BACKGROUND & AIMS: INTRODUCTION:Soft tissue reconstruction around the knee is challenging from a functional and aesthetic perspective. While locoregional options remain limited, free flaps produce additional scarring and longer hospitalization. We describe the most distal "D-perforator" of ALT-axis and present our 4-year experience with a distal perforator-only propeller anterolateral thigh (D-POP ALT) flap for reconstruction around the knee. METHODS:Seventeen patients (7 males, 10 females, mean age 57 years), had distal perforator-only propeller (D-POP) ALT flap reconstruction of defects following the wide local excision of melanoma around the knee joint between May 2014 and December 2018. The most distal perforator in the line between spina illiaca anterior superior (SIAS) and the upper lateral border of patella was identified and marked with audible-Doppler and perforator-only propeller ALT (POP-ALT) flap, which was designed around it. Perforators were dissected intramuscularly or intraseptally to allow adequate flap mobilization, but no division of main pedicle was ever performed to ensure anterograde blood supply. Flaps were rotated into defects while all donor-sites were closed directly. RESULTS:The largest flap measured 25 × 6 cm. The perforator was found between 4 and 9 cm proximal to the upper lateral border of patella in all cases. It was found to be septal in 10 cases and intramuscular in 7 cases. Healing was uneventful in all cases, and patients were ambulatory immediately postoperatively. All patients were discharged on postoperative day 1. Excellent long-term outcomes were observed on follow-up by the senior author. CONCLUSIONS:In our experience, this technique is simple, reliable, and versatile. Thin and pliable flaps can be safely raised based on the most distal (D-POP) ALT perforator. In addition, sizeable flaps can be performed while still preserving the main ALT pedicle, if free flap is required for the same patient in the future.

背景与目标：

BACKGROUND & AIMS: PURPOSE:To evaluate locoregional control and survival after mastectomy, as well as toxicity, in patients irradiated by a previously described postmastectomy highly conformal electron beam radiation therapy technique (PMERT). METHODS AND MATERIALS:We included all women irradiated by postmastectomy electron beam radiation therapy for nonmetastatic breast cancer between 2007 and 2011 in our department. Acute and late toxicities were retrospectively assessed using Common Terminology Criteria for Adverse Events version 3.0 criteria. RESULTS:Among the 796 women included, 10.1% were triple-negative, 18.8% HER2-positive, and 24.6% received neoadjuvant chemotherapy (CT). Multifocal lesions were observed in 51.3% of women, and 64.6% had at least 1 involved lymph node (LN). Internal mammary chain, supraclavicular, infraclavicular, and axillary LNs were treated in 85.6%, 88.3%, 77.9%, and 14.9% of cases, respectively. With a median follow-up of 64 months (range, 6-102 months), 5-year locoregional recurrence-free survival and overall survival were 90% (95% confidence interval 88.1%-92.4%) and 90.9% (95% confidence interval 88.9%-93%), respectively. Early skin toxicity was scored as grade 1 in 58.5% of patients, grade 2 in 35.9%, and grade 3 in 4.5%. Concomitant CT was associated with increased grade 3 toxicity (P<.001). At long-term follow-up, 29.8% of patients presented temporary or permanent hyperpigmentation or telangiectasia or fibrosis (grade 1: 23.6%; grade 2: 5.2%; grade 3: 1%), with higher rates among smokers (P=.06); 274 patients (34.4%) underwent breast reconstruction. Only 24 patients (3%) had early esophagitis of grade 1. Only 3 patients developed ischemic heart disease: all had been treated by anthracycline-based CT with or without trastuzumab, all had been irradiated to the left chest wall and LN, and all presented numerous cardiovascular risk factors (2-4 factors). CONCLUSIONS:This study demonstrated the good efficacy of this technique in terms of locoregional control and survival, and good short-term and long-term safety. Longer follow-up is required to analyze chronic cardiac events.

