Search Results (130)

Background/Objectives: Accurate visualization of peroneal perforator vessels prior to autologous transplantation of osteomyocutaneous fibular flap is essential for surgical success. Our aim was to improve and simplify pre-surgical diagnostics of peroneal perforators using a dedicated dual-energy Computed Tomography Angiography (CTA) protocol and semiautomatic Vessel Unfolding Reconstruction algorithm (VUR). Methods: CTA of both lower legs was performed in 22 patients using dual-energy acquisitions from a third-generation dual-source CT scanner and a high iodine flux (7 mL/s, 350 mg/mL). Low-energy virtual monoenergetic reconstructions (40 keV) were automatically reconstructed from the scanner and used for centerline labeling of the peroneal arteries and their perforators on a post-processing console using a dedicated vascular workflow. Separate segmentation and curved multiplanar reconstructions (MPRs) of each identified peroneal perforator vessel were regarded as the gold standard. Traditional visualization techniques of the entire volume like thin-slice maximum intensity projections (MIPs) or the volume rendering technique (VRT) were compared to a new VUR algorithm that aimed to adjust the visualization plane to the course of the vessels. The identified numbers and lengths of the perforator arteries were compared between curved MPRs, thin-slice MIPs in oblique coronal orientation, posterior-view VRT and coronal VUR of each lower leg. Results: The VUR algorithm was feasible in all patients and the same quantity of peroneal perforator vessels could be detected in comparison to the gold standard. The mean number of perforator vessels per lower leg was 2.6. Mean perforator length in VUR was slightly shorter by 1.6% and did not significantly differ from curved MPRs (p = 0.54), whereas length values from oblique coronal MIP and VRT reconstructions were significantly shorter (both p < 0.001). Conclusions: The combination of virtual monoenergetic reconstructions and the VUR algorithm enables comprehensive and precise depiction of small peroneal perforator vessels prior to autologous fibular flap transplantation, representing a diagnostic tool comparable to traditional visualization methods. Full article

Massive segmental bone defects present significant challenges in orthopaedic and maxillofacial reconstruction. As defect size increases, the disparity between tissue volume and diffusion-limited biological processes becomes more pronounced. This narrative review analyses distinctions between centimetre-scale defects and conventional fractures and evaluates current tissue-engineering strategies in relation to vascularisation, osteogenesis, mechanical stability, immune response, neural integration, and manufacturability. This review synthesises evidence from scaffold design, cell-based approaches, growth factor delivery, type-H vessel biology, NGF–TrkA signalling, large-animal models, and early clinical translation. Current findings indicate that no single scaffold, cell source, or growth factor can reliably reproduce the coordinated biological and mechanical environment required for durable regeneration of human long bones. The strongest preclinical evidence is derived from ovine tibial models employing medical-grade polycaprolactone/β-tricalcium phosphate composites or mechanobiologically optimised titanium lattices. Human data remain limited to case reports and small early clinical series, including hybrid vascularised flap–scaffold reconstructions. Successful clinical translation will require patient-specific constructs that integrate rapid vascularisation, appropriate load sharing, immune-compatible degradation, infection control, and scalable manufacturing. Until robust comparative clinical evidence emerges, established reconstructive methods will remain the standard of care. Hybrid vascularised scaffold-guided strategies should be regarded as promising translational approaches rather than definitive solutions. Full article

