Search Results (58)

Major reconstructive free-flap surgery often requires ICU admission, yet early signals associated with postoperative antibiotic escalation remain poorly characterized. We conducted a single-center retrospective cohort study of 119 consecutive postoperative ICU admissions after major free-flap reconstruction. Exposures were postoperative day-1 procalcitonin (PCT) and documented postoperative shock; the primary endpoint was clinician-initiated antibiotic escalation (“upgrade”), and secondary endpoints were documented microbiological positivity and ICU mechanical ventilation duration. Escalation occurred in 85/119 admissions (71.4%). Day-1 PCT was higher with escalation (median 0.25 vs. 0.135 ng/mL; p = 0.033), and shock was more frequent (59/85 [69.4%] vs. 13/34 [38.2%]; p = 0.003). Escalation was associated with longer ventilation (median 3515 vs. 2170 min; p < 0.001) and higher rates of any positive culture (54/85 [63.5%] vs. 8/34 [23.5%]; p < 0.001). In multivariable logistic regression adjusting for operative time and intraoperative IV volume, shock remained independently associated with escalation (adjusted OR 3.52, 95% CI 1.48–8.36; p = 0.004), whereas log-transformed PCT was not (p = 0.224). PCT showed modest apparent discrimination for escalation (AUC 0.63), improving to 0.71 when combined with shock. These findings should be interpreted as observational associations with escalation behavior, supporting prospective evaluation of physiology-plus-biomarker stewardship approaches. Full article

Background: Complex diabetic foot ulcers (DFUs) are a leading cause of morbidity and lower-limb amputation, and their management is profoundly challenging. Microvascular free tissue transfer is a primary limb salvage strategy, with the anterolateral thigh (ALT) free-flap recognized as a workhorse reconstructive solution. However, a quantitative summary of its performance specifically within this high-risk patient population is lacking. Methods: A systematic review and single-arm meta-analysis was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Five electronic databases (PubMed/MEDLINE, Embase, Scopus, Cochrane, and Web of Science Core Collection) were searched up to 9 September 2025 to identify studies reporting on outcomes of ALT free-flaps for diabetic foot reconstruction. The risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Primary outcomes were set as the complete and partial flap necrosis rate. Secondary outcomes included functional recovery status and complication rates. All data were synthesized using a random-effects model. Results: Six retrospective cohort studies met the inclusion criteria, including a total of 162 patients. The pooled rate of total flap failure was 5.2% (95% CI: 2.5–10.6%), a finding that was highly consistent across all studies (I² = 0%). The pooled incidence of partial flap necrosis was 13.0% (95% CI: 6.3–25.1%), resulting in an overall weighted flap success rate of 81.8%. Notably, the pooled rate of return to ambulation was 95.2% (95% CI: 88.5–98.1%), which also demonstrated no statistical heterogeneity (I² = 0%). Conclusions: The anterolateral thigh free-flap appears to be a robust and highly reliable strategy for diabetic foot reconstruction, associated with low failure rates, minimal long-term complications, and excellent functional recovery. However, the current evidence is limited to a small number of poor-to-moderate-quality retrospective studies. High-quality, prospective, and comparative multicenter trials are necessary to confirm these findings and establish the ALT flap’s effectiveness in high-risk cohorts. Full article

