Inferiorly based nasolabial flap for reconstruction of the moderate to large defects of lips following cancer resection

Background

Reconstruction of the lip defects following wide excision of the squamous cell cancer is challenging for the surgeon. Our aim was to define the role of the inferiorly based nasolabial flap for lip reconstruction in such cases with moderate to large size defects.

Methods

Lip defects were reconstructed with a unilateral or bilateral subcutaneous nasolabial flaps depending on the size of the defect following wide resection of their lip cancers.

Results

All the defects were reconstructed in a single stage. We achieved good lip seal and at least good function in eating and speaking. There was no entropion of the lip, and all the reconstructed lips preserved their height.

Conclusion

Simplicity of dissection, robust blood supply, best color match, short procedure time, and minimal donor site morbidity reinforce this flap as a useful adjunct in lip reconstruction.Level of Evidence: IV, therapeutic study.

     

Aesthetic rhinoplasty as the final step of nasal reconstruction with a forehead flap

Background

The reconstruction of nasal defects represents a difficult challenge for a plastic surgeon as it can be actually difficult to obtain good aesthetic and functional results. Reconstruction needs the use of several complex flaps, including the forehead flap. However, the use of the forehead flap does not give always the optimal aesthetic result. In our opinion, rhinoplasty can optimize the aesthetic outcome and can be used as the last step in nasal reconstruction.

Methods

From the patients admitted to our department, resulting in full thickness nasal defects and reconstructed using the forehead flap, ten were selected to perform rhinoplasty after passing the inclusion criteria.

Results

In the patients where rhinoplasty was performed we obtained aesthetic and functional improvement. The patients referred better acceptance of the residual surgical stigmata and improvement of social acceptance.

Conclusions

Optimizing the aesthetic appearance of the nose, making it look better than before surgery, is fundamental to improve patient’s life quality and better acceptance of the demolition or trauma.Level of Evidence: Level V, therapeutic study.

     

Reverse sural flap with an adipofascial extension for reconstruction of soft tissue defects with dead spaces in the heel and ankle

Introduction

The reconstruction of soft tissue defects with dead spaces in the heel and ankle is challenging. This article describes our experience in the reconstruction of such defects using the reverse sural flap with an adipofascial extension.

Method

Reverse sural flaps with an adipofascial extension were used in 26 patients with soft tissue defects in the heel (n = 24) or ankle (n = 2). Extended adipofascial tissue was utilized to fill the dead space. The sizes of the adipofascial extensions varied from 2.0 to 5.0 cm in length and 4.0 to 12.5 cm in width.

Result

Twenty-three flaps survived completely, and lateral marginal necrosis occurred in three flaps. All the recipient-site wounds healed without any signs of infection. The reconstruction outcomes were excellent in 20 patients and good in 6 patients according to the criteria of Boyden et al.

Conclusion

The extended adipofascial tissue of the reverse sural flap improves closure of the dead spaces in soft tissue defects of the heel and ankle and thus provides beneficial conditions for the treatment of infection and reconstruction of both the function and contour of the soft tissue defects with dead spaces in the heel and ankle.

     

Pre-expanded epigastric flap cover for ventral hernia following fungal necrotizing fascitis of caesarian section wound: An unusual complication

Introduction

Reconstruction of anterior abdominal wall after necrotizing abdominal wall infections is a challenge.

Material and methods

A 35-year-old lady presented with 20 × 18 cm sized defect of the anterior abdominal wall following fungal necrotizing fascitis. The defect was covered by an overlay prolene mesh and the soft tissue deficit was corrected by pre-expanded epigastric flap based on the superior epigastric artery.

Conclusion

A concerted multi-specialty effort is needed to correct these defects.

     

Versatility of lateral arm flap for hand reconstruction—a clinical experience

Background

The lateral arm free flap (LAFF) has several advantages in hand reconstruction due to multiple factors. We aimed to show the versatility of LAFF in treating hand defects.

