Search Results (732)

Background: Megaprosthetic reconstruction is the standard of care for limb salvage after tumor resection around the knee, but the full burden of unplanned revision surgery is rarely reported as a structured composite outcome. We evaluated 241 consecutive patients over 21 years at a tertiary orthopedic oncology center. Methods: This retrospective cohort included 241 patients (160 distal femur, 78 proximal tibia, three combined) treated between 2003 and 2024. Revision-free survival (RFS, composite of any unplanned revision or amputation) and amputation-free survival were estimated by Kaplan–Meier analysis; independent predictors were identified by Cox regression. A pre-specified major-event composite (amputation, implant removal, or recurrence resection) was used for sensitivity analysis. Results: Mean age was 34.9 ± 19.5 years; mean follow-up was 120.2 months. Negative resection margin (R0) was achieved in 85.5% (206/241). Unplanned revision was required in 25 patients (10.4%); overall limb salvage was 92.9%. Five-year RFS was 73.8% (distal femur) vs. 65.0% (proximal tibia; p = 0.084), and 5-year limb salvage was 88.9% vs. 84.3% (p = 0.081). Surgical margin was strongly associated with outcome: 5-year RFS 75.4% (R0) vs. 48.7% (R1/R2; p < 0.001); 5-year limb salvage 90.6% vs. 71.5% (p = 0.003). On exploratory multivariate Cox analysis, proximal tibia site and positive margin were associated with worse revision-free survival; within the proximal tibia subgroup, absence of gastrocnemius flap coverage was also associated with worse outcome (interpreted with caution given the small flap subgroup, n = 11, and limited event count). Conclusions: In this single-center series, megaprosthetic reconstruction around the knee achieved acceptable revision-free survival and limb salvage. Surgical margin status was the strongest independent predictor of both endpoints, reinforcing the well-established importance of oncologic margin quality and site-specific soft tissue strategies. Full article

Background/Objectives: Artificial intelligence (AI) is increasingly proposed to improve surgical planning, guidance, and postoperative surveillance. Yet many promising applications remain disconnected from the full surgical pathway and the feasible limitations of clinical deployment. In contrast to prior reviews that primarily catalog AI use cases, this review combines the literature to define the translational pathway—from label design through staged validation to workflow integration—required for clinically deployable computed tomography (CT)-based surgical AI. CT and particularly computed tomography angiography (CTA) are especially usable sources for surgical AI because they provide a standardized three-dimensional anatomic model that is already embedded in many clinical workflows. In autologous breast reconstruction, deep inferior epigastric perforator (DIEP) flap CTA offers an unusually strong model system: the anatomy is discrete, surgeon decisions are actionable, and downstream operative and postoperative outcomes are measurable. These characteristics make DIEP reconstruction suitable not only for technical model development, but also for exacting testing of how CT-based AI should be annotated, validated, displayed, and governed. Methods: This focused narrative review combines evidence across the surgical workflow, spanning preoperative planning and risk stratification, intraoperative support, and postoperative monitoring. Reporting standards, implementation frameworks, governance, and regulatory sources were also considered when directly relevant to clinical deployment. Results: Across the available literature on breast reconstruction with the DIEP flap, preoperative CTA has been associated with reductions in operative time of approximately 54–76 min in individual studies. Semi-automated perforator mapping can reduce review time from 2 to 3 h to approximately 30 min. Intraoperative extended-reality tools and surgeon-facing navigation systems illustrate the importance of the ‘last mile’ of translation, while postoperative monitoring models show how imaging-linked data can support a closed-loop learning system. Across these stages, recurring limits include target mismatch, weak external validation, protocol variability, inconsistent reporting, limited subgroup analysis, and inadequate integration of economic and governance considerations. Conclusions: We argue that the next important step is not a generic autonomous model, but a clinically deployable DIEP-CTA-AI program. The practical blueprint proposed here is staged: structured anatomical labels, separate imaging, surgeons’ decisions, and outcome reference standards, dense intermediate endpoints, retrospective and external validation, reader studies, prospective silent deployment, and workflow-impact assessment. If implemented in this way, DIEP flap CTA can serve as a practical blueprint for CT-based AI translation in surgery more broadly. Full article