Background: Reconstruction of the distal nose represents a major surgical challenge due to the aesthetic and functional relevance of this subunit. Various techniques—including local, regional and free flaps and grafts—have been described, but high-quality evidence comparing outcomes remains limited. Methods: Following PRISMA guidelines, a systematic review was conducted using PubMed/MEDLINE, Cochrane Library, Scopus, Embase, and Google Scholar. A single-arm meta-analysis was performed to evaluate complications, revision surgeries, and aesthetic and functional outcomes. Secondary outcomes included flap necrosis, revision procedures, and airway function. Results: Forty articles were included in the qualitative synthesis and 38 in the quantitative analysis, from an initial 587. The analysis involved 1362 patients (mean age 60.6 years) undergoing distal nasal reconstruction, most commonly for malignancy. The pooled complication rate was 11%, and was highest with regional flaps (26%). Flap/graft necrosis occurred in 5% of free flaps and 2% of regional flaps, with none reported for local flaps or grafts. Revision surgery was required in 7% overall, but was greater with mixed flaps (11%), compared to graft (3%), local (1%), and regional (0%) techniques. Dermabrasion and secondary contouring were infrequent. Aesthetic outcomes were inconsistently reported, precluding meta-analysis. Conclusions: This systematic review and meta-analysis provide an overview of reconstructive options and outcomes for distal nasal defects. Local and regional flaps remain the most reliable and versatile solutions for small-to-moderate, partial-thickness defects, offering low complication and revision rates. Free flaps, while essential for extensive or full-thickness reconstructions, are associated with greater morbidity and revision burden. Standardised reporting of outcomes relative to defect size and thickness is required to guide evidence-based decisions. Full article

Background and Objectives: Advanced gynecomastia/pseudogynecomastia (Simon grades IIb–III) in post-bariatric patients presents both esthetic and technical challenges. Conventional excisional methods often result in flattened chest contours, extensive scarring, and loss of nipple–areolar complex (NAC) sensation. There is a growing need for conservative, tissue-preserving strategies that respect the unique morphology of massive weight-loss patients. Materials and Methods: This consecutive case series included 15 male patients (median age: 38 years, IQR 36.5–39.5) with advanced gynecomastia/pseudogynecomastia and stable weight loss following bariatric surgery. All underwent a glandular transposition technique, preserving the NAC on a pedicle based on thoracic perforators and avoiding free grafting. Redundant lower-pole skin was excised, a new NAC site was created cranially, and the gland was repositioned beneath a dermo-adipose flap. Outcomes included complication rates, patient satisfaction, and changes in BODY-Q chest appearance scores. Results: No major complications occurred. NAC viability and sensation were preserved in all patients. One patient required secondary revision for residual contour bulging, while three developed minor hematomas that resolved spontaneously. At 3 months, the median Likert satisfaction score improved from 2 (IQR 2–3) preoperatively to 5 (IQR 4–5) postoperatively (p < 0.001, Wilcoxon signed-rank test). BODY-Q chest appearance scores improved significantly from 31 (IQR 28–35) to 78 (IQR 74–82) (p < 0.001). External observers preferred postoperative results in 90% of randomized photo-pair comparisons. Conclusions: Glandular transposition is a safe, reproducible, and esthetically effective technique for advanced gynecomastia/pseudogynecomastia in post-bariatric men. By preserving glandular continuity and avoiding free NAC grafting, this method achieves natural chest projection, maintains nipple sensitivity, and provides high patient satisfaction with minimal complications. It represents a compelling alternative to conventional radical excision strategies. Full article

Background: Reconstruction of distal forearm and hand soft tissue defects remains a complex surgical challenge due to the functional and aesthetic significance of the region. Several flap options have been established such as the posterior interosseous artery flap (PIA) or temporalis fascia flap (TFF), yet the anterolateral thigh flap (ALT) has gained increasing attention for its versatility and favorable risk profile. Methods: We retrospectively analyzed 12 patients (7 males, 5 females; mean age 51.8 years) who underwent free microvascular ALT reconstruction for distal forearm and hand defects between May 2020 and May 2025. Etiologies included infection, chemical burns, explosion injuries, and traffic accidents. The mean defect size was 75.4 cm², and the average operative time was 217 min. Secondary flap thinning was performed in eight cases. In one patient without available recipient veins, a pedicle vein was anastomosed using a coupler device anchored into a cortical window of the distal radius to establish venous outflow via the bone marrow. Results: All flaps demonstrated complete survival with successful integration. Minor complications included transient venous congestion in one case and superficial wound dehiscence in four cases. Functional outcomes were favorable, with postoperative hand function rated as very good in 10 of 12 patients at follow-up. The bone-anchored venous anastomosis provided effective venous drainage in the salvage case. Conclusions: The free microvascular ALT is a reliable and highly adaptable method for distal forearm and hand reconstruction. It provides excellent soft tissue coverage, allows for secondary contouring, and achieves both functional and aesthetic goals. Furthermore, intraosseous venous anastomosis using a coupler device might represent a novel adjunct that may expand reconstructive options in cases with absent or unusable recipient veins. Full article

