The interest of "ortho-plastic" collaboration in management of complex limb injury

Constantly evolving knowledge on fracture management, soft tissue coverage, microsurgery and vasculo-nervous repair now permits salvage of limbs that previously would have had to be amputated. Management of complex limb injuries of which the severity inevitably entails functional and esthetic sequelae calls for mastery of the full spectrum of bone and soft tissue reconstruction. Such mastery is rarely attainable by a single surgical specialty; individually and isolatedly, an orthopedic or plastic surgeon cannot ensure optimal management of the above-mentioned patients. While the orthopedist performs a key function in provisional or definitive fixation, the plastic surgeon's expertise is essential to restoration of the cutaneous envelope. Collaboration between the two specialties from the outset and throughout treatment characterizes the modern-day concept of "ortho-plastic" surgery. Through unification of the theoretical competence and practical skills of orthopedists and plastic surgeons, it provides a patient with the best possible functional and esthetic results in a wide range of clinical situations. In this article, we present a review of the literature illustrating the interest of "ortho-plastic" collaboration in management of complex limb injury; concrete examples will be given through evocation of clinical cases encountered by the team that was put together in August 2015 at the university hospital (CHU) of Lille.

One for two, ipsilateral reduction and contralateral reconstruction mammoplasty: A case report

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There is a considerable debate regarding implant or autologous reconstruction of breast.

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Single session reduction mammoplasty with contralateral autologous reconstruction is feasible.

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A novel procedure has been presented.

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Dividing the contralateral breast and creating a myocutaneous flap for reconstruction.

Introduction

The aim of this paper is to introduce a novel procedure for concomitant contralateral reduction and ipsilateral reconstruction mammoplasty by dividing the contralateral breast and creating a pectoralis myocutaneous flap for reconstruction.

Presentation of case

A 34-year-old female, with a history of left side mastectomy presented for reconstruction. Under general anesthesia, the scar of the previous operation was resected in an elliptical shaped incision, the right breast was divided in middle, leaving the flap (pectoralis myocutaneous flap) with pectoralis branch of thoracoacromial artery. The superiomedial part of right breast (the flap) was rotated under the bridge of intermammary skin into the left incision. Ten days after the operation, the flap was viable and healthy.

Discussion

The aim of breast reconstruction is to provide psychosocial support and improve quality of life in the long term by restoring the shape of the breast surgically. New techniques have emerged constantly, and each comes with its list of advantages and risks. The benefits of reconstruction are clear, yet often it is not found as a part of breast cancer treatment routinely.

Conclusion

In single session reduction mammoplasty in one breast and using the resected piece as a flap to reconstruct the contralateral breast is possible whenever indication.

Minimal internal limiting membrane peeling with ILM flap technique for idiopathic macular holes: a preliminary study

Background

Internal limiting membrane (ILM) peeling increases the idiopathic macular hole (IMH) closure rate but causes the inner retina dimplings. This study is to introduce a method to minimally peel the ILM, and with the ILM flap to ensure the IMH closure.

Methods

Twelve consecutive IMH eyes were treated with the minimal ILM peeling with ILM flap technique. The ILM around the MH is peeled off in an annular shape with a width of approximately 200 to 300 μm. A tongue-shape ILM flap is created in the superior retina and the inferior margin of ILM is not peeled off. The ILM flap is then inverted to cover the MH, followed by fluid-air exchange and air or silicon tamponade. Spectral domain-optical coherence tomography (SD-OCT) and en face OCT for morphological assessment, best corrected visual acuity (BCVA) and multifocal electroretinogram (ERG) for functional evaluation were performed at baseline and at each postoperative follow-up.

Results

All the 12 eyes achieved macular hole closure on SD-OCT after surgery (100%). At baseline, the mean preoperative BCVA was 0.83 ± 0.33 and it improved to 0.39 ± 0.28 postoperatively (p <  0.001). En face OCT showed the inner retinal dimplings were localized only in superior ILM-free retinas (7 eyes). The mERG response density in the central (R1), para-central (R2), R1/R2 ring ratios were remarkably improved at the last follow-up (p = 0.001, p = 0.033, p = 0.018, respectively).

Conclusions

The minimal ILM peeling with ILM flap technique can achieve favorable MH closure with less inner retinal dimplings and has promising visual recovery for IMH eyes.