Background: Complex elbow soft-tissue defects often combine exposed critical structures, unstable scars, and high mechanical stress, making durable coverage and early mobilization challenging. Among regional options, the reverse lateral arm flap provides thin fasciocutaneous tissue based on a reliable collateral circulation and preserves major forearm vessels. The aim of this study was to report our single-center experience with the pedicled reverse lateral arm flap for elbow soft-tissue reconstruction, focusing on stable coverage, donor-site morbidity, and functional recovery. Methods: A retrospective single-center case series was conducted at the Division of Plastic Surgery, University Hospital of Padua, Italy. All consecutive patients treated between 2013 and 2023 with a pedicled reverse lateral arm flap for elbow soft-tissue defects were included. Recorded variables included defect etiology, donor-site management, complications, range of motion, and follow-up. Elbow flexion–extension was recorded clinically preoperatively and at last follow-up. Minimum follow-up was 12 months in all patients. Results: Seven patients underwent reconstruction. Defect etiology was burn-related in four cases, shotgun trauma in one, crush injury in one, and melanoma resection in one. All defects were covered with a pedicled reverse lateral arm flap. All flaps survived completely without partial necrosis or flap-related reoperation. Donor-site closure was primary in four patients and required split-thickness skin grafting in three. One patient developed donor-site keloid, and one had donor-site skin-graft partial loss with delayed healing. Elbow flexion–extension improved in all seven cases, with a median gain in arc of motion of 25° (range 15–41°). Conclusions: In this series, the reverse lateral arm flap provided complete coverage of selected elbow defects with preserved motion and limited donor-site morbidity at a minimum follow-up of 12 months. Our findings suggest that it may represent a useful regional option in selected posterior and lateral elbow defects, particularly in post-burn and traumatic settings where thin vascularized tissue is needed, and free-flap reconstruction may be avoidable. Full article

Secondary lymphedema is a chronic, progressive condition characterized by limb swelling that arises after disruption of lymphatic channels from trauma or iatrogenic injury. In patients with complex soft tissue defects, reconstruction intended to restore the limb may inadvertently disrupt lymphatic drainage, highlighting the need for lymphatic-conscious surgical approaches. We present a retrospective case series of three patients with lower extremity soft tissue injuries who underwent flap-based reconstruction at our institution between 2021 and 2024. Reconstructive techniques, intraoperative decision-making, and postoperative lymphatic outcomes were analyzed over a follow-up period of 11 to 38 months. In the first two cases, disruption of established or new lymphatics during flap inset or repeated flap re-elevations may have contributed to the development of lymphedema. By contrast, indocyanine green (ICG) lymphography-guided flap planning and inset in the third case preserved lymphatic drainage pathways which could potentially lead to the development of lymphedema. Post-traumatic flap-based extremity reconstruction requires careful attention to native and transferred lymphatics to decrease the risk of secondary lymphedema. These cases draw attention to the concepts of preserving lymphatics, maintaining lymphatic axiality, and using ICG lymphography when planning flap-based reconstruction. 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

Objectives: This study evaluates the epidemiological characteristics and survival, functional, and esthetic outcomes of pediatric patients diagnosed with head and neck sarcoma (PHNS) who underwent individualized surgical treatment for local disease control and/or for defect reconstruction. Methods: A cohort of 45 patients aged 0–18 years with histologically confirmed PHNS who underwent surgical resection and/or reconstructive procedures was analyzed. Extracted variables included demographic data, tumor histology and stage, surgical margin status, and systemic therapy modalities. Reconstructive strategies were assessed, considering technique, sequencing, and total duration of treatment. Survival analysis was performed, focusing on both overall survival (OS) and event-free survival (EFS). Results: Rhabdomyosarcoma constituted the predominant diagnosis (19/45), followed by Ewing sarcoma (7/45) and chondrosarcoma (5/45). The maxilla represented the most common primary site (18/45), whereas orbital origin was the least frequent (3/45). Complete surgical excision (R0) was achieved in 80.5% of resected cases. Margin status showed no statistically significant association with final outcome (p = 0.7786). In contrast, nodal metastasis, local recurrence, and distant dissemination were independently and collectively correlated with mortality. Survival analysis demonstrated a 3-year OS of 100% and an EFS of 79.8%, and a 5-year OS of 94.7% with an EFS of 70.7%. Conclusions: Implementation of an individualized surgical and reconstructive protocol was associated with effective local tumor control and favourable reconstructive outcomes. Oncologic prognosis was driven primarily by nodal involvement and recurrent or metastatic disease rather than margin status alone. 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/Objectives: Reconstruction of complex lower extremity soft tissue defects remains challenging, particularly in the proximal and middle tibial regions, including the knee, where suitable recipient vessels are often limited due to prior trauma, infection, or surgical intervention. This study aimed to evaluate the feasibility and clinical applicability of anterior tibial vessel turnover as an alternative recipient vessel strategy in free flap reconstruction. Methods: A retrospective review was conducted of seven patients who underwent free flap reconstruction using anterior tibial vessel turnover as the recipient vessel between 2019 and 2024. Preoperative imaging was performed to assess vascular status and collateral circulation. Clinical data, including patient demographics, defect characteristics, flap parameters, and postoperative outcomes, were analyzed. Results: The mean patient age was 62.7 years (range, 38–86 years). Defects were primarily located in the proximal and middle tibial regions and were associated with trauma, postoperative infection, chronic osteomyelitis, or burn injury. The mean flap size was 137.4 cm² (range, 49.5–280 cm²). All flaps survived, resulting in a flap survival rate of 100%, with no cases of total flap loss or re-exploration due to vascular compromise. One patient experienced partial flap loss, while no other flap-related complications were observed. Most patients achieved stable wound coverage and favorable functional recovery. Conclusions: Anterior tibial vessel turnover may serve as an alternative recipient vessel strategy for selected cases of complex lower extremity free flap reconstruction. This technique enables microvascular anastomosis in a more superficial and accessible field and expands reconstructive options in cases with compromised recipient vessels. Full article