Background/Objectives: Historically, the treatment of subungual melanoma was based on amputation of the affected digit. However, extended wide local excision of the nail apparatus is now considered the conservative gold standard for in situ or minimally invasive forms. There are many after wide local excision reconstruction techniques, but few studies have objectively compared their results. The objectives were to carry out a systematic review of reconstruction after wide local excision reconstructions in the treatment of subungual melanoma. Methods: This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An exhaustive search was conducted in the PubMed (Medline), Embase, and Cochrane Library databases, up to July 2025. Articles reporting reconstructions after wide local excision for subungual melanoma of the fingers or toes were included. Clinical, technical, and outcome data were analyzed. Results: The literature review comprised 24 articles on 373 patients, primarily those with in situ subungual melanoma. Reconstruction was most often performed using total skin grafts, sometimes combined with dermal matrices. Some authors used local or free flaps. Few studies used validated functional scores. Local recurrences were significant, affecting 18% of patients and requiring secondary amputation. Conclusions: Nail apparatus reconstructions are primarily indicated for in situ or minimally invasive subungual melanomas. Immediate reconstruction carries a risk of performing the reconstruction over residual tumor tissue, particularly in the case of invasive melanomas. Reconstructive techniques, such as full-thickness skin grafts and the use of dermal matrices, can provide satisfactory functional and aesthetic outcomes. However, objective evaluations of these results remain limited, and better standardization of clinical practice, along with prospective studies, is needed to refine long-term outcome assessment. Full article

Prosthetic joint infections (PJIs) pose significant challenges, often requiring multiple surgeries that lead to soft tissue loss, dead space, and fibrosis. Wound breakdown increases the risk of polymicrobial infection and treatment failure. The vertical rectus abdominis myocutaneous (VRAM) flap is a proven method for complex wound coverage, but its role in managing hip PJI is underexplored. This study evaluates outcomes of VRAM flap reconstruction in polymicrobial hip PJI. We retrospectively reviewed five patients who underwent VRAM flap reconstruction for polymicrobial hip PJI between December 2020 and December 2023. Primary outcomes included flap survival, infection control, and wound healing. Secondary outcomes were implant retention, postoperative complications, and functional status. At a mean follow-up of 28 months, four patients achieved wound healing and remained infection-free, while one had persistent sinus drainage but retained the implant. Flap survival was 100%, with no necrosis or failure. No major complications requiring reoperation occurred. Two patients developed deep collections, managed with ultrasound-guided drainage (Clavien-Dindo IIIa). Minor complications included donor-site dehiscence (three), flap dehiscence (one), edge necrosis (two), and hernias (two), all managed non-surgically (Clavien-Dindo I/II). All patients retained implants and remained ambulatory. VRAM flap reconstruction is a reliable option for managing complex polymicrobial hip PJI. Flap survival was excellent, and most patients achieved infection control. However, persistent infection and the need for suppressive antibiotics highlight the ongoing challenges in these cases. Full article

