Surgical prevention of pharyngocutaneous fistula in salvage total laryngectomy: a systematic review and network meta-analysis

PURPOSE

To compare the efficacy of different reconstructive techniques in preventing pharyngocutaneous fistula (PCF) after salvage total laryngectomy (STL).

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model according to the PRISMA-NMA guidelines.

RESULTS

A total of 1694 patients with a median age of 64 years (n = 1569, 95% CI: 62-66 years) were included. If compared to primary pharyngeal closure alone, only a pedicled flap onlay (PFO) showed a statistically significant reduction in PCF rate (OR: 0.35, CI: 0.20-0.61). PFO seemed to perform better than other treatments according to the rank probabilities test (39.9% chance of ranking first).

CONCLUSIONS

A pedicled flap placed with an overlay technique might be preferred over a patch reconstruction to prevent PCF after STL.

Long-term survival analysis of free flap reconstruction in patients with collagen vascular disorders

BACKGROUND

Collagen vascular disorders (CVD) are inflammatory diseases that can affect the blood vessels and soft tissues. Patients with CVD are often immunosuppressed, prone to hyper-coagulation, and represent a challenging patient cohort for free tissue transfer.

METHODS

A retrospective review of patients with CVD who underwent free flap reconstructions from 2000-2020 was performed at our institution. Inclusion criteria were patients 18 years old or older with the clinical diagnosis of CVD, including rheumatoid arthritis, Raynaud phenomenon, systemic lupus erythematosus, scleroderma, and sarcoidosis. A time-to-event analysis was performed to identify predictors of surgical complications.

RESULTS

A total of 78 patients and 96 free flaps were included. The most common CVD were rheumatoid arthritis (n=36) and Raynaud's phenomenon (n=9). Type of flap included abdominal-based flap (26%), trunk-based flaps (32.3%), and extremity-based flaps (19.8%). The mean age was 56.7±14.6 years, and the mean BMI was 27.5±5.9 kg/m2. Antibody positivity was present in 25.6% of patients; 59% were on chronic steroids, 6.4% were on chronic anticoagulation, 35.9% had radiation therapy, and 29.5% had chemotherapy. Nine percent of patients had a history of prior flap loss, and 11.5% had a history of DVT or arterial thrombosis. The flap loss rate was 3.8%. Steroid treatment was associated with an increased risk of major complications after adjusting for the type of flap HR 2.5(1.3-4.9), p= 0.01. Specifically associated with a higher risk of cellulitis, OR 5.1 (1.1-24.5), p=0.02, and abscess, OR 5.7 (1.2-27.1), p=0.01.

CONCLUSION

Free flap reconstruction can be safely performed in patients with CVD. Perioperative optimization of steroids is important to promote wound healing and stabilize disease activity.

Aesthetic reconstruction of onco-surgical maxillary defects using free scapular flap with and without CAD/CAM customized osteotomy guide

BACKGROUND

Reconstruction of the maxillary defects following tumor ablation remains to be a challenge for surgeons. Virtual surgical planning (VSP), intraoperative cutting guides and stereolithographic models provides the head and neck reconstructive surgeon with powerful tools for complex reconstruction planning. Despite its use in fibular osteocutaneous reconstruction, application to the scapular free flap has not been as widely reported. The aim of this study was to compare aesthetic results and operation time of free scapular flap, with and without computer-aided design and computer-aided manufacturing (CAD/CAM) customized osteotomy guide, for reconstruction of maxillary defects.

METHODS

In this prospective randomized controlled clinical trial study, we randomly assigned 22 patients with maxillary defects who were scheduled to undergo maxillary reconstruction with either free scapular flap with CAD/CAM customized osteotomy guide; study group (n = 11) or free scapular flap without CAD/CAM customized osteotomy guide; control group (n = 11). All patients were followed up for 3 months. The aesthetic outcome, operation and ischemic times were evaluated and compared.

RESULTS

Aesthetic outcomes were evaluated objectively by means of differential surface area (sagittal and axial) measurement, which showed improved aesthetic outcome (contour symmetry) in the study group with a mean of (241.39 ± 113.74 mm²), compared to patients in control group with a mean of (358.70 ± 143.99 mm²). There were significant differences between the two groups (P < 0.05). Aesthetic outcomes were also evaluated subjectively by means of visual analogue scale (VAS) and patient's satisfaction score (PSS). The postoperative aesthetic appearance was better in the study group with more patients satisfied than that in control group and there were statistically significant differences (P = 0.039). The mean total operative time was 678.81 min and 777.18 min in the study group and control group respectively (P < 0.05) and the mean ischemia time was 133.18 min and 195.72 min for study group and control group respectively (P < 0.05). The ischemia time and total operative time were shorter in the study group compared to those in the control group and there were no flap losses in both groups.