Protective effects of dexmedetomidine on the survival of random flaps

BACKGROUND

Random flaps can be used to repair wounds and improve shape and functional reconstruction, but inflammation and necrosis limit their application. Modified McFarlane flap models were constructed on the backs of rats. We hypothesized that dexmedetomidine (DEX) could improve the survival rate of ischemic random flaps.

METHODS

Sixty rats were randomly divided into three groups: a low-dose DEX group (DEX-L group, 10 μg/kg/D), a high-dose DEX group (DEX-H group, 20 μg/kg/D) and a control group (0.9 % saline equivalent). On day 7 after flap construction, the survival percentage of the flap model was calculated. Hematoxylin and eosin staining (H&E) was used to evaluate the histopathological status of the flaps and microvessel density (MVD). Lead oxide/gelatin angiography was used to detect angiogenesis, and laser Doppler flow imaging (LDF) was used to detect blood perfusion. The levels of superoxide dismutase (SOD) and malondialdehyde (MDA) in the middle areas of the flaps were measured to show the level of oxidative stress. The expressions of Toll-like receptor (TLR4), nuclear factor-kappa B (NF-κB), interleukin (IL)-1β, IL-6, tumor necrosis factor-α (TNF-α) and vascular endothelial growth factor (VEGF) were detected by immunohistochemistry.

RESULTS

DEX significantly increased the average survival percentage of the flaps and reduced ischemia and necrosis of the distal end of the flaps. SOD activity significantly increased, while MDA significantly decreased, indicating that DEX reduces oxidative damage. The expression of inflammatory immunoregulatory proteins (TLR4, NF-κB) was downregulated, and the levels of inflammatory factors (IL-1β, IL-6 and TNF-α) were lower. In addition, DEX upregulated VEGF expression, promoted angiogenesis, and increased blood perfusion.

CONCLUSION

In random flap transplantation, a high dose of DEX is beneficial to flap survival.

Effects of microneedle length and duration of preconditioning on random pattern skin flaps in rats

To date, the surgical delay of skin flaps is the most common and reliable method that increases skin flap survival. In this study, we aimed to increase skin flap viability using preconditioning by microneedling. Seventy-two Sprague Dawley rats were randomly divided into control, surgical flap delay (SFD), and four microneedling groups (7 or 14 days of preconditioning with 0.5 mm or 1 mm needles). Modified McFarlane flaps were raised on the back of rats. In Group I, a caudal pedicled skin flap was raised and the flap survival rate was assessed on postoperative day 14. In the SFD group, a bipedicled flap was created and after 14 days of surgical delay, all skin flaps were raised. In the microneedling groups, 0.5 mm or 1 mm needles were used for 7 or 14 days. The flap survival rates of all microneedling and SFD groups were significantly higher than the control group. The plasma levels of vascular endothelial growth factor (VEGF) did not significantly differ between groups, but the VEGF level of skin samples in the SFD group was higher than the control group. The vessel counts of all microneedling and SFD groups were statistically higher than the control group in all skin samples taken before raising the flaps, but skin samples taken 14 days after raising the skin flap did not show any difference between groups. We showed that preconditioning by microneedling can be used to improve the viability of critical ischemic skin flaps at a level similar to surgical delay.

A Novel Way for Upper Eyelid Rejuvenation by Combination of Local Fat-Fascia-Muscle Flap Repositioning for Middle-Aged Asian Women

BACKGROUND

Upper eyelid aging is common among middle-aged Asians. Apart from skin aging, there has been an increasing recognition for the role of sunken eyelid playing in upper eyelid aging. Various methods have been developed to deal with the upper eyelid volume deflation. However, autologous fat tissue could not achieve stable and satisfying rejuvenation results, especially for middle-aged patients who have established extremely low adipose tissue survival rates. Therefore, efficient rejuvenation methods with consistent long-term improvement are needed, especially for middle-aged patients.

METHODS

A retrospective study was conducted of 248 middle-aged patients who underwent the upper eyelid tightening and local fat-fascia-muscle flap reposition for upper eyelid rejuvenation in our department between 2015 and 2017. A precise sunken upper eyelid calculation method was used to evaluate the patients' upper eyelid sunken volume prior to the operation for the guidance of sunken correction. The same method was also used to calculate the post-operation upper eyelid sunken volume to evaluate the operation efficiency.

