Der ein- und zweizeitige distal gestielte Suralislappen

Background

The distally pedicled suralis flap is used to cover local defects of the distal lower leg, ankle and hind foot. It is a local flap with no need for microvascular anastomosis, a constant blood supply and ease of elevation. Disadvantages are lack of sensation, donor site morbidity and venous congestion.

Methods and material

This study includes 25 patients. Apart from the defect extent, cause and location, complications were also determined.

Results

The defect site was located in the hind foot in 5 cases and the distal lower leg in 14 cases. In four patients the soft tissue of the lateral calcaneal region and in two cases the sole of the foot were affected. Severe venous congestion, which was only detected in 180° turned flaps, was seen in five cases. In five patients we successfully performed a two-stage flap transposition procedure to avoid venous congestion.

Conclusion

The sural flap remains a reliable solution for soft tissue defects. Under inappropriate circumstances (small pedicle or severe torque of pedicle) venous congestion or even thrombosis is possible. A two-stage approach with conditioning of venous drainage can have a positive effect on these problems.     

Versatility of the lateral circumflex femoral arterial (LCFA) system flaps for lower extremity soft tissue reconstruction

Background

Complex and extensive limb defects involve difficult reconstructive problems, and lateral circumflex femoral artery (LCFA) system flaps provide an adequate reconstructive answer for these challenging wounds.

Methods

A retrospective review on 50 patients treated with LCFA system flaps to cover lower extremity wounds was carried out. Data collected included age, gender, defect size, defect location, flap size, flap composition, anatomical findings, donor site closure, secondary procedures, and complications.

Results

The overall flap survival rate was 96 %. We performed three flap re-explorations with two subsequent failures. Four different combinations of tissues from LCFA system flaps were employed to restore defects produced by open fractures in tibia (16), severe crushing or avulsion injury (15), chronic posttraumatic osteomyelitis (13), and others (6). The mean size of the skin flap was 162.56 cm² (range 54–312 cm²) and the volume of the muscle flap was 160 cm³ (range 44–250 cm³). Debulking procedures were performed in seven patients. Donor sites were closed primarily in all but five patients who required a skin graft.

Conclusions

The LCFA system is efficient and its use, versatility, and reliability in lower limb reconstruction have been proven. No other donor site in the body offers such a large amount of tissue with minimal donor morbidity. Level of Evidence: Level IV, therapeutic study.     

Clinical and anatomical study of the distally based lesser saphenous veno-lateral sural neurocutaneous flap for lower extremity coverage

Background

The distally based sural flap has been widely and successfully used to reconstruct soft tissue defects of the distal third of the lower leg and foot. Sensory loss and venous congestion are possible complications of this treatment, but there has been limited research focused on improving the sensory loss and veneous congestion. This study aimed to determine the spatial relationship between the lesser saphenous vein and the cutaneous nerves, the venous anatomy in the lower leg, and the nerve distribution in the lateral dorsum of the foot, and we presented our clinical experience.

Materials and methods

Twenty freshly amputated lower limbs were dissected in the 2 h following amputation. The lesser saphenous vein, medial/lateral sural nerve, and sural nerve were identified. Based on the anatomical studies, an island flap supplied by the vascular axis of the lesser saphenous vein and the lateral sural nerve was designed for clinical reparative applications in 24 cases.

Results

We indicated the spatial relationship between the lesser saphenous vein and the cutaneous nerves and the venous anatomy in the lower leg. Among 24 flaps, 21 showed complete survival (87.5 %), while marginal flap necrosis occurred in two patients (8.33 %) and distal wound dehiscence in another (4.17 %). No symptomatic neuromas were observed. Their appearance and functioning were satisfactory, with filling maintained in the heel and lateral side of the foot.

Conclusion

The distally based lesser saphenous veno-lateral sural neurocutaneous flap provides effective coverage of variable-sized soft tissue defects on the lower third of the lower leg and foot, without sensory loss and venous congestion.     