Methods

A retrospective analysis of all LAAF for hand reconstruction carried out at our institutions between August 2006 and August 2012 was undertaken. Clinical records were reviewed with respect to patients’ age and gender, size and location of defect, type and size of flaps, and complications.

Results

Twenty-four hand defects were reconstructed using LAFF. These included 15 cutaneous flaps, 8 fascial flaps, and 1 osteocutaneous flap. All flaps survived well except for one case that developed arterial insufficiency and required anastomotic revision. Primary closure of the donor site was possible in all patients. No complications occurred during the healing procedure.

Conclusions

The free lateral arm flap is a versatile and reliable option for defect coverage at the hand for small- and medium-size defects. It can be raised as a cutaneous, fascial, or osteocutaneous flap. Several advantages favor the use of lateral arm flap in hand reconstruction. These include preservation of major arm blood vessels, its constant vascular anatomy, long pedicle, and low donor site morbidity.Level of Evidence: Level IV, therapeutic study.

     

Laparoscopic implantation of electrodes for bilateral neuromodulation of the pudendal nerves and S3 nerve roots for treating pelvic pain and voiding dysfunction

Introduction and Hypothesis

The objective of this video is to describe the technique for laparoscopic implantation of electrodes for bilateral neuromodulation of S3 and pudendal nerves. We report a successful case of a 48-year-old woman with spina bifida occulta referred with a 14-year history of intense acyclic pelvic pain, urinary hesitancy, and intermittent flow refractory to various conservative measures.

Methods

The procedure began with the removal of two previously placed InterStims. A quadripolar electrode was then laparoscopically inserted into Alcock’s canal and attached to the pelvic pectineal line. Another lead was placed juxtaneurally to S3. Lead contacts were then exteriorized, and the peritoneum closed. The same procedure was then performed on the contralateral side. The leads were connected to a 16-pole rechargeable pulse generator. Postoperatively, the patient developed an acute dissection and partial thrombosis of the external iliac artery, which was treated endovascularly.

Results

Complete pain resolution was observed with simultaneous S3 and pudendal stimulation, with pudendal stimulation turned off for voiding.

Conclusions

We conclude that laparoscopic implantation of neuromodulation electrodes allows simultaneous stimulation of S3 and pudendal nerves, providing more programming options and possibly increasing success rates in complex pelvic floor dysfunction cases.

     

Is there a place for a biological mesh in perineal hernia repair?

Purpose

This study aimed to determine the outcome of perineal hernia repair with a biological mesh after abdominoperineal resection (APR).

Method

All consecutive patients who underwent perineal hernia repair with a porcine acellular dermal mesh between 2010 and 2014 were included. Follow-up was performed by clinical examination and MRI.

Results

Fifteen patients underwent perineal hernia repair after a median of 25 months from APR. Four patients had a concomitant contaminated perineal defect, for which a gluteal fasciocutaneous flap was added in three patients. Wound infection occurred in three patients. After a median follow-up of 17 months (IQR 12–24), a clinically recurrent perineal hernia developed in 7 patients (47 %): 6 of 11 patients after a non-cross-linked mesh and 1 of 4 patients after a cross-linked mesh (p = 0.57). Routine MRI at a median of 17 months revealed a recurrent perineal hernia in 7 of 10 evaluable patients, with clinical confirmation of recurrence in 5 of these 7 patients. No recurrent hernia was observed in the three patients with combined flap reconstruction for contaminated perineal defects.

Conclusion

A high recurrence rate was observed after biological mesh repair of a perineal hernia following APR.

     

Influence of postoperative vasoactive agent administration on free flap outcomes

Background

The use of vasoactive agents (VAs) in free flap reconstruction remains controversial due to the potential risk of free flap failure. Most of the existing literature has focussed on intraoperatively administered VAs in free flap procedures. However, hypotension frequently requires VA support, both intraoperatively and in the first postoperative days. The objective of this study was to analyse the influence of postoperatively administered VAs on thromboembolic complications.