RESULTS

The average age of the patients who underwent the surgery was 49.5±7 years-old. The fat-fascia-muscle flap was repositioned according to each patient's pre-operation sunken upper eyelid evaluation result, and precise and satisfying immediate sunken correction was observed after the surgery. Long-term consistent improvement was achieved. Compared to the pre-operation evaluation, the upper eyelid sunken correction ratio was nearly 90% in one year's follow-up, and no major complication occurred.

CONCLUSIONS

The fat-fascia-muscle flap reposition combined with sunken upper eyelid calculation has been proved efficient and consistent for middle-aged Asians upper eyelid rejuvenation.

Total Auricular Reconstruction Using a Single Extended Postauricular Flap Without Skin Grafting in Two Stages: Experiences of 106 Cases

BACKGROUND

Postauricular fascial flap with skin grafting is popular as a solution in total auricular reconstruction, which might result in visible scars and mismatched color, especially in Asian people. Other methods using an expanded postauricular flap to avoid skin grafting often require three or more operations, which increases suffering for patients. This work aims to introduce a modified technique for auricular reconstruction using a single expanded postauricular flap without skin grafting in a two-stage operation.

METHODS

An 80-ml kidney-shaped expander was implanted in the mastoid area as the first-stage operation after preoperative evaluation. After a gradual expansion period and a 2-month rest time, the flap achieved the appropriate size and thickness. In the second stage, a three-layer cartilage framework was fabricated and inserted into the pocket through an incision at the remnant ear, and the earlobe and tragus were rebuilt simultaneously.

RESULTS

From September 2013 to October 2017, 106 microtia patients were selected for auricular reconstruction applying this method in our hospital. Patients were followed up to 6 months to 4 years. Most of them (93.4%) were satisfied with the reconstructed ears, especially with respect to suitable color and invisible scars. Complications of expander exposure or framework exposure happened in three cases, and all of them finally got a satisfactory result.

CONCLUSION

A single large expanded postauricular flap without a skin graft is an effective and efficient technique for auricular reconstruction with satisfying results. It can reconstruct an exquisite ear without a skin graft and can be finished in only two stages of operations.

LEVEL OF EVIDENCE IV

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.

Clinical Applications and Outcome of Proximally Based Medial Gastrocnemius Muscle Flap

BACKGROUND

Gastrocnemius muscle flap has been in vogue for approximately five decades. The current study was carried out to document the indications and outcome of proximally based medial gastrocnemius muscle flap in our patients.

METHODS

This case series was conducted in Department of Plastic Surgery and Orthopedics, National Institute of Rehabilitation Medicine (NIRM), Islamabad, Pakistan during 3 years. It included all patients who were managed with proximally based medial gastrocnemius muscle flap for various indications.

RESULTS

There were 31 patients with 24 (77.41%) males and 7 (22.58%) females. The age ranged between 16- and 53 years (mean: 27.47±10.33 years). The indications for gastrocnemius muscle flap included traumatic defects with exposed tibia/ knee joint (n=20; 64.51%), prophylactic coverage of megaprosthesis employed for knee joint reconstruction (n=9; 29%), excisional defect of cutaneous squamous cell carcinoma with exposed tibia (n=1; 3.22%), and salvage of infected total knee arthroplasty (n=1; 3.22%). The hospital stay was 7-16 days (mean: 12.41±2.87 days). The flap survival in our series was 100%. There was partial skin graft in two patients (n=2; 6.45%).

CONCLUSION

Gastrocnemius muscle flap was a quick, easy and reliable coverage tool for small to moderate sized defects around the knee, the proximal third of the tibia as well as coverage of prosthesesis employed for knee arthroplasty. Inclusion of 2-4 cm tendon enhances the flap dimension without causing any additional morbidity.

A decade of reconstructive surgery: outcome and perspectives of free tissue transfer in the head and neck. Experience of a single center institution

PURPOSE

Free flaps have become the standard option in reconstructive surgery of the head and neck. Even though many authors have outlined the reliability of free transplants, there is an ongoing discussion about treatment options for patients bearing particular risks as previous irradiation treatment. In this analysis, we aim to address these patients with particular risk profiles by comparing different flap entity outcome parameters.

