Free flap “steal” hastening amputation of a revascularized lower limb

Complex limb threatening wounds secondary to end-stage atherosclerotic peripheral occlusive disease remain significant challenges that frequently mandate vascularized tissue coverage that can only be achieved with a microsurgical composite tissue transfer. Following or concurrent with limb revascularization, the theoretical risk that such a free flap could divert flow to a comparably lower resistance system of the flap has been previously considered hypothetical. We present a case report where we believe such a steal syndrome did occur as suggested by arteriogram, and this adverse phenomenon hastened limb amputation. This possible risk must be carefully explained and accepted by these patients prior to embarking on these complex limb salvage attempts.     

“Three-dimensional evaluation of breast volume changes following autologous free flap breast reconstruction over six months”

ObjectivesTo date, little is known about postoperative changes in breast volume after autologous breast reconstruction. The purpose of this retrospective study was to investigate breast volume changes following autologous free flap reconstruction and the factors affecting flap volume.Materials and methodsPatients who underwent deep inferior epigastric perforator, superficial inferior epigastric artery and profunda artery perforator flaps between December 2016 and January 2019 were included. Exclusion criteria were breast complications requiring surgical debridement, and the absence of at least two suitable three-dimensional images postoperatively. Three-dimensional stereophotogrammetry volume measurements were performed at the time of standard surgical check-ups. Changes in breast volume were modeled using a quartic polynomial curve function in a nested mixed effects model.Results136 breasts in 101 patients were included. An average decrease of predicted breast volume was found from 637.8 cc (95%-CI [624.4, 651.1]) at two weeks to 566.6 cc (95%-CI [535.1, 598.0]) after three and 567.6 cc (95%-CI [515.9, 617.6]) after six months postoperatively. Reconstruction timing and first postoperatively measured breast volume showed a statistically significant difference in initial reconstructed breast volume and in the shape of the relationship between time and breast volume, whereas autologous technique and BMI only showed a statistically significant difference in initial reconstructed volume and mastectomy indication in the shape of the relationship.ConclusionThe final overall flap volume decreased to 88.9% of its original volume after six months. Gaining more insight into the factors influencing flap volume is of crucial importance to facilitate predictable surgical outcomes.     

Comparison of the outcomes of adipofascial and two–staged fasciocutaneous reverse sural flap in patients with lower leg trauma

BackgroundDistal one – third trauma of the lower limb is a complex condition to treat. The reverse sural flap is a time tested procedure for reconstruction of such defects especially in patients where free flaps are ruled out due to comorbidities. The purpose of this study is to compare the two modifications of the classical technique of reverse sural flap (adipofascial and fasciocutaneous) which is lacking in the literature.Material & methodsIn this study, the authors conducted a retrospective analysis of 67 patients with lower one-third leg defects reconstructed with either adipofascial reverse sural flap (Group A, n = 37) or two-staged fasciocutaneous reverse sural flap (Group B, n = 30) in a tertiary care hospital in North India between 2015 and 2019. An evaluation of the different flap characteristics of the two variants of the reverse sural flap was done and compared. Mean follow up period was 12 months.ResultsThe adipofascial group showed shorter operative time, was a single-stage and with better reach and aesthetic outcome. The complications did not differ except that for the adipofascial group was associated with unstable skin graft over the flap initially which did not require any treatment.DiscussionLower one-third defect of the lower limb has been a challenge for reconstructive surgeons all over the world. The goal of reconstruction is a functional lower limb. Although free tissue transfer is the preferred modality of treatment of such cases but it may not be possible in all cases due to various reasons. Reverse sural flap is a very lucrative local option for such reconstructions as it is easy to perform, reliable, low profile and bulk, require minimal facilities with less operative time. Adipofascial flaps represent an extremely useful modification of the reverse sural flap which is quick to perform with minimal donor site morbidity.ConclusionAdipofascial reverse sural artery flap is a good option for patients with lower limb trauma with the added advantage of being single-stage and with better donor site cosmesis as compared to the fasciocutaneous reverse sural artery flap.     