Chest wall reconstruction after recurrent breast cancer using the scapular flap

Background

Breast cancer is a common female malignancy with numerous reconstructive options following mastectomy. However, in recurrent disease, few donor sites exist. The scapular flap may reconstruct ablative defects after recurrence. This paper describes its 5-year application.

Methods

All patients with recurrent breast cancer necessitating chest wall reconstruction with a scapular flap were included in this 5-year study. Patients were prospectively followed up for clinical, surgical and patient-reported outcome measures.

Results

Eight patients underwent scapular flap chest wall reconstruction for recurrent breast cancer. The majority of tumours were invasive ductal carcinomas (n?=?5; 62.5 %). Mean duration from primary breast cancer to scapular flap reconstruction was 12 years (range 2–32 years). All flaps survived, including patients who smoked and received adjuvant radiotherapy. Donor site morbidity was minimal with full ipsilateral limb functioning.

Conclusions

Scapular flap reconstruction of the chest is a safe, reliable and consistent technique in recurrent breast cancer. Level of Evidence: Level IV, therapeutic study.     

Distally based posterior tibial artery perforator flap for coverage of defects around the ankle,heel and lower third of leg

Introduction

Reconstruction of distal leg region remained a difficult task. Free flaps had long been considered as a gold standard for these regions. However, due to various limitations of the free flap, a local fasciocutaneous flap could be considered as a good alternative. In this study, the use of a distally based posterior tibial artery perforator flap had been evaluated in the coverage of defects around the ankle, heel, and lower third of a leg. The study also outlined the donor-site morbidity and the technical details of the surgical procedure.

Methods

In this prospective study, a total of 42 patients with distal lower leg defects were included. The defects were located on the lower third of the leg (n?=?23), ankle (n?=?11), and heel (n?=?8). Reconstruction was performed using distally pedicled posterior tibial artery perforator flaps. Patients were evaluated in terms of viability of the flap, functional gain, and donor-site morbidity. The technical details of the operative procedure have also been outlined.

Results

All the flaps survived well, with the exception of one patient, who experienced complete flap loss. Minor complications were, however, noted in four other patients: One patient developed superficial epidermolysis; one developed postoperative venous congestion, which subsided within 3 days by conservative means, and in two patients, partial loss of the skin graft occurred at the donor site but healed completely with dressing and antibiotics. The patients were followed up for an average period of 6 months, ranging from 1 to 13 months. Donor-site morbidity was minimal.

Conclusions

It was concluded that the distally based pedicled posterior tibial artery perforator flap was a reliable, easy, less time-consuming, and versatile procedure for covering the defects around the ankle, heel, and lower third a leg. Level of Evidence: Level IV, therapeutic study     

Orbital exenteration for the treatment of advanced periocular skin cancer

Background

Orbital exenteration is a surgical procedure which typically involves removal of the entire contents of the orbit including the periorbit, appendages, eyelids and, sometimes, a varying amount of surrounding skin. This operation is reserved for the treatment of potentially life-threatening malignancies arising from the orbit, paranasal sinuses or periocular skin. We have reviewed the cases that underwent orbital exenteration and reconstructive techniques for closing the defect.

Methods

Twenty-six patients, who underwent orbital exenteration from April 2001 to September 2010, were retrospectively analyzed, and data including patient demographics, tumor location and characteristics were collected. The reconstructive techniques were reviewed.

Results

The study consisted of 16 males and 10 females with a mean age of 68.8 years (range 50 to 89 years). Fourteen left and 12 right exenterations were performed. The location of the tumor was most commonly at the medial canthus followed by the lateral canthus, nose, eyelids and cheek. Twenty-one out of 26 cases (80.76 %) were basal cell carcinomas and the remaining (19.23 %) were squamous cell carcinomas. Reconstructive techniques included superficial temporal artery-based forehead flap (73.07 %), the scalp flap (11.53 %), and the latissimus dorsi free flap (15.58 %).

Conclusions

Among various options available for the reconstruction of the orbital exenteration, the superficial temporal artery-based forehead flap is a relatively simple one and the final outcome, according to our experience, is comparable to that of more complex flap procedures, providing an acceptable cosmetic result with minimal donor site morbidity and short operating time. Level of Evidence: Level IV, therapeutic study.     

