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Pain control is crucial in surgical patients, being an essential part of enhanced recovery after surgery protocols. Lidocaine, an amide local anesthetic, was primarily used as an antiarrhythmic. It has analgesic, antihyperalgesic and anti-inflammatory effects, with various actions on cardiovascular, respiratory, and digestive systems. Lidocaine has been shown to also have antithrombotic, antimicrobial, and antitumoral effects. Numerous studies have reported its safe profile and role in managing perioperative pain after breast cancer, abdominal, genitourinary, gynecologic, obstetric, orthopedic, cardiothoracic, spine, thyroid, and upper airway surgery. Lidocaine, as part of multimodal analgesia, also shows promising results in ambulatory surgery. Therefore, the use of intravenous lidocaine in the perioperative period is mainly associated with better pain control, reduced opioid use, diminished incidence of postoperative nausea, vomiting, and ileus, and exhibits antithrombotic effects.

Thumb carpometacarpal (CMC) joint dislocation is rare, and the treatment options may vary from conservatives’ strategies to open reduction and fixation. In face of pain and joint instability persistence, surgical intervention is required. We present the case of a 67-year-old male that was referred to our hospital with pain and edema of the left hand, after the failure of a conservative treatment. After initial refusal of open surgery, due to the persistent joint instability, open reduction of the CMC joint dislocation was performed, and stabilized using two percutaneous Kirschner wires after repairing the joint capsule and dorsoradial ligament. Immobilization was required for 4 weeks. After that, the Kirschner wires were removed. Along with physiotherapy, the follow-up showed no pain persistence nor CMC joint luxation reoccurrence while the joint recovered its mobility. Further studies are required in order to determine the optimal therapy for such cases and to provide standardized recommendations, taking into account that the restoration of thumb CMC joint mobility is one of the most important goals in hand surgery.

The field of transplantation, including the specialized area of vascularized composite allotransplantation (VCA), has been transformed since the first hand transplant in 1998. The major challenge in VCA comes from the need for life-long immunosuppressive therapy due to its non-vital nature and a high rate of systemic complications. Ongoing research is focused on immunosuppressive therapeutic strategies to avoid toxicity and promote donor-specific tolerance. This includes studying the balance between tolerance and effector mechanisms in immune modulation, particularly the role of costimulatory signals in T lymphocyte activation. Costimulatory signals during T cell activation can have either stimulatory or inhibitory effects. Interfering with T cell activation through costimulation blockade strategies shows potential in avoiding rejection and prolonging the survival of transplanted organs. This review paper aims to summarize current data on the immunologic role of costimulatory blockade in the field of transplantation. It focuses on strategies that can be applied in vascularized composite allotransplantation, offering insights into novel methods for enhancing the success and safety of these procedures.

The reconstruction of bone defects still represents a great challenge for surgeons mainly because it is aimed to properly restore the site of the defect, to maintain the motor and sensate function, and, not lastly, to recreate or maintain the aesthetics of the region. The fibular flap is a great choice for bone defect reconstruction, with a large array of clinical utilization, but insufficiently used because of its demanding technique of harvesting. The ability to transfer simultaneously bone, muscle and skin in a one-stage vascular anastomosis makes this flap even more appealing when addressing composite defects.

Introduction. The field of composite tissue allotransplatation became a clinical reality since first hand transplant performed in 1998 at Lyon, France and has been progressing over the past two decades. Vascularized composite allotransplantation (VCA) is now performed for life enhancing indications in a selected group of patients under institutional protocols. Aim. This paper is an attempt to review the outcomes of VCA to date. Method. Analysis of relevant publications of composite tissue allotransplantation was performed, including the International Registry on Hand and Composite Tissue Transplantation (IRHCTT). Results and discussion. To date, there are more than 200 composite tissue allograft transplants performed worldwide, including upper limb, face, larynx, trachea, abdominal wall, lower limb, penis, and uterus. The technical aspects of VCA are no longer the factors limiting the widespread application of this treatment modality in the clinical setting. The feasibility of the procedure has been established, and the functional outcomes have been very good so far. The major challenge is at the immunologic level, long-term goal being to promote donor-specific tolerance and to avoid the toxicity of immunosuppression. Conclusions. Vascularized composite allografts transplatation is a viable treatment option well on the way of becoming a standard of care for those who have lost extremities and suffered large tissue defects. The initial ethical dilemmas and concerns of safety and feasibility have been overcome recently and with further standardized surgical and immunological protocols the field is likely to grow significantly in the future.

