Introduction Reconstruction of the distal lower limb is often complex due to limited local tissues. The pedicled extensor digitorum brevis (EDB) flap is a reliable, loco-regional option for small- to medium-sized ankle and foot defects. This review summarizes literature on pedicled EDB flaps, focusing on indications, outcomes, and donor-site morbidity. Materials and Methods A search of PubMed, Embase, and Scopus (1987–2024) using predefined terms identified studies on pedicled EDB flaps for lower limb reconstruction. Exclusions included anatomical studies, case reports, and free or multiple flaps. Out of 88 records, 26 met criteria, covering 296 patients. Results Trauma was the leading indication for reconstruction (31.4%), followed by postsurgical dehiscence, infections, and chronic ulcers. Most flaps were pure muscle with an average size of 14.55 cm², covering defects of about 11.89 cm². Complications included total necrosis (4.4%) and partial necrosis (3.7%), all in antegrade flaps. Donor-site issues were limited, mainly delayed healing (5.1%) and wound dehiscence (5.1%), rarely causing major problems. Discussion The pedicled EDB flap offers predictable anatomy, easy harvest, and minimal functional issues, ideal for small- to medium-sized defects when microsurgery isn't available. However, necrosis risk and trauma links emphasize the need for careful patient selection and vascular assessment. Conclusion The pedicled EDB flap is a reliable option for distal lower-limb reconstruction, showing good results with manageable complications. More studies are needed to define its long-term role.

Compartmental hemiglossectomy for oral cavity squamous cell carcinoma creates composite tongue/floor defects in which balancing mobility, bulk, and a supple lining is challenging. We report three consecutive reconstructions using a medial sural artery perforator (MSAP) flap, emphasizing preservation of the uninvolved tongue tip left intentionally unattached to maximize residual mobility. A 28-year-old woman, a 50-year-old man, and a 36-year-old woman with lateral tongue SCC underwent compartmental resection with selective neck dissection; defects measured ~4 × 3, 5 × 4, and 6 × 5 cm. Thin fasciocutaneous MSAP flaps (5 × 4, 6 × 5, and 7 × 6 cm) were harvested from the medial calf and inset intraorally after tumor ablation, with end-to-end microvascular anastomoses to cervical recipient vessels (typically the lingual or superior thyroid artery and the external or internal jugular vein). All flaps survived without surgical complications; donor sites were closed primarily. Oral feeding resumed on postoperative day 13, 18, and 12, respectively; speech was comprehensible in all cases after standard rehabilitation. Follow-up occurred 6 months after completion of adjuvant radiotherapy (case 1), during adjuvant radiotherapy (case 2), and 3 months after completion (case 3) with all patients tolerating a full oral diet of any consistency and calf scars were linear and inconspicuous with no lower-limb deficits. These findings suggest that, for medium-sized lateral tongue/floor defects, the MSAP provides a favorable balance of pliability and volume with low donor-site morbidity; when oncologically feasible, preserving and not suturing the native tongue tip may further enhance mobility and functional recovery.

Nipple–areola complex (NAC) reconstruction significantly contributes to postmastectomy body image and patient satisfaction. While nipple sharing has been described in delayed settings, its application in immediate reconstruction after skin-reducing mastectomy (SRM) is limited. We report the case of a 32-year-old BRCA1+ patient undergoing bilateral SRM with immediate implant-based reconstruction, in which a novel Yin–Yang nipple grafting technique was performed using the hypertrophic contralateral nipple. The donor nipple was harvested as a full-thickness non-vascularized graft, divided along a curved Yin–Yang fashion, and both halves were reshaped and grafted bilaterally to create two circular, natural-looking NACs. At the 6-month follow-up, the grafts showed complete take, satisfactory projection, and pigmentation. This report illustrates the feasibility and limitations of one-stage NAC reconstruction using a non-vascularized nipple graft technique in a selected patient undergoing SRM.