CONCLUSION

The use of CAD/CAM prefabricated cutting guides facilitates scapular flap molding and placement, minimizes ischemic time and operating time as well as improves aesthetic outcomes. Trial registration This trial was registered at ClinicalTrials.gov.

REGISTRATION NUMBER

NCT03757286. Registration date: 28/11/2018.

Anterior Longitudinal Ligament Flap Technique: Description of Anterior Longitudinal Ligament Opening During Anterior Lumbar Spine Surgery and Review of Vascular Complications in 189 Patients

BACKGROUND

One of the main concerns of anterior lumbar spine approaches are vascular complications. The aim of our study is to provide technical details about a flap technique using the anterior longitudinal ligament (ALL) when approaching the lumbar spine via an anterior corridor. This can help decrease complications by protecting the adjacent vascular structures. We also include a retrospective cohort review.

METHODS

This is a retrospective bicentric study: 189 patients with a mean age of 44.2 years underwent anterior lumbar spine surgery using the ALL flap technique. Patients were diagnosed with degenerative pathologies. We treated 239 lumbar levels primarily at the L4-5 and L5-S1: 88 single-level anterior lumbar interbody fusions, 9 two-level ALIFs, 51 total disk replacements (TDR), and 41 hybrid constructs (i.e., ALIF L5S1 and TDR L4L5). Anterior approaches were performed by two senior spine surgeons. The ALL flap technique was utilized in all of these cases, by carefully dissecting the ALL, with the flap suspended using sutures. As such, this ALL flap provided a "safe corridor" to avoid any potential vascular laceration.

RESULTS

The operative and early surgical complication rate was 3.2%. There was no arterial injury. There were only 2 minor venous lacerations (1.05%). No blood transfusion was required. Neither lacerations happened during disk space preparation.

CONCLUSIONS

Here, we provide technical details about a simple and reproducible technique using the ALL as a flap, which may help spine surgeons minimize vascular injuries during ALIF or even TDR surgeries.

Combined epiretinal and internal limiting membrane retracting door flaps for large macular holes associated with epiretinal membranes

PURPOSE

To assess the closure rate of large full-thickness macular holes (FTMH) associated with epiretinal membrane (ERM) with a combined epiretinal and internal limiting membrane retracting door flap.

METHODS

Retrospective chart review of patients treated at a single tertiary retina practice between January 2017 and November 2019. Individuals with FTMH larger than 400 μm and co-diagnosis of ERM who underwent surgical repair with an ERM flap were included. Patients underwent pars plana vitrectomy with peeling of ERM that was positioned as a retracting door flap to cover the FTMH. Primary outcome was closure rate at 6 months following surgery. Final surgical success rate and visual acuity were secondary outcomes.

RESULTS

Among 7 eyes of 7 patients, 6 eyes achieved primary surgical success and final surgical success rate was achieved in all 7 eyes with a large FTMH repaired with ERM flap. The mean minimum linear diameter of the FTMH was 681 μm ± 295. All patients had follow-up greater than 6 months, with a mean duration of 17 months (range 14-23 months). Visual acuity improved from a mean of 0.9 ± 0.3 logMar (20/160) before surgery to 0.3 ± 0.5 logMar (Snellen 20/40), postoperatively.

CONCLUSION

Large FTMH with concurrent ERM that are managed with an ERM flap have high single-surgery success rate.

Lower Extremity Soft Tissue Reconstruction Review Article

Reconstruction plays a valuable role in the management of lower extremity wounds for limb salvage. The goals of reconstruction are to improve function and quality of life, return to work, and pain reduction while providing a long-lasting durable reconstruction. The plastics and reconstructive surgical approach in conjunction with the orthopedic or trauma team, referred often as the "orthoplastic" approach, can yield the best outcomes for patients. The following sections discuss reconstruction principles and techniques that can be applied broadly for lower extremity wounds secondary to trauma, infection, and tumor resection.

Evaluation of Complication Rates of Free Flap Reconstruction in Pediatric Patients

Introduction

While there is extensive literature investigating surgical outcomes in free flaps for adults, there is a dearth of information on the efficacy of flap use in the pediatric population. This study is the first to measure complication rates following pediatric free flap reconstruction on a national level.