Background. Rhinoplasty is considered as one of the most challenging objectives in plastic surgery and tip rhinoplasty is arguably the greatest challenge for the surgeon performing rhinoplasty. No routine tip procedure is ever used and there are many ways to reconstruct and make nasal tips more attractive. Objective. The aim of this study was to evaluate the different correction techniques, in order to improve the outcomes in tip rhinoplasty. Methods. A prospective study was performed, including all patients with nasal tip deformities who underwent closed or open rhinoplasty between December 2015-August 2016 in Bombay Hospital, India. The patients were divided into two groups: group A – treated with various types of tip sutures (12 cases), and group B – treated with combined tip sutures and grafts (18 cases). Results. The study included 30 patients, 24 (80%) females and 6 (20%) males. 12 (40%) were patients with bulbous tips, 7 (23%) were patients with droopy tips, 5 (17%) were patients with boxy (broad) tips, 3 (10%) were patients with wide tips, and 3 (10%) were patients with bifid tips. A total of 27 (90%) cases involved primary rhinoplasties, and 3 (10%) cases involved revision. Patient’s and doctor’s satisfactions were recorded by a score from 0 to 3, with 0 being the less satisfied by the result of surgery and 3 being the highest satisfied. Conclusion. Aesthetic outcome following the management of nasal tips deformities with combined suture techniques and grafts is more satisfactory than the outcome that can be achieved following suture alone, especially in certain cases.

Iron deficiency is a major problem in worldwide populations, being more alarming in surgical patients. In the presence of absolute iron deficiency (depletion of body iron), functional iron deficiency (during intense bone marrow stimulation by endogenous or exogenous factors), or iron sequestration (acute or chronic inflammatory conditions), iron-restricted erythropoiesis can develop. This systemic review was conducted to draw attention to the delicate problem of perioperative anemia, and to provide solutions to optimize the management of anemic surgical patients. Systemic reviews and meta-analyses, clinical studies and trials, case reports and international guidelines were studied, from a database of 50 articles. Bone marrow biopsy, serum ferritin levels, transferrin saturation, the mean corpuscular volume, and mean corpuscular hemoglobin concentration were used in the diagnosis of iron deficiency. There are various intravenous iron formulations, with different pharmacological profiles used for restoring iron. In surgical patients, anemia is an independent risk factor for morbidity and mortality. Therefore, anemia correction should be rapid, with parenteral iron formulations—the oral ones—being inefficient. Various studies showed the safety and efficacy of parenteral iron formulations in correcting hemoglobin levels and decreasing the blood transfusion rate, the overall mortality, the postoperative infections incidence, hospitalization days, and the general costs.

Since 1998, when the first successful hand transplant was performed in France, at Lyon, an unpredicted development of reconstructive transplant surgery (transplant of VCA: vascularized composite allografts) occurred. Those procedures represents the only option for patients having extensive, complex tissue defects, involving multiple anatomical layers, impossible to approach using conventional reconstructive techniques. More than two hundred VCA procedures were reported worldwide, including: upper and lower limbs, face, larynx, trachea, abdominal wall, penis, uterus, knee allotransplant. Important aspects arise in the study of immunological mechanisms of acceptance and rejection of the allograft, the mode of action of immunosuppressive agents and protocols currently used in transplant programs for vascularized composite allografts. Immunosuppressive regimens that are used for solid organ transplantation (kidney, heart) are also effective for VCA transplants with good results regarding survival and functionality of the allografts. Current goal is the minimization of immunosuppression, composite tissue allotransplantation procedures being addressed for functional recovery (are not life-saving interventions like solid organ transplants). The ideal situation, which would allow a large scale utilization of VCA procedures, is the possibility of induction the donor-specific tolerance, allowing allograft acceptance without the need of immunosuppressive therapy. Currently this circumstance is difficult to achieve in clinical practice, resulting in large transplant centers ongoing research focusing on immunological difficult aspects.