Background: Patients undergoing head and neck surgery with free flap reconstruction are at a high risk for postoperative respiratory complications, including hypoxemia. Conventional oxygen therapy (COT) and non-invasive ventilation (NIV) may be poorly tolerated or contraindicated due to anatomical limitations. High-Flow Nasal Cannula (HFNC) therapy represents a promising alternative, offering better humidification, comfort, and oxygenation. Methods: This retrospective single-center study included 50 adult patients admitted to the ICU after head and neck oncologic surgery with flap reconstruction from January 2022 to November 2024. All patients received HFNC immediately after extubation. Hypoxemia was defined as a PaO₂/FiO₂ (P/F) ratio of < 300 mm Hg. The primary outcome was the incidence of postoperative hypoxemia. Secondary outcomes included reintubation rates and patient compliance. Data were collected at 1, 6, 12, and 24 h following HFNC initiation. Results: Out of 59 patients screened, 9 were excluded per predefined criteria. Among the 50 included, only 2 patients (4%) developed hypoxemia, with P/F ratios remaining above 250. No patients required reintubation. The respiratory rate–oxygenation index (ROX index) improved steadily during the first 24 h. HFNC was well tolerated; only three patients required minor adjustments due to discomfort. Conclusions: HFNC use in the immediate postoperative period after head and neck surgery was associated with a low incidence of hypoxemia and no reintubations. These findings suggest that HFNC is a safe and effective strategy for postoperative respiratory support in this high-risk population. Further prospective studies are warranted to confirm the benefit of HFNC in reducing hypoxemia and preventing reintubation in high-risk surgical populations. Full article

Background/Objectives: This systematic review and meta-analysis evaluates the surgical, functional, and aesthetic outcomes of scapular free flaps in maxillary reconstruction. The primary objective is to assess early surgical complications, fistula formation, donor site morbidity, dental restoration, normal dietary intake, aesthetic compromise, and eye-related issues. Secondary objectives include total free flap necrosis, the need for revision procedures, and functional performance of the upper limb. Methods: A systematic review was conducted following the PRISMA guidelines. Eligible studies were identified by searching PubMed/MEDLINE, Cochrane Library, Scopus, and Google Scholar, with the last search conducted on 10th February 2025. Inclusion criteria were studies reporting on patients undergoing maxillary reconstruction with scapular free flaps, and which provided data on at least one of the primary or secondary outcomes. A single-arm meta-analysis was performed to assess the outcomes of scapular free flap reconstruction. The risk of bias was assessed using the Newcastle–Ottawa Quality Assessment Scale, with two independent reviewers performing the assessment. Results: From an initial search of 310 articles, 6 studies were included in the qualitative and quantitative synthesis, encompassing 231 patients with a mean age of 52.9 years (95% CI 44.9–60.8). Early general surgical complications occurred in 24% (95% CI 13–40) of patients, while 12% (95% CI 4–31) experienced fistula formation. Donor site morbidity was reported in 10% (95% CI 6–17) of cases, with a mean DASH score of 10.49, indicating low upper limb impairment. Dental rehabilitation was achieved in 56% (95% CI 42–70), and 52% (95% CI 31–72) of patients resumed a normal diet. Aesthetic compromise was observed in 27% (95% CI 9–58), and 36% (95% CI 28–44) reported eye-related issues. Conclusions: Scapular free flap is a reliable option for maxillary reconstruction with favourable outcomes, particularly in complex composite defects requiring both bone and soft tissue reconstruction. However, the evidence is limited by risk of bias, significant heterogeneity, and imprecision due to the small number of studies and participants. Larger, more robust trials are needed to confirm these findings. Full article

