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Supermicrosurgery is defined as microsurgery in less than 0.8 mm vessels. It is an evolved form of microsurgery but with the same principle: (1) enhanced working environment including microscopes and finer instruments; (2) detailed preoperative evaluation and planning; (3) supermicrosurgical technique; and (4) postoperative care.Supermicrosurgery now provides reconstructive solutions to address lymphedema, distal finger amputations, allows minimal invasive reconstruction using a perforator to perforator approach, and will eventually allow targeted customized reconstruction.application of supermicrosurgery, lymphedema, oncologic reconstruction, perforator to perforator supermicrosurgery, supermicrosurgery

Background: Microsurgical lower extremity reconstruction remains a challenge. The use of perforator flaps in lower extremity reconstruction is expanding. The authors present an algorithm to guide in the selection of the ideal free perforator flap that can be tailored to each lower extremity defect. Methods: The authors conducted a retrospective review of lower extremity reconstruction using free perforator flaps over a 7-year period. Demographics, comorbidities, defect characteristics, operative details, complications, and secondary procedures were documented. Pairwise comparisons of flap types were performed to differentiate flaps on the basis of flap size, thickness, and pedicle length. Results: A total of 563 free perforator flaps were performed. The most common causes were trauma (36.5 percent) and diabetes (24.4 percent). Nine flaps were used, with the most common being superficial circumflex iliac perforator (51.2 percent) and anterolateral thigh (33.2 percent). Size differed significantly between flap types (p < 0.05), with the exception of thoracodorsal artery perforator versus gluteal artery perforator flaps (p = 0.26). The thinnest flaps were posterior interosseous artery perforator (3.7 ± 0.5 mm) and superficial circumflex iliac perforator (5.4 ± 0.8 mm). The thickest flaps were deep inferior epigastric perforator (11.1 ± 3.9 mm) and anterolateral thigh (9.0 ± 1.5 mm). The shortest pedicles were in posterior interosseous artery perforator (3.3 ± 0.3 cm) and superficial circumflex iliac perforator flaps (5.2 ± 0.8 cm). The longest pedicles were in deep inferior epigastric perforator (11.7 ± 1.4 cm), thoracodorsal artery perforator (9.3 ± 1.4 cm), and anterolateral thigh flaps (9.2 ± 0.8 cm). Conclusions: Free perforator flaps are reliable in lower extremity reconstruction. The authors believe their algorithm for flap selection helps to optimize form and function, decrease operative time, and minimize donor-site morbidity and secondary procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

ObjectiveTo evaluate the short-term clinical effects of the intra-articular injection of botulinum toxin type A (BoNT-A) for the treatment of adhesive capsulitis.MethodsA prospective, controlled trial compared the effects of intra-articular BoNT-A (Dysport; 200 IU, n=15) with the steroid triamcinolone acetate (TA; 20 mg, n=13) in patients suffering from adhesive capsulitis of the shoulder. All patients were evaluated using a Numeric Rating Scale (NRS) of the pain intensity and a measurement of the range of motion (ROM) at baseline (before treatment) and at 2, 4, and 8 weeks post-treatment.ResultsThe NRS at 2 weeks (BoNT-A vs. TA; 5.0 vs. 5.2), 4 weeks (4.1 vs. 4.9) and 8 weeks (3.8 vs. 4.6) of both treatment groups were significantly lower than that measured at baseline (7.4 vs. 7.6). The ROM of patients' shoulders increased significantly from baseline in both treatment groups. There was no significant difference in the NRS of pain intensity or the ROM between the two groups. Reduction in the pain intensity score was maintained for 8 weeks post-injection in both groups. There were no significant adverse events in either treatment group.ConclusionThe results suggest that there are no significant short-term differences between the intra-articular injections of BoNT-A and TA. Although BoNT-A has a high cost, it may be used as a safe alternative of TA to avoid the steroid-induced side effects or as a second-line agent, for patients who have failed to respond to the current treatments.

BT shows clinical usefulness in pain reduction and for functional improvement in patients with SIJ pain. This effect was maintained for 3 months following the injection, by which time the effects of TA had diminished.

