Autologous fat grafting is widely used for secondary contour refinement following head and neck reconstruction and is generally considered safe. However, irradiated reconstructed tissues exhibit fibrosis and reduced compliance, potentially predisposing patients to uncommon complications. Transient facial nerve paralysis following fat grafting has not previously been reported in an irradiated anterolateral thigh (ALT) free flap. A 57-year-old man underwent extensive oncologic resection for verrucous squamous cell carcinoma involving the temporal bone and parotid region, followed by ALT free flap reconstruction and adjuvant radiotherapy. After flap debulking and an initial lipofilling procedure, a second fat-grafting session (60 mL) was performed five months later for residual preauricular contour deformity. Immediately after surgery, the patient developed House-Brackmann grade V facial paralysis. Systemic methylprednisolone was initiated at 64 mg/day and tapered over five days. Facial function improved rapidly, with complete recovery within 36 hours and no residual deficit. Given the close temporal relationship to fat grafting and rapid recovery, transient pressure-related neuropraxia within the irradiated fibrotic tissue bed was considered a plausible mechanism; however, this remains hypothetical without objective evidence of nerve compression, edema, or ischemia. To our knowledge, this is the first reported case of rapidly reversible total facial paralysis following autologous fat grafting in an irradiated ALT free flap. Reduced tissue compliance secondary to radiation-induced fibrosis may contribute to transient nerve dysfunction. Awareness of this potential complication and cautious, low-pressure injection may be important when performing fat grafting near major nerve structures in irradiated reconstructive fields.
Reconstruction of complex scalp defects associated with calvarial involvement represents a significant challenge, particularly in patients who have undergone radiotherapy, experienced infection and undergone multiple surgical procedures. In these settings, locoregional reconstructive options are often unreliable and free tissue transfer plays a central role in achieving stable, well-vascularized coverage. We present a case of a 50-year-old woman with recurrent atypical meningioma who underwent multiple neurosurgical resections and radiotherapy. The postoperative course was complicated by wound dehiscence, infection, and cranioplasty failure. Upon evaluation, the patient exhibited a large posterior scalp defect (14 × 5 cm) with exposed calvarium. A multidisciplinary approach was adopted. Following neurosurgical debridement, tumor resection and calvarial reconstruction using a titanium mesh, soft-tissue coverage was achieved with a free latissimus dorsi muscle flap combined with a split-thickness skin graft. Microvascular anastomosis was performed using the superior thyroid artery and the jugular venous system, selected outside the irradiated field. The postoperative course was uneventful, with no signs of flap ischemia or venous congestion. At eight months of follow-up, the patient demonstrated complete wound healing, stable coverage, and a satisfactory morphofunctional outcome, with minimal donor-site morbidity. This report emphasizes that successful salvage reconstruction of irradiated scalp defects complicated by osteomyelitis depends not only on vascularized tissue transfer but also on meticulous recipient vessel selection. In particular, the superior thyroid artery represented a reliable recipient vessel outside the irradiated field, allowing safe microvascular reconstruction despite previous surgery, infection and radiation-induced vascular compromise.
Soleal sling syndrome (SSS) is an underrecognized cause of tibial nerve (TN) entrapment at the popliteal fossa, resulting in exertional calf pain, paresthesia and functional impairment. Five patients (seven limbs) underwent decompression with autologous fat grafting. Clinical improvement occurred without graft-related complications, supporting evaluation of fat grafting as an adjunctive treatment.