Background: Periocular necrotizing fasciitis (PNF) is a rare but life-threatening emergency that requires immediate recognition, as delayed diagnosis can worsen patient outcomes. To address this critical issue, we conducted the largest and most comprehensive systematic review to date, providing valuable insights into the diagnosis and treatment of PNF to improve clinical practice and patient prognosis. Methods: A search on Pubmed, Scopus, Embase, and WOS from January 2013 to August 2024 was performed. Only the cases of NF affecting the periocular region were included with no age limitations. Article selection and data extraction were performed independently by two investigators to avoid bias. Bias on individual studies is low as they represent case reports or case series, and publication bias is partially addressed including all the large case series even if no individual data could be retrieved. Results: The cohort included a total of 183 patients with PNF, with detailed patient-specific data for 107 individuals and only aggregated data for another 76. The average age at diagnosis was 54.2 years, and females constituted 44% of the population sample. Notably, 49.6% of the patients were immunocompromised. Streptococcus pyogenes was the predominant causative organism, identified in 79.8% of the cases. Most infections were unilateral (72.1%) without extension beyond the periocular area (54.7%). Most patients (89.6%) underwent surgical debridement alongside intravenous antibiotics. Septic shock occurred in 26.8% of the patients, and the overall mortality rate was 4.9%. Visual acuity was unaffected in 67.5% of the patients, though 18.2% progressed to blindness on the affected side. Reconstructive efforts predominantly involved skin grafting, both free and local pedunculate flaps as well as secondary healing in some instances. Conclusions: This systematic review summarizes the understanding of periocular necrotizing fasciitis’ (PNF) demographic trends, clinical manifestations, causative pathogens, and patient outcomes. Vigilance for PNF should be heightened when the clinical assessment of the patient’s eyelids reveals rapidly spreading edema and induration, subcutaneous emphysema, or necrotic bullae and/or eschar. Prompt identification and expedited intervention, including debridement and targeted antibiotic therapy, critically influence prognosis. Despite optimal management, patients may still suffer from significant aesthetic impairment, severe complications such as vision loss, or death due to septic shock. Full article

Objective: Reconstructing the anterior mandible in patients with irradiated and contracted soft tissues remains challenging despite advances in computer-assisted design and three-dimensional printing. Unpredictable soft-tissue changes reduce the effectiveness of these technologies. This paper explores an alternative using a single-adjustable-osteotomy fibula flap technique. Methods: A retrospective study was performed on patients with anterior segmental mandibular defects due to recurrent tumors, secondary reconstruction, or osteoradionecrosis and previously received radiotherapy who represented the highest risk of soft tissue complexity while limiting the utility of computer technology. All patients underwent mandible reconstruction using the adjustable, single-osteotomy fibula method, which eliminated the need for computer-assisted design. We evaluated the effectiveness and outcome. Results: From 2016 to 2023, 11 patients were included in this study. The median patient age was 58 (ranging 49–65) years. Included patients had either recurrent tumors (n = 6), secondary reconstruction needs (n = 3), or mandibular osteoradionecrosis (n = 2). No complete flap failures occurred. Five of six patients with recurrent cancer required two skin island fibular flaps for intraoral and external defect repair. One patient experienced partial skin paddle loss requiring an additional free flap, and another had plate exposure requiring removal after bone union was achieved. Conclusions: The adjustable single-osteotomy fibula flap technique offers a reliable alternative for anterior mandibular reconstruction in complex cases. This approach demonstrates advantages in surgical simplicity and flexibility while maintaining acceptable outcomes. However, careful patient selection and consideration of defect extent remain crucial for success. Full article

Introduction: Microvascular free flap surgery is a treatment method for patients with head and neck cancer requiring reconstruction surgery. Patients undergoing this complex, long-lasting surgery are prone to prolonged episodes of intraoperative hypotension, which is associated with increased incidence of postoperative mortality, morbidity, and free flap failure. A new technology recently approved, named the Hypotension Prediction Index (HPI), allows precise hemodynamic monitoring of patients under general anesthesia, with a significant reduction of intraoperative hypotension events. This study aims to assess the impact of the Hypotension Prediction Index (HPI) on the incidence and severity of intraoperative hypotension in patients undergoing free flap surgery. Methods and analysis: Eligible patients will be randomly assigned to one of two groups: Group A, receiving invasive blood pressure monitoring with standard medical therapy, or Group B, undergoing hemodynamic monitoring using the Hypotension Prediction Index (HPI) software. The primary outcome is the time-weighted average (TWA) of mean arterial pressure (MAP) < 65 mmHg. Secondary outcomes include free flap viability and perioperative complications. Ethics and dissemination: Ethics approval was obtained from the Poznan University of Medical Sciences Ethics Committee (KB-560/22; date 1 July 2022). Results will be submitted for publication in a peer-reviewed journal. Trial registration number: NCT 05738603. Full article