Background and objectives: Breast cancer is the most common cancer in women. The immunohistochemical profile, but also the stage of the tumor determines the therapeutic management, which varies from conservative surgery to mastectomy associated with chemotherapy, hormonal and biological therapy and/or radiotherapy. Mastectomy remains one of the most radical surgical intervention for women, having great consequences on quality of life, which can be improved by realizing immediate or delayed breast reconstruction. The objective of the study was to evaluate the period of time between the mastectomy and the breast reconstruction. Material and methods: We performed a retrospective study on 57 female patients admitted to the Plastic Surgery Department of the Clinical Emergency Hospital “Prof. Dr. Agrippa Ionescu”, Bucharest, Romania. All the patients underwent immediate or delayed breast reconstruction after mastectomy for confirmed breast cancer. Descriptive data analysis was realized with evaluation of type of breast reconstruction considering the staging of the tumor, the invaded lymph nodes, and the necessity of adjuvant chemoradiotherapy. Moreover, the median period between mastectomy and reconstruction was evaluated. Results: The immediate breast reconstruction was performed in patients with stage I, in patients with stage II, delayed reconstruction was performed after minimum six months, and the patients with stage III had the breast reconstructed with free flap (50%), 8−43 months post-mastectomy. Radiotherapy determines the type of breast reconstruction, in most of the cases the latissimus dorsi flap was used with implant (22.6%). Conclusions: Breast reconstruction is an important step in increasing the quality of life for women who underwent mastectomy after breast cancer. The proper timing for breast reconstruction must be settled by a team formed by the patient, the plastic surgeon, and the oncologist.

The clinical applications of the fibula flap for reconstructing bone defects in the limbs have been widely studied. This study aims to investigate the use of the fibula flap in the treatment of bone defects resulting from trauma, infections, or oncological pathology. Additionally, the study focuses on analyzing preoperative experiences, including imaging and intraoperative aspects, to optimize preoperative planning. The study includes a retrospective analysis of adult patients who underwent surgical treatment for extensive bone defects from 2014 to 2020. Demographic data, surgical interventions, and postoperative complications were collected. Specific anatomical elements of the fibula flap, such as vascularization and dimensions, were also studied. The findings of this study provide valuable insights into the clinical applications and optimization of the fibula flap for reconstructive surgery.

Microsurgery, a pivotal surgical field that changed medical perspectives in the 20th century, presents numerous technical challenges due to the precision it requires from the surgeon. To acquire the requisite skills, comprehensive training is imperative. Initiation into microsurgical training on experimental models is a prerequisite before translating these skills to clinical applications. The employment of non-living models in medical training offers a myriad of advantages, notably characterized by their accessibility and cost-effectiveness. Non-living models, such as latex gloves, leaves, flower petals, silicon tubes and chicken legs, provide aspiring microsurgeons an opportunity to train the essential technical skills required in microsurgical practice. Such models significantly alleviate ethical concerns associated with the use of live specimens and human cadaveric models. Furthermore, they exhibit a satisfactory emulation of human vascular properties, providing a realistic context for medical practice. Although the primary focus of this paper is on non-living models, it is important to highlight the transition to living models, specifically small animal models, as a mandatory and advanced phase in microsurgical training, before translating to clinical practice.

Background and Objectives: Hand septic arthritis is a potentially debilitating condition that can significantly affect patient functionality and quality of life. Understanding the demographic, clinical, and microbiological characteristics of this condition is crucial for its effective treatment and management. This study aimed to analyze the demographic and clinical profiles of patients with hand septic arthritis, to identify common microbial pathogens, and to evaluate the impact of various factors on clinical course and treatment outcomes. Material and Methods: This cross-sectional retrospective study examined patients diagnosed with septic arthritis of the hand, focusing on their demographic data, clinical presentation, causative organisms, treatment methods, and outcomes. Data on age, sex, cause of infection, affected sites, surgical interventions, microbiological findings, and patient outcomes were also collected. Results: This study found a higher prevalence of septic arthritis in males and identified bite as the predominant cause. Staphylococcus aureus is the most common pathogen. A large number of patients did not exhibit bacterial growth, and bacterial resistance did not significantly affect the outcome. Outcomes were statistically influenced by the timing of medical presentation and the presence of comorbidities. Conclusions: Early diagnosis and intervention are critical for effective management of hand septic arthritis. This study underscores the need for a comprehensive approach that considers patient demographic and clinical characteristics to optimize treatment outcomes. Awareness and preventive measures are essential to reduce the incidence and severity of this condition.

