Radial forearm flap versus antero-lateral thigh flap in oral soft tissue reconstruction: update and statistical analysis on our 77 consecutive cases for an objective selection criteria.

BACKGROUND AND AIM: The radial forearm free flap (RFFf) and the antero-lateral thigh flap (ALTf) are considered the "key flaps" for oral cavity reconstruction. Nowadays, the literature lacks of an objective and standardized decision-making algorithm for the flap choice. The aim of this study is to describe a decision-making algorithm concerning the more appropriate flap, RFFf or ALTf, in the reconstruction of intra-oral soft tissues based on the volumetric analysis of the defect with a pre-operative Magnetic Resonance Imaging (MRI), updating our previous surgical experience. METHODS: We conducted a retrospective observational study including 77 patients who underwent microsurgical reconstruction with RFFf or ALTf after tumor resection of the soft tissues in the oral cavity. During follow-up, patients were evaluated using the UW-QOL questionnaire. RESULTS: Analyzing the scores of the UW-QOL questionnaire based on the size of the tumor on preoperative MRI we found that for tumor volume <50cc and between 50-70cc, the patients reconstructed with RFFfobtained statistically significant better scores compared to the ALTf group, while for tumor volume >70cc, the patients reconstructed with ALTf reported statistically significant better scores. CONCLUSIONS: Pre-operative RMI-guided volumetric assessment of oral cancer plays a key role in the planning of adequate soft tissue reconstruction and can objectively help surgeons in the correct choice of the flap (RFFf vs. ALTf) for each case based on preoperative tumor size, suggesting for defects <50cc and between 50 and 70 cc a reconstruction with RFFf, while for defects >70cc a reconstruction with ALTf.

Adipose-derived stromal vascular fraction (SVF) for the treatment of androgenic alopecia (AGA): a systematic review.

BACKGROUND AND AIM: Androgenetic alopecia (AGA) is a common chronic, hereditary, cutaneous and androgen-dependent condition. Low self-esteem and negatively impact quality of life are often consequences of AGA. Clinical treatment of AGA using SVF (Stromal vascular fraction) has been effective. In fact, hair follicle is affected by various environment factors and one of the most important factors is the vascularity of the scalp which is itself affected bySVF. METHODS: During October 2022 we carried out a systematic review to identify all scientific publications discussing about hair loss treatment with stromal vascular fraction or adipose stem cell. We selected 140 articles. After screening process, we kept 9 articles complying with inclusion criteria.  Results: No serious adverse events were reported in all studies. Despite standardized protocol was not found, all studies reported a statistically significant increase in the number (density) of hair after SVF treatment. Two studies found a significant improvement at pull test. An increase of hair diameter was noticed after treatment. The combination between medical therapy and SVF proved to be advantageous. CONCLUSIONS: SVF is nowadays at the center of studies in the field of regenerative medicine due to its potential applications in many branches of medicine and surgery. The initial results are very promising but furthermore studies are necessary to establish a methodical and systematic research capable of demonstrating its real benefits and the creation of homogenous treatment protocols.

Nanodiamond Influence on the Nucleation and Growth of YBCO Superconducting Film Deposited by Metal-Organic Decomposition.

It was recently shown that the introduction of nanodiamond (ND) into a superconducting metal-organic deposited YBa2Cu3O7-δ (YBCO) film produces an increase in critical current density in self-field conditions (B = 0 T). Such improvement appears to be due to the formation of denser and smoother films than the samples deposited without ND. This paper presents the work done to understand the role of ND during YBCO nucleation and growth. A detailed study on YBCO+ND films quenched at different temperatures of the crystallization process was carried out. Results showed that the reaction responsible for YBCO production appeared effectively affected by ND. In particular, ND stabilizes one of the YBCO precursors, BaF2(1-x)Ox, whose conversion into YBCO requires a prolonged time. Therefore, the YBCO nucleation is slowed down by ND and begins when the experimental conditions favor both thermodynamically and kinetically the formation of YBCO along the c-axis. This effect has important implications because the growth of a highly epitaxial c-axis YBCO film enables excellent superconducting performance.