Ossifying fasciitis represents an uncommon benign lesion within the spectrum of reactive fibroblastic proliferations. It is defined by the coexistence of spindle-cell proliferation and heterotopic bone formation, a combination that can easily simulate malignant soft-tissue tumors. Because of its rapid growth and radiologic density, it is frequently mistaken for sarcomatous processes. Although most cases occur in the trunk and proximal extremities, presentation within the hand is exceptionally rare. We describe a 34-year-old male who developed a painless nodule on the palmar aspect of the right hand growing over two months. Imaging revealed a well-circumscribed lesion with heterogeneous signal intensity adjacent to the flexor tendon. The excised mass was composed of fibroblasts and myofibroblasts arranged in fascicles within a fibromyxoid stroma, showing osteoid formation rimmed by osteoblasts and scattered multinucleated giant cells. No cytologic atypia or atypical mitoses were present. Immunohistochemistry demonstrated diffuse smooth-muscle-actin (SMA) positivity and absence of H-caldesmon and ALK expression, confirming a diagnosis of ossifying fasciitis. This case underscores the diagnostic pitfalls of ossifying fasciitis, particularly when arising in unusual anatomic locations. Awareness of its characteristic histologic features and correlation with clinical and imaging findings is crucial to avoid misinterpretation as a malignant neoplasm and to prevent unnecessary radical surgery. Reporting such cases expands understanding of their variable presentations and contributes to refining clinical decision-making.
Introduction:Frontal sinus osteomas are rare benign tumors that may cause functional or cosmetic concerns. Virtual surgical planning (VSP) offers promising adjuncts to classic craniofacial techniques to improve surgical precision and minimize long-term morbidity. Patient:A previously healthy 15-year-old male presented with a two-year history of headaches and a slowly enlarging mid-forehead mass. Imaging revealed a 3 × 2 cm frontal sinus osteoma with mucocele formation and erosion of both the anterior and posterior tables, with early mass effect on the frontal lobes. VSP was used to design bi-frontal craniotomy and split-calvarial bone graft cutting guides. A combined approach by plastic surgery and neurosurgery was performed using resorbable plating for reconstruction. Results:The operation proceeded without complication. The osteoma was excised, cranialization of the frontal sinus was completed, and the frontal bone was reconstructed using a split-calvarial bone graft secured with resorbable fixation. The patient recovered uneventfully and was discharged on postoperative day four. At six-month, one-year and two-year follow-up, he remained asymptomatic, with six-month imaging showing stable reconstruction and no tumor recurrence. Pathology confirmed a mixed-type osteoma. Conclusion:This case illustrates the successful application of VSP, split-calvarial grafting, and resorbable plating for the resection and reconstruction of a frontal sinus osteoma. The use of patient-specific guides allowed for precise resection and autologous reconstruction. This technique may serve as a valuable model for similar cases in craniofacial surgery.
Abdominoplasty is a commonly performed body-contouring procedure with a predictable postoperative course. Early abdominal pain is typically attributed to surgical site discomfort, edema, rectus plication, or common complications such as seroma or hematoma. However, intra-abdominal pathology may present with overlapping or nonspecific symptoms, increasing the risk of diagnostic delay. We report two cases of postoperative abdominal pain following abdominoplasty in which intra-abdominal etiologies were identified or strongly considered. In Case 1, a 71-year-old woman with prior Roux-en-Y gastric bypass developed progressive abdominal pain and obstructive symptoms on postoperative day 1. Imaging revealed small bowel obstruction, and diagnostic laparoscopy confirmed an internal hernia through a Petersen’s defect requiring surgical intervention. In Case 2, a 34-year-old woman presented with progressive right lower quadrant pain and swelling after a combined reduction mammaplasty and abdominoplasty. Imaging demonstrated an incidental ovarian hemorrhagic cyst, and she was managed conservatively with resolution of symptoms. In both cases, the abdominal wall and surgical sites were clinically benign. These cases highlight that postoperative abdominal pain after abdominoplasty is not always attributable to the abdominal wall or operative field. Overlapping symptoms may contribute to diagnostic anchoring and delayed recognition of intra-abdominal pathology. Maintaining a broad differential diagnosis, particularly in patients with prior abdominal surgery or atypical symptom progression, is essential. Prompt evaluation and multidisciplinary collaboration can reduce morbidity and prevent delays in care.