The posterior thigh flap revisited: clinical use in oncology patients

Purpose

The posterior thigh flap is a reliable flap owing to the dependability of the inferior gluteal artery. Its utility for the reconstruction of sacral, perineal, ischial, pelvic, trochanteric and vulvar defects is well established. We herein describe the use of the flap for a variety of indications, and discuss the results with respect to postoperative complications in oncology patients.

Methods

We reviewed nine oncology patients who were treated with pedicled posterior thigh flaps. We assessed the use of this treatment by recording the site of the defect, the type of flap used, and the presence or absence of previous surgical procedures, radiation therapy and postoperative complications.

Results

Defects after resection of soft tissue sarcomas were the most common condition (n = 4), followed by skin cancers (n = 2), gastrointestinal cancers (n = 2) and radiation osteomyelitis (n = 1). Six patients (66 %) developed complications; three (33 %) were major and three (33 %) were minor. There was one case of total necrosis of the flap and two cases of partial necrosis.

Conclusions

In oncology patients, the posterior thigh flap is an excellent choice for the reconstruction of sacral, ischial, pelvic or buttock defects, since it does not cause any donor site morbidity.     

Usefulness in combined free anterolateral thigh and vastus lateralis muscle flaps

Background

The anterolateral thigh flap has been a popular flap in reconstructive surgery. However, the details concerning the anterolateral thigh flap combined with the vastus lateralis muscle flap have not been reported. We described the surgical procedures, complication of the donor site, and advantages and disadvantages of this combined flap.

Methods

We analyzed 29 patients who underwent reconstruction with an anterolateral thigh flap–vastus lateralis muscle flap.

Results

The recipient sites were in the head and neck area (n?=?25), extremities (n?=?3), and trunk (n?=?1). The vastus lateralis was used as a muscle flap in 28 cases. The rectus femoris was harvested in one case because the vastus lateralis could not be harvested with a skin flap. Four cases required two vastus lateralis muscle flaps with a skin flap. Partial ischemia of the muscle flap occurred in one case. Additional donor-site surgery was required in two cases. No donor-site dysfunction was observed in our series.

Conclusion

This combined flap is advantageous in that the volume and number of muscle flaps can be adjusted and the skin and muscle flaps can be placed in separate positions. Although harvesting this flap is safe and not difficult, attention should be paid to anatomical variations of the vascular pedicle supplying the skin and muscle flap and to the circulation of the muscle flap. Level of Evidence: level IV, therapeutic study.     

Serratus anterior free flap: A personal series and meta-analysis review

Background

Serratus anterior muscle free flap is a versatile flap used for various microsurgical reconstructive procedures, especially when the amount of needed muscle is limited.

Methods

Reviewing retrospectively our own series of 12 patients (13 flaps), we made an extensive review of the medical literature in order to proceed to a meta-analysis concerning that flap.

Results

The serratus anterior flap was used for reconstruction of eight lower limbs, three head and neck, and one abdominal soft tissue defects. The etiology of the tissue defect was trauma in four cases, cancer in five cases and complications of other surgical procedures in three cases.The meta-analysis did not show any specific occurrence or association relative to this flap and just reveals geographical differences concerning the indications, the type of flap, and sex ratio from a continent to another.

Conclusions

We consider this flap a very effective and useful tool in the daily armamentarium of the microsurgeon. The main advantage of this flap is the possibility to design a reliable small muscular free flap, with only one muscular digitation. Uses are many and various: trauma or post-trauma, cancers, vascular deformities or diseases, facial paralysis, and osteomyelitis. Level of Evidence: Level IV, therapeutic study     

Risk factors and complications in hip reconstruction for nonambulatory patients with cerebral palsy

Background

Hip dysplasia is prevalent in nonambulatory children with cerebral palsy, and may contribute to a decreased quality of life (Lonstein in J Pediatr Orthop 6:521–526, 1). Reconstructive procedures such as a femoral varus derotation osteotomy with or without a pelvic osteotomy are commonly employed with the goal of achieving and maintaining well reduced hips.