BT type B can be a useful strategy and has great potential for replacing steroids as a treatment for SB or SIS.

The objective of the study is to verify histopathologically the anti-inflammatory effect of botulinum toxin type A (BoNT-A) in a Complete Freund's Adjuvant (CFA)-induced arthritic knee joint of hind leg on rat model using immunofluorescent staining of anti-ionized calcium-binding adaptor molecule 1 (Iba-1) and interleukin-1β (IL-1β) antibody. Twenty-eight experimental rats were injected with 0.1 ml of CFA solution in the knee joint of the hind leg bilaterally. Three weeks after CFA injection, the BoNT-A group (N = 14) was injected with 20 IU (0.1 ml) of BoNT-A bilaterally while the saline group (N = 14) was injected with 0.1 ml of saline in the knee joint of the hind leg bilaterally. One and two weeks after BoNT-A or saline injection, joint inflammation was investigated in seven rats from each group using histopathological and immune-fluorescent staining of Iba-1 and IL-1β antibody. The number of Iba-1 and IL-1β immune-reactive (IR) cells was counted in the BoNT-A and saline groups for comparison. There was a significant reduction in joint inflammation and destruction in the BoNT-A group at 1 and 2 weeks after BoNT-A injection compared with the saline group. The binding of Iba-1 and IL-1β antibody was significantly lower in the BoNT-A group than the saline group at 1 and 2 weeks after BoNT-A injection. The number of Iba-1 and IL-1β-IR cells at 1 and 2 weeks after the injection of BoNT-A were significantly different from the corresponding number of Iba-1 and IL-1β-IR cells in the saline group. To conclude, BoNT-A had an anti-inflammatory effect in a CFA-induced arthritic rat model, indicating that BoNT-A could potentially be used to treat inflammatory joint pain.

The use of perforator flaps has steadily increased since the introduction of the concept by Koshima and Soeda. 1-3 The perforator flaps offer the advantages of sparing the underlying muscle, resulting in decreased donor-site morbidity. Hyakusoku et al first used the term "propeller flap" in 1991, to describe subcutaneous pedicled island flaps vascularized by a perforator artery and rotated 90°to reconstruct the defect after release of scar contractures in a burn patient. 4 Once a propeller flap has a reliable vascular pedicle, it can be easily mobilized and rotated as a local flap. Furthermore, the harvest is fast and easy and may not require microsurgery. 2 In 2006, combining the concept of propeller flaps and perforator based flaps, Hallock reported a fasciocutaneous flap that was similar in shape to the one described by Hyakusoku et al and further showed that Keywords ► propeller flaps ► rotation of flaps ► perfusion of flaps AbstractBackground This article investigates the effect of 180°rotating propeller flaps and evaluates whether each flap has a "preferable" rotating direction. Methods Part 1 evaluates the flap pedicle velocity and flow volume in neutral, 180°c ounterclockwise, and clockwise rotated position for 29 consecutive flaps. The data (velocity and volume) were divided into three groups: neutral, high value, and low value group then evaluated. Part 2 compares the outcome from the prospective study where a preferable rotation with high value was selected against 29 patients from 2012 to 2016 who had the same operation without selecting a preferable rotation direction. Results In part 1, the three groups (neutral, high value, and low value groups) showed mean velocity of 28.06 AE 7.94, 31.92 AE 10.22, 24.41 AE 8.12 cm/s, respectively, and mean volume of 6.11 AE 4.95, 6.83 AE 6.69, 4.62 AE 3.55 mL/min, respectively. The mean velocity and volume of the perforator in the high value group were significantly higher than that in the low value group (p ¼ 0.0001). In part 2, although no statistical significance in the outcome was observed, there were two cases of total, two cases of partial flap loss, and three cases of wound dehiscence in the patients where preferable rotations was not selected compared with only two wound dehiscence for flaps with preferable rotation. Conclusion The velocity and flow of the flap are significantly different based on the rotation direction of the flap. Using the preferred rotation direction with statistically higher value of velocity and flow may increase the overall outcome of the propeller flap, especially where larger flaps are used.