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Aims Carpal tunnel (CT) syndrome is a recognized red‐flag of cardiac amyloidosis (CA) and increased cardiovascular (CV) morbidity. We designed this study to characterize the CV profile of patients with CT syndrome at the time of first surgery and to identify high‐risk presentations. Methods and results We retrospectively reviewed 643 patients who underwent CT surgery between 2007 and 2019. Of them, 130 patients (77 years, 45% male patients, left ventricular ejection fraction 62%) with available CV characterization within ±12 months from CT surgery were included. Abnormal loading conditions causing cardiac left ventricular hypertrophy (LVH) were investigated to distinguish explained LVH (Ex‐LVH) from unexplained LVH (Un‐LVH). LVH was found in 66 (51%) patients, 33% of them presented Un‐LVH. Compared with the others, Un‐LVH patients were older (77 and 75 vs. 70 years in Un‐LVH, Ex‐LVH, and non‐LVH, respectively; P = 0.002), had higher rates of electrocardiogram‐echo discrepancy (70%, 14.3%, and 1.6%, respectively; P

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Surgical site infection in implant-based breast reconstruction is a complication with variable incidence reported in the literature. Due to potential loss of implant and reconstruction, it can have a strong psychological impact on patients. Background and objectives: This study aimed primarily at analyzing the current status of the surgical site infection (SSI), (type, time of onset, clinical presentation, pathogens and management) in patients who underwent implant-based breast reconstruction at our Breast Unit. Secondarily, we wanted to establish whether introduction of a new, updated evidence-based protocol for infection prevention can reduce SSI in implant-based breast reconstruction. Materials and Methods: A single-center retrospective study was performed primarily to evaluate the incidence and features of SSI after implant-based breast reconstruction from 2007 to 2020. In June 2020, a protocol for prevention of SSI in implant-based breast reconstruction was introduced in clinical practice. Secondarily, a data analysis of all patients who underwent implant-based breast reconstruction in compliance with this protocol was performed after preliminarily assessing its efficacy. Results: 756 women were evaluated after mastectomy and implant-based breast reconstruction for breast cancer. A total of 26 surgical site infections were detected. The annual incidence of SSI decreased over time (range 0–11.76%). Data relating to infections’ features, involved pathogens and implemented treatments were obtained. Since the introduction of the protocol, 22 patients have been evaluated, for a total of 29 implants. No early infections occurred. Conclusions: Surgical site infection rates at our Breast Unit are comparable to those reported in the literature. The SSI rates have shown a decreasing trend over the years. No SSI has occurred since the introduction of the prevention protocol for surgical site infection in June 2020.

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Damage to the weightbearing surface of the foot is a challenge for the reconstructive surgeon. The aim is to reconstruct the skeletal tripod and soft tissue, allowing the patient to walk normally. We report the case of a patient admitted with an acute right foot open fracture of the second, third, fourth, and fifth metatarsal bones. After debridement of all nonvital tissues, the patient required reconstruction of the metatarsal heads (third, fourth, and fifth) plus soft tissue coverage. We then performed a reconstruction with a free osteocutaneous fibular flap, insetting the bone perpendicular to the long axis of the metatarsal bones. This configuration allowed the reconstruction of the foot skeletal tripod. A second free flap, a thin radial forearm flap, was added during the revision surgery to improve the venous drainage of the skin paddle of the fibular flap and avoid tension after skin closure. At 1-year follow-up, the patient was able to walk entirely weightbearing on the forefoot, returning to her previous employment with no limitation in physical and recreational activities. To our knowledge, this is the first description of the use of a chimeric osteocutaneous fibular flap, oriented transversely, to reconstruct a complex bone/soft tissue defect after a traumatic loss of multiple metatarsal heads.

Background:. Chest-wall contouring surgery (chest-wall reconstructive surgery) is often the first surgical procedure in female-to-male (FtM) gender reassignment surgery (GRS). The main goal of this procedure is to create an aesthetically pleasing male-like chest contour. No universally accepted algorithm exists for detection of the appropriate surgical technique. Also, there is no tool for objective evaluation of the quality of life and satisfaction of these patients after the operation. Methods:. This study involves a single-center clinical trial assessing the patients who underwent subcutaneous mastectomy in FtM GRS between 2003 and 2019. The selection of patients was based on the new “simplified” algorithm consisting of 2 different surgical techniques: the semicircular and the double-incision with free nipple grafting. The selection was based on 3 criteria: breasts size, breast ptosis, and skin elasticity. The outcomes and complication rates were collected and analyzed. The patients’ satisfaction and Quality of Life was assessed with a 5-point Likert scale questionnaire, specifically conceived for FtM patients. The aesthetic evaluation was performed using a 5-point Likert scale dealing with the 5 items featuring as the main goals of GRS. Results:. 184 mastectomies were performed in 92 FtM GRS patients. The overall reoperation rate was 11.9%. The patient survey revealed both a high satisfaction rate and a good aesthetic result (4.4/5). Conclusions:. The proposed algorithm facilitates the selection of the most suitable technique for top surgery. The patient satisfaction rate evaluated by the proposed Health-Related Quality of Life questionnaire confirmed the outcomes of the use of the algorithm. Further studies to validate the proposed evaluating tools are needed.

