foot and heel is complex because of the limited availability of local tissue and multiple comorbidities like diabetes mellitus and peripheral vascular disease. Even though free and pedicled flaps are widely used, their comparative effectiveness remains incompletely defined. Methods: This study presents a narrative analysis of 21 studies. From each study, we extracted data related to flap type, characteristics of the patient, indications, and outcomes: flap survival, limb salvage, functional recovery and complications. Results: Free flaps were mainly used for the management of large, complex, infected, or weight-bearing plantar defects and generally showed high rates of survival (~95–97%) with good functional outcomes and limb salvage rates. On the other hand, pedicled flaps and perforator-based flaps were principally used for small-to-medium defects and showed comparable survival rates in selected cohorts (up to ~98–100%), although direct comparison is limited by differences in defect complexity and patient selection. Overall, the functional outcomes appeared comparable across techniques in appropriately selected patients. However, long-term complications, such as ulceration in weight-bearing heel regions, remained frequent (reported rates were up to 39–41% in some free flap series). Sensory recovery and vascular status were key elements of long-term success, often exceeding flap type in predicting outcomes. Conclusions: Both free and pedicled flaps are effective options for reconstructing lower limb defects when appropriately indicated. While pedicled flaps remain preferred for smaller defects and high-risk patients, free flaps are generally better suited for extensive and more complex defects. The outcomes are influenced by several factors: individualized reconstruction strategy, characteristics of the defects, vascular status and patient comorbidities. Full article