Background: Perioperative fluid therapy plays a critical role in the outcome of microvascular free-flap surgery. While both inadequate and excessive fluid administration may impair flap perfusion and systemic recovery, the impact of fluid balance and crystalloid volume—normalized to body weight and operative time—on postoperative complications remains underexplored. This study investigates the dose-dependent effects of intraoperative fluid and crystalloid administration on flap-related and systemic outcomes. Methods: This retrospective, single-centre cohort study included 495 adult patients who underwent microvascular free-flap transplantation between 2009 and 2020. Intraoperative fluid balance and crystalloid volumes were normalized to patient weight and operative duration (mL/kg/h) and stratified into pre-defined thresholds. The primary endpoint was the incidence of flap-related complications (partial/total flap loss, thrombosis, revision surgery). Secondary endpoints included flap loss, suture insufficiency, pneumonia, ICU length of stay (LOS-ICU), and in-hospital mortality. Results: Higher intraoperative fluid rates were significantly associated with higher complication rates. Flap-related complications occurred in 54.8% of patients receiving >10 mL/kg/h versus 37.1% in the ≤5 mL/kg/h group (p < 0.01) and reached 100% in patients receiving >20 mL/kg/h, although this category comprised only seven patients (p < 0.01). Suture insufficiency increased from 3.1% (≤5 mL/kg/h) to 57.1% (>20 mL/kg/h; p < 0.01). Pneumonia incidence rose from 8.8% (≤5 mL/kg/h) to 31.9% (>10 mL/kg/h; p < 0.01). A U-shaped trend was observed for flap loss, with the highest rate (24.6%) at >10 mL/kg/h. Crystalloid volume > 3000 mL was significantly associated with higher flap loss (20.2% vs. 0.2%; p < 0.01) and suture insufficiency (7.0% vs. 0.2%; p = 0.02). Red blood-cell (RBC) transfusions were associated with higher overall complication rates (45.6% vs. 34.2%; p < 0.01) and suture insufficiency (9.9% vs. 3.4%; p < 0.01). Gelatin-based colloids showed no negative impact. Operative time was the only strong independent predictor of total flap loss; each additional operative hour increased the odds of flap loss by 34% (p < 0.001). Intraoperative noradrenaline use and a history of neoadjuvant radiotherapy were not independently associated with flap-related complications or flap loss. Median LOS-ICU increased from 2 days to 10 days in patients receiving >20 mL/kg/h (p < 0.01). In-hospital mortality increased significantly with higher fluid volumes (0.3% for ≤10 mL/kg/h vs. 28.6% for > 20 mL/kg/h; p < 0.01). Conclusions: In 495 microvascular free-flap reconstructions, diagnosis, flap type, defect localization and operative time emerged as key determinants of postoperative outcomes, while defect type itself showed no predictive value. Intraoperative fluid overload—particularly crystalloid rates exceeding 10 mL/kg/h—is associated with a significantly higher risk of flap-related complications, pneumonia, prolonged ICU stay and mortality. These findings support the implementation of individualized or goal-directed fluid strategies in microvascular reconstructive surgery to optimize outcomes. Full article

The plain river network is characterized by low and flat terrain and a complex structure, resulting in slow water exchange and weak hydrodynamic conditions. To address these issues, a flapping-hydrofoil water pump driven by composite harmonic motion is proposed to promote water flow. First, a computational model for the flapping hydrofoil is established based on the finite volume method (FVM) and overlapping dynamic mesh technology. Five different distributed motion schemes for the flapping-hydrofoil devices at various points are selected, and the hydrodynamic performance of each scheme is computed to establish the corresponding relationship with water flow. Next, the river network of the Nanxun District in the Taihu Lake Basin is taken as the study area. A MIKE21 two-dimensional hydrodynamic-water quality model for river networks is constructed, where water flow is used as a variable factor. The objective function focuses on minimizing energy consumption under different motion schemes. The model is used to simulate and analyze the flow field distribution and water quality changes under different scenarios, aiming to explore optimization scheduling methods for enhancing hydrodynamics and improving water quality in the river network of the study area. The results show that, compared to the five motion schemes, the propulsion efficiency is maximized in Scheme IV, with a value of 49.34%. This represents a 1.12-fold increase in water propulsion efficiency compared to Scheme I (single flapping-hydrofoil motion). However, considering the water quality improvement, Scheme I exhibits the best effect in terms of flow increment. Under the conditions of Scheme I, the BOD (Biochemical Oxygen Demand) removal rate at the reference point 2 area reaches 40.94%, and the DO (Dissolved Oxygen) concentration improvement rate reaches 1.78 times. Full article

