Wan Azman Wan Sulaiman

Complex dorsal hand and forearm injuries with extensor tendon and soft tissue loss are challenging to manage. Single-stage reconstruction using composite anterolateral thigh (ALT) fasciocutaneous free flaps with vascularized fascia lata may reduce the need for multiple surgeries and accelerate functional recovery, but clinical evidence is limited. We conducted a retrospective case series of nine patients with complex extensor tendon and soft tissue defects who underwent single-stage reconstruction with composite ALT flaps between 2009 and 2018. Six patients were available for long-term follow-up (average 2–3 years). Data included demographics, injury characteristics, operative details, complications, and functional outcomes assessed using Miller's criteria. One donor site hematoma resolved without sequelae. Functional assessment revealed that two patients achieved excellent and poor outcomes in wrist and finger extension, respectively, while one patient demonstrated good and fair results . Poor outcomes were associated with missed follow-up, prolonged immobilization, and concomitant skeletal injuries. All patients returned to work and reported satisfaction with their functional status. This approach offers durable soft tissue coverage, restores tendon continuity, and allows early rehabilitation with minimal donor site morbidity.

Parotid gland arteriovenous malformation (AVM) may present as a parotid mass. Most parotid masses are benign, and the majority of these are pleomorphic adenomas; therefore, the initial diagnosis of vascular malformations can be challenging without the pathognomonic turkey-wattle sign. We present a case of a parotid gland AVM that was initially misdiagnosed as a parotid gland cyst. The clinical and radiological findings are also discussed here. The AVM was managed with surgical intervention and sent for histopathological study to confirm the diagnosis.

A craniossinostose, caracterizada pela fusão prematura das suturas cranianas, pode causar aumento da pressão intracraniana, anomalias craniofaciais e problemas de desenvolvimento neurológico. O avanço fronto-orbital (AFO) é uma intervenção cirúrgica que visa aumentar o volume craniano anterior (VCA) e melhorar a simetria craniana frontal. Avaliar o resultado do AFO na fossa craniana anterior de pacientes submetidos a uma fixação menos rígida com suturas não absorvíveis de nylon 2/0. O método de fixação com suturas não absorvíveis de nylon 2/0 foi utilizado em 19 pacientes com craniossinostose e acometimento das suturas coronais ou metópicas. As análises volumétricas pré- e pós-operatórias foram realizadas por meio de tomografia computadorizada (TC) tridimensional (3D) para avaliação do VCA, do índice de assimetria da abóbada craniana anterior (IAACA) e da alteração no formato da cabeça por meio do índice cefálico (IC) como desfechos primários. Os resultados demonstraram um aumento significativo no VCA médio de 259,15 (desvio-padrão [DP]: 162,61) para 314,38 (DP: 79,78) cm³ no pós-operatório (p = 0,042). Houve uma melhora na simetria (p = 0,05), indicada pela alteração do IAACA médio de 1,14 (DP: 4,78) para -1,63 (DP: 4,98). No entanto, a análise de IC não revelou modificações pós-operatórias significativas na classificação do formato da cabeça. Esses achados sugerem que o AFO com sutura não absorvível de nylon é um método eficaz e econômico para aumento do VCA e melhora da simetria, com manutenção da estabilidade estrutural. Assim, o AFO é uma opção viável para pacientes com recursos financeiros limitados. No entanto, a ausência de alterações significativas na classificação do formato da cabeça destaca a necessidade de maior refinamento das técnicas cirúrgicas. Recomenda-se acompanhamento em longo prazo e coortes maiores para avaliação da persistência desses desfechos e otimização das estratégias de tratamento. Os dados serão disponibilizados mediante solicitação ao autor correspondente. RCXY: conceitualização; metodologia; escrita – esboço original; escrita – revisão e edição. WAWS: escrita – revisão e edição. HMZ: metodologia; recursos; investigação; escrita – revisão e edição. CZCD: análise formal; escrita – revisão e edição. JYA: software; validação; escrita – revisão e edição. Todos os autores leram e aprovaram o manuscrito final. O Comitê de Ética e Pesquisa Médica da Malásia [NMRR ID-24-02969-TW0 (IIR)] e o Comitê de Ética em Pesquisa em Seres Humanos da Universiti Sains Malaysia [USM/JEPeM/KK/24080675] aprovaram este estudo. Editor-chefe: Dov Charles Goldenberg. Received: 24 May 2025 Accepted: 12 August 2025 Article published online: 28 April 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua Rego Freitas, 175, loja 1, República, São Paulo, SP, CEP 01220-010, Brazil

