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Diabetes mellitus (DM) is a comorbid condition involved in numerous post-operative complications.
Existing published reviews exploring the link between DM and free flap failure are not based on an essentially comprehensive approach, therefore do not allow to ascertain to what extent free flap surgery is affected by DM.
This meta-analysis uses an exhaustive approach in order to determine if and to what extent higher rates of free flap failure are associated with DM, with a focus on the anatomic region being reconstructed.

The search engines PubMed, Embase and Web of Science were browsed using specified terms. The studies’ characteristics, including patient demographics and study outcome, were recorded and analyzed.

Of the 1103 articles identified by the literature search, 358 articles met the inclusion criteria, amongst which 97 articles had extractable data pertaining to the outcome of interest. Another 5 articles were added from bibliographic searches, resulting in a total of 102 articles relevant to the meta-analysis. Of these 102 articles, 12 articles were excluded from the main statistical analysis to avoid overlapping populations.
Thus, the main statistical analysis comprises 90 articles representing 26128 flaps, including 4261 flaps in diabetic patients.
Flap failure rate is 3.9% overall, with a higher rate of free flap failure in diabetic patients (6.5% in diabetic patients vs 3.4% in non-diabetic patients, RR=2.29, p<0.00001, absolute risk difference of 3.1%).
Subgroup analyses show that DM is clinically and statistically associated with free flap failure in both head and neck indications (RR=2.12, p<0.00001, absolute risk difference of 2.1%) and extremity indications (RR=2.00, p=0.003, absolute risk difference of 4.2%), but not in breast reconstructions (RR=2.88, p=0.06, absolute risk difference of 0.1%).

The present meta-analysis clearly establishes a correlation between DM status and free flap failure, that is both statistically and clinically significant.
Further investigation is needed, notably by using population-wide databases, so as to provide a more precise insight into this correlation and to account for confounder variables. This could help shape relevant guidelines as regards performing flap surgery in DM patients.

Extensive soft tissue and extensor mechanism defects around the knee pose a significant reconstructive challenge, particularly in war related injuries with trauma, infection, or multiple surgeries. Standard options often fail, and knee arthrodesis may be the last resort to prevent amputation. We present four patients with destruction of the knee extensor mechanism, including two combat injured, whose knee function was restored with total knee replacement (TKA) and quadriceps reconstruction using microsurgical free flaps, either anterolateral thigh (ALT) or tensor fasciae latae (TFL).

Four patients with complex defects involving quadriceps, anterior knee soft tissue and, in some cases, joint structures underwent free flap reconstruction. Three received simultaneous TKA, two required synthetic ligament augmentation using a braided polyester band. ALT flaps, based on the descending branch of the lateral circumflex femoral artery, were chosen when a long vascular pedicle and fascia suitable for direct incorporation into the extensor mechanism were required. TFL flaps, pedicled via the transverse or descending branch, were used when broader coverage and a larger myo fascial block were needed. The skin paddle of both flaps enabled tension free closure and restoration of soft tissue coverage and motion. In selected cases, elements of both flaps were combined, such as distal TFL fascia with ALT vascular supply, enabling fascial interweaving into the quadriceps tendon. In all cases, flap inset involved anchoring vascularized fascia into residual tendon tissue or synthetic ligament to restore continuity.

All flaps survived without complication. Active knee extension was restored in all patients with flexion greater than 90 degrees. Functional outcomes were excellent, with all four regaining independent mobility, including one who rejoined active military service. These results highlight the transformative potential of this approach, providing reliable one stage reconstruction combining soft tissue coverage, extensor mechanism reconstruction, and joint replacement with minimal donor site morbidity.

Microsurgical reconstruction of the extensor mechanism offers a powerful option, especially in cases with previous arthrodesis. This strategy enables comprehensive, single stage restoration of knee function, with outstanding results even in the most challenging scenarios.

Microsurgical procedures can be technically demanding, resource-intensive, and may require high levels of interprofessional and interdisciplinary coordination. Lean management principles, originally developed in the automotive industry, aim to improve efficiency in operational processes by reducing waste and optimizing workflows. Given the complexity of healthcare workflows, particularly in microsurgery, adapting lean management principles has the potential to improve operative efficiency, reduce costs, and eventually enhance patient outcome without compromising patient safety. This systematic review evaluates the current evidence on how these principles have been applied in microsurgical practice and their measurable impact on operative and economic performance.

A systematic search of PubMed, Web of Science, was conducted up to March 18, 2025, following PRISMA 2020 guidelines. Search terms included “lean management” and “microsurgery.” Only English-language, peer-reviewed studies explicitly applying lean principles in a microsurgical context were included. Articles were screened independently by two reviewers.

Of 47 identified records, four studies met the inclusion criteria. Implemented strategies included Lean Six Sigma programs, value stream mapping, structured “plan of the day” protocols, and enhanced recovery pathways in microsurgical breast and head-and-neck reconstruction. Reported outcomes included reductions in operative time (up to 15% ), improved instrument utilization, decreased length of hospital stay, and eventually institutional cost savings. Complication and reoperation rates remained stable.

Although limited, current evidence suggests that lean management strategies can enhance efficiency and reduce overall costs in microsurgery without compromising patient safety. Successful implementation requires multidisciplinary engagement and adaptation to the local clinical environment.

The reconstruction of tissue defects by using flaps is recognized nowadays as the best solution. Large and/or complex posttraumatic or post oncologic resections can often include ischemia of a segment because of vascular defects. Such cases need a simultaneous coverage and revascularization of the segment. One of the methods able to solve both these problems is the flow-through-flap procedure. The procedure consists in using a free flap in which both ends of the vascular pedicle can be anastomosed, offering so the possibility to both cover a defect and revascularize a devascularized segment. This paper will try to clarify some aspects of this concept and to better classify the flow-through flaps.

