The world experience and experience of the Institute of Microsurgery (Tomsk, Russia) in rescuing dying free flaps are summarized in the paper. The issues related to the prevention of vascular disorders, which in 85–95% of cases lead to fatal complications in the form of total necrosis of the reperfused flap, are discussed. We are talking about the immediate, early and late complications due to the compromise of blood flow along the vascular pedicle (arterial, venous, arterial-venous). Unlike irreversible disorders, temporary disturbances in blood supply in free flaps are caused by the consequences of primary ischemia and reperfusion. Their duration and reversibility depend on the tissue composition, i.e. from the anoxic resistance of the tissues constituting the flap and, of course, the structures that form the wall of the flap vessels themselves. With a short duration of primary ischemia (up to 1 hour) and compensated reperfusion syndrome, temporary vascular disorders are manifested by flap skin flushing and metabolic edema of its tissues, which disappear 10-40 minutes after reperfusion. The indications for revision of the vascular pedicle are doubts about the adequacy of blood flow in the flap due to the appearance of the first signs of anastomotic thrombosis. The highest rates of flap rescue are achieved after revision of the vascular pedicle no later than 90 minutes after the first signs of thrombosis appear. It is important that the surgeon performing these microvascular anastomoses does the revision. The development of technologies for rescuing a perishing flap has become especially relevant in the last decade. This is due to the rapid development of reconstructive microsurgery of head and neck tumors. In such patients, there is practically no alternative to free transplantation of tissue complexes for the reconstruction of the lower jaw, tongue, soft tissue defect of the lower face and neck. The main technical problem leading to fatal complications after transplantation of a radial, peroneal, anterolateral femur flap is the difficulty of finding recipient vessels suitable for revascularization in soft tissues previously exposed to radiation. The search for alternative recipient vessels during the primary reconstruction of defects, for example, in the oral cavity, is accompanied by a significant increase in the duration of primary ischemia (up to 3–4 hours) and the death of flaps. The preservation of the viability of such free flaps is possible only by their temporary extracorporeal perfusion with extracorporeal membrane oxygenation. It is possible to preserve the viability of free flaps for 2 weeks (without microvascular anastomoses) during tertiary reconstruction of head and neck defects by continuous extracorporeal perfusion of the flap until it is completely engrafted in the recipient area. There is experience of using a tubular non-free radial flap on the long vascular pedicle of the radial vascular bundle (from the wrist to the ulnar fossa) in tertiary tissue reconstruction after removal of head and neck tumors.

The purpose of this study was to explore the effectiveness of combined one-stage reconstruction of extensive complex defects of lower limb tissues and to analyze postoperative complications.

Material and methods. The research involved 25 patients with bone and soft tissue defects of lower extremities. The first group included 16 patients, where the replacement of bone and soft-tissue defects of the lower leg was carried out with one complex bone-skin graft. The second group consisted of 9 patients who, along with major defects of the tibia, had concomitant extensive damage of soft tissues. To replace bone and soft-tissue limb defects, the autotransplantation technique of 2 free flaps, bone and soft-tissue (combined) was used.

Results and discussion. In our study, we analyzed early and late postoperative complications, as well as the average time of fusion of the graft with the recipient bed and restoration time of the lower limb supportability. In the second group of patients, we did not observe any critical complications in the early postoperative period that would affect the results of patient`s treatment. The increase in the incidence of vascular complications is not statistically significant. In the late postoperative period (30 days or more), stress fractures of the fibular graft, traumatic fracture of the fibular graft, delayed consolidation of the graft ends with the recipient bone lasting more than 6 months were observed in both groups of patients. The incidence of these complications was comparable in both groups, there were no statistically significant differences. The average time of fusion of the graft with the recipient bed and the time of restoration of the lower limb supportability did not have statistically significant differences.

Conclusion. One-stage reconstruction of extensive deep limb tissue defects by using an appropriate combination of two vascularized complex grafts (bone and soft tissue) provides a complete reconstruction of complex limb tissue defects without increasing the time of bone consolidation and the frequency of occurrence of critical complications in the postoperative period (total necrosis of vascularized flaps and deep wound infection process). 

The blood supply to the nipple-areola complex of hypertrophied mammary glands is variable and unpredictable in each patient who is planned to undergo reduction mammoplasty. The review provides historical aspects and modern views on reduction mammoplasty and the study of blood supply to hypertrophied mammary glands. The emphasis is also placed on the importance of preoperative diagnostics of the peculiarities of blood supply to the nipple-areola complex.