METHODS

We retrospectively analyzed a cohort of 494 patients who underwent flap surgery between 2009 and 2018 in our department. Focusing on free microvascular transplants, we additionally analyzed the pectoralis major myocutaneous flap as the most frequently used vascular pedicled flap. Data analysis was performed by uni- and multivariate statistics.

RESULTS

Overall flap success rate was 90%, with the radial forearm flap occurring to be most reliable (93%) in head and neck reconstruction. Previous radiation therapy (RT) and intraoperative revision of vascular anastomosis during primary surgery significantly resulted in impaired transplant outcome with a success rate of 91.8% (no RT) vs. 83.7% (RT), respectively. There was a negative linear correlation between incision to suture time and number of flaps per year (R² = 0.67).

CONCLUSIONS

Preoperative radiation therapy and intraoperative revision of anastomosis significantly impair outcome of microvascular flaps in the head and neck and oral cavity, whereas patient's age is not a predictor of flap failure. Increasing case number and experience reduces time of flap surgery as well as rate of complications and flap failure.

Comparison of Split Thickness Skin Grafts and Flaps in Bilateral Chronic Axillary Hidradenitis Suppurativa

BACKGROUND

Hidradenitis suppurativa is a chronic inflammatory disease with multiple inflammatory nodules and abscesses. We aimed to compare split thickness skin graft (STSG) and flaps in bilateral chronic refractory axillary hidradenitis suppurativa.

METHODS

Thirty patients were investigated from March 21, 2010 to March 20, 2015. Debridement of involved skin and subcutaneous fat was done until deep fascia. The second operation was a reconstructive procedure to cover bilateral axillary wounds with STSG in left side and random fasciocutaneous flaps in the right side.

RESULTS

Mean age of patients was 35.2±9.3 years. There were 16 men (53.3%) and 14 women (46.7%). Duration of the disease before trial was 6.5±2.1 years. The association between pain at one-month follow-up for graft or flap sites was not significant. The patients did not have pain at flap and graft sites at three-month, six-month and one-year follow-ups. Twenty-four patients (80.0%) had normal ranges of motion at one-month follow-up. At six-month and one-year follow-ups, all patients had bilateral normal ranges of motion. All patients were satisfied from symmetry of flap and graft sites at six-month and one-year follow-ups. All patients were satisfied from graft and flap donor sites at six-month and one-year follow-ups. At one-month, three-month, six-month and one-year follow-ups, recurrence of hidradenitis suppurativa was not seen.

CONCLUSION

Both STSGs and fasciocutaneous flaps were successful and satisfactory for tissue coverage in patients with axillary hidradenitis suppurativa. We recommend this technique in cases of bilateral axillary hidradenitis suppurativa.

Three-dimensional modeling and comparison of nasal flap designs

Few studies exist that compare local flap repair designs either mathematically or clinically. Previous mathematical studies use a two-dimensional modeling approach, which is not suited to complex structures like the nose. To quantitatively analyze and compare flap designs for nasal repair using three-dimensional, photographic models. via a three-dimensional imaging system (Vectra M3, Canfield Scientific, Parsippany, NJ, USA), images were captured of actual post-Mohs nasal defects on 12 consecutive patients. Transposition, rotation, and advancement flap designs were designed and assessed based on tissue efficiency (E_t = SA_wound/(SA_wound + SA_trimmed) × 100), suture efficiency (E_s = SA_wound/Length_sutured × 100), total area undermined, combined 1° and 2° flap motion efficiency (E_fm = SA_wound/(SA_undermined - (SA_wound + SA_trimmed)) × 100), incision efficiency (E_i = SA_wound/length_incision × 100), and undermining efficiency (E_u = SA_wound/SA_undermined × 100). Rotation flap designs are the most tissue efficient (p < 0.001). Transposition designs are the least suture efficient (p = 0.012) and require less undermining than the corresponding rotation flaps (although not statistically significant). Advancement flaps have the highest flap motion efficiency (p = 0.027). Incision and undermining efficiency is equivalent between all three designs (p = 0.308 and p = 0.158, respectively). While statistically significant differences exist between the flaps studied, the clinical significance is unknown. Consequently, the choice in repair design should be made based on its ability to attain a functionally and aesthetically successful reconstruction.