Objectives: Submucous cleft palate (SMCP) is a subtle and occult subtype of cleft palate. Diagnosis is often delayed due to inconspicuous clinical features of the SMCP. This study aims to investigate the demography of SMCP patients, to determine when SMCP patients are operated on, and to analyze the surgical technique applied to correct SMCP in our center.Methods: Medical records in Hospital Pakar Universiti Sains Malaysia (HPUSM) from 1999 to 2023 were retrospectively reviewed. Patients diagnosed with SMCP who were operated on were identified. The variables extracted from the records include gender, ethnicity, age at diagnosis, age at surgery, antenatal history, genetic study, associated signs and symptoms, other conditions and anomalies, associated syndromes, surgical techniques, and complications.Results: A total of 21 SMCP patients who underwent repair were identified. However, only 15 complete medical records were obtained. The mean age of surgery is 68.4 months, ranging from 5 to 212 months. The majority of patients at 47.6% underwent Bardach's two-flap palatoplasty. Other techniques identified were Veau-Wardill-Kilner palatoplasty, Von Langenbeck palatoplasty, Furlow double-opposing Z-palatoplasty, and intravelar veloplasty.Conclusions: This retrospective case series reported that SMCP patients were operated at a later age. The higher average age of surgery is multifactorial and likely includes delayed diagnosis. Various surgical techniques may be used to repair the SMCP. A high level of suspicion of SMCP is paramount when the clinical features of cleft palate are subtle, but patients exhibit other suspicious signs such as recurrent episodes of otitis media, nasal regurgitation, or speech impediments.

Introduction: Hematoma can adversely affect a flap in several ways, leading to flap compromise. The impact of hematoma on free flap is more complex than previously understood. Free flap compromise due to hematoma most commonly occurs during the early postoperative period. Aim: This article highlights the late compromise of the free fibula flap and the significance of flap monitoring after a secondary procedure. Case study: We present a case of late free fibula osteocutaneous flap compromise on postoperative day 13 due to hematoma. A 21-year-old woman with left tibia osteofibrous dysplasia underwent wide resection and left tibia reconstruction using the modified Capanna technique. Postoperatively, she developed a deep surgical site infection with implant exposure, secondary to partial thickness necrosis of the skin paddle caused by hematoma-induced ischemia-reperfusion injury. She was treated with antibiotics, dressings, and debridement. Implant removal was performed at postoperative month 5 following bone union. Results and discussion: Hematoma can exert pressure on surrounding tissues, leading to vascular pedicle compression and thrombosis. The time dependency of flap salvage rates is associated with the progression of irreversible ischemia-reperfusion injury. Complications such as surgical site infection with implant exposure may occur. Data on timing of implant removal remain limited. Conventional management involves debridement, antibiotics, and hardware removal. The implant may be preserved until bony healing is achieved, provided there is no implant failure, prolonged exposure, or active infection. Conclusions: Early recognition and prompt re-exploration are crucial for flap salvageability in the presence of hematoma. The removal of an exposed implant is controversial, as clear guidelines are still lacking.

Introduction: Unilateral cleft lip nasal (UCL/N) deformity severity presents complex anatomical challenges, with surgical outcomes influenced by preoperative status. Existing classification systems for UCL/N lack standardization, relying on subjective clinical assessments or isolated anthropometric measures that fails to assess anatomical deformity comprehensively. This limits their utility in objectively stratifying deformity severity and justifying postoperative outcomes. To address this gap, we developed UCL/N Deformity Rating Scale (DRS), an objective classification tool incorporating three validated anatomical indicators: alar facial symmetry ratio , nostril width ratio , and columellar angle . This study aims to (1) validate the scale’s reliability for grading preoperative anatomical severity and (2) establish its clinical applicability by correlating preoperative grades with postoperative aesthetic outcomes, thereby justifying surgical outcomes, not evaluating institutional surgical performance. Methods: This retrospective cohort study (Level III evidence) analyzed standardized, ethically approved two-dimensional photographs from 50 UCL/N pre- and postoperative patients. All photographs were deidentified, randomized, and independently assessed by three consultant plastic surgeons and three trainees to evaluate interrater reliability using the intraclass correlation coefficient (ICC). The DRS was applied to grade pre- and postoperative severity, and 12 paired cases were analyzed to correlate these grades with postoperative aesthetic outcomes, demonstrating the justification system’s clinical applicability. Results: Assessments of key anatomical indicators showed consistent agreement across pre- and postoperative evaluations, with no significant differences (p > 0.05). The UCL/N DRS demonstrated good interrater reliability (ICC = 0.64–0.72). In 12 cases, outcomes matched or surpassed predictions: 5 matched, 7 exceeded, and none were substandard. This demonstrates the system’s clinical applicability as a standardized tool to grade primary deformity severity and justify surgical outcomes by linking preoperative severity to postoperative results. Conclusions: Strong interrater reliability across assessors support the UCL/N DRS as a reliable objective tool for assessing the UCL/N anatomical severity and justifying the post-operative outcome. Level of Evidence III: This journal requires that authors assign a level of evidence to each article. 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 .