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Nowadays Integra™ is an integral part of the "reconstructive ladder", recently the new Integra™ Flowable Dermal Regeneration has appeared on the market. This is a semiliquid compound, malleable and those characteristics widen the indication for its use. In this report we describe two cases in which we used this product to repair undermined and tunnelled wounds. We believe that this product can be useful for treatment of tunnelled wounds of small dimensions reducing the need for major procedures.

Purpose The use of suture anchors has been described in orthopedic, hand, oculoplastic, temporomandibular joint and in aesthetic surgery, but no study reports the use of the Mitek® anchors (Depuy Mitek Surgical Products, Inc. Raynham, Massachusetts) for fixing the free flaps used in oncologic oral and oropharyngeal reconstruction. Materials and Methods In this prospective non-randomized study, 9 patients underwent surgical resection of oral or oropharyngeal cancer followed by a free flap reconstruction; mini anchors were used to fix the flap directly to the bone. We collected data regarding the patients, the tumor stage, the surgical procedure, the radiotherapy and the number of anchors used. Results The average follow-up was 28 months (range 24–38).We observed no complications with trans-oral, sub-mandibular and trans-mandibular approach in both oral and oropharyngeal reconstructions. All anchors became osteo-integrated and no complications occurred after radiotherapy. Conclusions In our opinion this device favors free flap adhesion to the bone. We registered no postoperative complications related to the use of the device which looks suitable for use in irradiated tissues. The radiotherapy did not cause any long-term complications related to the use of Mitek® mini bone anchors.

Background Licox® PtO2 is a minimally invasive monitoring system for continuous measurement of tissue oxygen tension in all types of free tissue transfers. Our study compares two consecutive series of patients undergoing microsurgical reconstruction monitored with standard clinical bedside surveillance and with the Licox® PtO2 system regarding flap loss and flap salvage, the sensitivity, specificity, and cost-effectiveness. Methods We performed a longitudinal observational prospective study of all patients undergoing microsurgical reconstructions between 2016 and 2017. Group 1 included 43 patients that underwent standard clinical bedside postoperative flap monitoring whereas group 2 included 44 consecutive patients also monitored with Licox® PtO2 system. Flap complications such as return to theater for vascular compromise, partial and total flap loss and flap salvage rate were analyzed. Results We recorded no significant difference between the two groups regarding the rate of vascular complications (P = .31), return to the theater (P = .31), flap salvage (P = .9), partial and total flap loss (P = .36 and P = .49, respectively). When analyzing the Licox® PtO2 system monitoring group, we documented six false-positive results (13.6%) and 0 false negatives with an accuracy of 0.86, a sensibility of 1.00, and a specificity of 0.85. Conclusions This is the first study that provides statistical data about the comparison of postoperative free flap monitoring by standard clinical bedside method and Licox® PtO2 system. For the monitoring of buried flaps, the Licox® PtO2 monitoring can be used only as a supplement to other systems. Its use, compared to near-infrared spectroscopy or clinical bedside monitoring, was not found cost-efficient.

From 2007 to 2017, 34 patients with subacute wounds to lower limbs were treated by the assisted healing and delayed selective reconstruction method (AH-GSR). Sixteen patients (47%) presented with a concomitant fracture; 18 patients (53%) sustained degloving with a soft tissue injury only. Negative pressure wound therapy was used in 28 patients (82.3%). Antibiotics were given to all patients, in 12 (35.3%) as prophylaxis and in 22 (64.7%) as therapy. The reconstruction was performed by split-thickness skin grafts (SG) in 16 patients (47%), by dermal substitutes (DS) in 8 patients (23.5%), by local fascio-cutaneous flaps in 2 patients (5.9%), and by free flaps in 8 patients (23.5%). In this case series, three (8.8%) complications were recorded. Adhering to the AH-GSR method of treatment of lower extremities subacute wounds guarantees results comparable to the ones obtained with the treatment of acute wounds during the first week after injury.