[Rieger-Marchac flaps: Complications and patient satisfaction]

PURPOSE

Like all surgical procedures, dorsal nasal flaps may be followed by both early and late complications. The aim of this study was to evaluate the surgical complications and cosmetic outcome of dorsal nasal flaps over a 7-year period in an academic dermatologic surgery unit.

PATIENTS AND METHODS

Data were collected retrospectively for all patients undergoing dorsal nasal flap between 1 January 2006 and 31 December 2013. Early and late complications were recorded. Patients were contacted by phone to assess long-term outcomes.

RESULTS

A total of 35 patients were included. Early complications included bleeding (n=2), local infection (n=2) and focal flap necrosis (n=1). Late complications comprised flap thickening (n=7), restriction of the medial canthus (n=2), opening of the labionasal angle (n=1), stitch granuloma (n=1) and telangiectasia on the flap (n=1). Regarding the aesthetic result, seven patients were very satisfied with the flap. Four patients underwent corrective surgery and one patient had laser treatment for telangiectasia on the flap.

CONCLUSION

Two thirds of patients were satisfied with the aesthetic results and one third had late complications of the flap. Consequently, patients undergoing Rieger-Marchac procedures must be informed of the potential need for further corrective measures following nasal dorsal flap repair.

Oncologic outcomes after immediate breast reconstruction following mastectomy: comparison of implant and flap using propensity score matching

Background

Although immediate breast reconstruction has been reported to be oncologically safe, no affirmative study comparing the two reconstruction methods exists. We investigated breast cancer recurrence rates in two breast reconstruction types; implant reconstruction and autologous flap reconstruction.

Methods

A retrospective cohort study was performed on propensity score-matched (for age, stage, estrogen receptor status) patients who underwent IBR after mastectomy at Seoul National University Hospital between 2010 and 2014. The main outcomes determined were locoregional recurrence-free interval (LRRFI) and disease-free interval (DFI).

Results

We analyzed 496 patients among 731 patients following propensity score matching (Median age 43, 247 implant reconstruction and 249 flap reconstruction). During median follow-up of 58.2 months, DFI was not different between the two groups at each tumor stage. However, flap reconstruction showed inferior DFI compared to implant reconstruction in patients with high histologic grade (p = 0.012), and with high Ki-67 (p = 0.028). Flap reconstruction was related to short DFI in multivariate analysis in aggressive tumor subsets. Short DFI after flap reconstruction in aggressive tumor cell phenotype was most evident in hormone positive/Her-2 negative cancer (p = 0.008). LRRFI, on the other hand, did not show difference according to reconstruction method regardless of tumor cell aggressiveness.

Conclusion

Although there is no difference in cancer recurrence according to reconstruction method in general, flap-based reconstruction showed higher systemic recurrence associated with histologically aggressive tumors.

Perforator Dissection Simulation: A High-Fidelity Five-Flap Porcine Training Model

Introduction

Perforator dissection can be technically demanding with a steep learning curve. Inadvertent perforator damage during dissection can be minimized with practice and familiarity with tissue-handling techniques unique to perforator dissection. There currently lacks a simulation model that mimics the human perforator in size and course. We present a porcine training model with five consistent perforator flaps per side that can be readily harvested and is a reproducible simulation model.

Materials and Methods

Five fresh cadaveric pigs were used in this study to evaluate the feasibility and location of the perforators. Ten perforators were dissected out in each pig (five per side) by the same surgeon. The length of perforator was measured and intramuscular route was noted. The ease of dissection was graded, and its similarity to actual surgery was graded as well.

Results

Five consistent perforators were identified across each side of five fresh cadaveric pigs. The perforators were located, namely in the neck, anterior flank, posterior flank, rectus and hindlimb. They were fasciocutaneous and had an intramuscular course of each (average 2.5 cm length). The perforators were found to be on each side of the pig, giving ten perforators for dissection practice in total.

Discussion

The five perforators named in this porcine model are easily replicated and can be performed for perforator dissection simulation and practice.

