OBJECTIVE: To evaluate exogenous hyaluronic acid (HA) derived from bacterial fermentation through enteral and parenteral routes in ischemic skin flaps induced in rats, using clinical and histological exams; and interleukins (IL) as tissue inflammatory biomarkers.
METHODS: Sixty-four male adults Wistar rats with ischemic skin flaps on the dorsum were randomized into four groups, based on the treatment protocol: subcutaneous administration of saline solution (0.9%) (GI); oral administration of distilled water (GII); subcutaneous administration of HA (0.3%) (GIII); and oral administration of HA (1%) (GIV). Flaps of all groups were comparable regarding clinical and macroscopic evaluation, histological examination, pro-inflammatory cytokines (IL-1β, IL-6, and tumor necrosis factor-α) and anti-inflammatory cytokine IL-10.
RESULTS: A lower percentage of necrosis was identified in flaps treated with subcutaneous administration of HA (0.3%). The pro- and anti-inflammatory cytokines, epidermis thickness, blood vessels, and inflammatory cells showed statistically significant inter-group and intra-group differences (p < 0.05).
CONCLUSIONS: High molecular HA (1,400 ~ 2,000 kDa) administrated by subcutaneous or oral route exhibited beneficial effects in ischemic skin flaps of rats. However, subcutaneous administration of HA (0.3%) showed better results in terms of the percentage of necrosis and epithelialization.

This video article presents a 47-year-old male patient who presented to the emergency department after a cleaver bounced off the grinding wheel and lodged between his eyebrows. The patient complained of clear nasal drainage since the trauma. Computed tomography showed a comminuted displaced fracture starting from the right frontonasal recess and extending along the right ethmoid roof. The patient underwent surgery. The skull base defect was reconstructed with a free fascia lata graft in the first operation. In the second session, the reconstruction of the skull base was reinforced with a flap that was prepared from the middle turbinate with the concha bullosa. The patient was followed for eight months. The patient\'s symptoms resolved completely and there was no evidence of rhinorrhoea or any other complication at the control examination. No complications were seen on control magnetic resonance imaging.

BACKGROUND: Random-pattern skin flaps are commonly used to repair skin tissue defects in surgical tissue reconstruction. However, flap necrosis in the distal area due to ischemia injury is still challenging for its applications in plastic surgery. The complications of diabetes will further increase the risk of infection and necrosis.
METHODS: This study induced type 2 diabetes mellitus (T2DM) rats with a high-fat diet and STZ. The survival rate of the skin flap was observed by adding inorganic sodium nitrate to drinking water. Histology and immunohistochemistry were used to detect the damage to the skin flap. The nitrate content was measured by total nitric oxide and nitrate/nitrite parameter assay. Dihydroethidium and malondialdehyde (MDA) assays were used to value oxidative stress. Rat colon feces were collected for 16s rRNA gene sequence.
RESULTS: Our studies showed that nitrate administration leads to anti-obesity and anti-diabetic effects. Nitrate directly increased the survival area of skin flaps in diabetic rats and mean blood vessel density by enhancing angiogenesis, inhibiting apoptosis, and reducing oxidative stress. The 16s rRNA sequence revealed that nitrate may regulate the homeostasis of the gut microbiota and re-store energy metabolism.
CONCLUSIONS: Dietary nitrate has been shown to maintain the homeostasis of oxidative stress and gut microbiota to promote flap survival in rats with T2DM.

Breast cancer is rising among women in India. Most of the cases are presented at the locally advanced stage where axillary dissection is needed. In this article, we have described our approach of axillary dissection in the technically challenging high nodal burden axillas.

OBJECTIVE: This study aims to investigate whether contrast-enhanced ultrasound (CEUS) could be used to reveal the status of blood supply of the superficial flap of rat model in the early postoperative stage.
METHODS: One viable and one ischemic random-pattern flap were prepared on the left and right back of the same rat respectively with a number of 40. CEUS examinations were applied within 12 h and 7 days postoperatively, and the quantitative measurements of microvascular blood volume (BV) of the base and the end of both flaps were expressed using acoustic intensity as a ratio to that of the healthy skin.
RESULTS: Within 12 h post operation, there was a smaller BV value of the ischemic ends than that of both the ischemic bases and viable ends (p < 0.001), while no difference was indicated between ischemic bases and viable bases or between viable bases and viable ends. The same result was provided 7 days post operation.
CONCLUSIONS: Microcirculation of superficial tissues such as random-pattern flaps in this rat model can be assessed quantitatively by CEUS. It could sensitively and accurately reveal the objective status of tissue perfusion in the early postoperative stage.