Altered pathways of keratinization, extracellular matrix generation, angiogenesis, and stromal stem cells proliferation in patients with systemic sclerosis.

Objective: Systemic sclerosis is characterized by endothelial dysfunction, autoimmunity abnormalities, and fibrosis of the skin and internal organs. The pathogenetic mechanisms underlying systemic sclerosis vasculopathy are still not clarified. A complex cellular and extracellular network of interactions has been studied, but it is currently unclear what drives the activation of fibroblasts/myofibroblasts and the extracellular matrix deposition. Methods: Using RNA sequencing, the aim of the work was to identify potential functional pathways implied in systemic sclerosis pathogenesis and markers of endothelial dysfunction and fibrosis in systemic sclerosis patients. RNA-sequencing analysis was performed on RNA obtained from biopsies from three systemic sclerosis patients and three healthy controls enrolled in our University Hospital. RNA was used to generate sequencing libraries that were sequenced according to proper transcriptomic analyses. Subsequently, we performed gene set enrichment analysis of differentially expressed genes on the entire list of genes that compose the RNA-sequencing expression matrix. Results: Gene set enrichment analysis revealed that healthy controls were characterized by gene signatures related to stromal stem cells proliferation, cytokine-cytokine receptor interaction, macrophage-enriched metabolic network, whereas systemic sclerosis tissues were enriched in signatures associated with keratinization, cornification, retinoblastoma 1 and tumor suppressor 53 signaling. Conclusion: According to our data, RNA-sequencing and pathway analysis revealed that systemic sclerosis subjects display a discrete pattern of gene expression associated with keratinization, extracellular matrix generation, and negative regulation of angiogenesis and stromal stem cells proliferation. Further analysis on larger numbers of patients is needed; however, our findings provide an interesting framework for the development of biomarkers useful to explore potential future therapeutic approaches.

Intra-individual variability in the neuroprotective and promyelinating properties of conditioned culture medium obtained from human adipose mesenchymal stromal cells.

BACKGROUND: Greater knowledge of mesenchymal stromal cell (MSC)-based therapies is driving the research into their secretome, identified as the main element responsible for their therapeutic effects. The aim of this study is to characterize the individual variability of the secretome of adipose tissue-derived MSCs (adMSCs) with regard to potential therapeutical applications in neurology. METHODS: adMSCs were isolated from the intact adipose tissue of ten subjects undergoing abdominal plastic surgery or reduction mammoplasty. Two commercial lines were also included. We analyzed the expansion rate, production, and secretion of growth factors of interest for neurological applications (VEGF-A, BDNF, PDGF-AA and AA/BB, HGF, NGF, FGF-21, GDNF, IGF-I, IGF-II, EGF and FGF-2). To correlate these characteristics with the biological effects on the cellular targets, we used individual media conditioned with adMSCs from the various donors on primary cultures of neurons/astrocytes and oligodendrocyte precursor cells (OPCs) exposed to noxious stimuli (oxygen-glucose deprivation, OGD) to evaluate their protective and promyelinating properties, using MSC medium as a control group. RESULTS: The MSC secretome showed significant individual variability within the considered population with regard to PDGF-AA, PDGF-AB/BB, VEGF-A and BDNF. None of the MSC-derived supernatants affected neuron viability in normoxia, while substantial protection by high BDNF-containing conditioned MSC medium was observed in neuronal cultures exposed to OGD conditions. In OPC cultures, the MSC-derived supernatants protected cells from OGD-induced cell death, also increasing the differentiation in mature oligodendrocytes. Neuroprotection showed a positive correlation with VEGF-A, BDNF and PDGF-AA concentrations in the culture supernatants, and an inverse correlation with HGF, while OPC differentiation following OGD was positively correlated to PDGF-AA concentration. CONCLUSIONS: Despite the limited number of adMSC donors, this study showed significant individual variability in the biological properties of interest for neurological applications for adMSC secretome, an under-researched aspect which may represent an important step in the translation of MSC-derived acellular products to clinical practice. We also showed the potential protection capability of MSC conditioned medium on neuronal and oligodendroglial lineages exposed to oxygen-glucose deprivation. These effects are directly correlated to the concentration of specific growth factors, and indicate that the remyelination should be included as a primary target in MSC-based therapies.