Summary:. Preoperative blepharoplasty markings might be challenging, especially for young surgeons. It takes experience to carefully evaluate the amount of skin excess that can be safely removed. In the current study, we explored the use of microsurgical vascular clamps as a novel and useful tool in the preoperative upper blepharoplasty markings; they made it possible to directly visualize the amount of skin to be removed, facilitating the surgeon (especially the young surgeon) preoperative markings process. In our series, 30 patients underwent upper blepharoplasty with preoperative application of microvascular clamps with satisfactory results.

Background Gustilo classification system defines IIIC fractures as open fractures associated with an arterial injury that requires repair. The aim of our study was to analyze the early outcome in terms of limb and flap salvage, early amputation, and early complication rate in patients with Gustilo IIIC open fractures treated in an emergency setup. Methods We retrospectively reviewed 20 patients with Gustilo IIIC injuries treated by the “fix and flap” principle during the first surgical procedure in the first 24 hours after injury (emergency free flap transfer). All patients underwent surgery with radical debridement, wound irrigation, skeletal stabilization, vascular repair, and immediate free flap coverage. Results In this study, 18 patients were men (90%) and 2 were women (10%). In all patients, a vascular repair was performed and in 17 cases (85%), the lower limb/foot was avascular and limb salvage was performed. Three patients had one vessels injured (15%) and 17 had two or three vessels injured (85%). In 9 out of 20 (45%), a revision surgery was needed for arterial (10%, 2 patients), arterial–venous (15%, 3 patients), and venous thrombosis (20%, 4 patients), while 4 patients required an early amputation (20%) and 1, a late one (5%). In three patients (15%), a flap loss occurred. Superficial infection occurred in seven cases (35%) and deep infection (osteomyelitis) in one (5%). Conclusion A single-stage procedure performed in an emergency operating room could lead to an effective outcome with a high rate of limb salvage and satisfying long-term results.

Microsurgical reconstruction of intraoral structures requires accurate planning of flap shape and dimensions. The goal of this study is to describe a method that allows to calculate surfaces of oral structures from preoperative CT-scan in order to determine a precise flap design before the surgery. We created casts of the human mouth from cadavers with a head and neck CT-scan available using an impression material. We digitalized the mouth casts and unwrapped the surfaces of the different structures of the mouth in a bi-dimensional plane in order to measure the area. Furthermore, we measured distances from pre-determined bony landmarks using the CT-scan 3D reconstruction model and we correlated the two type of measurements. We performed a simple regression analysis and afterwards a multivariate analysis using the more statistically correlated measurements. We found a statistical correlation between the surface of the tongue and the surface floor of the mouth with three bone distances that let us to create three mathematical formulas. With those formulas, we can calculate the surfaces of the tongue and the floor of the mouth using simple bony distances that can be easily measured from the head and neck preoperative CT scan. Using standard template's layouts, we can create a precise preoperative flap design in the reconstruction of the tongue and of the floor of the mouth.

We have already described the use of minisized Mitek® suture anchors (Depuy Mitek Surgical Products, Inc. Raynham, Mass, USA) to fix free flaps in the reconstructions of oral and oropharyngeal defects after resections for cancer.1,2 The anchors are available in different sizes: micro, mini, GII, and super. The minisized ones require that a hole 1 cm deep be placed in the recipient bone, but the thickness and quality of the bone may be insufficient to fulfill this requirement. Recently, we tested the microsized anchors for fixing regional pedicled flaps, which are typically used in the reconstruction of the floor of the mouth when the tumour has spared both the mylohyoid muscle and the mandible, and when harvesting nasolabial,3 intraoral facial artery musculomucosal,4 or submental flaps. Both the minisized and microsized anchors may be suitable for these reconstructions.

Background Dermal substitutes have been used in Europe since 1996 as a mean of reconstructing the dermal layer. Objectives To introduce the dermal substitute as a dual-stage reconstructing procedure using the dual-layer version and as a single-stage procedure, combining the single layer with a skin graft to achieve immediate closure. Our further objective was to evaluate the persistence of a commercial dermal substitute in the host's dermal layer using serial histologic studies. Materials and Methods The dermal substitute used was a membrane made using a porous coprecipitate of type I bovine collagen and glycosaminoglycan organized in a three-dimensional structure that allows the host's cell to migrate into it. It is available in a double-layer structure, covered by a silicone sheet, and in a single-layer structure without silicon. Results and Conclusion We describe the dermal substitute indications in dermatologic surgery and our first results with the single layer as a single-stage procedure with an 80% to 100% take rate. Our histological studies of both products show their perfect integration and the persistence of the peculiar three-dimensional structure (neodermis) 5 years from implantation of the dual-layer dermal substitute.