Methods

All pediatric free flap cases between 2012 and 2018 were identified and stratified by type of flap using current procedural terminology codes assigned to the primary procedure in the National Surgical Quality Improvement Program database. Each entry included the recipient location of the flap, postoperative complications, and demographics. Chi-square analysis was used to compare complication rates across various flap groupings. In addition, univariate and multivariate analyses were used to identify independent predictors of flap complications or failure.

Results

Multivariate regression analysis demonstrated that compared to bone flaps, there is increased risk of nonbleeding complications in skin (Odds Ratio (OR) =7.7, P = 0.029), muscle (OR = 10.6, P = 0.012), and osteocutaneous flaps (OR = 10.8, P = 0.018). Flap of the trunk (OR = 40.9, P = 0.003) and upper extremities (OR = 32.9, P = 0.041) had a higher odds of bleeding complications compared to head-and-neck flaps. Regression analysis also showed that older age is associated with bleeding complications, with patients aged 5-11 years (OR = 38.5, P = 0.027) and 12-17 years (OR = 30.6, P = 0.038) having greater rates compared to patients under the age of 2. The pediatric flap reoperation rate was found to be 3.6%-4.7%, with the highest flap anastomotic complication rate in the head-and-neck region (6.9%-8.0%).

Conclusion

Free flap reconstruction across flap type, anatomic location, and age ranges are safe and efficacious in the pediatric population.

Kaposi's Sarcoma Management from a Plastic Surgery Perspective

Kaposi's Sarcoma (KS) is a low-grade angioproliferative tumor arising from endothelial cells and associated with Human Herpes Virus 8 infection. Although KS cases are not rare and there are considerable number of patients referred for surgical excision, the plastic surgery literature on KS is exceptionally scarce. Thirty patients who were operated with the diagnosis of KS between March 2015 and January 2020 were included. Preoperative HIV tests and detailed whole-body examinations of the patients were performed. As a surgical method, for lesions with sizes ranging from 0.5 * 1 cm to 2 * 3 cm, excisions were made over the deep skin fascia by placing a margin between 0.5-1 cm, considering the anatomical location and elasticity of the skin. Primary repair was performed in 40 lesions and 12 lesions of 8 patients were repaired with a skin graft. In four patients the repair was performed with local skin flaps. Higher upper extremity involvement, less systemic involvement and less pronounced male predominance have been important results in our study that we have found different from the literature data. Compared to the therapies such as radiotherapy, laser, or chemotherapy which require several administrations; one-stage surgical excision of the lesions provides remarkable advantages.

Regionalized coverage of the totally degloved foot by a combination of "Boat sock" style free flap and skin graft

INTRODUCTION

To maximize the morpho-functional recovery on the totally degloved foot while not excessively introducing the technical complexity of microsurgery, we present a regionalized reconstruction, in which the highly functional subunit (weight-bearing area and ankle-around area) is covered by free skin flaps, and the less functional subunit (dorsum) by skin graft.

METHODS

From June 2011 to December 2017, 10 patients who had total degloving injury on foot underwent reconstruction based on regionalized coverage. As the shape of combined flaps resemble a boat sock in high-heeled shoe, we name it as "Boat Sock" flaps. Complication like vascular compromise, partial or total flap loss, Equinus deformity and delayed plantar ulceration were documented elaborately. Secondary surgeries were also recorded. Foot function was evaluated by Maryland foot score at the last follow up.

RESULTS

Twenty-one free skin flaps were used for "Boat sock" coverage on highly functional subunits. Flap dimension ranged from 19×5cm² to 28×8cm² (mean 151cm²). Among these flaps, one experienced partial necrosis which was treated conservatively, one experienced burn due to lack of protective sensation. Complication like Equinus deformity or delayed plantar ulceration did not occur. Secondary surgery included debulking on two cases. Mean Maryland foot score was 90.4.

CONCLUSION

This regionalized coverage by "Boat Sock" flaps and skin graft could serve as a standard procedure for reconstruction of the totally degloved foot, by offering the benefits of multi-plane coverage, a well-contoured ankle, an abrasion-tolerant planta, and eclectic surgical complexities.

Reconstruction of a fistula in the anterior soft triangle of the nose after basal cells carcinoma excision: A case report

Introduction and importance

Basal cell carcinomas represent the most frequent skin cancer and the nose is the most common site of presentation. This has an impact on both aesthetics and function of the nose and consequences in patients' psyche.

Case presentation

In our paper, the first case in literature of a cutaneous fistula in the nasal soft triangle, after a basal cell carcinoma excision, and its reconstruction, is reported.

Clinical discussion

One of the areas of weakness of the nose is the anterior soft triangle; here, any minimal alteration of the anatomy can potentially lead to severe impairment.