Infections represent the most common complication occurring during the evolution of the severely burned patient, hence requiring closer study and targeted result analysis. The fungal infections are one of the most aggressive types of existing infections, their opportunistic character enabling them to cause invasive infections, ultimately leading to a higher morbidity and a higher rate of mortality. The present study focuses on the presence of Candida spp. in 19 out of a total of 70 patients admitted to the Critical Care Burn Unit in the Clinical Emergency Hospital Bucharest, between 01.01.2019-31.12.2019. No other fungal species, besides Candida spp., were identified in this patient lot. The aim of this study was to analyze the risk factors and the dynamics of the biological parameters of the patients presenting Candida spp. infections, in order to determine how these contribute to the prognostic and final outcome of these patients. We can conclude that a precise diagnostic and prompt treatment can make a significant difference in the outcome of severely burnt patients presenting with a fungal infection.

Background and objectives: Burn injuries are the most severe type of trauma, with complex biological consequences associated with high rates of morbidity and mortality. Prompt recognition and management of burn-related complications are imperative for improving the vital and functional prognosis of the patient. Changes in biological parameters can be essential determinants in the prognosis of the burned patient. Thrombocytopenia in critically ill patients is linked to an elevated risk of mortality. We sought to investigate the significance of thrombocytopenia in severely burned patients while considering the limited available data in the literature. Materials and methods: A two-year retrospective study was conducted on 90 patients with severe burns admitted to our Burn Centre. Demographic data, burn lesion characteristics, and daily total blood counts, including platelet assessment, complications, and mortality, were recorded and analyzed. Results: Patients with extensive burns in our study had a poor prognosis based on their Abbreviated Burn Severity Index score (ABSI), age, percentage of total body surface area (TBSA) burned, presence of third-degree burns, and inhalation injuries. Regardless of the moment, patients with thrombocytopenia in our study died significantly more frequently. Compared with the survivors, the platelet count was significantly lower at any given time in the non-survivors group. Significant statistical associations between thrombocytopenia and ABSI score, burn surface area, presence of third-degree burns, and inhalation injuries were identified at different timeframes post-burn injury. Sepsis was encountered in one-third of the patients. Thrombocytopenia was more frequent in patients with sepsis who did not survive compared to survivors and did not normalize until the time of death. Conclusions: Thrombocytopenia represents an early indicator of severe complications and outcome predictor in severely burned patients. It is correlated with recognized negative prognostic factors and also with sepsis occurrence. Future research efforts should focus on refining early detection parameters and interventions to improve the prognosis of burn patients.

The field of plastic surgery is continuously evolving, with faster-emerging technologies and therapeutic approaches, leading to the necessity of establishing novel protocols and solving models. Surgical decision-making in reconstructive surgery is significantly impacted by various factors, including the etiopathology of the defect, the need to restore form and function, the patient’s characteristics, compliance and expectations, and the surgeon’s expertise. A broad surgical armamentarium is currently available, comprising well-established surgical procedures, as well as emerging techniques and technologies. Reconstructive surgery paradigms guide therapeutic strategies in order to reduce morbidity, mortality and risks while maximizing safety, patient satisfaction and properly restoring form and function. The paradigms provide researchers with formulation and solving models for each unique problem, assembling complex entities composed of theoretical, practical, methodological and instrumental elements.

Background and Objectives: Burn patients manifest all components of Virchow’s triad, amplifying the concern for venous thromboembolism (VTE). Routine prophylaxis for VTE remains a subject of debate, with the central concern being the occurrence of associated adverse events. Materials and Methods: We conducted a five-year retrospective study on burn patients admitted to our burn center. Demographic data, comorbidities, burn lesions characteristics, surgical interventions, anticoagulant medication, the need for transfusions, the presence of a central venous catheter, length of stay, complications, and mortality were recorded. Results: Of the overall number of patients (494), 2.63% (13 patients) developed venous thromboembolic complications documented through paraclinical investigations. In 70% of cases, thrombosis occurred in a limb with central venous catether (CVC). Every patient with VTE had a Caprini score above 8, with a mean score of 12 points in our study group. Conclusions: Considering each patient’s particularities and burn injury characteristics, individualized approaches may be necessary to optimize thromboprophylaxis effectiveness. We suggest routinely using the Caprini Risk Assessment Model in burn patients. We recommend the administration of pharmacologic thromboprophylaxis in all patients and careful monitoring of patients with Caprini scores above 8, due to the increased risk of VTE. Additionally, ongoing research in this field may provide insights into new strategies for managing thrombotic risk in burn patients.