Methods

A retrospective study was performed including all patients undergoing free flap reconstruction between February 2010 and June 2012. Logistic regression analysis identified predictors for postoperative VA administration and whether its use was a prognostic risk factor for the outcome parameters of revision surgery or free flap loss due to vascular compromise of the venous or arterial anastomosis.

Results

A total of 209 free flap procedures were performed, with an overall survival rate of 94.3 %. In 19.7 % of the free flap procedures performed, postoperative VA administration was noted. Predictors for postoperative VA administration were intraoperative VAs, age ≥50, ASA ≥3, hypertension and peripheral vascular disease. Postoperative VA administration was found to be a significant risk factor for the outcome parameter of revision surgery, particularly in the perforator free flaps used for lower extremity reconstruction. However, there was no significant correlation between the postoperative use of VAs and free flap loss.

Conclusions

We have demonstrated an association between postoperative VA administration and an increased revision rate in free flaps. Appropriate flap selection, close free flap monitoring and optimally adjusted anticoagulation therapy are recommended in patients receiving VA support during the early postoperative free flap period.Level of Evidence: Level III, risk/prognostic study.

     

Anatomische Rekonstruktion nach weiblicher Genitalbeschneidung

Background

Female genital mutilation/cutting (FGM/C) is a worldwide problem affecting millions and millions of women and is especially common in Africa and Arabic countries. Affected women suffer from severe physical and psychological problems. Anatomic reconstruction is therefore an important and life-changing option for many affected women.

Objective

This article gives an overview of specialized techniques developed by the author for functional and aesthetic vulvar reconstruction following FGM/C, in addition to some basic background problems of FGM/C.

Material and methods

The anterior obturator artery perforator flap (aOAP flap), the omega domed flap (OD flap), and a microsurgical procedure called neurotizing and molding of the clitoral stump (NMCS procedure) are described.

Results

The aOAP flap for vulvar reconstruction, the OD flap for clitoral prepuce reconstruction and the NMCS procedure for reconstruction of the glans of the clitoris showed natural, reliable and long-lasting results, all of which normalize the anatomy of the mutilated external female genitalia.

Conclusion

The reconstruction options presented contribute to re-establish normal anatomy and therefore support women’s health and likewise relieve the burden enforced upon them by FGM/C.

     

Robotic vesico-vaginal fistula repair with no omental flap interposition

Introduction and hypothesis

A vesico-vaginal fistula (VVF) is a fistulous tract that connects bladder and vagina, causing urine leakage via the vagina. In the developed world, iatrogenic postoperative VVF is the most common case. Classically, when treating a VVF via the abdominal route, an abdominal flap is mobilized and interposed between the bladder and the vagina.

Methods

In our video, we describe a robotic VVF repair technique with no omental flap interpositioning for a vaginal vault-located fistula.

Results

Duration of surgery was 95 min, estimated blood loss was <50 ml. The postoperative course was uneventful. At the 6-month follow-up, which included clinical and cystographic examinations, the patient had not experienced any recurrence.

Conclusion

In our opinion, a two-layered suturing technique using two semi-continuous sutures for vaginal closure and perpendicular interrupted stitches for bladder closure does not require omental flap mobilization, reducing operating time and possible complications related to accidental peritoneal injuries.

     

Robot-assisted ureteral reconstruction using a tubularized peritoneal flap: a novel technique in a chronic porcine model

Objective

To evaluate the feasibility and functional outcomes in porcine models of a novel robotic surgical technique for the treatment of complex ureteral injuries and strictures.

Materials and methods

Six pigs underwent robotic ureteral reconstruction using a long tabularized peritoneal flap and followed for 6–9 weeks after the surgery. Ureteral flap vascularity, intra-renal pressure, patency of the conduct, endoscopic aspect of the flap, renal function and histopathology were evaluated.