Conclusion

When the nasal soft triangle is damaged, its restoration is crucial. Our technique showed both functional and aesthetic good result.

•

The nose is the most common site of presentation of basal cell carcinomas.

•

One of the areas of weakness of the nose is the anterior soft triangle.

•

In our paper, the first case in literature of a cutaneous fistula in the nasal soft triangle is reported.

•

The reconstruction consisted of two steps: first to restore the inner layer, second to cover the new inner layer.

•

Aesthetic and functional outcomes were considered excellent by both the surgeon and the patient.

Reconstruction of lower and midfacial soft tissue defects with a submental island flap

This study aims to analyze the feasibility and utility of a submental island flap and to identify whether this flap procedure is a good choice for the reconstruction of lower and midfacial soft-tissue defects. This was a retrospective study that included 12 patients with lower and midfacial soft tissue defects, which were reconstructed using the submental island flap technique. The medical records of 12 patients who underwent reconstruction with submental island flaps from September 2015 to September 2020 were reviewed and included 11 patients with skin cancer and 1 patient with a history of trauma. The mean age of the patients was 64.9 years. The details of the flap harvest were studied for flap size, the procedure to elevate the flap, pedicle flow, and flap survival rate. In addition, information on demographics, histology, location, size, recurrence, and outcomes was recorded. All of the flaps survived. The skin paddle size ranged from 22 to 55 cm² (mean size 33 cm²). Ten flaps were anterograde pedicle flaps and two flaps were retrograde pedicle flaps. All donor sites were closed using primary closure without any difficulty in neck movement. None of the patients had symptoms of postoperative facial palsy. There were no signs of any local or regional cancer recurrence. The mean follow-up time was 22.9 months. There was an esthetic appearance of graft sites. The submental island flap is a feasible and reliable option for the reconstruction of lower and midfacial defects, which provides good cosmetic results.

The utility of the lateral orbital orbicularis propeller flap in periocular reconstruction

AIMS

The lateral orbital orbicularis propeller flap (LOOP) is a propeller flap raised on a non-axial orbicularis oculi pedicle. Once mastered, it is speedy to raise, extremely reliable, and capable of transposing thin, supple, and relatively hairless skin and subcutis from the temple region to the periocular region. We aim to present our experience in using the LOOP flap for the reconstruction of a range of periocular defects.

METHOD

Retrospective review utilising our Mohs database, electronic records, and image library.

RESULTS

A total of 44 reconstructions were performed. Of the 39 lower lid defects, 22 were full-thickness (bilamellar). Posterior lamella reconstructions in these 22 cases were free tarsoconjunctival graft (20), conchal cartilage with perichondrium (1), and Hewes flap (1). A total of 13 reconstructions of the 22 were total or near-total lid reconstructions. A further 17 patients had anterior lamella defects alone, of which 3 amounted to resurfacing the entire lid. However, 5 patients underwent upper lid reconstruction, 2 of which were 50% lid, 2 required a free tarsal graft, and 1 conchal cartilage graft with buccal mucosa. There were no instances of necrosis of either the flap or the posterior lamella grafts. There were 7 minor complications.

CONCLUSION

In our unit, the LOOP flap has become the reconstruction of choice for laterally based, transversely extensive defects of upper lid, lower lid, and malar areas. Its reliability, relative simplicity, and excellent cosmetic and functional outcomes merit much wider utilisation amongst the plastic and ophthalmic surgery community.

Histology and Vascular Architecture Study of Keloid Tissue to Outline the Possible Terminology of Keloid Skin Flaps

BACKGROUND

Using the keloid "epidermis" to cover a wound is widely used during treatment for keloids. Many flap terminologies have been used in literature. However, the definition of the flap is not well established. Here, we refined the definition of the flap and associated terminology and explored the survival mechanism of the 'flap' through histological analysis and blood supply studying.

METHODS

Histology and vascular study of keloid was carried out with keloid and its surrounding normal skin tissue which were collected from keloid patients following keloid resection operations. The histological structures and thicknesses of epidermal and subepidermal of the keloids were analyzed and measured using hematoxylin & eosin (H&E) staining. Vascular density and blood perfusion in the subepidermal layer of keloids (KDS) were analyzed using CD31 immunohistochemical staining and a laser speckle contrast imaging system (LSCI), respectively. The vascular network in KDS was visualized by CD31 immunofluorescence staining and three-dimensional reconstruction.