Folded Radial Forearm Free Flap for the Reconstruction of Total Soft Palate Defects: Operative Technique.

The surgical plan to reconstruct the palate must be carefully prepared given the morphological peculiarity of the soft palate forming both the roof of the mouth and the floor of the nasal cavity. This article focuses on the use of folded radial forearm free flaps to manage isolated defects of the soft palate in the absence of tonsillar pillar involvement. Methods: Three patients affected by squamous cell carcinoma of the palate underwent resection of the soft palate and immediate reconstruction with a folded radial forearm free flap. Results: All three patients showed good short-term morphological-functional outcomes as far as swallowing, breathing, and phonation were concerned. Conclusions: The folded radial forearm free flap seems to be an efficacious way to manage localized defects of the soft palate, given the positive outcomes of the three patients treated, and in accordance with other authors. In general, the radial forearm free flap was confirmed to be a versatile solution for those intraoral defects of the soft tissue requiring a limited quantity of volume as in the case of the soft palate.

Role of Autologous Fat Grafting in the Conservative Treatment of Fecal Incontinence in Children.

Treatment of organic fecal incontinence in children, typical of anorectal malformations, is most often conservative; however, when necessary, it can be surgical. Autologous fat grafting, or lipofilling, can be used to improve fecal incontinence. We present our experience with the echo-assisted anal-lipofilling and its effects on fecal incontinence in children and on the quality of life of the entire family. Under general anesthesia, fat tissue was harvested according to the traditional technique, and processed in a closed system Lipogems® set. Injection of the processed adipose tissue was guided by trans-anal ultrasound assistance. Ultrasound and manometry were also used for follow-up. From November 2018, we performed 12 anal-lipofilling procedures in six male patients (mean age 10.7 years). Five children had a stable improvement in bowel function with Krickenbeck's scale scores going from soiling grade 3 pre-treatment in 100% of children to grade 1 post-treatment in 75% of them. No major post-operative complications developed. An increase in thickness of the sphincteric apparatus was shown at ultrasound during follow-up. The quality of life of the entire family, evaluated with a questionnaire, improved after the surgical treatment of the children. Anal-lipofilling is a safe and effective procedure to reduce organic fecal incontinence thereby benefiting both the patients and their families.

Autologous Marrow Mesenchymal Stem Cell Driving Bone Regeneration in a Rabbit Model of Femoral Head Osteonecrosis.

Osteonecrosis of the femoral head (ONFH) is a progressive degenerative disease that ultimately requires a total hip replacement. Mesenchymal stromal/stem cells (MSCs), particularly the ones isolated from bone marrow (BM), could be promising tools to restore bone tissue in ONFH. Here, we established a rabbit model to mimic the pathogenic features of human ONFH and to challenge an autologous MSC-based treatment. ON has been originally induced by the synergic combination of surgery and steroid administration. Autologous BM-MSCs were then implanted in the FH, aiming to restore the damaged tissue. Histological analyses confirmed bone formation in the BM-MSC treated rabbit femurs but not in the controls. In addition, the model also allowed investigations on BM-MSCs isolated before (ON-BM-MSCs) and after (ON+BM-MSCs) ON induction to dissect the impact of ON damage on MSC behavior in an affected microenvironment, accounting for those clinical approaches foreseeing MSCs generally isolated from affected patients. BM-MSCs, isolated before and after ON induction, revealed similar growth rates, immunophenotypic profiles, and differentiation abilities regardless of the ON. Our data support the use of ON+BM-MSCs as a promising autologous therapeutic tool to treat ON, paving the way for a more consolidated use into the clinical settings.