Purposes

The goals of this study are both to characterize the complications of reconstructive procedures and to identify risk factors that may contribute to these complications.

Patients and methods

A retrospective analysis was conducted among 61 nonambulatory children (93 hips) with cerebral palsy who underwent a femoral varus derotation osteotomy, with or without an open reduction and/or pelvic osteotomy, from 1992 through 2008 at our institution. The average patient age was 8.1 years (2.6–14.7) and the mean follow-up time was 5.9 years (2.1–15.9).

Results

The cumulative complication rate per patient including failures to cure was 47.6 %. Spica casting was found to be a risk factor for all complications (P = 0.023); whereas patients younger than 6 years old (P = 0.013) and children with a tracheostomy (P = 0.004) were found to be risk factors for resubluxation following surgery.

Conclusions

Although reported complication rates of hip reconstructive procedures performed upon children with cerebral palsy have varied considerably, those with more severe disease have experienced more complications. We report our tertiary referral center’s complication rate and our institutional experiences with risk factors for complications and failures to cure.

Level of evidence

IV, Retrospective case series.     

The inferior pedicle flap used as “filler” in breast conservative therapy

Background

Oncoplastic techniques are capable of correcting or preventing morphological changes of the breast undergoing conservative surgery with the aim of improving the cosmetic outcome and therefore the quality of life. Literature reports several post-conservative surgical oncoplastic procedures using autologous or local glandular tissue.

Methods

Authors report their experience with 24 breast cancer patients (localized in upper and central quadrants). The flap used, described by Ribeiro, is a dermal–adiposal–glandular flap with an inferior pedicle prepared utilizing the lower breast pole. In the six cases, we have performed an immediate nipple reconstruction using C–V flap, sculpted with a skin island on the Ribeiro flap, and areola tattooing. The mean age was 56.3 years (range, 35 to 74 years), and mean follow-up was 26 months (12 to 40 months). The level of patient satisfaction was rated on a 1 (low) to 5 (high) scale, before and after radiotherapy (12 months).

Results

In all patients, no depression of the superior quadrants was noted, as well as no morphological change noted in the “oncological” breast contour and that of the “cosmetic” contralateral breast, with mean satisfaction score of 4.2. The degree of satisfaction symmetry, assessed at 1 year from radiotherapy, had a mean satisfaction score of 4.0.

Conclusions

The use of the Ribeiro flap as a filler in appropriate and selected indications can represent a good alternative to the many reconstructive methods available for partial breast resection. Level of Evidence: Level IV, therapeutic study.     

Frequent malpositions of peripherally inserted central venous catheters in patients undergoing head and neck surgery

Purpose

Peripherally inserted central venous catheters (PICCs) do not interfere with surgical access during neck dissection and are used in patients undergoing head and neck surgery. However, severe complications associated with malpositioning of PICCs have been reported in these patients. We conducted a retrospective study to determine the incidence of aberrant positioning of PICCs in patients undergoing free flap reconstructive (FFR) surgery for head and neck malignancies.

Methods

We analyzed a database of 269 patients undergoing FFR surgery. After induction of general anesthesia, a PICC was inserted successfully in 130 patients (48%) at bedside without image guidance. A PICC was not used in 139 patients (52%). A chest x-ray was performed at admission to the postanesthetic care unit, stored digitally, and reviewed retrospectively by two independent observers. Based on the chest x-ray findings, the PICC position was classified as proper, suboptimal, or aberrant and defined according to the position of the PICC tip, i.e., proper, if situated in the ipsilateral innominate vein or in the superior vena cava; suboptimal, if situated in the subclavian vein; and aberrant, if situated in any other location.

Results

Proper, suboptimal, and aberrant PICC positions were found in 68 (52%), 17 (13%), and 45 (35%) patients, respectively. The proper position was confirmed more frequently with a left- than with a right-sided approach: 23/29 (79%) vs 45/101 (44%) patients, respectively (P < 0.001).