RESULTS

29 pieces of keloid and its surrounding normal skin tissue sample from ten patients were collected. Keloid samples were about 2 cm wide and 5 cm long. The normal skin samples were about 2 to 3 mm in width. The thickness of epidermal layer of keloids was (136.4 ± 35.3) μm, and the thickness of epidermal layer of surrounding normal skin was (78.8 ± 13.9) μm. There was statistical thickness difference between the two layers, t(20) = 7.469, P < 0.001. The total thickness of keloid epidermal and subepidermal layers was 391.4 ± 2.3 μm. The vascular density (13.9 ± 3.4/field) and blood flow perfusion (132.7 ± 31.3) PU in KDS were greater than that of surrounding normal skin (7.8 ± 2.3/field, 73.9 ± 17.9 PU), P < 0.001. Horizontally distributed vessels with several vertical branches were observed in 3D vascular network reconstruction.

CONCLUSION

The epidermal layer of keloid is thicker than that of surrounding normal skin. There is a vascular network structure under it. The vessels mainly locate at a depth of about 150 to 400 μm from the surface of keloid epidermis, randomly distribute and run parallel to the epidermis. Based on these characteristics which may ensure an adequate blood supply, we propose the concept of a "keloid subepidermal vascular network flap."

LEVEL OF EVIDENCE V

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 .

Radical resection and reconstruction in patients with adenoid cystic carcinoma in the minor salivary glands of the palate

Background

This study evaluated the clinical outcomes of the patients with adenoid cystic carcinoma (ACC) of the minor salivary glands of the palate.

Methods

Forty-four patients with stage I–II disease and 14 patients with stage III–IV disease underwent radical excision and reconstruction with a facial-submental artery island flap (FSAIF) and titanium mesh plus a free anterolateral thigh flap (ALTF) and radiotherapy respectively. Patients with stage III–IV disease subsequently received cobalt Co 60 adjuvant radiotherapy. Ki-67 expression was determined semiquantitatively in 52 patients with ACC by based on the cytoplasm staining intensity and percentage of positively stained tumor cells.

Results

The median (range) follow-up was 32.9 (14–58) months. Forty-one (71.7%) patients survived without disease recurrence. Nine patients (15.5%) survived with recurrent tumors (four with local recurrence, three with regional recurrence requiring salvage surgery, and two with distant metastasis); among these patients, five had overlapping recurrence. Eight patients (13.8%) died of regional, distant, or multiorgan metastasis (range: 22–42 months). The overall median (95% CI) survival time was 32.5 (25.0–39.5) months, and the median (95% CI) progression-free survival time was 32.9 (28.5–36.9) months. Rates of survival and recurrence differed significantly between patients with low- and high-grade tumors, patients with clinical stage I–II disease and those with stage III–IV disease, patients with and without lymph node metastasis, patients who underwent radical excision with versus without radiotherapy, and patients with low and high Ki-67 expression.

Conclusion

Radical resection and reconstruction with FSAIF is suitable methods for the the treatment of stage I–II ACC of the minor salivary glands of the palate. Stage III–IV tumors require radical resection, reconstruction with titanium mesh and free ALTF, and radiotherapy.

Circumferential pharyngeal reconstruction after total laryngopharyngectomy: A systematic review and network meta-analysis

OBJECTIVE

To compare the functional outcomes of different reconstructive techniques for circumferential pharyngeal reconstruction.

METHODS

A comprehensive electronic search was performed on PubMed/MEDLINE, Cochrane Library, and Google Scholar databases. Retrospective and prospective studies were included. Two independent reviewers extracted thirty-four studies after applying the eligibility criteria. An arm-based network analysis was conducted using a Bayesian hierarchical model. The main outcomes were pharyngo-cutaneous fistula (PCF) incidence, stenosis incidence and feeding tube dependence (FTD) incidence. Network estimates from outcome variables were presented as absolute risks, odds ratio [OR] with 95% credible intervals (CIs), and ranking probability.

RESULTS

A total of 1357 patients were included for 5 different interventions (tubed pectoralis muscle myocutaneous flap, t-PMMCF; tubed anterolateral tight flap, t-ALTF; tubed radial forearm free flap, t-RFFF; free jejunal flap, FJF; U-shaped pectoralis muscle myocutaneous flap, u-PMMCF). FJF showed a 92.8% chance of ranking first in terms of pharyngo-cutaneous fistula prevention (absolute risk: 10%), while the highest PCF incidence (42%) was measured for t-PMMCF. u-PMMCF showed the lowest absolute risk (11%) of stenosis incidence (62.2% chance of ranking first). t-PMMCF (5%), FJF (8%), and u-PMMCF (8%) showed similar results in terms of feeding tube dependence, with a 53.2%, 23.1% and 18.9% chance of ranking first, respectively.