Oncoplastic surgery after conservative breast cancer treatment, in appropriately selected patients, is considered the gold standard in breast reconstruction.1,2 Among the reconstructive options available, a key role is played by loco-regional perforator flaps and particularly by the lateral intercostal artery perforator (LICAP) flap3,4 with regard to breast defects after quadrantectomy localized in the external quadrants (volume replacement) or after mastectomy in patients with small breasts (in thin patients with mammary volume < 100 cc).

Free flap perfusion and arterial pressure management have always had a crucial role in free flap reconstruction. Blood pressure values requested can be reached either by using vasoactive agents or fluid replacement or the combination of both.1,2 In contrast to the most frequently tested phenylephrine, norepinephrine, and dobutamine,3,4 this work evaluates dopamine efficacy in perioperative blood pressure management. In our institution, dopamine infusion is the only vasoactive agent authorized in a non-intensive care unit department. This drug stimulates α- and β-adrenergic receptors with positive chronotropic and inotropic effects and reduces peripheral vascular resistance helping in this way to achieve an increase of blood pressure and free flap perfusion.5

Since the 70s when the first autologous breast reconstruction by a free flap has been performed by Fujino, the interest for finding the optimal recipient vessels is ever present. Being centrally located on the chest, the internal mammary vessels have been a logical solution. However, the use of these vessels has serious limits: the internal mammary artery (IMA) should be spared, if possible, to serve as a by-pass conduit for revascularization of ischemic heart and the vein usually divides in the 4th ICS and may be inappropriate for a matching diameter anastomosis with the free flap pedicle. The unknown anatomy of the IMV has been a limiting factor for selection of IM vessels as recipient until detailed studies of anatomy in cadavers and clinical set-up have been performed in the 90s. From then on, there has been a constant progress in understanding the IMV, its course, ramifications, branches, interconnections and perforators. The classic approach to the IM vessels has been replaced by a less invasive rib-sparing and IMA preserving approach and anastomosis to perforators from IMA and IMV. Algorithms for selection of appropriate recipient vessels have been proposed.

The Mitek® suture anchors (Depuy Mitek Surgical Products,Inc.Raynham, Massachusetts) are produced in a number of differentsizes(micro, mini, GII, and Super) but we use the mini. It is composed of a body and two wings, the body being made oftitaniumalloy, and the wings of nickel-titaniumalloy, which benefits from superelasticity and its memory of shape. The packaging includes both the anchor and the insertion device, in which the anchor is already preloaded. The bottom of the anchor has a loop that contains the suture, which is charged on to the insertion device.

This book is especially focused on the surgical aspect on Gender Dysphoria. Male to female surgery is widely discussed as well as the female to male conversion. Full information on hormone administration and surgical procedures are provided. Mental health issues are also described, as well as ethics, the law and psychosocial issues. The text is extensively referenced and includes numerous photos, tables and figures to clearly illustrate information. Based on collaboration between international experts in transgender health, this book is an essential guide for health care professionals, educators, students, patients and patients’ families concerning the psychological, hormonal, surgical and social support of transgender individuals.

The contouring of the chest wall is usually the first surgical step in female-to-male transsexuals. Its aim is to transform the female chest in one with a male appearance. It is usually the most sought after procedure in female-to-male transsexuals and the one that is performed almost on every patient with this gender disorder, as it provides the most visible result and has major implications in daily social interactions. The goals of the ideal chest wall contouring are the removal of breast tissue and excessive skin, the repositioning and remodelling of the nipple-areola complex (NAC) and the minimization of chest wall scars. These goals can be achieved with different techniques: in patients with large breasts, the technique that gives the best result is the mastectomy with free nipple-areola complex grafting. For medium-sized breasts, there are two options, based on breast volume and NAC position relative to the inframammary fold. In young patients with elastic skin and a NAC positioned cranially to the inframammary fold, the semicircular technique is the best choice. If the NAC is positioned caudally to the inframammary fold, the concentric circular or free NAC grafting technique is preferred.

Since its first description more than 20 years ago, phalloplasty using a free sensate flap is commonly considered as the gold standard for phallic reconstruction in female-to-male (FTM) transsexuals. Surgeons performing this procedure have to face different patient’s needs, including a good cosmetic result, a good rigidity, a tactile sensitivity and voiding while standing. The procedure may include the reconstruction of the urethra. Different techniques have been adopted during decades. Free flaps from nearly all parts of the body were described for penile reconstruction, but after an initial and euphoric phase, more recent publications of larger series of patients revealed a restriction to only two favourite donor sites: forearm flaps and fibula flaps.