Robotic surgery has been widely used in surgical gastric cancer treatments, including proximal gastrectomy. Single-port robotic system is gaining more popularity in robotic surgery, but there has been no report on its application in robotic proximal gastrectomy with right-sided overlap and single-flap valvuloplasty (RPG-ROSF). Here, we report an RPG-ROSF using a novel single-port robotic system in a 51-year-old male patient with an early-stage gastroesophageal cancer detected by gastroscopy. It took 90 min for robotic setup, 143 min for dissection, and 161 min for digestive tract reconstruction. There was no complication during and after the surgery. The patient was discharged in 8 days postsurgery. The pathological staging of the adenocarcinoma was pT1aN0M0. This preliminary study demonstrated the feasibility and safety of a novel single-port robot in RPG-ROSF.

Since its inception, microvascular free tissue transfer has broadened possibilities for oncologic ablation and restoration of form and function. Developments throughout recent decades have resulted in increasing flap success rates and complexity. Advances in technology and knowledge gained from past experiences will continue to improve surgical efficiency, flap success rates, and ultimately, patient outcomes.

Pure vascularized periosteal transplants have been shown to be extremely effective at achieving rapid bone healing in children with biologically complex non-union. Free tibial and fibular periosteal transplants are generally indicated when large periosteal flaps are necessary. We report using a vascularized femoral myo-periosteal graft (VFMPG) to treat distal tibial osteotomy non-union in a six-year-old boy with congenital pseudarthrosis of the tibia. The graft consisted of a 9 cm myo-periosteal flap (after 50% of elastic retraction) that incorporated the vastus intermedius muscle and diaphyseal femoral periosteum nourished by the descending branch of the lateral circumflex femoral vessels. Plantaris medialis was used as a recipient vessel. Healing occurred 10 weeks after surgery. The patient resumed gait and sports activity without orthosis. No donor or recipient site complications occurred 17 months after surgery. Employing a VFMPG might be an alternative to other free or large vascularized periosteal flaps currently in use for complex pediatric non-unions.

BACKGROUND: Catastrophic loss of the penis following post-circumcision necrosis is a rare and devastating complication. Treatment options are limited, and the process is highly challenging. This study aims to report the successful application of our combined treatment approach for a 6-year-old patient who experienced total penile loss due to progressive necrosis 1 year after circumcision.
RESULTS: Following penile degloving, proximal penile mobilisation and separation and reshaping of the corpora were performed. The penile shaft was covered with a tunnelled composite anterior-lateral inguinal skin flap. Glanuloplasty was performed using a left buccal mucosal graft, followed by 10 sessions of hyperbaric oxygen therapy. At 1.5 months postoperatively, urethral dilation was performed once because of minor voiding difficulties. At 10 months postoperatively, the patient had excellent voiding function and no additional complaints. The patient expressed high satisfaction with the outcome and is still under close follow up.
CONCLUSIONS: A standard treatment for serious complications such as necrosis and total penile loss has not been established yet. Although scrotal skin flap is a straightforward technique, it was not preferred in our case because of fibrosis following scrotal necrosis and potential risk of hair growth. The developed approach could be an effective alternative to other techniques.

BACKGROUND: Elevated body mass index (BMI) is a known perioperative risk factor for complications such as delayed wound healing and infection. However, there is a gap in understanding how elevated BMI impacts outcomes after posttraumatic lower extremity (LE) microvascular reconstruction.
METHODS: A retrospective review was performed at a level 1 trauma center between 2007 and 2022 of patients who underwent posttraumatic microvascular LE reconstruction. Demographics, flap/wound details, complications, and outcomes were recorded. Patients were stratified into BMI Center for Disease Control categories.
RESULTS: A total of 398 patients were included with an average BMI of 28.2 ± 5.8. Nearly half (45%) of LE defects were located in the distal third of the leg, 27.5% in the middle third, and 34.4% in the proximal third. Most reconstructions utilized muscle-containing flaps (74.4%) compared with fasciocutaneous flaps (16.8%). Surgical approaches included free flaps (47.6%) and local flaps (52.5%). Class III obese patients were significantly more likely to be nonambulatory than nonobese patients (OR: 4.10, 95% CI 1.10-15.2, p = 0.035). At final follow-up, 30.1% of patients with Class III obesity were ambulatory, requiring either wheelchairs (42.3%) or assistance devices (26.9%). There were no significant differences in complication rates based on obesity status (0.704). The average follow-up time for the entire cohort was 5.8 years.
CONCLUSIONS: BMI is critical for patient care and surgical decision-making in LE reconstruction. Further research is warranted to optimize outcomes for higher BMI patients, thereby potentially reducing the burden of postoperative complications and enhancing overall patient recovery.