Automatic detection of perforators for microsurgical reconstruction

The deep inferior epigastric perforator (DIEP) is the most commonly used free flap in mastectomy reconstruction. Preoperative imaging techniques are routinely used to detect location, diameter and course of perforators, with direct intervention from the imaging team, who subsequently draw a chart that will help surgeons choosing the best vascular support for the reconstruction. In this work, the feasibility of using a computer software to support the preoperative planning of 40 patients proposed for breast reconstruction with a DIEP flap is evaluated for the first time. Blood vessel centreline extraction and local characterization algorithms are applied to identify perforators and compared with the manual mapping, aiming to reduce the time spent by the imaging team, as well as the inherent subjectivity to the task. Comparing with the measures taken during surgery, the software calibre estimates were worse for vessels smaller than 1.5 mm (P = 6e-4) but better for the remaining ones (P = 2e-3). Regarding vessel location, the vertical component of the software output was significantly different from the manual measure (P = 0.02), nonetheless that was irrelevant during surgery as errors in the order of 2-3 mm do not have impact in the dissection step. Our trials support that a reduction of the time spent is achievable using the automatic tool (about 2 h/case). The introduction of artificial intelligence in clinical practice intends to simplify the work of health professionals and to provide better outcomes to patients. This pilot study paves the way for a success story.

[McGregor's flap: a salvage technique: about a case, clinical features and outcome]

Le lambeau inguinal est un lambeau « axial » pédiculé à distance. Il s'agit d'un lambeau très fiable pour les couvertures des grandes pertes de substance du membre supérieur, même si son inconvénient majeur est de nécessiter deux temps opératoires. Il reste un lambeau de choix dans l'arsenal thérapeutique de la chirurgie de la main gauche, en urgence ou en chirurgie réglée. Cela s'explique par son épaisseur graisseuse et son pédicule court, de petit calibre, aux variations anatomiques fréquentes. Le but de cette étude est de montrer son intérêt en mettant en balance ses avantages et ses inconvénients. Nous rapportons le cas d'une patiente âgée de 33 ans qui a présenté suite à un traumatisme ouvert complexe de la main une déformation grave avec fermeture de la première commissure et ankylose de la première articulation métacarpo-phalangienne. Il a été opéré en deux temps avec ouverture la première commissure et arthrodèse M1-trappez stabilisé par embrochage suivi d'une couverture cutané immédiate par un lambeau inguinal de McGregor et en deuxième temps après 21 jours pour sevrage et suture du site donneur. Le résultat anatomique et fonctionnel a été jugé bon. Les patients étaient satisfaits par la cicatrice du site donneur aisément dissimulable dans les sous-vêtements, par la fonctionnalité et l'esthétique de la main. Le lambeau de Mac Gregor est une solution de couverture intéressante avec des avantages non négligeables tant du point de vue fonctionnel qu'esthétique. Sa place devrait être remise en valeur dans l'arsenal thérapeutique des lambeaux de recouvrement des membres.

The Use of Pectoralis Major Musculocutaneus and Deltopectoral Flaps in Oromandibular Defects Reconstruction

The main complication in patients with combined treatment of head, neck, mandibular and maxillary tumors is osteoradionecrosis, which appears after radiation therapy. Radiation therapy is widely used to treat cancer, but growing concern is related to the risk of osteoradionecrosis after treatment. This can occur after radiation therapy. Below, we would like to describe the treatment of osteoradionecrosis, which appeared 5 years after radiation therapy in a 54-year-old male patient. In 2012, a patient in Turkey was diagnosed with adenocystic carcinoma of the tongue base, and surgery was performed to remove the tumor after the patient underwent a course of radiotherapy. In 2016, the patient underwent again a surgery for tumor recurrence. In December 2017, the patient was admitted to our clinic with osteoradionecrosis. We performed segmental resection of the mandible, type I right-sided modified neck dissection, reconstruction of the mandible with a titanium plate and a pectoralis major muscle skin flap. The technique described in this case is the insertion of a well-vascularized tissue into the pre-irradiated and necrotic hypovascular region of the mandible with a skin-muscle flap of the pectoralis major muscle wrapped around the plate for reconstruction. As a result, a pectoralis major flap coverred the mouth floor on internal side and the outside skin defect was covered with a deltopectoral one. The viability of the skin-muscle flap of the pectoralis major muscle was assessed using clinical monitoring, checking the flap every four hours for the first 3 days. This study describes a successful outcome.