There is great interest in the development of prosthetic limbs capable of complex activities that are wirelessly connected to the patient’s neural system. Although some progress has been achieved in this area, one of the main problems encountered is the selective acquisition of nerve impulses and the closing of the automation loop through the selective stimulation of the sensitive branches of the patient. Large-scale research and development have achieved so-called “cuff electrodes”; however, they present a big disadvantage: they are not selective. In this article, we present the progress made in the development of an implantable system of plug neural microelectrodes that relate to the biological nerve tissue and can be used for the selective acquisition of neuronal signals and for the stimulation of specific nerve fascicles. The developed plug electrodes are also advantageous due to their small thickness, as they do not trigger nerve inflammation. In addition, the results of the conducted tests on a sous scrofa subject are presented.

Introduction. Bromelain-based enzymatic debridement may be considered the standard in patients with upper extremity burns management, regarding the low risk of bleeding, wound infections, reduction of surgical timing, and the decreased risk of compartment syndrome development. Case presentation. We present the case of hand and face burns in a patient presenting deep venous thrombosis of the lower limb extended to the level of the vena cava, and bilateral pulmonary embolism. The enzymatic debridement reduced periprocedural bleeding and allowed a faster recovery and therefore the resumption of oral anticoagulation and antiplatelet medication in a patient with important cardiac, arterial, and renal comorbidities. Conclusion. Bromelain-based enzymatic debridement use is recommended in patients presenting upper limb deep burns, especially in anatomically challenging areas, like hand fingers, and especially in those with a previous medical history that predisposes them to periprocedural bleeding and increased risk of poor healing.

Burn injuries have a long-term negative impact on patients, families, and healthcare systems, and prevention remains the primary goal. Head and neck lesions have a reported prevalence between 6-65.6%, sometimes even 95.1%. There are various risk factors and predictors of facial burns, like younger age, male sex, flame or flash burns, and work-related injuries. Surgical and non-surgical management is chosen depending on the burn type and extension, and the patients’ previous health status. Tangential necrosectomy is the gold standard of third-degree burn care. In the last years, enzymatic debridement showed promising results. Long-term complications, from altered sensibility, and face motor dysfunction, to hypertrophic scarring and mutilating aspects, frequently lead to depression, post-traumatic stress disorders, and social exclusion. To improve patients’ quality of life, various programs targeting reconstructive surgeries with cosmetic purposes, social skill training, and cognitive behavioural therapies should be implemented.

Venous thromboembolism (VTE), essentially deep venous thrombosis and pulmonary embolism, urinary tract infection, and renal failure are the main unplanned hospital events with negative long-term impact on burn patients’ rehabilitation. Due to the hypercoagulable state induced by severe critical burns, either in the acute or recovery phase and the intimal vascular damage, the risk of VTE is increased, with an incidence varying from 0.4% to almost 60%. Other risk factors for VTE in burn patients are prolonged immobilization, long and multiple surgical interventions, central venous catheterization, wound infection and sepsis, extensive burns, and red blood cell transfusion. To avoid underdiagnosing VTE, in face of increased incidence of asymptomatic venous thromboembolism, high risk-patients should be routinely screened using Doppler ultrasound. Patients’ weight and burn size, as well as the high incidence of heparin resistance in the first weeks after injury, should be considered when establishing the optimal dose for venous thromboembolism prophylaxis, targeting an anti-Xa level of 0.2-0.5 IU/mL.

Burns represent one of the worldwide leading causes of injury. Burn wounds are associated with increased mortality and morbidity, especially the impaired quality of life due to hypertrophic scarring, scar pain and itching, paresthesia, and contractures. To properly influence the burn wound healing, it is important to establish a correct classification of the acute injury and to understand the main phase of burn wound healing process. There are various local and systemic factors that can be influenced to obtain proper healing. The most important factors include local necrosis and infection, increased local pressure and edema, anemia, hypoxia, hypotension, the presence of important chronic disease and medication, immunosuppression, nutritional status, age, and body constitution. After adequate fluid resuscitation and patient stabilization, the main step is represented by the detachment of the devitalized tissues and rapid coverage of the lesion. There are various methods to be used, like autologous or allogenic skin grafting, the use of skin substitutes, or tissue bioengineering. Knowing all these aspects, allows clinicians to properly define a therapeutic management for patients presenting severe burns.