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BACKGROUND & AIMS: BACKGROUND:Pectoralis major muscle flaps (PMMFs) and fasciocutaneous free flaps (FFFs) are commonly used for reconstruction of the surgical defect after salvage total laryngectomy. This study compared swallowing function in patients who underwent reconstruction with either PMMF or FFF. METHODS:This study was based on a retrospective cohort of patients treated at the CHU de Québec between January 2000 and March 2015. Demographics, chemoradiation data, surgical protocol, pathologic results, complications, evolution, esophageal dilation, diet intake, and feeding tube dependence were documented. RESULTS:A total of 126 patients were analyzed (93 PMMFs and 33 FFFs). Of the patients who received PMMFs, 38.7% had a limited oral intake compared to 15.2% of patients who received FFFs (odds ratio [OR] 3.54; 95% confidence interval [CI] 1.25-9.99; P = .02). The need for esophageal dilation tended to be greater for PMMF patients (25% vs 9%; OR 3.38; 95% CI 0.94-12.13; P = .06). Complication rates were similar. CONCLUSION:The FFF reconstruction led to better results in terms of swallowing function than PMMF reconstruction.

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BACKGROUND & AIMS: -2

背景与目标： -2

BACKGROUND & AIMS: BACKGROUND:New surgical innovations of nipple-sparing mastectomy (NSM), such as endoscopic NSM (E-NSM) or robotic NSM (R-NSM), were emerging. However, there was a lack of evidence comparing the effectiveness and safety in the management of breast cancer. METHODS:A case-control comparison study was conducted for patients with breast cancer underwent E-NSM or R-NSM with immediate prosthesis breast reconstruction (IPBR) from July 2010 to February 2019 at a single institution to compare the clinical outcomes, learning curve, patient-reported cosmetic results, and medical cost. RESULTS:A total of 91 E-NSM and 40 R-NSM procedures were retrieved and analyzed. The surgical margin involvement rate in both R-NSM (2.5%) and E-NSM (4.4%) procedures were relatively low (P = 0.52). The R-NSM group was associated with higher satisfaction rates in terms of scar appearance, scar length, and surgical wound position compared with the E-NSM group. Compared with E-NSM, the R-NSM operation time took longer (241 ± 61 vs. 215 ± 70 min, P = 0.01), less blood loss (32 ± 29 vs. 79 ± 62 ml, P < 0.01), and higher medical cost (10,587 ± 554 vs. 6855 ± 936 U.S. dollars, P < 0.01). There was no statistically significant difference in nipple ischemia/necrosis or overall complication between R-NSM and E-NSM. In the learning curve analysis, it took the 27th procedure in E-NSM and 10th procedure in R-NSM to decrease operation time significantly. CONCLUSIONS:R-NSM was associated with higher wound-related satisfaction, lesser blood loss, and shorter learning curve compared with E-NSM, however, at the price of longer operation time and higher medical cost.

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BACKGROUND & AIMS: BACKGROUND:The management of chronic pulmonary aspergillosis remains a challenge for thoracic and reconstructive surgeons. Different management options have been proposed with no consensus regarding the best treatment modality. The goal of this study is to report our experience with the use of intrathoracic muscle flaps for the management of pulmonary aspergillosis. METHODS:We retrospectively reviewed all patients who underwent intrathoracic muscle flap transposition for the management of pulmonary aspergillosis between 1990 and 2010. Demographics, surgical characteristics, and treatment outcomes were collected and analyzed. RESULTS:A total of 39 patients who underwent 48 muscle flaps were identified. The majority were classified as ASA 3 (n=30, 77%) or ASA 4 (n=8, 21%). Serratus anterior was the most common flap used (n=34), followed by latissimus dorsi (n=6) and pectoralis major (n=5). Flap loss was encountered in three (8%) patients (2 partial, 1 total). Bronchopleural fistula and empyema comprised the two most common intrathoracic complications (26%, 29% respectively). Median follow-up was 33 months (range, 0-216). Successful treatment was achieved in 77% of patients, while operative mortality was 23%. CONCLUSION:The use of intrathoracic muscle flaps can be a helpful adjunct to surgical resection in the treatment of chronic pulmonary aspergillosis with low rates of flap loss.