The Utility of Strap Muscle in Complex Type I Thyroplasties

INTRODUCTION

Type I thyroplasty is a common procedure used to improve dysphonia secondary to glottic insufficiency caused by vocal fold paralysis, paresis, or bowing. Revision often involves more complex procedures that can be complicated by mucosal violation, hemorrhage, infection, and shifted or extruded implants. Intraoperative challenges can be managed successfully using autologous strap muscle rotation flaps.

OBJECTIVES

Review vocal fold medialization with strap muscle as a viable option for thyroplasty, particularly operations with inadvertent mucosal disruption.

METHODS

All operative records of the senior author's 30-year experience were queried for modified, complex, or revision type I thyroplasties. Each of these was reviewed, and only those utilizing autologous strap muscle rotation flaps for vocal fold medialization were included. Changes in voice quality were assessed using strobovideolaryngoscopic assessment of glottic closure and Voice Handicap Index-10 (VHI-10) scores when available.

RESULTS

Seven patients were found to have undergone eight type I thyroplasty using autologous strap muscle flaps. Improved glottic closure was seen in all patients except one. This patient, complicated by a laryngeal fracture of unknown origin discovered at the time of surgery, had worse voice with strap muscle implantation intraoperatively; therefore, the patient's fracture was reduced, and medialization was postponed. All other patients reported improved voice quality both intra- and postoperatively. Pre- and postoperative VHI-10 scores were available for two of the seven cases with successfully implanted strap muscles. A decrease in VHI-10 was observed in both cases (mean = 11). No postoperative complications occurred in any patient.

CONCLUSION

Although revision thyroplasties are relatively rare, they can be challenging. The seven cases presented herein illustrate the successful and safe use of autologous strap muscle rotation flaps for complex, revision type I thyroplasty procedures. They are particularly helpful in cases requiring additional soft tissue between the thyroid cartilage and mucosa in preparation for possible future medialization after Gore-Tex or Silastic implants, and for inadvertent mucosal disruption in which using a foreign implant might pose a risk of infection. Future studies should be performed with larger populations and longer follow-up to confirm the efficacy and safety of this procedure.

An Important Role of Macrophages for Wound Margin Regeneration in a Murine Flap Model

Background

Macrophages have been known to have diverse roles either after tissue damage or during the wound healing process; however, their roles in flap wound healing are poorly understood. In this study, we aimed to evaluate how macrophages contribute to the flap wound regeneration.

Methods

A murine model of a pedicled flap was generated, and the time-course of the wound healing process was determined. Especially, the interface between the flap and the residual tissue was histopathologically evaluated. Using clodronate liposome, a macrophage-depleting agent, the functional role of macrophages in flap wound healing was investigated. Coculture of human keratinocyte cell line HaCaT and monocytic cell line THP-1 was performed to unveil relationship between the two cell types.

Results

Macrophage depletion significantly impaired flap wound healing process showing increased necrotic area after clodronate liposome administration. Interestingly, microscopic evaluation revealed that epithelial remodeling between the flap tissue and residual normal tissue did not occurred under the lack of macrophage infiltration. Coculture and scratch wound healing assays indicated that macrophages significantly affected the migration of keratinocytes.

Conclusion

Macrophages play a critical role in the flap wound regeneration. Especially, epithelial remodeling at the flap margin is dependent on proper macrophage infiltration. These results implicate to support the cellular mechanisms of impaired flap wound healing.

Versatility of the O-Z flap for back reconstruction after giant basal cell carcinoma resection: A case report and review of the literature

•

Giant basal cell carcinomas are rare and potentially aggressive tumors.

•

Aggressive surgical resection with suggested wide free margins is suggested.

•

Soft tissue reconstruction for back lesions may be challenging.

•

The O-Z flap represents a safe and reliable alternative for back reconstruction.

Introduction

Giant basal cell carcinomas are rare and potentially aggressive skin malignancies that are infrequently reported in the Literature, and they usually require aggressive surgical resection and immediate soft tissue reconstruction with skin grafts or flaps. The large size of GBCCs has relevant implications not only for the metastatic potential, but even for the reconstructive challenging due to the possible limited availability of tissues for flap coverage.

Presentation of case

We report the peculiar case of an old patient who underwent to GBCC resection of the back measuring 16 × 13 cm, and immediate reconstruction with a large O to Z flap harvested from the back; one-year follow-up examination revealed a satisfactory result and no recurrence of the disease was observed.