Defining the Inframammary Fold by Liposuction: An Essential Tool in Aesthetic Shaping of the Reconstructed Breast. Technique and Long-term Results in a Series of Patients.

BACKGROUND: A good inframammary fold (IMF) definition and position is essential to achieve a satisfactory and natural result in breast surgery. This structure can be damaged, especially during mastectomies. Multiple methods are reported in the literature to restore IMF or improve its definition. In this study, we present the results achieved in a series of patients treated with subdermal liposuction. METHODS: We report on all our patients who underwent IMF liposuction between January 2016 and June 2020. Subdermal liposuction was performed with a blunt 3 mm cannula along the new IMF to promote skin retraction and adherence between skin and fascia. Results were evaluated subjectively by the patients and objectively by 8 individuals not involved with the treatment. RESULTS: We performed IMF liposuction in 88 breasts (69 patients), aged 21-74 (mean 52) years for 82 implant-based reconstructions, 2 tuberous breasts, and 4 contralateral breast augmentations. Mean follow-up was 28 months (6-64). Subjective results: the overall result evaluated with the VAS scale reached 86.6/100. All the 22 patients interviewed judged as well defined the new inframammary fold. Objective results: in 83% of cases the definition of the inframammary fold was judged as good or excellent, while symmetry with contralateral IMF, natural appearance, and overall aesthetic outcome were judged as good. CONCLUSION: Based on our long-term satisfactory results, we recommend the technique of subdermal liposuction to improve the definition of IMF in breast reconstruction after mastectomy and other breast procedures. It is effective, easy to perform, minimally invasive, and durable. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Use of the Spare-Part Strategy to Reconstruct the External Auditory Canal After Subtotal Auriculectomy for Basal Cell Carcinoma.

After removal of an infiltrative BCC of the auditory meatus, a soft tissue defect of the temporal-mastoid area with bone exposure, needed reconstruction. Several options have been taken into account and a simple yet effective solution has been found following the spare-parts principle. The ear lobe, preserved during cancer removal, was split and used as a thin skin flap. Adequate coverage of the bone exposure and resurfacing of the external auditory canal was obtained with minimal donor site morbidity and a short surgery in a fragile patient with several comorbidities. The spare-parts strategy can provide successful solution to difficult reconstructive cases regardless of the anatomical area.

Safety of Reconstructive Microsurgery in the Elderly Population: a Multicentric Prospective Study.

BACKGROUND: Safety of reconstructive microsurgery in elderly patients is still a topic of debate, because no conclusive evidence exists that provides indications and risk evaluation in elderly patients. The purpose of this study, which the Italian Society for Plastic, Reconstructive, and Aesthetic Surgery (SICPRE) has promoted, is to evaluate the safety and the complication risk of elective reconstructive microsurgery in elderly patients as well as to identify patient- or procedure-related risk factors. The secondary aim is to evaluate the predictive role for complications of the Geriatric 8 score (G8). METHODS: A total of 194 consecutive patients from 18 centers, aged 65 or older, who received an elective microsurgical flap between April 2018 and April 2019 were prospectively evaluated. Patient-related, treatment-related, and outcomes data were recorded and statistically analyzed through multiple-adjusted logistic regression models. RESULTS: Our study showed an increased risk of complications and a longer hospitalization in patients aged ≥75 years with the American Society of Anesthesiologists (ASA) score ≥3 (or G8 score ≤11) as compared to patients >65 years of age and <75 years of age who undergo reconstruction with a microsurgical flap. Instead, flap survival did not significantly vary with age, but was associated only with ASA score ≥3 (or G8 score ≤11) and surgeries that last longer than 480 min; however, flap survival (92.3%) was slightly lower than that commonly reported for in the general population. CONCLUSIONS: Reconstructive microsurgery in the elderly is generally safe. The ASA score is easier and quicker than the G8 score and equally useful for risk stratification.