Surgical treatment of deep-lying ano-/rectovaginal fistulas using a de-epithelialized “Singapore flap” (pudendal thigh flap)

European Surgery - Rectovaginal fistulas represent 5% of all anorectal fistulas. For affected women, this pathology is associated with a reduction in quality of life (QoL) and self-esteem....     

Preservation of the lateral thoracic vein in axillary dissection – Its role in breast reconstruction using the DIEP flap

Axillary clearance is still an integral part of the surgical treatment of breast cancer. Despite evolution in surgical technique, some accessory axillary structures such as the lateral throacic vein, may be sacrificied in order to achieve and adequate oncological clearance. Recent years have seen rapid advances in onco-plastic surgery and its involvement in breast cancer patients. As many onco-plastic procedures necessitate an adequate blood supply, structures which were thought to be expendable such as the lateral thoracic vein, are now viewed as useful vessels for success. We describe the use of the lateral thoracic vein as a salvage option in the Deep Inferior Epigastric Perforator (DIEP) flap and encourage surgeons to preserve this vessels when appropriate and safe to do so.     

Correction of hypospadias with a vertical preputial island flap: the Göteborg experience of 47 patients

We report the follow-up of 47 patients with penile hypospadias who were treated by the Scuderi procedure between 1988 and 1998 at Sahlgrenska University Hospital, Göteborg, Sweden. Forty of the patients (85%) had had no previous operations, while the remaining seven had had meatotomy with chordectomy only, or an unsuccessful Dennis-Browne procedure. Hypospadias was distal in 35 (74%), mediopenile in 8 (17%), and proximal in 4 (9%); 21 (45%) showed signs of curvature. After a Scuderi urethroplasty one patient developed a fistula (2%) and 4 developed mild stenosis. The early success rate was therefore 42/47 (89%) and this later increased to 46/47 (98%) after non-surgical treatment of the stenoses. The results support the use of the Scuderi procedure for correction of primary and secondary penile hypospadias with a low complication rate.     

The horseshoe flap. An “emergency” oncoplastic breast surgery technique

Since 2003, oncoplastic breast surgery was introduced combining breast cancer resection and reconstruction. The goal of OBS is to achieve an oncologically safe surgery with the best possible cosmetic result. This type of procedure must be carefully planned preoperatively by taking into account several factors. However, sometimes this does not happen, and as a response to this factors’ neglect, we developed a technique to correct the defect from an upper quadrant breast cancer lumpectomy, which resulted to be wider than expected. This technique is called the horseshoe flap. Data were collected retrospectively from the Teramo Breast Unit database from June 2013 to December 2014. Both preoperative and postoperative data were recorded. The horseshoe flap was used in resections of 20 % or more of the breast volume and consisted in the dissection of the remaining breast tissue from the overlying skin flap, and the mobilization of the remaining part of the upper pole from the pectoralis muscle. The two upper extremities were folded to cover the substance loss in the lumpectomy. A total of five patients underwent a horseshoe flap to correct their defect resulting for an upper quadrant cancer excision. Average resection volume was 131 cc, and no poor or bad cosmetic results were observed. During the follow-up, no cancer recurrences were observed. Sometimes breast surgeons need to perform resections larger than expected, and we are challenged with the correction of the defect without the possibility of a preoperative planning. In this pilot work, we present a valid solution for this situation in case cancers are located in the upper quadrants of the breast.Level of Evidence: Level IV, therapeutic study.     

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.     