Upper extremities are frequently involved in fire burns due to the natural protective reflexes. The presence of bilateral Dupuytrenʼs disease and COVID-19 disease in patients with circumferential upper extremity burns can negatively impact the outcome, through severe contracture and a tendency to hypoxia or infections, which affects normal wound healing. Enzymatic debridement with a concentrate of proteolytic enzymes enriched in bromelain prevents compartment syndrome development in such patients, reduces blood loss, surgery duration, and appears to favor a more rapid recovery.

Facial nerve paralysis is a debilitating condition with multiple etiologies, with aesthetic, functional, psychological and social impact. Given the complex multitude of causes that may generate such condition, a therapeutic algorithm is mandatory when attempting reconstruction. Severity, timing, patient adherence to a rehabilitation program, status of ipsilateral and contralateral facial nerves and particularities of each patient are all criteria which should be accounted when choosing a treatment option. After initial assessment, a variable treatment panel is available based on condition type include medicamentous therapy, rehabilitation program, dynamic and static procedures surgical procedures, having as primary aim functional restoration achieving aesthetic balanced facial features. This paper summarizes current knowledge in facial paralysis reconstruction and presents an algorithmic approach that eases decision making and therapeutic strategy.

Non-syndromic toe syndactyly is a regular cause of foot malformation in children, bilateral form being less common. Syndactyly release procedures had few contraindications, as uncomplicated malformation or important patient comorbidities. Reported data show that corrective surgery using skin grafts is associated with an increased risk of infection, contractures, and web creep. Reconstruction surgical techniques, using flaps reduce morbidity, revision surgery, complication, may be associated with skin grafts and have superior aesthetic and functional results. We present a case of simple bilateral incomplete asymmetric toe syndactyly, released using a modified personalized local flaps reconstruction technique. The normal function and aesthetic of the feet was obtained, with no complications at one-year follow-up.

Tumor nerve compressions in the upper limb are relatively rare, usually involving ganglion cysts and benign tumors. We present a case series of five patients with peripheral nerve compression in the upper limb due to tumor or cystic masses- ulnar nerve compression in the Guyon’s tunnel due to a ganglion cyst, large median nerve schwannoma compressing anterior interosseous nerve and median nerve, voluminous lipoma compressing median nerve in the proximal forearm, superficial branch of radial nerve compression by a synovial cyst and elbow region lipoma compressing radial nerve. In the beginning, those benign lesions are asymptomatic but, as they continue to grow adjacent to a peripheral nerve clinical manifestations appear progressively as compressive neuropathies. After a preoperative imagistic analysis, tumor resection with careful dissection, in order to preserve the neurovascular structures, is the elective surgical procedure in order to obtain an optimal functional recovery.

Lymphedema represents a chronic condition with impaired lymphatic transport, having primary and secondary etiologies. The most common type of secondary lymphedema in western countries is represented by breast cancer related upper limb lymphedema. This condition, once installed, determines limb structure changes, progressive functional impairment, specific complications, consequently impacting the quality of patient’s life. An accurate diagnosis is mandatory, using both clinical and imagistic methods with clear definition disease extent as per standardized staging systems, in order to further provide an adequate therapeutic strategy. The main therapeutic goal in patients with lymphedema is represented by limb volume reduction with subsequent symptoms relief, improving quality of life and avoiding complications such as recurrent infections. Through this paper, we aim to present a comprehensive overview of current therapeutic options of breast cancer upper limb related lymphedema. Therapeutic approach comprises of non-surgical (conservative) therapy, which is mandatory as initial therapy and surgical procedures for selected cases. Most patients with lymphedema benefit from conservative treatment alone. In non-responsive cases, in patients with progressive disease, in late stage complicated lymphedema, and also recently added as prophylactic strategy, surgical treatment, trough recent developed techniques, offer very good results in long-term control of disease. Surgical options are classified firstly in physiologic procedures that aim to create new lymphatic channels, promote physiologic drainage of the lymph and should be considered early in the course of the disease, and secondly ablative procedures that reduce through liposuction or various excision techniques the volume of the affected limb. Both types of techniques can be combined to ensure the best functional outcome of the patient.