Background/Objectives: The reconstruction of hand defects, especially involving the dorsal region of the hand, has remained a challenge for surgeons because of its anatomical features and complex functions. The goal of reconstruction should include functional restoration as well as being esthetically pleasing. The flap transfer reconstruction strategy is essential for satisfying these requirements. Methods: Free flaps were used to cover traumatic defects of the hand dorsum in eleven patients from 2016 to 2022. Eight males and three females with a mean age of 41 years were enrolled. The size of the flaps ranged from 6 × 5 cm to 20 × 9 cm, and the selected flaps included five anterolateral thigh flaps, three lateral arm flaps, and three superficial circumflex iliac artery flaps. Results: All flaps survived, with one case of partial necrosis. One patient experienced joint stiffness during recovery. The donor sites were closed primarily, and there was no need for skin grafting. Secondary debulking or thinning was also not required. The majority of cases recovered excellent function of the hand (mean Q_DASH: 2.5) with satisfactory esthetic outcomes. The postoperative observations were followed by more than six months. Conclusions: Small defects can be treated using local, pedicled, and island-type flaps. However, larger defects involving the exposure of tendons, nerves, and other critical structures commonly require free tissue transfers. The flap reconstruction for hand dorsum in the study is feasible to produce acceptable outcomes in large sized defects. Full article

Background: Post-extraction ridge resorption is an inevitable phenomenon that cannot be eliminated but is significantly reduced using additional surgical techniques known as socket preservation. They aim to create favorable conditions for implant placement and prosthetic restoration. This study aims to assess the effect of socket sealing (SS) with free gingival grafts on the vertical resorption of socket walls at the premolar and molar regions over 3 months. Methods: This randomized two-arm controlled trial with parallel groups (1:1 allocation) was conducted at the Department of Oral Surgery, Medical University-Varna, Bulgaria, from 27 June 2022 to 20 April 2023. Forty patients aged 30–65 were equally and randomly allocated to the SS or the control groups. Atraumatic tooth extraction was performed. In the control group, the socket was left on secondary wound healing. In the SS group, the socket orifice was “sealed” with an FGG harvested from the hard palate or maxillary tuberosity. Results: Data analysis demonstrated that SS with an FGG is a successful method for reducing the post-extraction resorption of the socket walls. In addition, this study confirms that the thickness of the buccal wall is a significant factor in its vertical resorption. Conclusions: Socket sealing with an FGG is a valuable method that eliminates the need for flap reflection and compensates for the soft tissue deficit when immediate implant placement or bone augmentation is required. Further research is necessary to determine the role of different factors influencing bone resorption and compare the effect of different socket preservation methods. Full article

The purpose of this study was to analyze computer-aided surgical planning (CAS) and margin status following oncological reconstructive surgery of the jaws. A retrospective study was conducted on patients who underwent microvascular reconstructive surgery from 2014 to 2021. The predictor variable was the use of CAS. The primary and secondary outcomes were histopathological bone margin status, local recurrence, and disease-free survival (DFS). Covariates included demographic, operative, pathological, and clinical outcomes. Thirty-five CAS and fifty-two non-CAS subjects were included for analysis. Demographic characteristics such as age, sex, and comorbidities were comparable between the study groups, with all p-values > 0.05. For operative variables, the osteocutaneous radial forearm flap was more commonly used in the non-CAS group (34.6%) compared to the CAS group (2.9%) (p < 0.01). The mean follow-up period was shorter in the CAS group (31.9 months) than in the non-CAS group (42.6 months) (p < 0.01). CAS was not associated with margin status (p = 0.65) or local recurrence (p = 0.08). DFS was comparable between the study groups (p = 0.74). Bone margin involvement was not associated with any covariates. The use of CAS in oncological reconstructive jaw surgery was not associated with increased bone margin involvement. Full article