Objectives: Free flap transplantation is a fundamental technique in reconstructive surgery, and the free fibular flap presents a unique challenge owing to its composite tissue nature. Despite the difficulty of this procedure, there is a lack of research on the learning curve associated with free fibular flap harvesting.

Methods: This study, conducted between April 2011 and March 2023, aimed to calculate the learning curve for fibular flap elevation on the basis of the experience of a single surgeon. The power-law approximation formula was used to model the learning curve, with the flap elevation time as the key parameter.

Results: The average tourniquet time for 36 cases in which the first author performed as the primary surgeon was 72.8 minutes, with a range of 32 minutes to 178 minutes. The power-law approximation formula, derived using Python, was y = 187.76x^-0.376, indicating a strong correlation (maximal information coefficient = 0.870) between the formula and actual elevation times. The target elevation time was set at a single tourniquet time of 90 minutes, requiring experience with seven to eight cases.

Conclusions: This study suggests that mastering the elevation of the fibular flap requires experience with seven to eight cases, within the duration of a single tourniquet application. The findings contribute to understanding the learning curve associated with fibular flap transplantation and provide valuable insights for surgical training.

Objectives: Cellulitis is a significant prognostic factor for lymphedema, rendering its prevention and prediction critical for effective lymphedema management. Given the influence of climatic conditions on abdominal aortic aneurysm rupture and considering that the lymphatic system is part of the circulatory system, we hypothesized that lymphedema may be classified as a meteoropathy. Therefore, we aimed to investigate the correlation between climatic conditions and the onset of cellulitis in lymphedema-affected limbs.

Methods: The clinical records of patients with lymphedema admitted for cellulitis to our institute between January 2007 and December 2017 were reviewed. Forty patients were identified, with 25 residing in the same geographic area (Yokohama City). The association between the frequency of patient admissions according to season and the meteorological data obtained from the Japan Meteorological Agency database was analyzed.

Results: The mean age of the 40 participants was 56.1 (range, 15-79) years, of whom 7 were men and 33 were women. Among the 25 patients who lived in Yokohama City, 13 were admitted in summer, whereas only one patient was admitted in winter. In summer, the temperature was higher (p = 0.0016), while the atmospheric pressure was lower (p = 0.0018) compared with the other seasons. Notably, higher temperatures and lower atmospheric pressure around the day of admission were associated with the occurrence of cellulitis.

Conclusions: Lymphedema may be considered a meteoropathic disease, as climatic conditions were found to be associated with cellulitis in lymphedema-affected limbs.

Objectives: To report our single institution multidisciplinary step-by-step management of Fournier gangrene and specifically focus on our surgical reconstructive strategy.

Methods: This was a retrospective single-arm monocentric study including all consecutive Fournier gangrene treated at our institution between May 2001 and February 2020. Data on initial management, including urological care, resuscitation in collaboration with the infectious disease unit, and reconstructive strategies based on defects location, were collected. Patient self-reported functional and aesthetical results were assessed using a 5-point Likert scale.

Results: Overall, 45 patients were included in this study. All patients had surgical debridement on admission and 26 (57.8%) required repeated surgical debridement. Additional surgical procedures were colostomy in 31 (68.9%) cases, suprapubic catheter in 5 (11.1%) cases, orchiectomy in two cases, and penectomy for one patient. Overall, 14 (31.1%) patients had septic shock and required active resuscitation. Following surgical debridement, vacuum-assisted closure was used in 19 (42.2%) patients. No patient died. Thirty-six (80%) patients had reconstructive surgery. The median time from admission to reconstruction procedure was 37.5 days (range: 11-70). According to our reconstructive algorithm, reconstruction of the penile, scrotum, medial thigh, suprapubic, and the anal area was performed in respectively 19 (52.8%), 18 (50%), 11 (30.6%), 3 (8.3%), and 2 (5.6%) cases. Aesthetic and functional results of reconstruction were reported to be satisfying or extremely satisfying by 15 (71%) of the 21 patients who could be contacted.

Conclusions: Multidisciplinary step-by-step management of Fournier gangrene including our reconstruction approach based on lesion extension can be achieved with minimal mortality and with good results for the patients.

Background: In Japan, resection of basal cell carcinoma (BCC) with a margin of at least 4 mm is recommended by guidelines.

Objectives: This study aimed to investigate the effectiveness of surgical margins for well-defined pigmented BCC in Japanese patients.

Methods: Between 2010 and 2017, 25 cases of well-defined nodular pigmented BCC measuring 20 mm or less on the face were surgically resected with a margin of 4 to 5 mm, and pathological measurements were performed at the National Hospital Organization Nagasaki Medical Center. The measurement item was subclinical extension of the tumor, which is the difference in distance between the actual tumor border confirmed under a microscope and apparent tumor border determined clinically from the outside.

