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Scalp defects commonly occur as a result of tumour excision or trauma. The reconstruction of medium to large defects can be challenging due to the scalp laxity and hair growth pattern. We compare the outcome of patients who have had snail flap reconstruction in comparison to skin grafts. We conducted a retrospective case study of 45 consecutive patients’ over a 3-year period (2016–2018), across three sub-groups, viz. Fibonacci sequence flap, split skin graft and full-thickness skin grafts. The sub-cohorts were all matched for age, sex, indications and defect sizes before being analysed in terms of complication rates and wound healing rates over a 4-month period. The Fibonacci ‘snail’ flap was found to heal significantly faster than the full-thickness skin graft group and with lower complication rates overall, compared to skin grafts, but the latter outcome did not reach statistical significance. The aesthetic outcome of the Fibonacci flap though was superior to skin grafts both in terms of colour and contour match as well as hair restoration. The Fibonacci ‘snail’ flap is a sound option for the reconstruction of medium to large size defects of the scalp, even in those with poor performance scores, especially since its lower flap: defect ratio allows it to be performed under local anaesthesia. The advantage of the ‘snail’ flap over other scalp flaps will be determined in a future comparative study. Level of evidence: Level III, therapeutic study.

The common limitation of surgical revascularization procedures for severe tissue ischemia due to cardiovascular diseases is the need to interrupt blood flow during the intervention. We aim to introduce a new technique that allows a sutureless, non-occlusive revascularization. A 3-step technique was developed using rabbit's aorta to simulate a side-to-side anastomosis model. It enables the creation of a bypass circuit for revascularization. The first step was the soldering of 2 vessels in a side-to-side fashion based on the laser-assisted vascular anastomosis (LAVA) principle using a diode laser emitting irradiation at 810 nm with an albumin-based solder patch between them, followed by the creation of a channel within the patch using either a holmium-doped yttrium aluminum garnet laser (Ho:YAG) at λ = 2100 nm or a xenon-chloride excimer laser (XeCl) at λ = 308 nm. Thereby, a bypass circuit was created, thus allowing a non-ischemic revascularization. The system was deemed functional when a flow was observed across the anastomosis. The highest average tensile strength recorded after side-to-side LAVA using a diode laser power of 3.2 W for 60 s was 2278.6 ± 800 mN (n = 20). The Ho:YAG laser created the channels with less tension on the anastomosis than the excimer laser. Histological analysis showed limited thermal damage and good patch-tissue adaptation. The preliminary results of this feasibility study outline the foundations for an entirely sutureless laser-assisted revascularization procedure. The next studies will evaluate the rheological parameters across the bypass circuit to optimize the post-anastomotic flow.

The scalp rotation flap is still the flap of choice for scalp defects as it provides hair-bearing skin, replacing “like with like,” and can be designed to respect hairlines and patterns.1 Conventionally, these flaps are planned to be up to 8 times the diameter of the defect to allow for sufficient recruitment of scalp laxity and allow for primary closure of the secondary defect. Nevertheless, its use is limited by large flap to defect ratios (See Video [online], which displays the surgical technique of the “snail flap”). Video 1. This video displays the snail flap technique demonstrated in the article. From “The "Snail Flap": A Rotation Flap in Scalp Reconstruction” Following the creation of the scalp defect, the thickness of the scalp is measured. If it is less than 5 mm, a snail flap is raised, as shown in the video, with a “flap:defect” ratio of 2:1. The tip of the flap is folded onto itself and advanced into the primary defect first. The secondary defect is then closed by spreading the tension across the entire arc. In younger patients, where the scalp thickness tends to be greater than 5 mm and there is increased scalp laxity, a “flap:defect” ratio of 1.5:1 may be chosen as the greater scalp laxity accords ease of closure (Fig. 1).

Background. Lower extremity reconstruction has always been a challenge. Some of the published articles had a major impact on the field but are often not considered as classics because they have fewer citations. We therefore conducted a scientometric analysis of the most cited articles with a focus solely on the lower limb. Methods. A search was conducted on Medline, the Web of Science database, Google Scholar, and Scopus identifying articles relevant to reconstructive surgery of the lower limb. All journals were included with no time frames. Articles relating solely to orthopedics or vascular reconstruction were excluded. The number of citations obtained were then plotted and compared between the different search engines. The mean citation number was calculated by taking into consideration the total number of years since the article’s first year of publication. Articles were then ranked and classified according to their authors, their years of publications, and their countries. They were furthermore categorized and analyzed. Results. Highly cited articles were easily retrieved with Google Scholar, mostly published in Plastic and Reconstructive Surgery (n = 37) and were mainly authored by American Medical Centers (n = 22). Fifty-four percent (54%) of these classic articles discussed the design of new flaps or were anatomical studies. Conclusions. We were not able to find a correlation between the year of citation and the number of citations. The citation pattern of a paper cannot be predicted, but a majority of highly cited article allowed the design of new reconstructive techniques.

Pancreatic cancer is the 10th leading cause of death worldwide. It is a very lethal and aggressive tumor, with a 5-year overall survival rate under 5 % for confirmed ductal adenocarcinoma. Even though many genes have been identified as possible treatment targets, surgery remains the only curative treatment. Imaging is essential to the initial workup and is mostly based on CT-scan and MRI studies. Resectability is based on the absence of distant metastases and arterial vasculature infiltration. 3D imaging reconstruction could add precision to the surgical evaluation. Many phase II non randomized studies have shown that neo-adjuvant chemotherapy had a positive effect on pancreatic cancer. Nevertheless this approach is only reserved for cases with locally advanced tumors.Le cancer du pancréas est la 10

Microvascular surgery is time consuming and requires high expertise. Laser-assisted vascular anastomosis (LAVA) is a promising sutureless technique that has the potential to facilitate this procedure. In this study, we evaluate the handling of our soldering material and the 1-week patency rate in a porcine model. Six pigs were subjected to LAVA. For each pig, the saphenous artery on one side was transected while the contralateral side was used as control. A porous polycaprolactone scaffold soaked in 40% (w/w) bovine serum albumin solution in combination with 0.1% (w/w) indocyanine green was wrapped at the anastomosis site and at the control site. Both sides were then soldered with a diode laser coupled into a light diffuser fiber emitting radiation with a wavelength of 808 nm and a power of 2-2.2 W. Vessels were successfully soldered with a 100% immediate patency rate. The 1-week patency rate was 83% for the anastomoses versus 67% for the control side. Vessels irradiated for 80 to 90 s tended to maintain the highest patency rate. Macroscopically, there was no difference between the two sides. The patch was easy to handle provided that the environment could be kept dry. This study shows the potential and the limitations of endoluminal LAVA as a one-step procedure without the use of stay sutures. Further studies are needed to improve the soldering material, the long-term patency rate, and standardized irradiation parameters. The long-term effects of laser soldering on the vessel wall remain to be determined.