SUMMARY:Thighplasty is a widely performed body contouring procedure, using various surgical techniques for thigh lifting, including medial scar positioning, vertical and horizontal procedures, and liposuction. Despite its popularity, thighplasty is associated with high complication rates and suboptimal postoperative outcomes. This article presents a novel technique: the J-medial thighplasty combined with helium plasma radiofrequency (HPRF) technology to address moderate skin and soft-tissue laxity and ptosis in the inner thighs. Between 2020 and 2023, 21 patients underwent this combined procedure. The surgical approach involved selective liposuction in targeted areas, skin resection, and preservation of deep tissue layers, coupled with the application of HPRF in the lower third of the medial thigh. Results demonstrated significant reductions in thigh laxity, correction of skin overhang, and fat reduction, yielding improved functional and aesthetic outcomes in the lower thigh region. By strategically avoiding lymphatic vessels in superficial areas, the risk of secondary lymphedema was minimized. Patient satisfaction was notably high, with both patients and surgeons reporting favorable results. In conclusion, the J-medial thighplasty combined with HPRF offers an effective and straightforward method for enhancing the lower thigh area with minimal complications. This innovative technique provides a promising solution for patients seeking improved thigh contouring while ensuring high levels of patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.

This case report describes the closure a large tracheal defect with forearm fascia in a young woman who underwent total thyroidectomy for papillary thyroid cancer.

Background/Objectives: Medial thighplasty is a widely performed body contouring procedure, particularly in patients with massive weight loss. Despite advancements in surgical techniques, complications remain a significant concern. The integration of liposuction into thigh lift procedures has shown promise in improving both aesthetic and functional outcomes while reducing risks. This review aims to assess the role of liposuction in medial thighplasty by evaluating its impact on surgical outcomes and complications. Methods: This systematic review was conducted following PRISMA guidelines. A comprehensive search was performed in the MEDLINE/PubMed database using predefined keywords. A total of 52 records were identified, of which 19 studies met the inclusion criteria, encompassing 1113 patients who underwent liposuction-assisted medial thighplasty. Two independent reviewers screened and selected the studies, resolving discrepancies through discussion or consultation with a third reviewer. Data on surgical techniques, complications, and outcomes were extracted and analyzed. Statistical comparisons were performed using the Chi-square test, with significance set at p < 0.05. Results: The incorporation of liposuction significantly reduced the overall complication rate (36.75% vs. 70.68%, p < 0.001). Specific complications, including infections (1.77% vs. 9.02%), hematomas (1.30% vs. 6.77%), and seromas (8.95% vs. 24.81%), were markedly lower in the liposuction group. Conclusions: Liposuction appears to reduce complication rates and improve surgical outcomes in medial thighplasty. Further standardization of techniques and additional research on advanced liposuction technologies are necessary to refine this surgical approach and optimize patient outcomes.

BackgroundOver the past two decades, liposuction techniques have significantly evolved, moving from basic fat removal to sophisticated methods aimed at improving safety, efficiency, and cosmetic outcomes. This study evaluates the efficacy and safety of a combined approach using ultrasound-assisted liposuction (UAL) and helium plasma radiofrequency (HPRF) technology to enhance skin tightening without the need for extensive surgical interventions.MethodsWe conducted a retrospective analysis of 639 patients who underwent the combined UAL and HPRF liposuction technique. The patient cohort had an average age of 31.5 years and a mean BMI of 27.9 kg/m2. The procedure predominantly targeted the abdomen, with an average of 2.4 body areas treated per patient. Surgical duration averaged 118 minutes, with a mean aspirate volume of 1698 mL.ResultsMinimal residual skin laxity was observed in 87% of patients, and 91% achieved excellent improvement in body contouring. The complication rates were low, with minor occurrences of seroma (5.6%) and a very low incidence of infection (0.3%). This combined technique demonstrated safety and efficacy, providing significant skin tightening and reducing recovery time compared to more invasive procedures.ConclusionsThe combined use of UAL and HPRF technology offers a safe and effective method for enhancing skin tightening and improving body contouring outcomes. Despite the promising results, this study acknowledges the limitations of its retrospective design. Future prospective, multicenter studies are recommended to further validate these findings. This technique represents a significant advancement in the field of cosmetic surgery, emphasizing minimally invasive solutions with substantial esthetic benefits.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Background: The breast-sharing technique uses the lower quadrants discarded from a contralateral symmetrizing reduction mammoplasty to reconstruct the breast after mastectomy. The aim of our study was to revisit this old technique and to improve its vascular predictability by preoperative computed tomography angiography (angio-CT) and intraoperative indocyanine green (ICG) imaging. Methods: Twenty-six patients were enrolled and assessed by a preoperative angio-CT to localize and evaluate the internal mammary artery perforator (IMAP). In the selected patients, a Wise skin-pattern reduction was designed to allow elevation of a transversely oriented flap including both inferior poles. The flap was based medially on the IMAP. After elevation, evaluation of its arterial and venous perfusion was assessed with ICG. Results: Eight patients were excluded after pre- and intraoperative studies. Sixteen breast-sharing flaps were performed. A distal flap venous compromise appeared in 2 cases, requiring debridement and flap repositioning, and an infection occurred in 1 case. Four patients had detectable firm lumps that resolved. There were no issues with donor site healing, and a repositioning of the areola was necessary in 2 patients. Conclusions: Breast-sharing techniques have not gained popularity for many reasons. By combining current understanding of breast cancer behavior, experience with perforator anatomy, and angio-CT and ICG, we believe this study gives a second life to this flap, identifying its weaknesses and improving them. The IMAP propeller flap, simpler and safer in the presence of comorbidities than a free flap, can be a good choice for well-selected candidates.