Introduction: Decompressive craniectomy (DC) is often required to stabilize the intracranial pressure (ICP) in patients with traumatic brain injury (TBI). Both sinking flap syndrome (SFS) and hydrocephalus are known complications of DC. The pathophysiology of each is unknown. Case Report: We report on a patient who underwent DC for TBI who suffered both SFS and low-pressure hydrocephalus. We measured the changes in volumes of each hemisphere and the ventricles with CT and the cerebral blood flow (CBF) and aqueduct flow with phase-contrast MRI during different stages of the disease process. Discussion: The SFS in this patient was associated with a reduction in volume of both supratentorial cavities. There was a significant reduction in CBF bilaterally, which increased by an average of 26% following cranioplasty. During the low-pressure hydrocephalus phase of the patient’s illness, there was reversed CSF flow directed toward the ventricles. Once the ventricles returned to normal size, this reversed flow was lost. Conclusions: Lumped parameter modelling of the patients’ CSF and vascular systems suggested a new hypothesis, i.e., that the reduction in blood flow was due to reversible constriction of the arterioles secondary to a reset of the autoregulation rather than compression of the venous structures. We suggest there is an increase in CSF absorption efficiency despite the known CSF-absorption mechanisms being unlikely to function at such a low ICP. A hypothesis is put forward that CSF absorption occurs via the brain capillary bed in these diseases. Full article

Background: Despite the rise of endoscopic approaches, the direct brow lift remains one of the most effective procedures for correcting brow ptosis for both functional and cosmetic indications. It continues to offer superior control when correcting brow shape, height, and asymmetry. However, visible scarring remains a concern. This systematic review was conducted to synthesize recent evidence on strategies that minimize visible scarring in direct brow lift surgery. Methods: A systematic literature search was performed to retrieve English-language publications from the past decade, discussing scar-minimization strategies in direct brow lift. A total of 124 records were identified through database searches in Ovid MEDLINE and Embase. Records were screened manually according to predetermined criteria, and those not in English, not addressing scarring, or not focused on direct brow lift were excluded. After this process, ten publications were included in the final qualitative synthesis. Results: The qualitative synthesis of all included publications (together comprising data on approximately 900 patients) revealed several strategies for scar minimization. (1) Incision beveling: A shallow cranially directed bevel between 20° and 45° preserves brow hair follicles and allows hair regrowth through the scar, providing natural camouflage. (2) Undermining: Gentle subcutaneous undermining in a limited 1–2 cm field, while preserving subcutaneous fat, allows tension-free advancement and maintains brow volume. (3) Periosteal suspension: Anchoring the mobilized brow flap to the frontal periosteum redistributes tension away from the dermal closure, maintaining elevation and improving scar quality. (4) Layered closure: Two- or three-layered wound closure with deep dermal anchoring and fine everting skin sutures minimizes dermal traction and scar widening. (5) Adjunctive measures: Evidence for topical silicone gel was inconclusive, whereas postoperative laser therapy and perioperative neuromodulator use demonstrated improved scar appearance. Across studies, outcomes were consistent, with high patient satisfaction, inconspicuous scars in over 85% of cases, and low complication or revision rates. Conclusions: Direct brow lift has historically been criticized for conspicuous scarring, contributing to the popularity of endoscopic techniques. Nevertheless, the traditional direct brow lift remains a fundamental skill in the oculofacial plastic surgeon’s armamentarium, offering unmatched accuracy in brow repositioning, reliability, and symmetry. Contemporary evidence demonstrates refinements that can markedly minimize scar visibility. This systematic review and qualitative synthesis allow us to continue to refine and improve our techniques to minimize scarring in direct brow lift to the benefit of our patients. Full article

Simultaneous autologous breast reconstruction (ABR) and lymphatic surgery has emerged as a strategy to address breast cancer-related lymphedema (BCRL) while restoring breast contour within a single operative procedure. In light of the diversity of surgical strategies, we aimed to evaluate the current literature on combined ABR and lymphatic surgery, with particular focus on surgical techniques, clinical outcomes, complications, and patient-reported satisfaction. A systematic review was conducted according to PRISMA guidelines and registered in PROSPERO (CRD420251135446). Medline, Embase, CENTRAL, Web of Science, and PubMed were searched through 9 January 2026 Studies reporting outcomes of simultaneous ABR and lymphatic reconstruction were included. Data on surgical techniques, complications, changes in limb volume and cellulitis incidence, and patient-reported outcomes were extracted. Twenty-seven studies including 499 patients (mean follow-up 23 months) were analyzed. The most common approach was a chimeric deep inferior epigastric perforator (DIEP) flap with inguinal lymph nodes (459 patients), followed by ABR with a separate vascularized lymph node transfer and ABR with lymphovenous anastomosis. Most studies reported postoperative reductions in limb volume and cellulitis, with cellulitis reduction rates up to 100%. Patient-reported outcomes (LYMQOL, ULL-27, LYMPH-Q) showed improved quality of life. Complication rates were low, including 4% seroma and 1% flap loss after chimeric DIEP. Simultaneous ABR and lymphatic reconstruction is feasible and associated with improved clinical and patient-reported outcomes. However, heterogeneity limits comparison between the different surgical techniques, and prospective studies with standardized outcomes measurements are needed. Full article