“Emergency” definitive reconstruction of a necrotising fasciitis thigh debridement defect with a pedicled TRAM flap

INTRODUCTIONNecrotising fasciitis (NF) is a rare, severe, rapidly progressing and life-threatening synergistic infection primarily affecting the superficial fascia. A novel method of definitive and aesthetic reconstruction of NF thigh defects by using a pedicled transverse rectus abdominis myocutaneous (TRAM) flap without recourse to temporising skin grafts is presented.PRESENTATION OF CASEA 30-year-old parous woman presented in extremis with fulminant NF of her left anteromedial thigh. Following emergency radical debridement and intensive care stabilisation she was reconstructed 48 h later in a single stage with a pedicled TRAM flap islanded on the ipsilateral deep inferior epigastric vessels. There was excellent contour restoration of her thigh and coverage of the exposed femoral vessels.DISCUSSIONPedicled flaps based on the rectus abdominis muscle provide a large, readily available reconstructive option for correction of substantial regional defects as herein illustrated. They are robust when based on dominant inferior vascular pedicle with a long reach and wide arc of rotation when designed transversely (as a TRAM flap).CONCLUSIONThis case also illustrates that definitive flap reconstruction of NF can be successfully undertaken in the emergent setting, thereby negating the need for large areas of skin grafting which can lead to contractures with consequent functional impairment and suboptimal aesthetic results.     

“Hammock” reconstruction of full-thickness excised lower lip: a case report

A number of techniques have been described to reconstruct lower lip defects. A microsurgical total lower lip reconstruction was performed in a 48-year-old female patient affected by a squamous cell carcinoma of the lower lip. The patient underwent a wide lower lip resection and an immediate aesthetic and functional lower lip reconstruction. The lower lip was reconstructed with a composite radial forearm palmaris longus flap. The subcutaneous layer of the residual upper lip was undermined and palmaris longus tendon was transfixed to the paranasal portion of the orbicularis oris muscle, giving to the flap a good aesthetic “hammock” effect and achieving a nearly impairment free function. The use of a forearm free flap for lower lip reconstruction has previously been described, with poor functional results. We have described a different technique to inset and fix the flap using palmaris longus tendon: the suspension vector of the flap and the preservation of the residual orbicularis oris fibers seem to be of great importance to achieve a satisfactory functional recovery. We propose that the radial forearm free flap comprising palmaris longus tendon, inset and fixed with the described technique, may be a good alternative among the surgical options for full-thickness lower lip defects in order to achieve a satisfactory aesthetic and functional reconstruction.     

Retrospective study of reverse dorsal metacarpal flap and compound flap： a review of 122 cases

SincethereversedorsalmetacarpalflapisreportedbyLUetalinChina,QuabaetalandMaruyamainBritainin1990,14thisflapanditscompoundflaphavebeenappliedtorepairsofttissuedefectson fingersuniversallyduetoitstextureandcolormatched withnormalfingers.Inordertogainbetterapplianceofthiskindo flap,weanalyzedrespectivelytheoperativeindications andtherangeofrepairingbasedonfollow upof122casesfor112years.METHODS ClinicaldataFrom1990to2003,weappliedthereversedorsa metacarpalflapanditscompoundflapin122cases,whic…     

Reduction of the opposite breast in patients with a breast reconstructed with an implant: Validity of the inverted “T”, superior pedicle technique,with an inferiorly-based dermal adipose flap

Abstract

We reviewed 28 cases of breasts reconstructed with implants and reduction mammaplasty on the other side for symmetry, with the aim of assessing the stability and aesthetic result in the reduced breasts five years postoperatively. An inverted "T", superior pedicle technique, with an inferiorly-based dermal adipose flap was used in patients who did not have overstretched Cooper's ligaments. At the 5-year follow-up, the sternal notch-to-nipple and inframammary fold-to-nipple distances were measured and the degree of ptosis was evaluated (Regnault's classification). The patients recorded their satisfaction using a verbal numerical rating scale (1–5). The patients' photographs were also sent to 12 plastic surgeons for aesthetic assessment of the reduced breasts (same verbal numerical rating scale). The comparison of the preoperative and postoperative measurements and degrees of ptosis showed reasonable stability at least during a 5-year period. The patients' mean rating of the aesthetic result was 4.3, more than good, and the surgeons' mean rating was 3.4, more than satisfactory.     

Correction of the “Simian” forehead deformity

A procedure for the correction of the simian forehead deformity is described.     

Use of a “kickstand” modification for external fixation of lower extremity fractures in children

Purpose  

To evaluate and describe the kickstand modification and its use in children with lower extremity fractures.