背景与目标：

BACKGROUND & AIMS: OBJECTIVE:to assess the haemodynamic effect of a free muscle flap on the midterm success of a pedal bypass. DESIGN:prospective consecutive study. MATERIALS:a pedal bypass (autogenous vein graft) combined with a free muscle flap was performed in 13 patients with critical leg ischaemia. The feeding artery of the flap was anastomosed end-to-side to the bypass. METHODS:blood flow was measured in the bypass before and after transplanting the flap. Doppler was used postoperatively to assess the patency. RESULTS:the bypass and flap pedicle were patent in 11 cases six months postoperatively. Two grafts were thrombosed and the legs amputated. In the successful group the median (range) blood flow in the bypass was 50 (10-100) ml/min. It increased (p<0.05) after transplantation to 64 (20-113) ml/min, being 44 (14-97) ml/min distributed to the foot. Blood flow through the flap was 20 (6-37) ml/min. The two failing grafts had a flow of 30 and 51 ml/min before and 48 and 52 ml/min after transplantation, respectively. Blood flow through the flap was 47 ml/min and 36 ml/min, respectively. In the failure group the free flap received most of the blood supply through the bypass. CONCLUSIONS:a free muscle flap connected to an infrapopliteal bypass increases the distal outflow bed and thus decreases the outflow resistance and increases graft flow.

背景与目标：

BACKGROUND & AIMS: :We treated a case with left tibial adamantinoma by use of a contralateral fibular osteoadiposal flap. The donor site of conventional fibular osteocutaneous flap must be covered with a skin graft because if we close the donor skin defect directly, compartment syndrome might occur. We were able to close the donor skin defect because this combined type flap included only a small monitoring skin paddle. We present herein the utility of the osteoadiposal flap and show the value of a skin-sparing approach with a minimal aesthetic defect.

背景与目标： : 我们使用对侧腓骨成骨瓣治疗了一例左胫骨成骨瘤。常规腓骨皮瓣的供体部位必须覆盖皮肤移植物，因为如果我们直接关闭供体皮肤缺损，可能会发生筋膜综合征。我们能够关闭供体皮肤缺损，因为这种组合型皮瓣仅包括一个小的监视皮肤桨。我们在此介绍了骨脂瓣的实用性，并显示了具有最小的美学缺陷的皮肤保留方法的价值。

BACKGROUND & AIMS: :A new model of soft-tissue infection is used to investigate the effect of the local wound environment on the septic focus. Island pedicle flaps were raised on the buttock of 24 adult ewes and multiply inoculated with Staphylococcus aureus. Flaps with bacterial inoculation, without compromise of venous outflow, showed distal necrosis (mean +/- SEM percent of surface area, 25.8% +/- 8.6%) and developed septic foci with bacterial counts one log less than the amount injected. Flaps with inoculation and venous outflow obstruction underwent subtotal necrosis (mean percent of surface area, 73.3% +/- 11.2%) and had counts two logs higher than the nonobstructed flaps but without discrete septic foci. Flaps without inoculation, with or without venous obstruction, survived completely. Venous outflow obstruction is shown herein to potentiate tissue necrosis by raising bacterial counts in a septic focus and preventing defensive abscess formation by the host.

背景与目标： : 一种新的软组织感染模型用于研究局部伤口环境对脓毒症灶的影响。在24只成年母羊的臀部上举起岛状蒂皮瓣，并多次接种金黄色葡萄球菌。在不影响静脉流出的情况下接种细菌的皮瓣显示远端坏死 (平均表面积的/- SEM百分比，25.8%/- 8.6%)，并形成败血性病灶，细菌计数比注射量少1 log。接种和静脉流出阻塞的皮瓣发生了次全坏死 (平均表面积百分比，73.3%/- 11.2%)，其计数比未阻塞的皮瓣高两个对数，但没有离散的败血症灶。未经接种，有或没有静脉阻塞的皮瓣完全存活。本文显示静脉流出梗阻可通过增加败血症灶中的细菌计数并防止宿主形成防御性脓肿来增强组织坏死。

BACKGROUND & AIMS: :Nasal ala, due to its characteristics, is a unique anatomical part of the body. Unfortunately, nasal ala often suffers traumas or is affected by cancers, the treatment of which can imply all-thickness amputation. In such cases, complex reconstruction is necessary to recreate both a satisfying cosmetic structure and to ensure free airflow. We present a clinical case of nasal ala major substance loss due to cancer, which was treated by use of the new Mutaf triangular flap.