Objectives: The management of idiopathic subglottic stenosis (iSGS) poses a clinical challenge due to high recurrence rates following both endoscopic and open approaches, often leading to tracheostomy. The activation of abnormal T-cells and cytokine pathways has been linked to iSGS pathogenesis. Autologous adipose tissue centrifugation yields lipoaspirate, offering optimal anti-inflammatory effects and biocompatibility widely utilized in various medical settings. This report presents the first 3 cases employing endoscopic dilation (ED) in combination with local lipoaspirate injection to address recurrent iSGS.Methods: A prospective observational study was conducted, involving multidisciplinary evaluation by the Tracheal Team at the University of Modena. Patients meeting specific criteria were directed to undergo ED + lipoaspirate injection.Results: Three patients fulfilled the inclusion criteria. The mean number of prior endoscopic procedures performed was 8. Endoscopic examination revealed 90% stenosis in patient A, 60% stenosis in patient B, and 60% stenosis in patient C. All patients presented inflammatory tissue or incipient granulations at the stenotic site, with an average time of 6 months between previous procedures. After 15 months, none of the patients required further procedures, and endoscopic examination revealed a significant reduction or disappearance of inflammatory tissue with a stable airway lumen.Conclusions: The observed results are encouraging in terms of reducing local inflammation and halting stenosis progression, especially in cases of short-term relapsing iSGS.

Reconstruction of defects of the jaws is mainly performed via free fibula flap. An incidence of 2–21% of overall flap failure is still described. We investigated the roles of volume, length and number of fibula flap segments on flap survival using novel three-dimensional segmentation tools. We also analyzed the role of other possible risk factors. Seventy-one consecutive patients with a follow up of at least three months and who underwent free fibula flap reconstruction in a single center between 2002 and 2022 have been evaluated. A total of 166 fibula segments were analyzed. Malignancies were the main reason of resection (45.1%). In 69% of the cases a reconstruction of the mandible was performed. The flaps were mainly divided in two segments (39%) (range 1–4), with a mean length of 2.52 cm and a mean volume was 3.37 cm3. Total flap failure (TFF) occurred in 12 cases, (16.9%), while partial flap failure (PFF) appeared in 3 patients (4.2%). Volume, length and number of fibula flap segments did not seem to influence flap failure incidence in uni- and multivariate analysis. Reconstruction of the maxilla and use of a recipient vessel different from the facial artery seemed to significantly impact on flap failure. Smoking and previous surgeries showed a higher trend to flap failure, but they did not reach statistical significance. Prospective and multicentric analysis on a wider population should be assessed.