Conclusions

There is a high incidence of aberrant positioning when PICCs are inserted without image guidance. The left-sided approach might be preferable due to a lower incidence of malpositions. The risk-benefit ratio should be estimated carefully before using a PICC in patients undergoing FFR procedures.     

Clinical experience using a tensor fascia lata flap in oncology patients

Purpose

The tensor fascia lata (TFL) flap is used to reconstruct various anatomical structures in different regions of the body. We herein describe the use of TFL flaps for a variety of indications, and discuss the results of such procedures with respect to postoperative complications in oncology patients.

Methods

We reviewed 15 oncology patients who were treated with TFL flaps.

Results

The lesions were located in the groin in five patients, the lower abdomen in five, and the buttocks, ischium, shoulder, thigh and upper abdomen in one patient each. Abdominal wall reconstruction was performed in nine patients. Three patients underwent resection of femoral vessels and the tumor in the groin, followed by a vascular graft implant. In these patients, the combined flaps were transferred to reconstruct the defects. Nine patients developed complications. No total flap loss occurred in any patient.

Conclusions

Postoperative complications, such as necrosis in the distal part of the flap (33 %) and ventral hernias (11 %) were seen, but these percentages were comparable to those seen in previous reports. Our review shows that the TFL flap is useful to reconstruct the defects in various anatomical sites in oncology patients.     

Soft tissue coverage of war extremity injuries: the use of pedicle flap transfers in a combat support hospital

Purpose

Definitive management of extremity injuries including soft tissue coverage is seldom achieved in battlefield medical treatment facilities due to limited resources and operational constraints. The purpose of this study was to analyse the French Army Medical Service experience performing such reconstructive surgery in a Combat Support Hospital (CSH) in Afghanistan.

Methods

A clinical study was performed in the KaIA (Kabul International Airport) CSH from July 2012 to January 2013.

Results

During this period 23 Afghan patients treated for soft tissue coverage of combat-related extremity injuries were included. They totalled 28 extremity injuries including 18 blast trauma (BT) and ten non blast trauma (NBT). Overall, 35 extremity pedicled flaps were performed. There were 26 fasciocutaneous flaps, eight muscle flaps and one composite flap. Soft tissue coverage was achieved on all patients reviewed with a mean follow-up of 59 days. Five postoperative complications occurred including two deep infections, one partial flap necrosis and two flap failures, without difference according to injury mechanism.

Conclusion

Reconstruction of traumatic soft tissue defect can be achieved in CSHs for local nationals. Pedicle flap transfers provide simple and safe coverage for war extremity injuries in this challenging environment whatever the injury mechanism.     

Midterm outcomes of sutureless technique for postoperative pulmonary venous stenosis

Background

The efficacy of a sutureless technique for postoperative pulmonary venous stenosis (PVS) following repair of total anomalous pulmonary venous connection (TAPVC) has been reported, though detailed clinical advantages remain unclear. We retrospectively reviewed our surgical experience, and compared outcomes between conventional procedures and a sutureless technique.

Methods

For relief of postoperative PVS after TAPVC repair, five patients underwent a conventional procedure, such as orifice cutback or resection of a proliferated intima, from 1999 to 2004 (Conventional group, 4 males, median 93 days old, 3.6 kg), then seven underwent a sutureless technique (Sutureless group, 5 males, 119 days old, 3.4 kg) from 2005 to 2011. Patients with a functional single ventricle were excluded. There were no significant differences regarding patient characteristics. Follow-up examinations were completed in all patients.

Results

The rate for cumulative survival at 5 years was 60 % in the Conventional group and 71.4 % in the Sutureless group. Re-stenosis after relief of PVS occurred in 100 % (10/10) of patients in the Conventional group and 31.6 % (6/19) of patients in the Sutureless group (p = 0.0088). For bilateral venous stenosis patients, the survival rate was 66.7 % (4/6) in the Sutureless group and 0 % (0/2) in the Conventional group (p = 0.10). Out of three patients who developed whole 4-vein stenosis, only one in the Sutureless group survived.