Total phallic construction is an important step in surgical treatment of female-to-male transsexuals (FTMT) for gender reassignment. Female-to-male gender reassignment consists of subcutaneous mastectomy, hysterectomy, salpingooophorectomy, and vaginectomy which are performed typically prior to phallic construction and insertion of penile and testicular prostheses which can be done simultaneously or at a later stage. The ideal total phallic reconstruction should create an aesthetically acceptable, sensate phallus with the neourethra permitting voiding in a urinal and enough tissue to allow for insertion of a penile prosthesis permitting sexual intercourse [ 1 ]. However, selection of the reconstructive method depends largely on patients’ desires: some of the patients prefer a reconstruction without the neourethra; others may refuse insertion of a penile prosthesis. Historically, the fi rst penile reconstructions started in the late 1930s with random pedicled oblique abdominal tube fl aps with no neourethra and optional insertion of costal cartilage to obtain rigidity [ 2 ]. Later, in the 1940s, in order to reconstruct the neourethra, the “tube-within-a-tube” concept was added to the original Borgas’ technique [ 3 , 4 ]. With the advent of axial pattern fl aps, the groin fl ap was introduced into phallic reconstruction. Because it was wedge shaped and insensate, it never gained popularity [ 5 – 7 ]. Pedicle musculocutaneous fl aps from the thigh (gracilis) led to poor results and were abandoned [ 8 , 9 ]. In 1984 Chang and Hwang published a series of 7 total phallic reconstructions by the free radial forearm fl ap which revolutionized phallic reconstruction. This fl ap offered the possibility of reconstructing a well-vascularized, sensate penile shaft of generous dimensions and neourethra using the “tube-within-a-tube” principle from the non-hirsute skin in one stage, making possible an insertion of a penile prosthesis [ 10 ]. Later, the design of this fl ap has been modifi ed to improve the aesthetic results and to reduce the complication rate (mainly connected to meatal stenosis and urethral fi stulae) and the donor site morbidity. Other microvascular reconstructions include the island lateral arm fl ap [ 11 , 12 ], deltoid fl ap [ 13 ], pedicled TFL [ 14 ] fl ap, SCIP fl ap [ 15 ], Z. M. Arnež , MD, PhD (*) Department of Medicine , Surgery and Health University of Studies of Trieste , Strada di Fiume 447 , Trieste 34149 , Italy e-mail: zoran.arnez@aots.sanita.fvg.it

Purpose Computer-aided design–computer-aided modeling (CAD-CAM) has become standard in mandibular reconstruction because it offers better outcomes. Occasionally, the reconstructive plans need to be changed intraoperatively and the custom-made prefabricated devices may become inadequate. We present an efficient adjunct to the standard CAD-CAM technique that resolves this problem. Materials and Methods Customized surgical devices with our “triple-cut” concept were used in 5 patients for mandibular reconstruction with free fibula flap (4 after mandibular resection for squamous cell carcinoma and 1 after mandibular osteoradionecrosis). In all patients the mandibular and fibular cutting guides were provided with 3 different cutting levels per side. Results Three different cutting levels on the mandible permitted an accurate resection based on the intraoperative needs. The corresponding 3 “cutting levels” on the fibula created perfectly matching segments of vascularized bone. Good contact of bony segments was obtained in all patients. Conclusions The prefabricated triple-cut cutting guides make changing the dimensions of bony resection, while still using the prefabricated CAD-CAM reconstructive plate, possible.

Macrovascular arteriovenous shunt (MAS) between ulnar artery and its venae comitantes: The cause of arterial thrombosis and insufficiency in a distally based ulnar forearm perforator (UAP) flap used for intraoral reconstruction.

Patients often are being referred to plastic surgery for reconstruction of complex wounds in the subacute phase of healing. According to Godina,1 the time interval for the acute reconstruction (early free flaps) is less than 72 hours.2 Byrd et al,3 however, believe that the acute period of the wound lasts 1 week. Only after that, the wound enters in the subacute phase in which treatment of complex wounds becomes more prone to complications (bone and soft-tissue infection, free flap failure).

Reconstruction after excision of non-melanoma skin cancer involving the medial canthal region is a functional and aesthetic challenge. Several important anatomical structures (the lacrimal duct, the medial canthal ligaments and the superior and inferior eyelids with anterior and posterior lamellae) that the surgeon must preserve or has to reconstruct may be involved in the excision. Several techniques for reconstructing this region have been described in the literature but all of them present several limits.