Fingertip amputation at Tamai Zone I remains technically challenging due to extremely small vessel size and the frequent absence of suitable veins for venous anastomosis. Venous congestion is a major cause of failure, and various strategies have been proposed to address limited venous outflow. We report a 28-year-old man with a complete Tamai Zone I amputation of the left index fingertip following a motorcycle chain injury. Replantation was completed approximately 8 h after injury. As no suitable vein for conventional venous anastomosis, a composite microsurgical strategy was implemented, integrating multiple coordinated components: arterial repair, direct arteriovenous (AV) anastomosis, controlled ligation of the distal palmar arterial arch, nail plate removal, and short-term postoperative anticoagulation. At one-year follow-up, the replanted fingertip survived completely with satisfactory aesthetic and functional outcomes. The nail regrew with minimal deformity, the distal interphalangeal joint regained full range of motion, and sensory recovery was satisfactory with a two-point discrimination of 7 mm. This case demonstrates the feasibility of a composite microsurgical approach for Tamai Zone I fingertip replantation in the absence of suitable veins. However, given the combined nature of the interventions, the relative contribution of each component cannot be determined, and further studies are required to validate this strategy.
Lipomas have been previously documented in the literature. Here, we present a rare case of a lipoma with exceptionally unusual size, localization, and structure. Due to exceptional presentation, we reviewed the literature for differential diagnoses. A 62-year-old female presented with a history of a slow-growing mass in the mons pubis over the past five years. The patient underwent open surgical excision. Postoperative pathological examination revealed a tumor measuring 210 × 150 × 90 mm and weighing 1,280 g; notably, no capsule formation was observed, and no evidence of malignancy was detected. During a three-year follow-up, no recurrence was observed. The rare localization and unusually large size of the lipoma may represent a component of a broader diagnostic spectrum, including liposarcoma, lipodystrophy, and rare adipose disorders (RADs). In unusual presentations of lipoma, preoperative MRI is recommended to assist in excluding malignancy, defining lesion margins, and assessing involvement of adjacent tissues, thereby minimizing unnecessary resection and improving surgical outcomes.
A 22-year-old male sustained a high-energy blast injury after stepping on an anti-personnel mine during combat operations in eastern Ukraine, resulting in an extensive plantar soft tissue defect predominantly involving the central arch, while preserving critical weight-bearing structures, including the calcaneal tuberosity and metatarsal heads. The aim of this report is to describe a staged reconstructive strategy and evaluate the clinical effectiveness of prolonged negative pressure wound therapy (NPWT) combined with delayed split-thickness skin grafting for functional limb salvage in complex combat-related injuries. The patient was managed using a structured multi-stage protocol that included repeated radical debridement to achieve a viable wound bed, prolonged NPWT to promote granulation tissue formation, reduce edema, and control exudation, along with gradual wound edge approximation using retention sutures. Targeted antimicrobial therapy was administered according to microbiological findings, followed by delayed split-thickness skin grafting and a structured rehabilitation program. Complete graft integration was achieved without purulent-septic complications. At 6.5 months of follow-up, the patient demonstrated restoration of full weight-bearing capacity, preservation of plantar contour and biomechanics, stable gait, and a satisfactory functional outcome without chronic ulceration, infection, or neuropathic pain. This case highlights the clinical value of an integrated, stepwise reconstructive approach in managing severe blast-induced plantar defects and underscores the importance of prolonged NPWT as a key modality for optimizing wound bed preparation and improving reconstructive outcomes when critical anatomical structures are preserved.