背景与目标： : 鼻ala，由于其特征，是身体独特的解剖部位。不幸的是，鼻腔ala经常遭受创伤或受癌症影响，其治疗可能意味着全厚度截肢。在这种情况下，需要进行复杂的重建以重建令人满意的美容结构并确保自由气流。我们介绍了一个因癌症引起的鼻ala主要物质损失的临床病例，该病例通过使用新的Mutaf三角皮瓣进行治疗。

BACKGROUND & AIMS: :In secondary reconstruction of the maxilla, skeletal reconstruction as well as soft tissue augmentation is required to obtain a good contour. We present a new strategy for combining a costal cartilage graft with a rib-latissimus dorsi flap. We used this method to treat a 39-year-old man who had previously undergone total maxillectomy. First, a vascularized rib, elevated together with a latissimus dorsi flap, was fixed between the middle of the maxilla and the edge of the zygomatic arch. The small defects that could not be reconstructed with the rib only were reconstructed with a costal cartilage graft. The patient did not develop any postoperative infection or flap necrosis. Thirteen months after the secondary reconstruction, he presented with a good contour of the cheek. Our method was effective for the reconstruction of a complex skeletal defect of the maxilla.

背景与目标： : 在上颌骨的二次重建中，需要骨骼重建以及软组织增强才能获得良好的轮廓。我们提出了一种将肋软骨移植物与肋骨背阔肌皮瓣相结合的新策略。我们使用这种方法治疗了一名39岁的男性，该男性先前接受了上颌骨全切除术。首先，将带血管的肋骨与背阔肌皮瓣一起抬高，固定在上颌骨中部和the弓边缘之间。用肋软骨移植物重建仅无法用肋骨重建的小缺损。患者术后未发生任何感染或皮瓣坏死。二次重建后的13个月，他的脸颊轮廓良好。我们的方法可有效重建上颌骨的复杂骨骼缺损。

BACKGROUND & AIMS: BACKGROUND:The efficacy and safety of nipple-sparing mastectomy and areola-sparing mastectomy for the treatment of breast cancer are still questionable. It is estimated that the local recurrence rates following nipple-sparing mastectomy are very similar to breast-conserving surgery followed by radiotherapy. OBJECTIVES:To assess the efficacy and safety of nipple-sparing mastectomy and areola-sparing mastectomy for the treatment of ductal carcinoma in situ and invasive breast cancer in women. SEARCH METHODS:We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Center Register of Controlled Trials (CENTRAL), MEDLINE (via PubMed), Embase (via OVID) and LILACS (via Biblioteca Virtual em Saúde [BVS]) using the search terms "nipple sparing mastectomy" and "areola-sparing mastectomy". Also, we searched the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov. All searches were conducted on 30th September 2014 and we did not apply any language restrictions. SELECTION CRITERIA:Randomised controlled trials (RCTs) however if there were no RCTs, we expanded our criteria to include non-randomised comparative studies (cohort and case-control studies). Studies evaluated nipple-sparing and areola-sparing mastectomy compared to modified radical mastectomy or skin-sparing mastectomy for the treatment of ductal carcinoma in situ or invasive breast cancer. DATA COLLECTION AND ANALYSIS:Two review authors (BS and RR) performed data extraction and resolved disagreements. We performed descriptive analyses and meta-analyses of the data using Review Manager software. We used Cochrane's risk of bias tool to assess studies, and adapted it for non-randomised studies, and we evaluated the quality of the evidence using GRADE criteria. MAIN RESULTS:We included 11 cohort studies, evaluating a total of 6502 participants undergoing 7018 procedures: 2529 underwent a nipple-sparing mastectomy (NSM), 818 underwent skin-sparing mastectomy (SSM) and 3671 underwent traditional mastectomy, also known as modified radical mastectomy (MRM). No participants underwent areola-sparing mastectomy. There was a high risk of confounding for all reported outcomes. For overall survival, the hazard ratio (HR) for NSM compared to SSM was 0.70 (95% CI 0.28 to 1.73; 2 studies; 781 participants) and the HR for NSM compared to MRM was 0.72 (95% CI 0.46 to 1.13; 2 studies, 1202 participants). Local recurrence was evaluated in two studies, the HR for NSM compared to MRM was 0.28 (95% CI 0.12 to 0.68; 2 studies, 1303 participants). The overall risk of complications was different in NSM when compared to other types of mastectomy in general (RR 0.10, 95% CI 0.01 to 0.82, 2 studies, P = 0.03; 1067 participants). With respect to skin necrosis, there was no evidence of a difference with NSM compared to other types of mastectomy, but the confidence interval was wide (RR 4.22, 95% CI 0.59 to 30.03, P = 0.15; 4 studies, 1948 participants). We observed no difference among the three types of mastectomy with respect to the risk of local infection (RR 0.95, 95% CI 0.44 to 2.09, P = 0.91, 2 studies; 496 participants). Meta-analysis was not possible when assessing cosmetic outcomes and quality of life, but in general the NSM studies reported a favourable aesthetic result and a gain in quality of life compared with the other types of mastectomy. The quality of evidence was considered very low for all outcomes due to the high risk of selection bias and wide confidence intervals. AUTHORS' CONCLUSIONS:The findings from these observational studies of very low-quality evidence were inconclusive for all outcomes due to the high risk of selection bias.