The use of an omental pedicle flap as an adjuvant treatment has gained popularity in veterinary medicine due to its versatility. This technique has been successfully applied in both intra-abdominal and extra-abdominal surgeries in human as well as veterinary medicine. In most intra-abdominal procedures, the greater omentum can be easily accessed through a midline laparotomy and directed to the area of interest. However, dogs and cats are typically positioned in lateral recumbency for extra-abdominal surgeries involving the thorax or limbs. In such cases, a lateral approach to the greater omentum could minimize the risk of infection or trauma associated with patient repositioning. This cadaver study evaluated the feasibility of accessing the greater omentum through a lateral approach laparotomy in both left and right lateral recumbency. A total of 22 cadavers (13 cats and 9 dogs) were included. Dorsal extension of the greater omentum was successfully performed in all specimens without major structural damage. Further elongation using an inverted L-shaped pedicle flap was achieved without rupture in 17 of 22 cadavers (77.3%). The results demonstrate that lateral approach laparotomy provides reliable access to the greater omentum and allows successful mobilization of the omentum for potential extra-abdominal applications, with no significant differences observed between left and right lateral approaches. This technique may represent a useful alternative in clinical situations where repositioning the patient is not feasible or carries increased surgical risk. 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

Severe nasal vestibular stenosis in brachycephalic cats involves species-specific anatomical structures distinct from those in dogs, often leading to a high recurrence rate even after standard surgical correction. This case report introduces an innovative surgical strategy for a refractory Exotic Shorthair cat presenting with obligate open-mouth breathing and complete nasal obstruction despite three previous surgical interventions. To remove the recurrent scar tissue and maximize the nasal vestibular lumen, a combined surgical approach was performed, incorporating a ventral vertical resection, bilateral wedge resections, and bilateral single pedicle advancement flaps. To maintain the acquired airway and prevent restenosis, a steroid-eluting bioabsorbable implant (PROPEL Contour) was placed within the resected nasal vestibule, marking its first application in veterinary medicine. Postoperatively, open-mouth breathing resolved immediately. At the long-term 20-month follow-up, normal nasal breathing was maintained without restenosis or nasal discharge, with complete resolution of all preoperative clinical signs, and no implant-related adverse effects or infections were observed. The concurrent application of radical structural resection and a PROPEL Contour implant effectively suppresses tissue regrowth and maintains stable nasal patency, offering a highly promising therapeutic protocol for refractory feline nasal vestibular stenosis. Full article

Ossification of the vascular pedicle following fibula free flap (FFF) reconstruction is an uncommon and typically asymptomatic complication. Symptomatic cases requiring intervention are rare. We report a 29-year-old man with anterior maxillary osteosarcoma who underwent tumor resection followed by reconstruction with an osteocutaneous FFF. Calcification within the surgical site region was noted on imaging at two months after fibular reconstruction. By five months, he developed progressive trismus and pain with mastication. Computed tomography demonstrated a calcified structure extending from the mandible to the reconstructed maxilla along the flap pedicle, raising concern for tumor recurrence. Surgical excision was performed, and histopathology revealed benign woven bone without evidence of malignancy. Postoperatively, trismus improved, and flap viability was preserved. Retained periosteum during FFF harvest maintains osteogenic potential and may result in pedicle ossification. In symptomatic patients, particularly when recurrence is suspected, surgical resection is both diagnostic and therapeutic. Full article