CONCLUSIONS

FJF seems to be the best reconstructive choice after total laryngo-pharyngectomy in terms of PCF, stenosis and FTD incidence. If this reconstructive method is not feasible, a u-PMMCF should be favored over tubed free and pedicled flaps. Further comparative studies are needed to confirm these results.

At The Forefront of Penile Surgical Reconstruction: A Bibliometric Study of the 100 Most-Cited Articles

PURPOSE

The citation count of a scientific article is considered as the recognition it received from this field. The purpose of this bibliometric analysis was to identify the top 100 most-cited scientific articles in penile surgical reconstruction.

METHODS

The Web of Science database was used to extract the top 100 most-cited articles. Individual articles were reviewed to identify the authorship, published journal, journal impact factor (IF), primary disease, article type, institution and country of origin, and year of publication.

RESULTS

The top 100 most-cited articles were published between 1947 and 2013. The number of citations ranged from 23 to 233. Journal of Urology contributed the most articles (n = 36). Articles with a high level of evidence like prospective analysis (n = 5), systematic review and meta-analysis (n = 2), and guideline (n = 1) were all published after 2000. The average citation per year of articles published in high-IF journals was significantly higher than that of other articles (p = 0.0129). There was a positive linear correlation between citation count per year and publication year (r² = 0.26, p < 0.001). Among the top 100 articles, 74 articles were interlinked via citation of each other. The major topic of co-citation network was the application of flaps in penile reconstruction.

CONCLUSIONS

The analysis of top 100 most-cited articles facilitates the comprehensive recognition of current focus in the field of penile surgical reconstruction, which is the exploration of flaps and development of new techniques in penile reconstruction. In the future, more attention should be paid to evidence-based medicine to provide high-level evidence for research.

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 .

Comparison of Thigh-Based versus Groin-Based versus Lateral-Thoracic-Based Flaps for Hand Resurfacing: A Review Article

BACKGROUND

Thigh-based, groin-based and lateral-thoracic-based flaps are available for microsurgical hand resurfacing – which is the best?

METHODS

BestBETS methodology was used to systematically evaluate the advantages and disadvantages. PubMed, EMBASE and Cochrane databases were searched up until Sep 2020, using the search strategy: hand re-surfacing, free-flap, groin-flap, thigh-flap, lateral thoracic-flap, advantages, and disadvantages.

RESULTS

Overall, 31 papers were identified which were used to synthesize the discussion and conclusions.

CONCLUSION

Thigh-based anterolateral thigh (ALT) flaps offer the greatest versatility.

Penoscrotal fistula secondary to urethral diverticulum treated with ventral penile skin flap urethroplasty: A case report

Voiding symptoms and penoscrotal mass with/without fistula are typical findings of urethral diverticulum. We present a case of 55-year-old male patient who was evaluated for voiding symptoms, soft palpable penoscrotal mass and fistula. Retrograde urethrography, scrotal ultrasonography and cystoscopy revealed a urethral diverticulum and fistula. The defect developed after excision of the diverticulum associated with the penile ventral urethra was closed with a penile skin flap. In the 6-month follow-up, the patient did not have any voiding complaints and no signs of recurrence. Urethroplasty using a penile skin flap may be preferred in the repair of penile ventral urethral defect.

Flap survival and functional outcomes in elbow soft tissue reconstruction: A 25-year systematic review

INTRODUCTION

Different elbow flap reconstructions have been described in the literature. We aim to define the optimal flap technique based on defect size and etiology.

METHODS

A systematic review was undertaken using the terms "(Elbow reconstruction) AND ((Soft tissue) OR (flap))". Flaps were grouped under fasciocutaneous (FCF), muscular (MF), distant pedicled (DPF), and free flaps (FF). The primary outcome was flap survival. The secondary outcomes were postoperative complications and range of motion (pROM).

RESULTS

Twenty articles with 224 patients were included. Defect sizes were small (<10 cm²) (18%), medium (10-30 cm²) (23%), large (30-100 cm²) (43%), and massive (>100 cm²) (16%). Etiologies included trauma (26%), burn contractures (26%), infection (26%), hardware coverage (16%), and others (6%). FCF (54%) was the preferred flap followed by MF (28%), DPF (13%), and FF (5%). The rate of flap necrosis was 4% and that of other complications was 10%. The postoperative range of motion (pROM) (reported in 154 patients) was >100°, 50-100°, and <50° in 82%, 17%, and 1% of the cases, respectively. Small defects were most commonly reconstructed with MFs (83%), medium defects were reconstructed with MFs (52%) or FCFs (46%), and large defects were reconstructed with FCFs (91%). Massive defects predominantly required DPFs (60%) and FFs (26%). FCFs were the most common reconstruction method for burn contractures (84%), infections (55%), and traumatic defects (51%). Hardware coverage was predominantly performed using MFs (86%). No difference in complications and pROM was found between flap techniques.