Variations in the branching pattern of the facial artery may affect the planning and outcome of reconstructive and aesthetic procedures in the midface. Here, we report a rare anatomical variant in which the facial artery trifurcates early into three distinct branches, including a novel buccinator branch. In January 2025, the right-sided facial artery of a 67-year-old male Caucasian cadaver, injected with colored acrylic resins, was dissected at the ICLO Teaching and Research Center (Verona, Italy). Following identification of the external carotid artery, the facial artery was traced via an oblique submandibular approach. Branching patterns were documented through digital photography and schematic illustration. Instead of the classical singular course, the facial artery formed a common trunk that, 2 cm distal to its origin, trifurcated within a 1 cm span along the inferior mandibular margin. The anteromedial branch followed the standard facial artery trajectory; the posterolateral (premasseteric) branch supplied the masseteric region; and the central (buccinator) branch penetrated the buccinator fascia, arborizing extensively within the muscle belly. This buccinator branch exhibited a markedly dense microvascular network not previously described. This variant expands the known spectrum of facial arterial anatomy. While the direct clinical impact of a single observation remains limited, awareness of such configurations may be relevant in selected surgical contexts, particularly in flap planning and in procedures involving the buccal region. Unlike the classical buccal artery arising from the internal maxillary system, this branch originated directly from the facial artery and appeared to provide predominant intramuscular vascularization of the buccinator. Further bilateral cadaveric and imaging studies are necessary to determine the prevalence and clinical relevance of this and related anatomical configurations.
The clinical severity of snakebite envenomation depends on several factors, including the snake species, the amount of venom injected, the site of envenomation, the timing of antivenom administration, and patient-specific factors. Compartment syndrome is a rare but serious complication of severe envenomation, caused by toxin-induced tissue damage and swelling. We present a case of a 71-year-old man with extensive swelling and ecchymosis of the right upper limb, signs of hand ischemia, and systemic effects, including hypotension, anuria, bradycardia, bradypnea, and somnolence, two days after a Vipera ammodytes (horned viper) bite to his right forearm. Delayed initial treatment and antivenom administration (six hours post-bite due to the heavy influence of alcohol) aggravated the clinical course. Emergency fasciotomies were performed to decompress all compartments of the upper limb. Wound closure was achieved with progressive tension closure, split-thickness skin graft, and platelet-rich plasma (PRP) to the volar side of the forearm. The patient achieved complete recovery with full functional restoration of the upper limb. Post-snakebite compartment syndrome (PSCS) results from a multifactorial cascade of venom-induced local tissue injury, leading to increased intracompartmental pressure and microvascular ischemia. Prompt surgical treatment is necessary if symptoms persist or worsen despite antivenom administration.
This paper describes the Octopus Technique, a technical modification for tension-free abdominoplasty closure using short vertical relaxing incisions for multidirectional tension redistribution. In 12 consecutive patients, no wound dehiscence or flap necrosis occurred. Preliminary results suggest it is safe and reproducible.
Lobomycosis, also known as lacaziosis, is a chronic subcutaneous mycosis caused by Lacazia loboi and endemic to tropical regions of South America. Medical therapy alone has demonstrated limited efficacy, and wide surgical excision remains the mainstay of treatment, particularly in extensive or long-standing disease. However, radical resection may result in complex soft tissue defects requiring advanced reconstructive strategies. We report the case of a 42-year-old male with advanced lobomycosis involving the left lower hemiabdomen. Wide local excision with 2 cm macroscopic margins was performed, resulting in exposure of the anterior rectus sheath and external oblique aponeurosis. Immediate reconstruction was achieved using a pedicled anterolateral thigh (ALT) flap based on musculocutaneous perforators of the descending branch of the lateral circumflex femoral artery. The flap was rotated 180 degrees to increase its arc of reach and allow tension-free inset without microvascular anastomosis. The donor site was managed with split-thickness skin grafting. Postoperatively, adjuvant systemic itraconazole therapy was administered. The flap demonstrated complete viability with no vascular compromise, and satisfactory functional and aesthetic outcomes were achieved. This case highlights the pedicled ALT flap as a safe, versatile, and reliable reconstructive option for extensive abdominal defects secondary to deep mycoses, offering robust vascularity and low donor-site morbidity while preserving abdominal wall function.