Injuries to the upper limb may determine unexpected simple or complex soft tissue defects, due to different types of underlying injury mechanism, clean cut/stabs, crushing, torsion, avulsion or mixed types, which pose a challenge for the reconstructive surgeon. Ideally, all arterial, venous and nervous lesions, in the distal upper limb should be repaired in an end-to-end technique, outside of injury zones, with healthy ends, in a tension free manner. However, situations arise where, either a tension-free repair is not possible, or a considerable defect is met, often representing a challenge to the surgeon. Therefore, a timely decision is imposed in order to find the most favorable approach to restore limb or segment perfusion, ensuring efficient venous return, as well as providing a sensate repair. Usage of vein grafts represents an essential tool comprised in the reconstructive surgeon’s armamentarium, with high versatility in nerve, arterial and venous reconstruction. Not only does it provide an ideal solution, with high adaptability to each case, but it also may enhance short- and long-term outcome, offering an optimal reconstructive option in any upper limb trauma situation, regardless of etiology. We aim to describe our therapeutic strategies in a series of challenging trauma cases involving digital structures from the upper limb. Interposed vein grafts were used to re-stablish sensate function in a patient with a collateral digital nerve defect, but also to bridge vital digit arterial defect in a torsion-avulsion thumb amputation, as well as re-establishing venous flow in patients with Urbaniak II finger degloving injury.

Upper limb trauma cases vary from simple to high energy impactful injuries, with different etiologies; situations which frequently require unique, demanding and challenging endeavors in order to obtain the most favorable outcome. Experience, good decision-making and knowledge of functional goals are mandatory in order to elaborate a therapeutic plan and execute it accordingly. Although cases differ in nature and prognosis, respecting a set of therapeutic principles whilst dealing with either simple or complex cases, will enhance patient outcome and give the surgeon the confidence to tackle any kind of upper limb trauma. After clearing out vital threat, the emergency surgery represents the first threshold in achieving and restoring normal function and biomechanics, mostly in young and labor active patients, with the mindset to salvage as much tissue as possible, with a thorough debridement and step-by-step approach to different types of tissues. Secondary surgery and reconstructive surgery can be planned timely, with prior discussion with both the therapist and the patient in order to enhance patient’s upper limb function and aesthetic and ensure social reintegration.

Electrocutions are a particular type of trauma, usually affecting young active people, leading to high morbidity and mortality rates in extensive injured patients. Those patients require complex, multidisciplinary treatment in specialized burn centers. We conducted a three-year retrospective study in the Burn Unit of the Clinical Emergency Hospital Bucharest, Romania, aiming to identify different factors that characterize electrical injuries, with the goal to improve our clinical practice, in order to decrease overall complications, the morbidity and mortality rates and obtain an optimal functional prognosis for those severely injured patients. Patient-related and injury-related parameters were analyzed, and particularities observed in our burn unit were noted. A clear understanding of the physiopathology of those injuries and their complications is essential for providing an optimal therapeutic strategy. Rapid initiation of systemic supportive measures, accurate diagnostic and an adequate surgical treatment, correctly conducted, are essential for improving the vital and functional prognostic of patients who suffer electric injuries.

Traumatic dog bite total scalp avulsion is a rare condition. We present a case report on an emergency case, a 52 year old female patient with total scalp avulsion treated in our clinic, with a complex reconstruction using a free microsurgical latissimus dorsi transferred flap.

The presence of inhalation injury has a negative impact on the evolution of burned patients, being associated with increased mortality. It occurs as a direct consequence of thermal action, or secondary to the presence of respiratory irritants or absorption of toxins, and actual therapeutic management is mainly supportive. Several clinical findings are relevant to raising suspicion and guiding further examinations, fiberoptic bronchoscopy being the gold standard of diagnosis and staging. In burned patients with inhalation injuries, various reports showed that nebulized heparin (5,000 or 10,000 units) with a 4-hour administration regimen leads to improved outcome, reduces the days of mechanical ventilation and consequently the length of hospital stay, reduces pulmonary complications and improves lung function, having a safe profile, with fewer side effects.