Results: Subclinical extension of the tumors ranged from 0 to 3.5 mm, with a mean of 1.0 mm, standard deviation of 1.0 mm, and 95% confidence interval of 0.7 to 1.6 mm. Regardless of the malignancy grade, resection with a 3-mm margin for nodular pigmented BCC with a clear border and long diameter of 20 mm or less was effective, with a complete resection rate of 96%.

Conclusions: Surgical excision with a 3-mm margin is reliable treatment for well-defined, primary pigmented BCC, with a complete removal rate of 96%. These results suggest that resection margins recommended in guidelines can be narrowed in Japanese patients with BCC.

Loss of the entire extensor mechanism of the knee presents a major reconstructive challenge. We encountered a patient who was missing the patellar tendon, patella, and quadriceps tendon following a remote trauma. A prior attempt at allograft reconstruction failed due to infection and dehiscence at the allograft-muscle connection. To avoid an allograft, we reconstructed the entire knee extensor mechanism with an ipsilateral functional free gracilis transfer, maintaining the enthesis at the tibia, rerouting the muscle across the anterior knee, and attaching the origin to the fascia lata. We vascularized the muscle with the descending branch of the lateral circumflex femoral vessels and innervated the muscle with a motor branch of the femoral nerve. The transfer was successful, with the patient able to ambulate without a brace by 6 months and to perform squats by 9 months. Complications commonly seen with allograft were obviated, and functional recovery was excellent.

Fournier's gangrene is a severe, rapidly progressing necrotizing fasciitis with a high capacity for compromising tissues at different levels. It primarily affects perianal and genital areas with a high mortality rate due to extensive impact. Although typically observed in adult males (incidence of 1.6 cases per 100,000 men), there exists an out-of-standard population that can be affected by the disease, becoming the window of opportunity for underdiagnosis, deterioration of prognosis, and increased mortality. The lack of standardized treatment protocols contributes to the high morbidity and mortality rates. Increased awareness and rapid intervention are essential for improving outcomes in integral medical attention. Based on the literature we report a Caucasian neonatal case of Fournier's gangrene based on the Surgical Case Report (SCARE) guidelines and complemented with the literature available. This article aims to enhance clinical understanding, encouraging standardized management strategies for special populations at risk of this life-threatening condition.

Run-over injuries, particularly those involving burns from vehicle exhaust systems, present significant challenges due to the complexity of associated trauma. This report details two cases where enzymatic debridement using anacaulase was employed for burns sustained during run-over incidents. Both cases involved extensive injuries, including fractures and pulmonary complications, necessitating careful timing of debridement. Anacaulase facilitated early, selective removal of necrotic tissue, preserving healthy dermal layers and reducing the area for autografting. Despite initial challenges, including insufficient debridement in areas with low petechial bleeding, outcomes were favorable with minimal blood loss. The first case required a skin graft on Day 35, while the second was on Day 48, highlighting variability based on injury severity and thermal exposure. These cases suggest anacaulase as a valuable alternative to surgical debridement, especially in complex trauma cases where conventional methods are less feasible. Further research is warranted to optimize its use in burn treatment protocols.

Intraorbital surgery, including orbital wall repair, often requires surgeons to work in a confined surgical space, obstructed by overhanging tissue and exudate. Conventional retractors, used to maintain an accessible surgical working space, are not always effective in overcoming these challenges. Moreover, excessive retraction to obtain sufficient space in the surgical field can cause oculocardial reflexes and trauma. Here, we report the effective use of silicone sheets during intraorbital procedures as a spacer to maintain sufficient surgical space and as a template to shape reconstructive materials in two illustrative cases. The use of silicone sheets served as a surgical template and spacer, resulting in smooth procedures for both case reports.

Congenital midline cervical cleft (CMCC) is a rare defect of the midline neck which is often misdiagnosed. The aim of this study is to show the efficacy and safety of a novel surgical technique for CMCC to get excellent aesthetic and functional results. We report a series of four cases, two female and two male patients, affected by midline cervical cleft who underwent surgical excision and primary reconstruction of the neck defect through a double opposing Z-plasty, at the Pediatric Plastic and Maxillo-Facial Surgery Unit of a third-level referral hospital in Rome. No complications nor recurrences were noted; cosmetic results were satisfactory in all cases with progressive scar improvement. Early and complete surgical excision is essential to ensure good aesthetical results. The double opposing Z-plasty closure allowed us to obtain an excellent functional outcome and reduce cervical contracture.

We report the usefulness of the parallelogram skin graft harvest method, using a device that facilitates direct donor site closure by harvesting the skin in a parallelogram shape. The skin graft was designed as a parallelogram, and an electric dermatome was used to slide across the area at an oblique angle to the direction of travel. The donor site was then sutured directly. Early (hematoma, infection, and wound dehiscence) and late (pain and itching of the scar) donor site complications were also investigated. Twenty-seven patients were included in the study. Twelve patients were 75 years old or older, and two were consuming prednisolone. The maximum size of the harvested skin was 150 cm² (5 cm× 30 cm). None of the patients experienced donor site complications. The parallelogram skin graft harvest method is effective for the direct closure of the split skin graft donor site to promote healing.