CONCLUSION

Elbow flap reconstruction can be performed using different techniques. FCFs are the most commonly used reconstruction method. MFs are useful for smaller defects and hardware coverage. DPFs and FFs are needed for massive injuries.

High-resolution magnetic resonance imaging for the follow-up of intracranial arterial dissections

High-resolution magnetic resonance imaging (HRMRI) with a 3-T system can be utilized to identify intracranial arterial dissections (ICADs) as it reveals more than three key features with better clarity than other conventional imaging modalities. This study aimed to assess the changes in the key features of ICADs on HRMRI over time. We screened patients who had undergone HRMRI within 7 days of symptom onset for the evaluation of characteristics associated with intracranial steno-occlusive lesions. Among them, patients who (1) were diagnosed with ICAD based on HRMRI findings and (2) underwent follow-up HRMRI 3-12 months after the initial HRMRI were included in the final study. Baseline HRMRI revealed an intramural hematoma, a flap, and a double lumen in 17 (100%), 15 (88%), and 10 (59%) individuals, respectively. At the 3-months follow-up, an intramural hematoma was still observed in two patients; however, there were various changes in the double lumen and intimal flap. At the 6-months follow-up, an intramural hematoma was not observed in most patients, whereas the double lumen and intimal flap persisted in most patients. The 9-months follow-up displayed distinct differences from the initial status, whereas the 12-months follow-up exhibited no intramural hematomas, intimal flaps, or double lumens in most patients. In those with ICAD, radiological changes were observed between the initial HRMRI and subsequent HRMRI. Moreover, typical ICAD features were hardly retained at the 1-year follow-up. These changes might reflect dynamic processes, including the healing state of the patients.

Preimaging and Postimaging of Graft and Flap in Head and Neck Reconstruction

Head and neck reconstructive surgical techniques are complex; now the microvascular free tissue transfer is the most frequently used. The postreconstruction imaging interpretation is challenging due to the altered anatomy and flap variability. We aim to improve radiologists' knowledge with diverse methods of flap reconstruction for an accurate appreciation of their expected cross-sectional imaging appearance and early detection of tumor recurrence and other complication.

Strategy of harvesting extended thoracodorsal artery perforator flaps for resurfacing the large soft-tissue defects of extremities

BACKGROUND

The authors presented their strategy to harvest extended thoracodorsal artery (TDA) perforator flaps for resurfacing the large soft-tissue defects of extremities.

MATERIALS AND METHODS

Thirty-three free extended TDA perforator flaps were harvested in 33 patients. The mean flap size was 145.2 cm². The maximal flap length and the width were 30 cm and 10 cm, respectively. The color Doppler sonography (CDS) was used for preoperative assessment of perforators. Indocyanine green angiography (ICGA) was used for intraoperative assessment of flap viability in three patients.

RESULTS

The vascular thrombosis, donor-site scar widening, and delayed recipient-site wound healing were not significantly related to the patient and flap characteristics. Flap tip or partial necrosis was significantly related to age and peripheral vascular disease. True positive rate, false negative rate, and positive predictive value of CDS for perforator identification were not different significantly between attending surgeon and residents. In the distance discrepancy of CDS, significant difference was found based on the classifications of perforator size, perforator type, and sonographic operator. The ICGA identified a hypoperfused distal area in a 30 cm long flap.

CONCLUSION

The CDS locates the TDA perforators more precisely when scanned by experienced hands, in larger size or septocutaneous perforators. Using reliable and more perforators, applying muscle-sparing technique, considering suprafascial course of perforator and proper flap orientation are helpful in harvesting extended TDA perforator flaps. ICGA is an option for assessing flap viability, especially in elders and patients with peripheral vascular diseases.