Summary: The overwhelming post-splenectomy infection (OPSI) is a feared late complication of splenectomy, with high morbidity and a mortality rate of up to 50%. Although the management of this syndrome is the duty of clinical physicians, the interest of plastic surgeons in OPSI is related to the injury that can occur in tissues with an end circulation, such as the limb extremities, nasal tip, and lips. In the management of OPSI, surgical techniques are not highlighted. The role of the plastic surgeon can be fundamental for the prevention of further extension of the necrotic tissue, improving as much as possible the vascularization around it. Moreover, a critical role in the management of OPSI is avoiding superinfection of the necrotic areas by combining different techniques and methods, such as surgical debridements, negative pressure wound therapy, and conservative treatment. Last but not least, functional and aesthetic restoration of the injured parts is of paramount importance for the final outcome. In this article, we describe the management of two unvaccinated patients with necrosis of the extremities after OPSI.

Gynecomastia is the benign enlargement of breast's the glandular tissue in male population. Gynecomastia can involve fatty and/or glandular tissue. At the basis of pediatric gynecomastia there is a multifactorial imbalance in the ratio of estrogen to androgens tissue levels. In more than 95% of the cases gynecomastia development is idiopathic. Secondary causes of gynecomastia in adolescents are relatively rare (less than 5%) and may arise from uncommon pathological conditions. Gynecomastia is self-limited and regresses in 1-3 years in 84%, 47% and 20% of adolescents with mild, moderate and severe gynecomastia. The correct first line of therapy is observation and reassurance in the treatment of mild cases. In order to manage adolescent gynecomastia is advised to adopt a tailored therapy. Despite gynecomastia is a common condition only few adolescents need cosmetic or antalgic treatment. Medical therapy should be considered in patient with emotional distress or psychological limitation on normal activities. Finally, if gynecomastia does not go in remission after two years surgical procedures should be performed. The aim of this article is to be an updated discussion of pubertal gynecomastia in every way and report our surgical experience with a retrospective study. In conclusion surgical treatment of this condition is a quiet rare procedure but, in according to global literature we demonstrated that it is a safe surgery with low rate of complications.

IntroductionRadiotherapy and esophageal stenting are usually employed to manage esophageal localization of distant cancer. However, they are also related to the occurrence of an increased risk of tracheoesophageal fistula. Tracheoesophageal fistula management in these patients involves dealing with poor general conditions and short-term prognosis. This paper presents the first case in literature of bronchoscopic fistula closure through an autologous fascia lata graft placement between two stents.Case report and aimA 67-years-old male patient was diagnosed with pulmonary squamous cell carcinoma in the inferior lobe of the left lung with mediastinal lymph node metastasis. After a multidisciplinary discussion, bronchoscopic repair of tracheoesophageal fistula with autologous fascia lata was decided without the removal of the esophageal stent due to the high risk on the esophagus possibly related to such a procedure. Oral feeding was progressively introduced without the development of aspiration symptoms. Videofluoroscopy and esophagogastroduodenoscopy were performed at 7 months showing no signs of tracheoesophageal fistula patency.ConclusionThis technique might represent a low risks viable option for patients unsuitable for open surgical approaches.

Microsurgical techniques are an important part of clinical and experimental research. In this paper, we present our survey of Italian microsurgery training and our experience of the importance of a free access microsurgical laboratory. A cross-sectional observational study was performed by administering a questionnaire regarding the current situation about microsurgical training in Italian Plastic, Reconstructive and Aesthetic Surgery residency programs. A case–control study was performed on 12 residents divided into four groups of attendance to the microlaboratory. Two hundred and seventy-six trainees replied to the questionnaire, representing 94.7

BACKGROUND AND AIM:The radial forearm free flap (RFFf) and the antero-lateral thigh flap (ALTf) are considered the "key flaps" for oral cavity reconstruction. Nowadays, the literature lacks of an objective and standardized decision-making algorithm for the flap choice. The aim of this study is to describe a decision-making algorithm concerning the more appropriate flap, RFFf or ALTf, in the reconstruction of intra-oral soft tissues based on the volumetric analysis of the defect with a pre-operative Magnetic Resonance Imaging (MRI), updating our previous surgical experience. METHODS:We conducted a retrospective observational study including 77 patients who underwent microsurgical reconstruction with RFFf or ALTf after tumor resection of the soft tissues in the oral cavity. During follow-up, patients were evaluated using the UW-QOL questionnaire. RESULTS:Analyzing the scores of the UW-QOL questionnaire based on the size of the tumor on preoperative MRI we found that for tumor volume <50cc and between 50-70cc, the patients reconstructed with RFFfobtained statistically significant better scores compared to the ALTf group, while for tumor volume >70cc, the patients reconstructed with ALTf reported statistically significant better scores. CONCLUSIONS:Pre-operative RMI-guided volumetric assessment of oral cancer plays a key role in the planning of adequate soft tissue reconstruction and can objectively help surgeons in the correct choice of the flap (RFFf vs. ALTf) for each case based on preoperative tumor size, suggesting for defects <50cc and between 50 and 70 cc a reconstruction with RFFf, while for defects >70cc a reconstruction with ALTf.