Results

All animals successfully underwent ureteral reconstruction using a tubularized peritoneal flap. Median operative time was 223 min (162–360). Flap tubularization suture took 31 min (19–47), and proximal anastomosis took 20 min (15–38). Bladder mobilization with psoas hitch and distal anastomosis took 9 min (7–12) and 23 min (13–46), respectively. On follow-up, significant shrinkage of the ureteral flap in both length and width was observed. Antegrade pyelograms confirmed dilation and tortuosity of the proximal ureter, dilation of the renal pelvis, and major and minor calyxes without any definitive strictures. Microscopically, focal urothelial lining was seen in the neoureter. Creatinine level was significantly higher at the end of the follow-up period (p = 0.003).

Conclusions

Robot-assisted ureteral reconstruction using a tubularized peritoneum flap is technically feasible and reproducible. The flap sustained abundant vascular supply after different intervals of follow-up and the peritoneal mesenchymal cells differentiated into urothelium and myofibroblasts. Further studies are needed to address the issue of functional obstruction to improve long-term renal function outcomes.

     

Rekonstruktion bei schweren Weichteilverletzungen an der Hand

Background

Severe soft tissue defects of the hand are often caused by occupational trauma and frequently lead to considerable functional impairment.

Objective

Which reconstructive options and what supportive treatment measures are available for severe soft tissue defects of the hand?

Material and methods

A representative summary of treatment measures concerning primary care and further covering of defects as exemplified by selected cases from our own patients and additional recommendations for treatment are presented.

Results

The reconstruction of severe soft tissue defects of the hand usually consists of several steps and is performed according to individual patient needs. For this purpose, different types of local, pedicled and free flaps are available.

Conclusion

Hand surgery provides a wide range of options for the reconstruction of tissue defects of different etiologies. The spectrum of operative procedures encompasses both local and pedicled flaps as well as free flaps taken from other regions of the body with microvascular connection to the recipient region. Free flaps are an essential pillar in the reconstructive treatment and due to the safety in the execution, the application of free flaps should not only be seen as a last resort. Many kinds of free flaps can be harvested with parts from different tissue types or as a combination of several free flaps. As a result individual solutions can be provided depending on patient needs. Supportive measures following free flap surgery can help to improve the postoperative result with respect to blood supply, complaints and function.

     

Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap

Introduction and hypothesis

Urethrovaginal fistula is a rare disorder that may occur following sling procedures for stress urinary incontinence, excision of a urethral diverticulum, anterior vaginal wall repair, radiation therapy, and prolonged indwelling urethral catheter. The most common clinical manifestation is continuous urinary leakage through the vagina, aggravated by an increase in the intra-abdominal pressure. Appropriate management, including timing of the surgical intervention and the preferred technique, remains controversial.

Methods

This video presentation describes the transvaginal repair of a urethrovaginal fistula using the Latzko technique and a bulbocavernosus (Martius) flap.

Results

The patient’s postoperative course was uneventful. At her follow-up visit 2 months later, she was free of urinary leakage, and a pelvic examination revealed excellent healing, with complete closure of the fistula.

Conclusions

Transvaginal repair using the Latzko technique with a vascular bulbocavernosus (Martius) flap is an effective and safe mode of treatment.

     

Results of the modified bi-pectoral muscle flap procedure for post-sternotomy deep wound infection

Purpose

Post-sternotomy deep sternal wound infection (DSWI) is a severe complication of cardiac surgery. The introduction of omental and muscle flaps has resulted in a significant decrease in morbidity and mortality. In this article, we present the findings for a series of 55 consecutive patients with DSWI treated using an alternative bi-pectoral musculofascial flap technique.

Methods

The patients were stratified into two groups (one-or two-stage intervention). Patients with septic wounds initially underwent debridement and wound treatment, while vacuum therapy was used in a subset of the subjects. All patients were treated with wound debridement and bi-pectoral advancement flap reconstruction.

Results

30-day mortality was 5.4 %. Most patients (72 %) were treated in two stages, while vacuum therapy was used in 20 % of the patients. The mean number of hospitalization days was 8 and 12 for the one- and the two-stage groups, respectively. Reconstruction was successful in all but three patients, each of whom developed recurrent infection. No major morbidity was reported at a mean follow-up of 82 months with excellent functional and aesthetic outcomes.