Hydrotherapy represents the use of water for medical purpose, being involved in burn wound care since the 17th century. Burn wound cleansing, performed daily, twice a day, or as needed, as part of standard care, should be scheduled by a burn surgeon and supervised by proper specialists. It can be performed by various methods, like shower, immersion, bedside irrigation or wiping. Due to the high risk of cross-contamination, immersion is no longer recommended. Tap water seems to be superior to saline solution in burn wound care, and adjuvants can be added, especially chlorhexidine, povidone-iodine, or special detergents. Disposable plastic sheets use during showering and the following of cleaning protocols for washing areas have decreased the risk of infection. Apart from the wound-cleansing role, hydrotherapy reduces itching and pain, improves wound healing, favours early mobilization and increases patients’ comfort. Controversy persists around the optimal method and appropriate solutions for cleaning burn injuries and clinical studies are further required to solve this matter. In the absence of standardized recommendations, most burn centers are guided by experience.

Severe burn injuries represent a major challenge to the entire healthcare system in developing countries and even for states with a high standard of care. A clear understanding of the physiopathology of burn injuries is essential for providing an adequate prompt treatment to ensure an optimal patient outcome. Early recognition and treatment of burns complications, especially severe infections represent an important prevention strategy, improving survival after these severe injuries. Specific treatment must be conducted according to the characteristics of the patients in order to reduce morbidity and mortality and avoid the development of antimicrobial resistance. A diagnostic and therapeutic algorithm is presented, centered on infectious source prevention and control with early surgical excision and skin grafting together with culture-guided antimicrobial therapy. It is a known fact that, indifferent of the involved germ, the best intervention for both prophylaxis and treatment of infections in the burn patient is the early excision of the devitalized tissue and subsequent closure of burn wounds with skin grafts, measures that diminish local and systemic mediator releasing effects in burnt tissue, attenuating the progressive inflammatory.

Burn injuries are unique in comparison to other types of trauma because of their severity and major systemic impact produced by extensive lesions with disfunctions that can persist even several years after the injury. Multiple complications can occur during burn injury evolution, from which infections are the most severe and the most frequently encountered, requiring adequate diagnosis and treatment. In most burn centers, increased mortality rates associate with severe burn injuries aggravated by the development of sepsis. There are multiple sources of infections in burned patients: lungs, wounds, catheters, gastrointestinal and urinary tract. Pathogens are often multi-resistant bacteria but also fungi and viruses appear as opportunistic infections. The main goal is represented by prevention of organ dysfunction development through specific supportive measures that avoid its onset. Early excision of the burn eschar and wound grafting is essential for patient outcome, decreasing duration of hospitalization, infectious risk and mortality. As a principle, antibiotic treatment in burn infectious complications is started empirically, with broad spectrum agents if the results of microbiological cultures are not available and immediately after the antibiogram is available, targeted antibiotic is introduced. De-escalation strategy is promoted in order to prevent antimicrobial resistance: narrow spectrum drugs with proven efficacy on determined germs are administered, avoiding if possible, reserve antibiotics.

Due to its complex structure, the abdominal wall is vital as it serves to protect the internal organs, maintain the upright position and regulate the intraabdominal pressure. Complex abdominal defects are a major health problem, with challenging treatment, many complications and risks. It is not a completely elucidated pathology as there is no consensus in literature regarding the definition and classification. Although there are various reconstruction techniques, there is no sistematic protocol in literature that allows the surgeon to choose the best treatment suitable for each patient. Therefore, the first step to manage these patients is a carefull assesment of the patient background and only after that, a complete analysis of the actual wound should be made. Second step is appropriate abdominal wall closure. After the analysis of current data from international literature, we identified a decision-making algorithm to offer guidance in surgical management in order to obtain an optimal functional outcome. The foundation of the algorithm is the idea of gradually improving the local tissue status, in order to deal with a clean wound as much as possible. This way, the success rate of the surgical reconstruction improves.

Treating complex abdominal wall defects is challenging for the reconstructive surgeon as there are many possible complications and high reccurence rates. To date, there is no consensus on a definition of complex abdominal wall defects, as the level of complexity can be different from case to case. Thorough knowledge of the etiology of defects and relevant anatomy, adequate management during hospitalization and in postoperative period are key elements in obtaining optimal functional results. Although the etiology of abdominal wall defects is varied, reconstructive goals are well established, including recovery of structural integrity to ensure visceral coverage and maintenance of intraabdominal pressure, prevention of hernia formation, if possible with an aesthetic pleasant result; long hospitalizations increasing morbidity and costs should be avoided. Choosing the right therapeutic strategy may be very demanding, because there is no standard treating protocol to guide the management of these patients.. We present, through five clinical cases, our experience with managing abdominal wall defects having in mind the general reconstructive priciples and trying to individualize the treatment for each of them.