Autologous platelet-rich fibrin: a novel method for tracheoesophageal puncture site closure: a case report.

Closure of a tracheoesophageal puncture site performed during voice prosthesis implantation may sometimes be required. Besides local techniques, more elaborate procedures, such as closure by means of free microvascular flaps, have been advocated. In this report, we describe a case of local treatment of a hard-to-heal fistula with local application of autologous platelet-rich fibrin matrix in a 77-year-old male patient. At one-week follow-up, the size of the fistula had decreased dramatically but some leakage remained when drinking. After one month, the patient was able to drink and eat normally without any leakage. There was no recurrence of the leakage at two years' follow-up. In summary, local application of platelet-rich fibrin seems to be a simple, safe and effective procedure for tracheoesophageal fistula closure.

Different Hydraulic Constructs to Optimize the Venous Drainage of DIEP Flaps in Breast Reconstruction: Decisional Algorithm and Review of the Literature.

BACKGROUND: Venous congestion is the most common perfusion-related complication of deep inferior epigastric artery perforator (DIEP) flap. Several hydraulic constructs can be created for venous superdrainage in case of flap venous engorgement or as a preventive measure. These can be classified based on the choice of the draining vein of the flap, either a second deep inferior epigastric vein (DIEV) or a superficial inferior epigastric vein (SIEV), and of the recipient vein, either a vein of the chest or the DIEV. METHODS: We conducted a comprehensive systematic literature review in Medline, Scopus, EMBASE, Cochrane Library, and Google Scholar to find publications that reported on venous congestion in DIEP flap. The keywords used were DIEP Flap, breast reconstruction, venous congestion, supercharging, superdrainage, SIEV, and DIEV. RESULTS: Based on the studies found in the literature, we developed an algorithm to guide the surgeon's decision when choosing the veins for the superdrainage anastomosis. CONCLUSION: Several alternatives for venous anastomosis in superdrainage are available. We propose an algorithm to simplify the choice. The use of the ipsilateral SIEV to be connected to a vein of the chest appears to be advantageous. The anatomical position that allows the easiest anastomosis dictates which chest vein to favor.

Meta-analysis of the effects of venous super-drainage in deep inferior epigastric artery perforator flaps for breast reconstruction.

INTRODUCTION: Venous congestion is the most common vascular complication of the deep inferior epigastric artery perforator (DIEP) flaps. Adding a second venous drainage by anastomosing a flap vein and a recipient vein (super-drainage) is considered the solution of choice. Evidence to support this procedure, had not yet been confirmed by an analysis of the literature. We aimed to provide this evidence. MATERIALS AND METHODS: We searched the literature (MedLine, Scopus, EMBASE, Cochrane Library, and Google Scholar), for studies discussing venous congestion and venous super-drainage in DIEP flap for breast reconstruction. Thirteen of the 35 articles compared results between one or two venous anastomoses. Meta-analysis was performed following PRISMA guidelines. Pooled risk ratio (RRs) for congestion, fat necrosis, partial necrosis, and total necrosis with corresponding 95% confidence intervals (CI) were calculated using a fixed-effect model with the Mantel-Haenszel method. The need to return to surgery (95% CI) was estimated with a random effect model using the DerSimonian and Liard method. RESULTS: We showed a statistically significant advantage of super-drainage to reduce the venous congestion of the flap (RR: 0.12, 95% CI: 0.04-0.34, p-value <.001), partial flap necrosis (RR: 0.50, 95% CI: 0.30-0.84, p-value .008), total flap necrosis (RR: 0.31, 95% CI: 0.11-0.85, p-value .023), and the need to take the patient back to surgery for perfusion-related complications (RR: 0.45, 95% CI: 0.21-0.99, p value .048). CONCLUSIONS: Performing a second venous anastomosis between the SIEV and a recipient vein (venous superdrainage) reduces venous congestion and related complications in DIEP flaps for breast reconstruction.