Background: Over the past two decades, with the collaboration between periodontists and orthodontists, the concept of a surgically facilitated orthodontic therapy (SFOT) approach was developed, which not only provides acceleration in tooth movement as a result of a stimulated regional acceleratory phenomenon but also increases the alveolar bone volume for orthodontic tooth movement range by bone grafting. Despite the benefits, hard and soft tissue defects can sometimes be observed in patients post SFOT, especially among groups with thin periodontal phenotypes. Methods: In the current study, we compared the traditional SFOT with allograft only and the modified SFOT with allograft and collagen matrix to explore if the addition of a collagen matrix between the bone graft and periodontal flap could achieve soft tissue augmentation and reduce the prevalence of the complications of SFOT. Six patients were initially enrolled in the current study. Four patients showed up for the 1-week and 2-week post-operation evaluations. However, only one subject of each group agreed on periodontal evaluation by bone sounding and CBCT during the 6-month follow-up appointment. Results: Six months post SFOT, the patient with the modified SFOT presented with a larger amount of soft tissue thickening compared to the patient with traditional SFOT. However, the location of bone generation was different between groups, with the modified SFOT group presenting with bone generation more apically. In addition, patients with modified SFOT reported a more severe level of discomfort than patients with traditional SFOT. Conclusions: The modified SFOT may potentially improve soft tissue phenotype; however, further modifications are needed to reduce the patient’s discomfort level and to ensure that bone particles are contained more incisally. Full article

Traumatic thumb loss causes severe functional impairment, as the thumb provides approximately 40% of total hand function. Toe-to-thumb transfer remains the gold standard for thumb reconstruction, yet donor site morbidity represents a significant functional and aesthetic limitation. A total thumb reconstruction using a “trimmed” right great toe transfer, combined with immediate donor site reconstruction using a free SCIP (superficial circumflex iliac perforator) flap and iliac crest bone graft. The flap was designed as a tubular skin island to create a neo-hallux with optimal contour and volume, minimizing visible scarring and avoiding microcirculatory compression. The patient, a 33-year-old man with post-traumatic thumb avulsion, underwent delayed reconstruction three months after injury. The postoperative course was uneventful, with no vascular or wound complications. At 12 months, he resumed full ambulation and manual activities, including motorcycle driving and work tasks. Baropodometric analysis demonstrated symmetric load distribution and gait dynamics. Thumb opposition was satisfactory (Kapandji score: seven); the patient rated the aesthetic results as excellent. This case demonstrates that SCIP flap reconstruction with iliac crest bone graft enables complete functional and aesthetic restoration of the great toe donor site after total toe transfer. Compared to previous techniques using cross-flaps, skin grafts, or peroneal flaps, this approach minimizes morbidity, optimizes cosmetic outcomes, and preserves gait. Although representing a single case, this constitutes the first documented instance of total hallux reconstruction following toe-to-thumb transfer, emphasizing the importance of the foot as a functional and aesthetic unit and the need for donor-site preservation in microsurgical reconstructive planning. Full article

Background: The latissimus dorsi (LD) flap remains a reliable option for breast reconstruction in irradiated, salvage, and non-microsurgical candidates. Despite the availability of multiple LD-based variants, practical guidance for technique selection remains limited. Methods: We retrospectively analyzed 40 consecutive LD-based breast reconstructions performed over 5 years at two Italian centers. Cases were categorized as classic LD, hybrid LD, extended LD, V-FALD, or KISS flap. Clinical variables, reconstructive setting, complications, and reoperations were described, and a decision-making algorithm was derived from institutional practice and literature integration. Results: The cohort was characterized by a high-complexity profile, with 36/40 patients (90%) exposed to radiotherapy and 22/40 (55%) treated in a salvage setting. Hybrid LD was the most frequently used technique, accounting for 23/40 cases (57.5%), followed by KISS flap in 6/40 (15%), extended LD in 5/40 (12.5%), V-FALD in 4/40 (10%), and classic LD alone in 2/40 (5%). Technique selection was primarily driven by skin-envelope adequacy, breast volume requirement, and the feasibility of a fully autologous reconstruction. Major complications occurred in 2/40 patients (5%), revision surgery occurred in 3/40 (7.5%), and no total flap necrosis was observed. Donor-site morbidity occurred in 10/40 (25%) of cases and was managed conservatively. Conclusions: LD-based breast reconstruction should be viewed as a versatile reconstructive platform rather than a single technique. A pragmatic algorithm may support surgical planning and help tailor the most appropriate LD variant to defect characteristics and reconstructive goals. Full article