Conclusions

Pectoralis-major muscle flaps remain relevant in the modern management of post-sternotomy mediastinitis. The addition of an omental flap should be considered in cases in which the lower sternum is involved. Prompt diagnosis and a meticulous surgical technique ensure favorable results for the majority of patients.

     

Transverse preputial onlay island flap urethroplasty for single-stage correction of proximal hypospadias

Aims and objectives

Transverse preputial onlay island flap urethroplasty (TPOIF) was described initially for distal hypospadias, but has seen extended application for proximal hypospadias. We describe a set of modifications in the technique and results in a large series of proximal hypospadias.

Materials and methods

All children who underwent TPOIF repair for proximal hypospadias (proximal penile, penoscrotal and scrotal) from June 2006 to June 2013 by a single surgeon were prospectively followed till June, 2014. A standard technique and postoperative protocol were followed. Salient points to be emphasized in the technique: (1) dissection of the dartos pedicle till penopubic junction to prevent penile torsion, (2) incorporation of the spongiosum in the urethroplasty, (3) midline urethral plate incision in glans (hinging the plate), (4) Dartos blanket cover on whole urethroplasty.

Results

Out of 136 children with proximal hypospadias, 92 children who underwent TPOIF formed the study group. Out of 92 children, 48 (52 %) children required a tunica albuginea plication for chordee correction. In total, 16 (17 %) patients developed 24 complications and 11 children (12 %) required second surgeries: fistula closure in 7 (with meatoplasty in 5), glansplasty for glans dehiscence in 2 and excision of diverticulum in 2. Two children required a third surgery. Only 5 children had a noticeable penile torsion (less than 30 degree), and 7 had a patulous meatus.

Conclusions

Transverse preputial onlay island flap urethroplasty can deliver reliable cosmetic and functional outcomes in proximal hypospadias.

     

Weichteiltumoren des Bewegungsapparates

Background

Resection of musculoskeletal soft tissue tumors can cause large resection defects.

Objective

Which defects after resection of musculoskeletal soft tissue tumors can be covered?

Methods

A literature search was carried out, the results were analyzed and are discussed.

Results

Musculoskeletal soft tissue tumors are comparatively rare tumors in Germany. There are guidelines for oncological therapy. Even though there are no guidelines for the plastic reconstruction after musculoskeletal soft tissue tumor resection, multiple concepts have been described in the literature. A differentiation must be made between the resection defect coverage and the restoration of function. The donor site morbidity must also be taken into account when planning the covering. In addition to reconstructions with autologous tissue, a reconstruction with prostheses is also possible.

Conclusion

Decisive for the successful therapy is the early involvement of the plastic or reconstructive surgeon in the treatment planning in order to achieve an optimal result for the patient.

     

A technique for pediatric chest wall reconstruction using custom-designed titanium implants: description of technique and report of two cases

Purpose

We present a surgical technique for chest wall reconstruction using custom-designed titanium implants developed for two female patients to provide both chest wall symmetry and adequate stability for staged breast reconstruction.

Methods

A retrospective review was performed for two adolescent female patients with large chest wall defects who underwent the described technique. The etiology of the chest wall deficiency was secondary to Poland’s syndrome in one patient, and secondary to surgical resection of osteosarcoma in the other patient. For each patient, a fine-cut computed tomography scan was obtained to assist with implant design. After fabrication of the prosthesis, reconstruction was performed though a curvilinear thoracotomy approach with attachment of the implant to the adjacent ribs and sternum. Wound closure was obtained with use of synthetic graft material, local soft tissue procedures, and flap procedures as necessary.

Results

The two patients were followed post-operatively for 35 and 38 months, respectively. No intra-operative or post-operative complications were identified. Mild scoliosis that had developed in the patient following chest wall resection for osteosarcoma did not demonstrate any further progression following reconstruction.

Conclusions

We conclude that this technique was successful at providing a stable chest wall reconstruction with satisfactory cosmetic results in our patients.