Background: Achieving a well-balanced and symmetrical facial appearance is a primary objective in cleft lip and palate repair. The long-term nasolabial appearance serves as a key indicator of surgical success. This study aims to assess the correlation between patient satisfaction and surgeon evaluation of nasolabial outcomes following unilateral cleft lip repair. It explores whether patient satisfaction may serve as a reliable indicator of long-term surgical success. Methods: A retrospective cross-sectional study was conducted using records of patients with unilateral cleft lip who underwent surgical repair by the Reconstructive Science Unit at Universiti Sains Malaysia Hospital. Inclusion criteria required that patients had undergone lip repair before the age of two and were at least 14 years old at the time of follow-up assessment. A total of 50 patients met these criteria and were included in the analysis. Surgeon assessments and patient-reported satisfaction regarding nasolabial appearance were extracted and analyzed to evaluate their correlation. Results: No significant differences were observed between surgeon assessments and patient-reported satisfaction with nasolabial appearance. A statistically significant association was found between surgeon evaluations and patient satisfaction (χ²(1) = 14.881, p < .001), indicating that higher surgeon-rated outcomes were associated with greater patient satisfaction. Conclusion: This study demonstrates a significant correlation between surgeon evaluations and patient satisfaction with long-term nasolabial appearance, suggesting that patient satisfaction may serve as a practical and meaningful indicator for assessing long-term surgical outcomes in unilateral cleft lip repair.

Exposure to electrical current, whether through accidental contact in residential or industrial settings or via lightning strikes, represents a serious global health concern. Although numerous studies have been published on the differences between electrical and lightning injuries, they are often discussed together due to the similarities in their clinical presentations, management approaches, and outcomes. The question of whether electrical and lightning injuries should be studied together remains a matter of debate. Here, we present two cases: one of a lightning injury and another of an electrical injury. Our discussion aims to improve the understanding of lightning and electrical injuries as distinct entities. Vigorous resuscitative measures are recommended and given the complexity of electrical and lightning injuries and their long-term sequelae, patients should be managed in a multidisciplinary burn center. Furthermore, the knowledge and awareness of the general population must be improved to reduce the incidence of such injuries.

Surgical management of femur osteomyelitis remains challenging. The burden of this chronic disease invariably results in composite bony and soft tissue defects that can interfere with bony stability. Therefore, reconstructive surgery is integral to functional limb salvage and limb preservatives. To the best of our knowledge, we are the first to report the limb salvaging method and important planning considerations for a case of chronic refractory osteomyelitis. We presented a case of a 31-year-old female with chronic post-traumatic osteomyelitis of the right femur. This intractable disease results in frequent remission of infection and non-union of the midshaft fracture. Surgical management with the implant, external fixation, and cement spacer failed due to infection. This rendered vascularised bone graft with massive allograft the only option. We described the anatomical aberrant during the harvest of free fibula flap and modified chimeric fibula flap to overcome the soft tissue defect complicated with severe fibrotic tissue with a background of an obese patient. She had undergone emergency hematoma evacuation 20 hours after the surgery. Otherwise, the flap survived well, and the patient started to have partial weight bearing. Chimeric fibula osteocutaneous free flap is a useful armament to provide a complex 3-dimensional spatial arrangement in a case of chronic osteomyelitis with huge bony and soft tissue defects.