Microsurgical Reconstruction of the Nose: The Aesthetic Approach to Total Defects.

BACKGROUND: Reconstruction of complex defects involving nose and close facial units represents an aesthetic and functional challenge. Restoring satisfactory nasal shape, combining aesthetic, nasal function and patent airways is mandatory. In this paper, we describe our approach to total nose defects and we report our 20-year experience in microvascular nose reconstruction.Clinical cases are shown to illustrate different surgical techniques and the evolution of our approach. METHODS: Nasal reconstruction procedures were performed on 21 patients between 2000 and 2020 using the radial forearm flap (RFF) or anterolateral thigh (ALT) flap. Reported reconstructions included total/subtotal nasal defects, caused by cancer resections. The key point of our approach is the expanded forehead flap for skin coverage. Reconstruction is completed by cartilage grafts to restore nasal framework and to shape nasal tip. Ancillary procedures were needed in some cases to optimize aesthetic outcomes. RESULTS: Twenty-one patients completed the multistage nasal reconstruction. The RFF flap was used in 56% of the cases (n = 11), while the ALT flap was used in 44% (n = 10) of our case series. No difference has been detected in the number of reconstructive stages required to achieve the final result comparing RFF and ALT reconstruction (3.3 vs. 3.1 reconstructive steps). Ancillary procedures were performed in 7 patients. CONCLUSION: Microvascular tissue transfer plays a key role in full-thickness nasal defects restoration. Comparing the two groups, both the RFF and ALT are effective and reliable options in lining reconstruction, although with different indications. Expanded forehead flap, combined to free cartilage graft, is our gold standard to provide external skin coverage to rebuild the nasal framework. According to our current approach, accurate preoperative planning, supported by modern technologic tools, multistage reconstruction, and ancillary procedures are useful to accomplish satisfactory functional and aesthetic outcomes.

Preliminary Study on the Echo-Assisted Intersphincteric Autologous Microfragmented Adipose Tissue Injection to Control Fecal Incontinence in Children Operated for Anorectal Malformations.

AIM OF THE STUDY: To assess the efficacy of a novel technique (echo-assisted intersphincteric autologous microfragmented adipose tissue injection, also called "anal-lipofilling") in the management of non-responsive fecal incontinence in children born with anorectal malformations (ARMs). METHODS: Following ethical committee approval (CHPED-MAR-18-02), anal-lipofilling was proposed to patients with fecal incontinence not responsive to medications or bowel management (bowel enema and/or transanal irrigation automatic systems), then a prospective study was conducted. Anal-lipofilling consisted of three phases: lipoaspiration from the abdominal wall, processing of the lipoaspirate with a Lipogems system and intersphincteric injection of the processed fat tissue via endosonographic assistance. A questionnaire based on Krickenbeck's scale (KS) was administered to the patients to evaluate the clinical outcome. MAIN RESULTS: Four male patients (three recto-urethral fistula, and one recto-perineal fistula) underwent the anal-lipofilling procedure at a mean age of 13.0 ± 4.2 yrs. There were no complications during or after the procedure. From an initial assessment of the patients there was an improvement in the bowel function at a median follow up of 6 months, with better scores at KS (100% Soiling grade three pre-treatment vs. 75% grade one post-treatment). CONCLUSIONS: Even if our Study is preliminary, echo-assisted anal-lipofilling could be considered as a feasible and safe alternative technique in the management of the fecal incontinence in non-responding ARMs patients. More studies are still necessary to support the validity of the implant of autologous adipose tissue in the anal sphincter as a therapy for fecal incontinence in children born with ARMs.

3D Exoscope-Assisted Microvascular Anastomosis: An Evaluation on Latex Vessel Models.