Discussion

The review of the Literature showed that reconstructive options are mainly determined by the site and extent of the defect, exposed structures and patient characteristics and comorbidities, and previous series reported the use of skin grafts only, pedicled myocutaneous or perforator flaps, exclusively free flaps and a combination of techniques. Therefore, in this scenario local flaps such as O-Z flaps are less invasive procedures, that usually have lower rate of postoperative complications and shorter hospitalization compared to more complex procedures.

Conclusions

Despite the use of O-Z flap is quite unusual for back reconstruction, we believe that this flap represents a valid and safe alternative in selected cases, particularly in the elderly and medically compromised patients with multiple comorbidities.

A new flap combination for reconstruction of lower nasal dorsum and supra-tip skin defects

Repairing surgical defects of the nose is still challenging due to its tridimensional shape and its aesthetic concern. Difficulty in reconstructing nasal subunits lies in their contour, skin texture and limited availability of adjacent skin. For lower nasal dorsum and supra-tip regions, we design a new combined local flap as existing local flaps may give disappointing results. This combination flap was performed on two patients for reconstruction of the lower nasal dorsum area after basal cell carcinoma excision. Size of the excision ranged from 20 to 25 mm diameter and safe margins were obtained. The defects were reconstructed with a local flap that combined a rotation nasal flank flap and a V-Y advancement nasolabial flap. Excision and reconstruction were performed in a one-stage surgery under intravenous sedation and local anesthesia. There were no postoperative complications and no flap loss occurred. Aesthetic and functional results after 6 months postoperatively were satisfying without modification of nasal shape. This flap is reliable and offers interesting functional and aesthetic outcomes. It can be considered as a new reconstruction alternative for supra-tip and lower nasal dorsum skin defects performed in a one-stage procedure under local anesthesia.

Defect-oriented reconstruction after transoral robotic surgery for oropharyngeal cancer: a case series and review of the literature

Transoral robotic surgery (TORS) is a fascinating new technique that has been shown to be a safe and feasible treatment for selected oropharyngeal cancers. Furthermore, TORS might offer some advantages in selected locoregionally advanced cancers. Thus, the patient selection is the keypoint for the useful application of TORS. However, the reconstruction of large oropharyngeal defects is challenging due to the restoration of velopharyngeal competency and swallowing. Moreover, the absence of mandibular splitting increases the difficulties faced by reconstructive surgeons. The paradigm for oropharyngeal reconstruction has undergone changes paralleling reflecting the overall change in the trend of the treatment alternatives over the last few decades. Flap choice and harvesting should be tailored to obtain significant advantages both in functional terms and for easy insetting. In this review, we analyse the strengths and weaknesses of the various flaps used in TORS framework with particular regards on our preliminary experience.

Closure of Oro-Antral Communication Using Buccal Advancement Flap

Improper and inadequate treatment can lead to oro-antral communication and fistula. Certain surgical procedure during operation in posterior maxilla can lead to communication between oral cavity and sinus. In children and adolescents, the risk of oro-antral communication is less, due to smaller volume of the maxillary sinus defect smaller than 2 mm that would adequately heal without any intervention, but larger communications more than 2 mm would require immediate attention from surgeon and treatment should be done as soon possible in order to avoid further complications, infection and patient's discomfort.

Giant Dorsalis Pedis Pseudoaneurysm Following Cannulation for Arterial Line in a Patient with Systemic Lupus Erythematosus

Dorsalis pedis artery (DPA) aneurysms are very rare and fewer than 60 cases have been reported in the literature. Most affected patients present with false aneurysms after orthopedic surgery or trauma. Here we report an unusual case of a giant DPA pseudoaneurysm after cannulation for arterial line placement in a patient newly diagnosed with systemic lupus erythematosus (SLE). A diagnostic delay resulted in necrosis of the overlying skin. Excision of the pseudoaneurysm, ligation of the DPA, and debridement of the foot dorsum were performed, followed by a second flap coverage surgery. Although a DPA false aneurysm is rare after arterial line removal, it can cause the serious complications of skin necrosis, rupture and toe necrosis. Arterial puncture sites should be carefully monitored, especially in patients with SLE or other vasculitis.