Fibular tunnel syndrome (FTS) is the most common neuropathy of the lower extremity. Compression of the peroneal nerve leads to movement and sensory disorders, which is manifested by weakness of the muscles that normally provide dorsiflexion of the foot and toes, gait disturbance and loss of sensitivity. Our study involved 30 patients with symptoms of FTS. All underwent microsurgical two-level decompression of the peroneal nerve. In the postoperative period, the results of the operation were assessed by changes in sensory and motor neurological deficits according to the British Medical Research Council Scale (BMRCS). It has been proven that the peroneal nerve decompression technique is an effective way to treat primary and secondary FTS. In this case, the restoration of sensitive fibers occurs earlier than motor ones. Taking into account the similarity of clinical manifestations with proximal lesions and the structural features of the canal, it is necessary to develop a clinic-diagnostic algorithm to determine the therapeutic tactics and the volume of surgical intervention.

The purpose of the study: to determine the features of the state of the microcirculatory bed in women with post-mastectomy syndrome as a cause of fibrosis.

Material and methods. The study involved 76 women, of whom two groups were formed. The first group consisted of 46 patients aged 25 to 49 years (mean age – (43.8 ± 3.8) years old) with post-mastectomy syndrome (PMES), the average period after radicle treatment of breast cancer was (4.3 ± 2.1) years. All patients underwent mastectomy, radiation and chemotherapy for the treatment of breast cancer, followed by a comprehensive examination to exclude metastasis and continued tumor growth, as well as to exclude hemodynamically significant violations of venous and arterial blood flow of the upper extremities. The second group was formed of 30 healthy female volunteers aged 25 to 43 years, whose average age was (33.75 ± 10.70) years old. Clinical and instrumental methods of examination were used: anthropometric method, lymphoscintigraphy of the upper extremities, laser Doppler flowmetry, determination of the expression level of intercellular adhesion molecules sICAM-1, sPECAM-1.

The results. Gross violations of the function of the microcirculatory bed were revealed: endothelial dysfunction, spasm of precapillary sphincters, decrease in the intensity of blood flow in the metabolic capillaries, the predominance of passive mechanisms of blood flow regulation. These changes lead to tissue hypoxia, which may be the trigger for the development of fibrosis and lymphedema. Endothelial dysfunction, which is confirmed by increased expression of specific biomarkers, may be the basis of these disorders. A complex, long-term change in the work of microvessels leads to a breakdown of compensatory mechanisms.

Conclusion. The study of the pathogenetic mechanisms of the development of post-mastectomy syndrome will allow forming preventive strategies in patients after treatment of breast cancer, improving the quality of life of these patients. Further search for promising predictors of the development of fibrosis, the study of changes in the microcirculatory bed will provide additional information about the pathogenesis of PMES, to identify changes in the soft tissues of the upper extremities at an early stage of post-mastectomy syndrome, may be important for the development of more effective methods of treatment of PMES.

The purpose of this study was to develop a clinical classification of large defects of long tubular bones of the extremities and protocols for surgical treatment by vascularized bone grafting.

Material and methods. The results of treatment of 51 patients with large defects of the long tubular bones of the upper and lower extremities were analyzed. In 25 cases, along with bone defects, there were significant defects of the soft tissues of the limb with trophic and scar changes. In order to replace the bone defect vascularized grafts were used: bone-muscular fibular, bone-cutaneous fibular, bone-cutaneous iliac, bone-cutaneous radial, bone-cutaneous tibial, and combined bone-cutaneous fibular with an allograft from the tibia. The results of treatment of patients were evaluated according to the clinical criteria of R. Johner, O. Wruhs (1983), proposed for the lower limb. The DASH questionnaire was use to evaluate the results of treatment for upper limb defects.

The results and discussion. The classification is based on 4 variable criteria: the size, anatomical localization of the bone defect, the size of the soft tissue defect and the shortening of the damaged limb segment. The size and anatomical location of the defect in the long tubular bone is important in choosing a bone flap. Based on the anatomical localization of the bone defect, soft tissue damage and limb shortening, the patients were classified into 4 types. The first 3 types were divided into 2 subtypes, depending on the size of bone damage and soft tissues defect of the limb. Based on the proposed classification, we have developed protocols for microsurgical reconstruction of large bone defects of the extremities for each subtype of bone defect.

