Objectives Random-pattern skin flaps remain vulnerable to distal ischemia and partial necrosis despite surgical refinements. Hydrogen sulfide (H₂S) is an endogenous gasotransmitter with cytoprotective and proangiogenic properties. This study evaluated the effects of sodium hydrogen sulfide (NaHS) on flap viability, microvascular perfusion, and histological outcomes in a rat dorsal random-pattern skin flap model. Methods Twenty-one male Sprague–Dawley rats were randomized into control, sham, and NaHS groups (n = 7 each). NaHS (200 µg/kg/day) was administered intraperitoneally for 15 days prior to flap elevation. A 9 × 3 cm caudally based dorsal flap was created using the McFarlane model. On postoperative day 7, perfusion was objectively assessed using indocyanine green fluorescence angiography. Inflammation, re-epithelialization, vascularization, and collagen organization were assessed using semi-quantitative scoring, whereas the apoptotic index was determined quantitatively based on TUNEL-positive cell counts. Results NaHS significantly increased viable flap area and reduced distal necrosis compared with control and sham groups. Fluorescence imaging demonstrated enhanced distal perfusion and a denser microvascular network in the NaHS group. Histologically, NaHS promoted complete re-epithelialization, organized collagen structure, and markedly increased vascularization (p < 0.01), while significantly decreasing inflammation and apoptosis (p < 0.001). Conclusions Sodium hydrogen sulfide improved random-pattern skin flap viability by enhancing microvascular perfusion and attenuating ischemia-induced inflammation and apoptosis. These findings suggest that H₂S donors may represent a potential pharmacologic approach to improve ischemic flap survival in reconstructive surgery.
Background The optimal number of drains after postmastectomy tissue expander (TE)-based breast reconstruction remains uncertain. Although double-drain placement may theoretically improve fluid clearance and reduce seroma formation, it may also increase patient discomfort, prolong drain-related morbidity, and potentially increase contamination risk. This systematic review and meta-analysis compared postoperative outcomes between single- and double-drain strategies following TE-based breast reconstruction. Methods PubMed, Embase, and Cochrane Library were searched from inception to May 16, 2026. Comparative studies evaluating single versus double drains after postmastectomy TE-based reconstruction were included. Outcomes of interest included seroma formation, surgical site infection (SSI), hematoma, return to the operating room, skin flap necrosis, drain duration, and TE/implant-related complications. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using random-effects models. Risk of bias was assessed with ROBINS-I and certainty of evidence with the GRADE approach. Results Three retrospective observational studies comprising 1350 reconstructions were included, with 660 reconstructions in the single-drain group and 690 in the double-drain group. There were no significant differences between single- and double-drain strategies in seroma formation (RR 0.84, 95% CI 0.47 to 1.49; p = 0.54; I² = 63%), SSI (RR 1.01, 95% CI 0.75 to 1.37; p = 0.93; I² = 39%), hematoma (RR 0.84, 95% CI 0.44 to 1.63; p = 0.61; I² = 0%), return to the operating room (RR 0.66, 95% CI 0.30 to 1.43; p = 0.29; I² = 12%), skin flap necrosis (RR 0.74, 95% CI 0.46 to 1.19; p = 0.22; I² = 0%), or drain duration (MD −3.90 days, 95% CI −12.42 to 4.63; p = 0.37; I² = 97%). Leave-one-out analyses did not materially alter the findings for seroma formation or SSI. Certainty of evidence was low for seroma, SSI, and skin flap necrosis, and very low for hematoma, return to the operating room, and drain duration. Conclusion Current evidence does not demonstrate a benefit of routine double-drain placement after TE-based breast reconstruction. The certainty of evidence was low, and these findings indicate a lack of demonstrated benefit rather than equivalence between the two strategies. Selective second-drain placement based on intraoperative findings remains reasonable, and adequately powered prospective studies are needed.
Digital lymphatic anatomy has been defined largely by cadaveric studies. We evaluated whether photoacoustic lymphangiography (PAL) could depict three-dimensional anatomy and motion-related deformation in vivo. Two healthy volunteers and one patient with secondary upper-extremity lymphedema underwent fingertip indocyanine green injection, near-infrared fluorescence imaging, and static and dynamic PAL. In healthy fingers, lymphatic vessels coursed mainly along the lateral aspects toward the dorsal hand and lay between superficial veins and digital arteries. Flexion produced spiral-like deformation or abrupt angulation, whereas vessels were relatively straight during extension; segmental lymphatic signals moved proximally during motion. In the patient, PAL visualized vessels beneath dermal backflow that appeared more irregular and showed frequent short-segment tortuosity, and guided lymphaticovenular anastomosis. These findings support the feasibility of finger-specific, in vivo three-dimensional and motion-resolved assessment of digital lymphatic morphology using PAL.
Trauma related, extreme, high-level lower extremity amputations are uncommon procedures and pose complex challenges with soft tissue and bony reconstruction. This case reports presents a challenging ortho-plastic trauma reconstruction with a hip disarticulation and a massive pelvic wound, and soft tissue reconstruction with a full leg pedicle fillet flap. We describe a step-by-step operative plan performing a pedicle full leg fillet flap for a massive pelvic wound.
Background Cosmetic medical tourism has grown considerably in Europe, with many patients travelling abroad seeking lower-cost procedures. However, heterogeneous practices and the absence of postoperative follow-up inherent to geographical distance may lead to life-threatening complications with delayed management. We report a case of necrotising fasciitis following abdominoplasty performed abroad. Case presentation A 42-year-old female patient underwent abdominoplasty, liposuction, and gluteal lipofilling in a foreign country. The postoperative course was complicated by anaemia, wound dehiscence, and an inflammatory syndrome, initially managed conservatively. Her condition deteriorated, necessitating medical repatriation. On admission, clinical examination revealed abdominal soft tissue necrosis with fever and purulent discharge, alongside a severe inflammatory response on laboratory investigations. Emergency surgical exploration confirmed extensive necrosis of the abdominal fascia and a gluteal collection. Wide debridement with bacteriological sampling and drainage were performed. Empirical broad-spectrum antibiotic therapy was initiated, and postoperative vasopressor support was required. An early second-look procedure was performed the following day. Following vacuum-assisted closure (VAC) therapy, reconstruction with a split-thickness skin graft was carried out. The patient was discharged after six weeks of hospitalisation with significant aesthetic sequelae. Clinical relevance Necrotising fasciitis is a rare but potentially fatal condition whose prognosis depends on the promptness of management. Medical tourism, owing to heterogeneous practices and lack of postoperative follow-up, may lead to diagnostic and therapeutic delay, exposing patients to this type of complication. Even in cases of favourable outcome, functional and aesthetic sequelae can be significant.