Objective: To investigate the method and clinical outcomes of employing plantar propeller perforator flaps for the repair of defects in the plantar region. Methods: This was a retrospective case series of 40 patients (20 males, 20 females; age range 20–75 years) who underwent plantar defect reconstruction using the horn-shaped perforator flap technique between January 2020 and October 2025. Defect etiologies included malignant melanoma (n = 24), melanocytic nevus (n = 3), and refractory wounds (n = 13). Defect sizes ranged from 2 cm × 1.5 cm to 5 cm × 5 cm. The primary outcome was flap survival; secondary outcomes included functional recovery (American Orthopaedic Foot and Ankle Society AOFAS score), sensory recovery (Semmes–Weinstein monofilaments), and time to full weight-bearing. Results: Complete flap survival was achieved in 38/40 patients (95%). Two patients (5%) experienced minor distal wound dehiscence and necrosis, successfully managed with full-thickness skin grafting and dressing changes without compromising final outcomes. Mean follow-up was 14.2 ± 6.8 months (range 3–24 months). Mean AOFAS score was 91.3 ± 5.6, with 80% achieving excellent functional recovery. Protective sensation was present in 87.1% of the tested patients. Mean time to full weight-bearing was 6.4 ± 1.8 weeks. No local tumor recurrence occurred in melanoma patients during follow-up. Conclusions: The horn-shaped perforator flap provides a reliable source of homologous glabrous skin for reconstructing small-to-medium-sized plantar defects while avoiding skin grafting at the donor site. Its combined rotation–advancement mechanism, flexible triangular leading-edge strategies, and preservation of multiple perforators contribute to favorable functional and aesthetic outcomes. Prospective comparative studies with standardized plantar-specific outcome measures are warranted. Full article

Background: Eyelid reconstruction is particularly challenging because of the delicate anatomy and its critical functional and aesthetic roles. Although various methods have been described for anterior and posterior lamellar repairs, no standardized approach has been established. We developed a single-stage technique integrating reconstruction of both lamellae. Methods: This retrospective case series included seven consecutive patients who underwent full-thickness eyelid reconstruction between 2012 and 2024. Patients were included if they had full-thickness defects requiring reconstruction of both lamellae, underwent reconstruction using a nasal septal chondromucosal graft combined with a large local flap, and had at least 12 months of follow-up. The posterior lamella was reconstructed using nasal septal chondromucosal grafts, and the anterior lamella using large local flaps. Donor sites were managed using various methods. Results: All patients (7/7) achieved complete graft survival without partial or total graft loss. All patients achieved complete eyelid closure without lagophthalmos, and no cases of ectropion, corneal complications, or graft failure were observed. Buccal mucosal grafting demonstrated the most favorable donor-site outcomes, with uneventful healing and no septal perforation or airway-related complications. Conclusions: This single-stage approach combining chondromucosal grafts and local flaps is a feasible and reproducible option for selected patients, providing reliable structural support and satisfactory functional outcomes. Full article

Background: Despite advances in cleft rhinoplasty, the nasal sill remains an underappreciated subunit, yet it plays a crucial role in nostril symmetry and aesthetic balance. Hypoplasia or absence of the nasal sill on the cleft side often persists after primary repair and may complicate secondary nasal base correction. Current methods for sill reconstruction are limited by donor site morbidity, variability in tissue match, or non-anatomic tissue substitution. Methods: This technical note describes a surgical protocol utilizing the Tela Cutis Nasi flap, a pedicled fibro-adipose flap harvested from the adjacent nasal base, to reconstruct the deficient sill in patients with previously repaired unilateral cleft lip. The flap concept, anatomical rationale, stepwise operative steps, and patient selection considerations are outlined. Results: This technical note details the surgical steps, anatomical rationale, and flap design. No formal morphometric or patient-reported outcome analysis is included in this report; these data are being collected within an ongoing prospective outcome study designed to evaluate efficacy and long-term stability. Conclusions: The Tela Cutis Nasi flap is intended as an anatomically based local option for nasal sill reconstruction that can be integrated into secondary cleft nasal base surgery. This article contributes a standardized operative description, indications, technical constraints, and anticipated pitfalls, without assessment of clinical outcomes or long-term stability. Full article