Conclusions

Although overall survival rate was similar in both groups, the Sutureless technique for postoperative PVS following TAPVC repair successfully rescued more pulmonary veins without re-stenosis than conventional procedures. Further follow-up may demonstrate therapeutic advantages.     

Using pedicled TRAM flap in conjunction with the bony anchoring reinforcement system (BARS) for abdominal wall reconstruction

Background

Pedicled transverse rectus abdominis myocutaneous (TRAM) breast reconstruction is associated with increased abdominal wall morbidity. We present a method of abdominal wall reconstruction using an adjunct technique to validated procedures of hernia repair.

Methods

This study is a retrospective, single-surgeon analysis of 21 patients between 2005 and 2012. Patients had bony suture anchoring of synthetic polypropylene mesh to the anterior superior iliac spine bilaterally and the pubic symphysis after the abdominal fascia was reconstructed.

Results

Patient mean follow-up was 62 months. Of the series, five patients underwent bilateral pedicled TRAM breast reconstruction. None of the 21 patients developed abdominal wall hernias. One patient developed postoperative bulging, which was retreated successfully. Two patients developed mesh infections; none required radical removal of mesh. There were no flap failures or loss in the series.

Conclusions

The BARS technique for abdominal wall reconstruction provides excellent reinforcement of abdominal reconstruction in conjunction with pedicled TRAM breast reconstruction. Level of Evidence: Level IV, therapeutic study.     

Statistical Analysis of Surgical Site Infection After Head and Neck Reconstructive Surgery

Background

Surgical site infections (SSIs) occur at a rate exceeding 40 % after head and neck reconstruction and are due in part to the clean-contaminated surgical field, in which cutaneous fields interact with oral or pharyngeal fields. The aim of this study was to clarify the most important risk factors for SSI and to identify effective strategies for preventing SSI.

Methods

In 2011 and 2012, 197 patients who underwent head and neck reconstructive surgery were studied at National Cancer Center Hospital East, Japan. The SSI rate, risk factors for SSI, and biological aspects of SSI were evaluated prospectively.

Results

A total of 42 patients (21.3 %) had SSIs, and 62 bacterial species were identified at infection sites. Significant risk factors for SSI identified with multivariate analysis were hypoalbuminemia [P = 0.002, odds ratio (OR) = 3.37], reconstruction with vascularized bone transfer (P = 0.006, OR = 3.99), and a poor American Society of Anesthesiologists Physical Status score (P = 0.041, OR = 3.00). Most bacteria identified were species that persist around cutaneous and pharyngeal fields, but multidrug-resistant bacteria were rare.

Conclusions

The SSI rate at our hospital is lower than rates in previous studies. To minimize SSI, intervention to improve the patient’s perisurgical nutritional status and a more appropriate mandible reconstructive strategy should be considered.     

What Is the Effect of Stoma Construction on Surgical Site Infection After Colorectal Surgery?

Introduction

The aim of our study was to evaluate the effect of stoma creation on deep and superficial surgical site infections after an index colorectal surgical procedure.

Methods

We designed a retrospective cohort study from the National Surgical Quality Improvement Program. We evaluated all patients who underwent colorectal surgery procedures from January 2005 to December 2009 with or without creation of a stoma and sought to identify the effect of stoma creation on deep and superficial surgical site infections.

Results

A total of 79,775 patients underwent colorectal procedures (laparoscopic 30.7 %, open 69.3 %), while 8,113 patients developed a surgical site infection (10.2 %). The univariate analysis revealed that surgical site infections were much more common in patients with a stoma compared to those with no stoma (11.8 % vs. 9.5 %, p?<?0.0001). On multivariate analysis, stoma construction during the index colorectal procedure (OR 1.3, CI 1.2 to 1.4), ASA class ≥2, smoking, and abnormal body mass index were associated with surgical site infection.

Conclusions

The construction of a stoma with colorectal procedures is associated with a higher risk of surgical site infection. Although the stoma effect on surgical site infection is attenuated with laparoscopic techniques, the association remained statistically significant.