Laryngotracheal stenosis (LTS) is a complex and heterogeneous disease whose pathogenesis remains unclear. LTS is considered to be the result of aberrant wound-healing process that leads to fibrotic scarring, originating from different aetiology. Although iatrogenic aetiology is the main cause of subglottic or tracheal stenosis, also autoimmune and infectious diseases may be involved in causing LTS. Furthermore, fibrotic obstruction in the anatomic region under the glottis can also be diagnosed without apparent aetiology after a comprehensive workup; in this case, the pathological process is called idiopathic subglottic stenosis (iSGS). So far, the laryngotracheal scar resulting from airway injury due to different diseases was considered as inert tissue requiring surgical removal to restore airway patency. However, this assumption has recently been revised by regarding the tracheal scarring process as a fibroinflammatory event due to immunological alteration, similar to other fibrotic diseases. Recent acquisitions suggest that different factors, such as growth factors, cytokines, altered fibroblast function and genetic susceptibility, can all interact in a complex way leading to aberrant and fibrotic wound healing after an insult that acts as a trigger. However, also physiological derangement due to LTS could play a role in promoting dysregulated response to laryngo-tracheal mucosal injury, through biomechanical stress and mechanotransduction activation. The aim of this narrative review is to present the state-of-the-art knowledge regarding molecular mechanisms, as well as mechanical and physio-pathological features behind LTS.

Osteonecrosis of the femoral head (ONFH) is a progressive degenerative disease that ultimately requires a total hip replacement. Mesenchymal stromal/stem cells (MSCs), particularly the ones isolated from bone marrow (BM), could be promising tools to restore bone tissue in ONFH. Here, we established a rabbit model to mimic the pathogenic features of human ONFH and to challenge an autologous MSC-based treatment. ON has been originally induced by the synergic combination of surgery and steroid administration. Autologous BM-MSCs were then implanted in the FH, aiming to restore the damaged tissue. Histological analyses confirmed bone formation in the BM-MSC treated rabbit femurs but not in the controls. In addition, the model also allowed investigations on BM-MSCs isolated before (ON-BM-MSCs) and after (ON+BM-MSCs) ON induction to dissect the impact of ON damage on MSC behavior in an affected microenvironment, accounting for those clinical approaches foreseeing MSCs generally isolated from affected patients. BM-MSCs, isolated before and after ON induction, revealed similar growth rates, immunophenotypic profiles, and differentiation abilities regardless of the ON. Our data support the use of ON+BM-MSCs as a promising autologous therapeutic tool to treat ON, paving the way for a more consolidated use into the clinical settings.

Since the introduction of fibula flap as a reconstructive technique, an evolution of indications has been observed. Our first report of a traumatic mandibular reconstruction using fibula flap was in 1992. The vast majority of indications for surgery, are: malignant tumors, benign neoplasms, osteoradionecrosis and traumas. Nevertheless, extended indications have been described such as the treatment of dentoalveolar defect without bone discontinuity or reconstruction of maxilla defect up to type III (A and B), according to Cordeiro's classification. Unusual indications include cleft palate malformations with bone discontinuity less than 6 cm. Moreover, a particular attention should be focus on fibula flap harvest with more innovative technologies than traditional use of monopolar or bipolar and their advantages in pre and postoperative management.

Here we describe the case of a 60-year-old-woman with systemic sclerosis sent to our Scleroderma Unit to treat digital stumps. The stumps were successfully treated with autologous fat grafting (crown-shape infiltration). Our technique of autologous lipotransfer improved wound healing in a scleroderma patient with stump-digital ulcers where all other options failed.