BACKGROUND: Over the last few years, advances in technologies and digital imaging have led to the introduction of systems that enable a new approach to microsurgery and supermicrosurgery. The exoscope is a new magnification system that provides a 3D image of the surgical field: microsurgical procedures can be performed with the aid of this instrument. Here, we describe our preliminary experience with a high-definition 3D exoscope (VITOM®, Karl Storz, Tuttlingen, Germany), evaluating the characteristics of the instrument, and also its use as a magnification device for microanastomosis training. METHODS: Six microsurgeons with various levels of experience were asked to perform three end-to-end anastomoses and two end-to-side anastomoses on latex vessel models, using, as a magnification system, the VITOM® 3D 4K exoscope. None of the surgeons involved had previous experience with the exoscope, with robotic surgery, with endoscopic surgery, nor with training simulators. RESULTS: The results of the reported evaluation of the tool's qualities, (VITOM Quality Assessment Tool) included: a good focusing of the surgical field; high image quality; strong luminance; good magnification; clear stereoscopy; and excellent freedom of movement. The exoscope proved to be user-friendly. A constant reduction in the time needed to perform the microsurgical anastomosis at each exercise was recorded. Among other advantages were the easy switching from the magnified image to the macroscopic view, superior ergonomics allowing a relaxed posture while performing the anastomosis, adequate space, and a convenient setting for the assistants to view the operating field. CONCLUSIONS: Our study showed that the exoscope VITOM 3D can be successfully used as a magnification tool for microsurgical anastomosis on synthetic vessels, and that it can also be helpful during training courses in microsurgery.

Our Definition of Propeller Flaps and Their Classification.

The term propeller flap was introduced for the first time by Hyakusoku to define an island flap, based on a subcutaneous pedicle hub, that was rotated 90 degrees to correct scar contractures due to burns. With the popularization of perforator flaps, the propeller movement was applied for the first time to a skin island vascularized only by an isolated perforator, and the terms propeller and perforator flap were used together. Thereafter, the surgical technique of propeller flaps evolved and new applications developed. With the "Tokyo consensus," we proposed a definition and a classification schema for propeller flaps. A propeller flap was defined as an "island flap that reaches the recipient site through an axial rotation." The classification included the SPP (SPP) flap, the perforator pedicled propeller (PPP) flap, and the supercharged PPP (SCP) flap. A recent update added a new category, the axial pedicled propeller (APP) flap. Here we propose our updated and comprehensive classification of propeller flaps, taking into account the previous classification and subsequent publications. Based on their vascular pedicle, we consider the following five types of propellers: (1) SPP flap, 2.PPP flap, its subtype (2a) SCP flap, (3) APP flap, (4) muscle propeller flap, and (5) chimeric propeller flap. The variables that can be taken into account in the classification are as follows: type of nourishing pedicle, degrees of skin island rotation, position of the nourishing pedicle, artery of origin of the pedicle, and flap shape.

How to Design and Harvest a Propeller Flap.

Propeller flaps are local flaps based either on a subcutaneous pedicle, a single perforator, or vessels entering the flap in such a way so as to allow the flap to rotate on their axis. Depending on the kind of pedicle and the anatomical area, the preoperative investigation and the harvesting techniques may vary. An adequate knowledge of skin and subcutaneous tissue perfusion in the different areas of the body is very important to plan a propeller flap to be successful. The surgeon should begin by finding the most suitable perforators in the area surrounding the defect using available technology. The position, size, and shape of the flap are planned about this point. For perforator-pedicled propeller flaps, the procedure starts with an exploration from the margins of the defect or through a dedicated incision to visualize any perforators in the surroundings. The most suitable perforator is selected and isolated, the skin island is replanned, and the flap is harvested and rotated into the defect. The variations in surgical technique for other types of propellers and in specific anatomical areas are also described. Compared with free flaps, propeller flaps have the advantage of a simpler, shorter operation, without the need for a recipient vessel for microanastomosis. Yet, from a technical point of view, an adequate experience in dissecting perforators and the use of magnifying glasses are almost always required.