Soft-tissue reconstruction in lower-leg fracture-related infections: An orthoplastic outcome and risk factor analysis

Introduction Fracture-related infection (FRI) is a severe post-traumatic complication which is occasionally accompanied by a deficient or even avital soft-tissue envelope. In these cases, a thoroughly planned orthoplastic approach is imperative as a vital and intact soft-tissue envelope is mandatory to achieve fracture union and infection eradication. The aim of this study was, to analyse if soft-tissue reconstruction (STR) without complications is associated with a better long-term outcome compared to FRI patients with STR complications. In particular, it was investigated if primary flap failure represented a risk factor for compromised fracture union and recurrence of infection. Patients and Methods Patients with a lower leg FRI requiring STR (local, pedicled and free flaps) who were treated from 2010-18 at the University Hospital Basel were included in this retrospective analysis. The main outcome measure was the success rate of STR, further outcome measures were fracture nonunion and recurrence of infection. Results Overall, 145 patients with lower leg FRI were identified, of whom 58 (40%) received STR (muscle flaps: n = 38, fascio-cutaneous flaps: n=19; composite osteo-cutaneous flap: n = 1). In total seven patients required secondary STR due to primary flap failure. All failures and flap-related complications occurred within the first three weeks after surgery. Secondary STR was successful in all cases. A high Charlson Comorbidity Index Score was a significant risk factor for flap failure (p = 0.011). Out of the 43 patients who completed the 9-month follow-up, 11 patients presented with fracture nonunion and 12 patients with a recurrent infection. Polymicrobial infection was a significant risk factor for fracture nonunion (p = 0.002). Primary flap failure was neither a risk factor for compromised fracture consolidation (p = 0.590) nor for recurrence of infection (p = 0.508). Conclusion: A considerable number of patients with lower-leg FRI required STR. This patient subgroup is complex and rich in complications and the long-term composite outcome demonstrated a high rate of compromised fracture consolidation and recurrent infections. It appears that secondary STR should be performed, as primary flap failure was neither a risk factor for compromised fracture consolidation nor for recurrence of infection. We propose to monitor these patients closely for three weeks after STR.

Free functional muscle transfer for upper limb paralysis - A systematic review

BACKGROUND

Functional restoration of upper limb paralysis represents a major reconstructive challenge. Free functional muscle transfer (FFMT) enables reanimation in patients with a lack of local donor tissues or delayed presentation. This systematic review summarises the evidence for FFMT in the reconstruction of upper limb paralysis.

METHODS

A comprehensive search of MEDLINE and EMBASE was performed with a systematic review using methodology adapted from the Cochrane Handbook and the PRISMA statement. Data from included studies were compiled and narratively synthesised. Studies were assessed for risk of bias.

RESULTS

A total of 1155 records were screened, with 39 observational studies of 904 patients included. The most common aetiology was brachial plexus injury (736, 81.4%). Mean time from injury to intervention was 26 months. Restoration of elbow flexion was the commonest reconstructive goal. The most common donor muscle was gracilis (91.5%). Reported outcomes were heterogeneous with patient-reported outcome measures (PROMs) available in only 7 of 39 studies. Nearly half of FFMTs had a post-operative MRC grade of <4 and 18.1% had an MRC <3. Mean flap failure rate was 3.6% (range 0-10.5%). All studies were at high risk of bias.

CONCLUSIONS

FFMT may be an effective surgical intervention for upper limb paralysis; however, the current evidence has significant shortcomings. There is no consensus regarding outcome measures nor is it possible to identify prognostic factors for its effectiveness. This review highlights a need for improved study design with pre-operative assessment, standardisation in outcome reporting, and the use of PROMs to determine the effectiveness of FFMT in upper limb paralysis.

The pedicled lateral forehead flap in reconstructing oral floor defect - The last resort; case report

INTRODUCTION AND IMPORTANCE

Locoregional flaps, particularly the pedicled lateral forehead flap, are not usually used in reconstructing oral floor defects following oncologic resection. Rather, microscopic free flaps have evolved to be the standard of care in head and neck reconstruction. However, the pedicled lateral forehead flap could be valuable in floor of the mouth reconstruction in the absence of resources or other options.

CASE PRESENTATION

A-56 years old lady with multiple comorbidities who underwent near total glossectomy, bilateral supraomohyoid neck dissection, and right lateral mandibulotomy due to a locally advanced lingual squamous carcinoma. The last resort was the pedicled lateral forehead flap after many unsuccessful reconstructive attempts utilizing the free anterolateral flap, free radial forearm flap, and pedicled pectoralis major flap.

CLINICAL DISCUSSION

Decreased donor site morbidity and reliable anatomy are among many of the advantages that made free flaps favorable over locoregional pedicled flaps, especially in oral cavity defects coverage. Of the latter, the pedicled forehead flap, rich in vascularity and neighboring the oropharyngeal defects, could be used with different techniques and modifications. Close monitoring and patient condition optimization is required.

CONCLUSION

Choosing a particular reconstructive option should be done considering the available resources and expertise and the patient's condition. The pedicled forehead flap remains valuable when other options are inappropriate or have failed.