In autologous microtia reconstruction, achieving optimal skin adherence to the cartilage framework is critical for aesthetic success. This study validates a novel, low-cost closed suction system assembled from a 20 mL syringe, a 5 mL syringe barrel acting as a rigid internal lock, and a fenestrated butterfly cannula. In a prospective cohort of 100 consecutive cases, the system effectively coapted the skin flap in all patients without major complications. Clinical data revealed a mean drainage duration of 6 days and 19 h (95% CI: 6 d 11 h to 7 d 4 h) and a mean collected fluid volume of 17.36 mL (95% CI: 16.77–17.95 mL). Blinded expert evaluation using the weighted 13-point Sharma scale demonstrated “Excellent” framework definition in 81.7% of patients. This system offers exceptional reliability and disruptive cost-efficiency, achieving stable vacuum pressure at a production cost of approximately 0.60 USD. These findings provide a compelling proof-of-concept for an accessible, high-performance alternative in auricular reconstruction, establishing a robust foundation for broader clinical adoption and future comparative validation in resource-limited surgical settings. Full article

Background: Craniopharyngiomas are histologically benign but clinically aggressive epithelial tumors that pose significant surgical challenges due to their proximity to the hypothalamic–pituitary axis. While traditional transcranial approaches are well-established, the endoscopic endonasal transplanum–transtuberculum approach (EETTA) has emerged as a specialized corridor offering direct midline access. This systematic review evaluates the surgical efficacy, functional outcomes, and complication profiles of the EETTA over two decades of clinical evolution. Methods: Following PRISMA guidelines, a systematic search was conducted across five databases. Eligible studies included patients of all ages undergoing EETTA for craniopharyngioma. Data on the extent of resection (EOR), visual and endocrine outcomes, and CSF leak rates were extracted. Quality was assessed using NIH/JBI tools, and evidence was graded via AANS/CNS criteria. Results: Fifty-one studies (677 patients) were included. The cohort had a mean age of 43.4 years and predominantly suprasellar tumors (mean diameter 2.9–4.0 cm). Gross total resection (GTR) was achieved in 66.4% of cases (364/548). Postoperative visual improvement was reported in 79.8% of patients, while 7.1% experienced deterioration. Endocrine morbidity remained significant, with 120 patients developing new-onset diabetes insipidus and 105 developing new anterior pituitary deficits. The pooled CSF leak rate was 9.2%, with contemporary series frequently reporting 0% due to advanced multilayer reconstruction with nasoseptal flaps. The pooled recurrence rate was 7.8% over a mean follow-up of 37.4 months. Conclusions: The EETTA is a safe and effective primary strategy for suprasellar and retrochiasmatic craniopharyngiomas, offering more favorable visual outcomes and resection rates in this specific cohort. While endocrine dysfunction remains a pervasive challenge inherent to the tumor’s location, technical refinements in skull base reconstruction have successfully addressed historical concerns regarding CSF leaks. These findings support the use of the EETTA at high-volume centers with multidisciplinary expertise. Full article