Total nipple-areola necrosis following breast reduction is a rare and unfortunate event. Several causes may be responsible for it, including compression of the vascular pedicle, venous congestion, infection, hematoma, or inappropriate surgical technique. Considering the importance of the nipple areola complex (NAC) in the overall appearance of a breast mound, it is clear that the complete loss of the nipple areola complex is one of the most traumatizing complications for both the patient and the surgeon. Herein we describe the case of a patient who developed complete NAC necrosis following breast reduction. After initial wound management and stabilization, the patient underwent delayed reconstruction using an innovative NAC implant specifically designed to restore nipple projection and contour. Delayed reconstruction of the left NAC was performed using a silicone implant (FixNip, GC Aesthetics, Caesarea, Israel), specifically designed to restore natural projection and contour. The implant was positioned under local anesthesia as an outpatient procedure. Postoperative course was uneventful. At 8 months, after ultrasound confirmed proper implant integration, medical tattooing of the areola was completed. Implant based NAC reconstruction achieved a stable and well-projected NAC reconstruction. No minor or major complications occurred, and the patient reported high satisfaction with the aesthetic result and psychological benefit from restoration of breast harmony. To our knowledge, this is the first described case demonstrating a successful implant-based NAC reconstruction following total necrosis after breast reduction. The FixNip implant, combined with medical tattooing, provided a safe and reliable solution with excellent cosmetic outcomes.
We report a 64-year-old immunocompromised patient receiving chemotherapy for metastatic colorectal adenocarcinoma who presented with a purulent forearm lesion. Surgical debridement identified Nocardia paucivorans. PET-CT and MRI revealed pulmonary and cerebral involvement. Escalated antimicrobial therapy achieved complete regression of brain lesions; the patient died 11 months later from underlying disease.
Extended radical excision of aggressive tumors, such as the carotid paraganglioma involving the ethmoid, maxillary and intracranial spaces, results in massive composite craniofacial defects. Successful reconstruction requires simultaneously achieving effective dead space refilling and creating a stable anophthalmic orbital socket. This report highlights the utility of the chimeric anterolateral thigh (ALT) flap in addressing this reconstructive challenge. A 28-year-old man presented with a complex craniofacial defect following the wide excision of an extensive carotid paraganglioma. A chimeric ALT musculocutaneous flap (22 × 10 cm) was harvested, containing two independent skin paddles and a part of the vastus lateralis muscle. One musculocutaneous flap (8 × 14 cm) was de-epithelialized to augment the dead space after total maxillectomy and orbital exenteration. The fasciocutaneous flap (6 × 8 cm) was thinned and molded into a double-layer flap, which was rolled into a socket configuration for orbital reconstruction. Microvascular anastomosis was performed end-to-end to the facial vessels. Intraoperatively, perfusion of all flap components was excellent. The flap remained well perfused postoperatively without congestion or ischemia. At the 25-month follow-up, the patient demonstrated stable healing, a well-contoured midface profile, and adequate socket depth for prosthetic fitting. The chimeric ALT flap offers a highly reliable and versatile solution for the complex reconstruction of massive composite craniofacial defects following extensive tumor resection. This chimeric approach effectively meets the simultaneous requirements for dead-space obliteration and stable orbital socket formation using a single donor site.
Introduction Fibrous dysplasia (FD) is a slow-growing, benign fibro-osseous tumor with a recurrent character distinguished by replacement with fibrous connective tissue instead of normal bone. The medullary bone is substituted by fibrous connective tissue, leading to immature, poorly mineralized bone. FD is responsible for approximately 2.5% of all bone tumors and 7% of all benign bone tumours. Patients may show involvement of one bone (monostotic FD; MFD) or multiple bones (polyostotic FD; PFD). The present case report describes FD’s clinical, imaging and therapeutic aspects in the maxillary and mandibular region.Case We present four cases of fibrous dysplasia affecting the maxilla and mandibular region, which were identified over 6 months at a single institution. All (n = 4) patients underwent surgical procedures: 2 patients in the mandibular region, one in the maxillary region, and one in the maxillary and mandibular region. No complications occurred at the six-month follow-up.Case management The diagnosis of FD is established based on clinical, radiographic, and histopathological features. Imaging analysis showed an expansive, non-destructive mass, with a well-circumscribed cortical and appearance of ground glass, involving either the maxilla or mandible. After diagnosis of FD, 3 patients undergo a conservative bone reshaping surgical procedure, and 1 patient undergoes a surgical resection and bone reshaping with primary wound closure.Conclusion The diagnosis of FD remains challenging because of its clinical, imaging, and histological similarities with other fibro-osseous tumors. A conservative approach of bone reshaping could be adopted as the first line of treatment for patients suffering from FD. A complete surgical removal by resective surgery and immediate reconstructive procedures also produces satisfactory clinical results after adequate follow-up.
Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive cutaneous sarcoma. Forehead involvement is uncommon and poses significant reconstructive challenges due to complex aesthetic and functional demands. Most reported reconstructions utilize staged flaps or tissue expansion. To the best of our knowledge and based on a comprehensive literature review, there are no previous reports specifically documenting forehead DFSP reconstruction performed exclusively with full-thickness skin grafting (FTSG) following wide local excision.We report a case highlighting this technique's reconstructive and aesthetic advantages. A 50-year-old woman presented with a long-standing, enlarging paramedian forehead mass above the right eyebrow, measuring approximately 7.5 × 6.5 cm. A punch biopsy and imaging confirmed DFSP. Wide local excision with 3 cm margins was performed, resulting in a 10.5 × 9 cm defect. Reconstruction was achieved using a single-stage FTSG harvested from the suprapubic region, including a segment of hair-bearing skin aligned to restore the forehead hairline. At 10 month follow-up, the patient had full graft take, preserved frontalis function, and satisfying aesthetic outcome with no recurrence. Forehead DFSP reconstruction typically involves complex, multi-stage flap procedures that risk distortion of key facial landmarks and increased morbidity. Our case demonstrates that immediate full-thickness skin grafting offers a simpler, single-stage alternative preserving eyebrow position, facial symmetry, and function. Harvesting the graft from the suprapubic area, utilizing a prior cesarean scar, allowed restoration of the hairline with hair-bearing skin-an innovative aesthetic advantage not previously reported. This unique case demonstrates that FTSG can provide favorable aesthetic and functional outcomes in selected forehead DFSP cases, representing a valuable addition to reconstructive options.
Progressive hemifacial atrophy, also known as Parry-Romberg syndrome (PRS), is an uncommon condition that causes slow and progressive unilateral soft-tissue atrophy of the face. This atrophy affects the skin and subcutaneous tissue, including fat and muscle, and in some cases, may also involve the underlying bone and muscle. The exact cause of this syndrome is unknown, but several possible factors have been suggested. These include genetic predisposition, autoimmune responses, and infections or trauma. We report a case of a young female who presented with an asymptomatic one-sided atrophy of the face for the last ten years. This case highlights autologous fat grafting as a safe and effective option for restoring facial symmetry in PRS.
Large nasal defects in children are rare and create significant reconstructive challenges due to limited donor tissue, ongoing facial growth, and higher perioperative risks. These challenges are amplified in immunocompromised pediatric patients, particularly when infections such as herpes simplex virus (HSV) contribute to tissue destruction. The paramedian forehead flap is a reliable option for major nasal reconstruction in adults, but its use in children remains uncommon. We report a 4-year-old girl with an undiagnosed primary immunodeficiency and recurrent HSV infection who developed a full-thickness defect of the right nasal ala with partial auricular loss. A staged reconstruction was performed adaptively over five stages, including flap elevation with delay, transposition with native nasal skin lining and Matriderm application to reduce wound burden, partial division with alar sculpting, and final inset with eyebrow reconstruction. Intraoperative indocyanine green angiography confirmed adequate flap perfusion at each stage. The patient’s postoperative course was uneventful, and she demonstrated improved nasal airway patency, stable alar contour, and high parental satisfaction with cosmetic outcomes. This case suggests that a tailored, multi-stage paramedian forehead flap reconstruction may be safely performed in young children with complex nasal defects, including those with undiagnosed primary immunodeficiency and recurrent HSV infection, though further experience is needed to validate this approach. Careful staging, vascular assessment, and multidisciplinary collaboration were central to achieving successful functional and aesthetic results.