Conclusion. The application of the developed clinical classification of large bone defects of long tubular bones and protocols for their surgical treatment by vascularized bone grafting made it possible to restore limb function in 96% of cases.

Objective. The world statistics on lightning strike outcomes reveals 6000 to 24000 human deaths annually. The lightning strike regular mortality is 20–30% with two thirds of survivors having serious complications and long lasting consequences. Every third person struck by lightning bears skin damage.

Clinical observation. The man, 27 years old, was traumatized after the lightning struck into his forehead area.  A contused-lacerated wound of soft tissues was diagnosed. The patient was taken to the local district hospital for primary care. 20 days after receiving the injury, he turned to the Saratov Regional Clinical Center for Combustio- logy, where he underwent autodermoplasty of the defect in the integument of the skull.

Discussion. Direct lightning strike is technically a result of the immediate contact of the injured with the atmospheric electricity. It comprises no more than 5% all lightning strike cases. The outcome is often lethal as the electrical discharge received is the highest.

Conclusion. Autodermotransplanting is advantageous in the replacement of damaged skin integument, inclu- ding that caused by atmospheric electricity. In such situations adequate first aid treatment, timely transportation, staged medical treatment, specialized stationary treatment, proper surgical treatment, and post-operative care are important. 

The report presents a brief historical outline of spontaneous rupture of the esophagus, modern data on the incidence of the disease, difficulties in diagnosis and treatment, as well as the high incidence of complications and mortality in this pathology. A case of successful staged treatment of a patient with spontaneous rupture of the esophagus complicated by purulent mediastinitis and pleural empyema, who was admitted 6 days after the onset of the disease, is described. The surgical tactics and features of the postoperative management of the patient are described in detail.

The result of using the temporal fascial flap in combination with autodermoplasty in the reconstruction of the total postburn auricle and parotid area defect is presented in this paper. The techniques of reconstructive otoplasty in conditions of cicatricial process of parotid zone are described.

The paper was prepared by the authors of the two-volume edition “Scientific heritage of E.G. Salishchev”. It is dedicated to the first results of the search for the grave monument of Professor E.G. Salishchev on the site of the cemetery of John the Baptist Convent destroyed in the 30s of the last century. A large volume of archival research was carried out with the involvement of specialists from the State Archives of the Tomsk Region, the Center for Documentation of the Contemporary History of the Tomsk Region and the analysis of scientific research works of the Tomsk Regional Museum of Local Lore named after M.B. Shatilov on this topic. Some discrepancies between archival information and official information were revealed.

The paper presents the main years of the life and scientific work of the prominent Russian surgeon and scientistinnovator Professor A.E. Rauer (1871–1948). Little-known milestones from the scientist's life are marked. The paper analyzes the fact that from 1922 to the end of life (26 years) Alexander Eduardovich headed the maxillofacial department of the Central Institute of Traumatology and Orthopedics (CITO). Since 1932, Professor A.E. Rauer was the head of the Department of Maxillofacial Surgery of the CIU, organized by him on the basis of the maxillofacial department of the CITO (Moscow). It is noted that Alexander Eduardovich is the author of about  100 scientific works. He summarized all his rich experience in his final work “Plastic Surgery on the face”, awarded in 1946. The Stalin Prize. The range of scientific and surgical interests of A.E. Rauer was wide and diverse. His main works were devoted to the problems of maxillofacial surgery. Rauer proposed a number of valuable ways to eliminate facial disfigurement, which have become widespread (for example, oblique osteotomy for ankylosis of the jaws, surgery for habitual dislocations, plastic surgery of through facial defects, etc.). Under the leadership of Alexander Eduardovich, the clinic also developed methods of plastic surgery for fan-shaped neck scars after thermal injuries and restoration of the pharyngeal arches with soft palate defects. It is noted that he worked a lot on plastic surgery of other organs and proposed methods of interventions for congenital malformations of the bladder, limbs, etc. During the Great Patriotic War, A.E. Rauer introduced into practice a method of treating granulating surface wounds by forming secondary plate ligatures. It is shown that after him there were many worthy students who continued his work on the further development of maxillofacial surgery, which has become an important and necessary branch of clinical medicine.