Background: Defects following total parotidectomy represent a distinctive reconstructive challenge. Restoration of facial volume and contour must be balanced with protection of the preserved facial nerve and reliable healing, particularly after extensive dissection and when adjuvant radiotherapy is anticipated. Multiple reconstructive options exist, each involving trade-offs regarding volume, pliability, long-term stability, and donor-site morbidity. We report our early clinical experience using the adipofascial infragluteal perforator (AIGP) free flap for reconstruction after total parotidectomy with skin and facial nerve preservation. Methods: We retrospectively reviewed the results of three consecutive patients undergoing total parotidectomy for parotid tumors, receiving immediate reconstruction with an AIGP free flap, operated between June and July 2025. The flap, based on terminal branches of the infragluteal vessels, was anastomosed to cervical recipient vessels. To address the two-compartment defect created by facial nerve preservation, the adipofascial tissue was tailored in a chimeric configuration to separately restore the superficial and deep parotid spaces. Results: All flaps survived. One patient developed a postoperative hematoma managed conservatively. Two patients developed minor donor-site seromas after drain removal, which resolved without intervention. Facial contour was satisfactorily restored in all cases, with mild overcorrection in one patient. Facial nerve function improved during follow-up. Donor-site scars were concealed within the infragluteal crease. Conclusions: In this preliminary case series, the AIGP free flap proved to be a feasible option for reconstruction after total parotidectomy with skin and facial nerve preservation, offering satisfactory contour restoration and low donor-site morbidity. Larger studies with longer follow-up are required to define indications and long-term outcomes. Full article

Background/Objectives: Trochanteric pressure ulcers represent a challenging reconstructive problem due to their depth, frequent infection, and tendency for recurrence. Durable coverage with well-vascularized tissue capable of effective dead-space management is essential for long-term stability. The pedicled musculocutaneous anterolateral thigh (ALT) flap offers substantial soft-tissue volume with reliable regional vascularity. Methods: A retrospective review was performed of consecutive patients with Stage IV trochanteric pressure ulcers who underwent reconstruction using musculocutaneous pedicled island ALT flaps between January 2020 and August 2023. Ulcers were classified according to the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance International Guidelines. Patients with a minimum follow-up of 24 months were included. Demographic characteristics, ulcer etiology, prior flap history, comorbidities, flap dimensions, postoperative complications, and recurrence rates were analyzed. Results: Eight patients (4 males, 4 females; mean age 46.4 years, range 35–63) were included. Six ulcers (75%) were related to prolonged immobilization, and two (25%) developed following entrapment during the 2023 Kahramanmaraş earthquake. All donor sites were closed primarily. Minor recipient-site complications, including seroma and limited suture dehiscence, occurred in two cases. No partial or total flap necrosis was observed. During a mean follow-up of 42.4 months (minimum 24 months), no recurrence occurred. Conclusions: Musculocutaneous pedicled ALT flaps incorporating a substantial portion of the vastus lateralis muscle allowed effective dead-space obliteration and durable soft-tissue coverage in Stage IV trochanteric pressure ulcers. Primary donor-site closure was achievable without major morbidity. These findings support the use of the pedicled ALT flap as a consistent regional option in complex trochanteric defects, including both chronic immobilization-related and acute compression-related cases. Full article

Background/Objectives: Adequate peri-implant soft tissue thickness is essential for long-term peri-implant health and esthetics. Horizontal platelet-rich fibrin (H-PRF) has been proposed to support soft tissue regeneration; however, experimental and translational evidence for its application in peri-implant soft tissue augmentation remains limited. This study aimed to evaluate a H-PRF membrane block approach primarily through an experimental animal model, with clinical cases presented to illustrate translational feasibility. Methods: A customized compression device was used to fabricate the H-PRF membrane block. The biological performance of the H-PRF membrane block was first evaluated in a rabbit model, with histologic assessment of peri-implant soft tissue thickness and integration at 8 weeks. Representative clinical cases requiring peri-implant mucosal thickening were subsequently treated with H-PRF membrane block on the buccal aspect of the alveolar bone beneath a supra-periosteal flap to demonstrate clinical applicability. Results: In the animal model, the H-PRF membrane block resulted in a significant increase in peri-implant soft tissue thickness by increasing the lamina propria compared with control sites demonstrated by histologic analysis. The clinical illustrations showed stable buccal soft tissue volume and contour with minimal patient morbidity. Conclusions: Within the limitations of this experimental study, the horizontal H-PRF membrane block technique demonstrated promising biological performance for peri-implant soft tissue augmentation in an animal model. The accompanying clinical illustrations support the translational feasibility of this approach. Clinical relevance: This experimental study provides biological and translational insight into a minimally invasive strategy for peri-implant soft tissue thickening and may inform future controlled clinical investigations. Full article