This study enrolled more than 50 patients with complex injuries of both upper or lower limb with tissue defects and devascularization of distal segments or with need to reconstruct some missing segments. We used in these cases either a flow-through flap to cover a defect and revascularize a segment and/or a second flap.

All the flaps, used either as true flow-through flap or flow-through conduit survived, without any kind of complications.
Based on our observations, we elaborate a new possible classification of this kind of flaps, in true flow-through flap sand flow-through conduit flaps.

Both the true flow-through flaps and flow-through conduit flaps represent a very important tool in solving the complex cases associating tissue defects and vascular defects in the upper extremity. Most indicated is the use of traditional axial and perforator flaps because an arterial conduit offers more long-term patency. Even if the venous flaps have more possible complications, because some technical modifications they proved to be useful in covering small to medium large defects.

Primary Raynaud’s syndrome presents a significant challenge in reconstructive microsurgery, as pathological vasospasms can severely jeopardize free flap survival.

We report the case of a 60-year-old male patient who developed a wound healing disorder and peri-implant infection after the surgical fixation of an ankle fracture. Following hardware removal and debridement, an initial attempt at soft tissue reconstruction using a free gracilis muscle flap failed due to necrosis resulting from severe perioperative vasospasms. A salvage procedure was performed using a free anterolateral thigh (ALT) flap.

To counteract the intense vasospastic response and ensure flap survival, an immediate and aggressive multi-modal treatment strategy was implemented. This approach included the systemic administration of Iloprost via perfusor, oral Amlodipine and Acetylsalicylic acid, as well as transdermal Nitroglycerin. Intraoperatively, mechanical arterial dilatation of the anterior tibial artery was conducted using a Fogarty catheter, and medical leeches were applied postoperatively to further stabilize the perfusion. Under this intensified regimen, the ALT flap was successfully stabilized, allowing for subsequent split-thickness skin grafts to cover residual defects in December 2025.

This case demonstrates that successful free flap reconstruction in patients with primary Raynaud’s syndrome requires a proactive and comprehensive perioperative management strategy that combines mechanical dilation, intensive systemic vasodilatation, and adjunctive therapies to overcome extreme vasospastic complications.

Autologous tissue transfer is a reliable option for cutaneous and soft-tissue reconstruction and is often preferred to skin grafting when better stability, function, and tissue quality are required. Although free flaps are standard for large/composite defects, microsurgery may be unsafe or contraindicated in medically complex patients because microvascular anastomosis increases risk and operative time. In such cases, pedicled flaps are a key alternative. Yet a single pedicled flap may not provide enough volume, surface area, or tissue diversity. Combining multiple pedicled flaps may enable tailored reconstruction, including donor-site coverage when primary closure is not possible, with improved functional and aesthetic outcomes.

Retrospective case series of 18 patients with soft-tissue defects in different anatomical regions treated with multiple combined pedicled flaps. Indications were: (1) large/deep defects requiring >1 tissue component and/or a wider skin surface than a single pedicled flap could provide; (2) reconstruction of a flap donor site not amenable to primary closure; and (3) defects in comorbid patients in whom free-flap reconstruction was contraindicated or high risk. We reviewed demographics, indications, flap combinations, postoperative complications, wound healing, and short-term functional/aesthetic outcomes.

All flaps survived completely, with no vascular compromise or flap loss. Complete wound healing was achieved in all cases, with no dehiscence at recipient or donor sites. No postoperative complications occurred. At 6-month follow-up, all patients were satisfied with functional recovery and aesthetic outcome. No secondary revision procedures were required.

Combining multiple pedicled flaps may be a safe and useful option for complex cutaneous and soft-tissue defects, especially in patients who are poor candidates for free tissue transfer. By avoiding microvascular anastomosis, this approach may reduce operative complexity and morbidity while allowing customized tissue replacement and favorable functional-aesthetic results. The main limitation is anatomical dependence, since local/regional tissue availability, rotation arc, and characteristics vary by defect site. With careful planning, combined pedicled flaps can expand reconstructive options and improve outcomes in challenging patients.

Hourglass like constriction (HLC) is an uncommon spontaneous mononeuropathy that is typically characterised by a sudden onset of pain followed by palsy.
The origin of this disorder remains unclear, and the rarity of the condition makes its diagnosis difficult and its management uncertain.
We report the case of a man who presented with acute left fingers drop due to HLC of the posterior interosseous nerve (PIN). Microneurolysis was performed after 4.5 months of conservative management without clinical evidence of recovery.
Our hypothesis is that microneurolysis is an effective procedure for treating patients with muscle weakness showing no signs of spontaneous recovery, in the context of radiologically confirmed hourglass constriction.

We report the story of a 34 years old left handed patient, who presented acute non-traumatic pain centered on the left forearm , non responsive to oral medication (NSAID, Paracetamol) which lasted 48h and ended with a complete loss of fingers extension. The pain was radiating in the arm and shoulder and associated with burning sensation or electric shock without allodynia.
The patient was quickly addressed to a neurologist who conduct an ENMG exam which describes a focal motor neuropathy of the PIN. An echographic exam done in the same time found and hourglass like constriction of the PIN 3cm distal to the elbow. After 4 months of physiotherapy, ergotherapy and electrical muscle stimulation, the clinical evaluation and the successive EMG exam were showing no evidence of recuperation. In this setting microsurgical epi/perineurolysis was performed while taking care of preserving the axonal continuity.

2 months post operatively the patients was showing clinical evidence of recovery with EDC M2, at 4 months M4.

Our conclusion is that microsurgical epi/perineurolysis is an effective procedure in the setting of HCL, further follow up is needed to confirm that hypothesis.