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BACKGROUND & AIMS: RATIONALE:Circumcision is one of the most frequently used surgical procedures worldwide. Extensive penile skin defects, which can occur as a rare but severe complication of circumcision, are serious and frustrating problems for patients who experience them. Procedures for correcting these problems can pose a challenge to plastic surgeons in the clinic. PATIENT CONCERNS:A 31-year-old man was admitted to our care with an extensive defect of the penile skin caused by a circumcision performed 20 days previously. PRIMARY DIAGNOSES:Infection, necrosis, and defects of the penile skin. INTERVENTIONS:A reverse bilateral anterior scrotal flap was used to correct complete penile skin loss following debridement of the infected and necrotic tissue. OUTCOMES:The patient experienced no complications during the 10-year follow-up period. The patient reported normal erectile function and the ability to perform intercourse. LESSONS:The reverse bilateral anterior scrotal artery flap is suitable for repairing skin defects of the penis and allows for satisfactory cosmetic and functional improvement following defects of the penile skin.

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BACKGROUND & AIMS: OBJECTIVE:Mastectomy is known to effect body posture after a change in the center of gravity of women due to a missing breast. Although previous studies on short-term postural changes in mastectomy patients using photogrammetry or Moiré topography suggested ipsilateral inclination of the trunk, our clinical observations during breast reconstruction surgeries indicated a contralateral shoulder elevation in women with unilateral mastectomy. Because the change in body posture can affect spinal alignment, we aimed to evaluate the long-term physical effects of unilateral mastectomy on spine deformity by radiographic examination. METHODS:Posteroanterior chest radiographs of 60 women (mean age 56.3 ± 8.5 years) taken before and 12 months after the mastectomy were evaluated for Cobb angle and the presence or absence of a tilt from the midline in the coronal plane of vertebral body alignment. RESULTS:Cobb angle decreased in 14 and increased in 38 of 60 patients after unilateral mastectomy, and the angular change was found to be independent of the mastectomy side (P < .001). A shift in Cobb angle to the mastectomy side was observed in 11 of 53 patients (P > .05), whereas a statistically significant shift in Cobb angle to the opposite of the mastectomy side was observed in 33 of 53 patients (P < .001). The results of this observational retrospective study indicated long-term spinal deformation in women with unilateral mastectomy. Two patients with idiopathic scoliosis before mastectomy even developed scoliosis. CONCLUSION:We recommend informing the patients of the possible change in body posture in the long term, which should be supported or limited with physical therapy.

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BACKGROUND & AIMS: :The nose has a robust blood supply derived from both internal and external carotid arteries. The main blood supply of the nasal tip and skin is derived primarily from the lateral nasal arteries, with a variable contribution from the columellar arteries. We present a patient with cut nose resulting from a homicidal attack in which the lower two-thirds of the nose was severed starting at the bony-cartilaginous junction of the dorsum of the nose down to the tip of the nose. The skin-cartilage flap was attached only to the columella and to the caudalmost 3 mm of the left ala nasi. The detached skin-cartilage flap was replaced and sutured anatomically, and the flap completely survived in spite of cutting of both lateral and dorsal nasal arteries.

背景与目标： : 鼻子具有来自颈内动脉和颈外动脉的强大血液供应。鼻尖和皮肤的主要血液供应主要来自鼻外侧动脉，而小柱动脉的贡献各不相同。我们介绍了一名因杀人袭击而导致鼻子割伤的患者，其中鼻子的下3分之2从鼻背的骨-软骨交界处开始一直切断到鼻尖。皮肤软骨瓣仅附着在小柱和左鼻腔3mm mm的尾骨上。分离的皮肤软骨皮瓣被替换并在解剖学上缝合，尽管切断了鼻侧和鼻背动脉，该皮瓣仍完全存活。