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Kasmirski JA, Alessandri-Bonetti M, Liu H, Corcos AC, Ziembicki JA, Stofman GM, Egro FM. Free Flap Failure and Complications in Acute Burns: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5311. [PMID: 37817922 PMCID: PMC10561810 DOI: 10.1097/gox.0000000000005311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/21/2023] [Indexed: 10/12/2023]
Abstract
Background Severe acute burn injuries represent a challenge to the reconstructive surgeon. Free flap reconstruction might be required in cases of significant critical structure exposure and soft tissue deficits, when local options are unavailable. This study aimed to determine the free flap complication rate in acute burn patients. Methods A systematic review and meta-analysis were conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and registered on the International Prospective Register of Systematic Reviews database (CRD42023404478). The following databases were accessed: Embase, PubMed, Web of Science, and Cochrane Library. The primary outcome was the free flap failure rate. Results The study identified 31 articles for inclusion. A total of 427 patients (83.3% men, 16.7% women) accounting for 454 free flaps were included. The mean patient age was 36.21 [95% confidence interval (CI), 31.25-41.16]. Total free flap loss rate was 9.91% [95% CI, 7.48%-13.02%], and partial flap loss was 4.76% [95% CI, 2.66%-8.39%]. The rate of venous thrombosis was 6.41% [95% CI, 3.90%-10.36%] and arterial thrombosis was 5.08% [95% CI, 3.09%-8.26%]. Acute return to the operating room occurred in 20.63% [16.33%-25.71%] of cases. Stratified by body region, free flaps in the lower extremity had a failure rate of 8.33% [95% CI, 4.39%-15.24%], whereas in the upper extremity, the failure rate was 6.74% [95% CI, 3.95%-11.25%]. Conclusion This study highlights the high risk of free flap complications and failure in acute burn patients.
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Affiliation(s)
- Julia A. Kasmirski
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | | | - Hilary Liu
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Alain C. Corcos
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jenny A. Ziembicki
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Guy M. Stofman
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Francesco M. Egro
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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Lacroix G, Jeanne M, Martinot V, Pasquesoone L. "Extensive necrosis following extravasation of alkali in the crease of the elbow after voluntary intravenous injection: A case report". ANN CHIR PLAST ESTH 2023; 68:81-85. [PMID: 35902288 DOI: 10.1016/j.anplas.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/28/2022] [Accepted: 07/06/2022] [Indexed: 01/18/2023]
Abstract
Chemical burns are often deep with difficult initial clinical evaluation, especially those due to alkalic agents, which have a strong penetrating power. They therefore require specialized care in a Burn Unit. Self-inflicted burns are infrequent but their management represents a real challenge. We report the case of a 47-year-old referred to our Burn Center for the evaluation of a self-inflicted corrosion with an alkalic agent (soda), injected at the crease of the left elbow. The patient, right handed, was a nurse and had notably a psychiatric history of depressive syndrome. We observed a deep, well-defined necrosis area, associated with intense peri-lesional inflammation and extensive cellulitis. Faced with this unusual clinical appearance for a chemical burn, the patient's questioning was repeated and the patient finally admitted to having injected himself with a basic caustic product intravenously. Surgical treatment was carried out in two stages: debridement with exposure of vascular and neural structures then coverage with a free anterolateral thigh flap. The postoperative consequences were uneventful with a satisfactory functional result. Factitious disorders are underestimated and often misleading. Among factitious disorders, self-inflicted wounds remain a real challenge requiring multidisciplinary management. Many etiologies exist, among which injection of drugs or substances, in any anatomical localization, leading to variable loss of substance. The use of a free flap for acute extravasation is rare but sometimes essential. The anterolateral thigh flap allows good resurfacing on areas with important functional requirements.
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Affiliation(s)
- G Lacroix
- Plastic Surgery and Burn Centre, CHU de Lille, 59000 Lille, France.
| | - M Jeanne
- Anesthesia and Critical Care, Burn Centre, CHU de Lille, 59000 Lille, France; Inserm, CIC 1403 - centre d'investigations cliniques, University of Lille, 59000 Lille, France; ULR 7365, GRITA - groupe de recherche sur les formes injectables et les technologies associées, University of Lille, 59000 Lille, France
| | - V Martinot
- Plastic Surgery and Burn Centre, CHU de Lille, 59000 Lille, France
| | - L Pasquesoone
- Plastic Surgery and Burn Centre, CHU de Lille, 59000 Lille, France
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Predictors for limb amputation and reconstructive management in electrical injuries. Burns 2022:S0305-4179(22)00208-X. [PMID: 36031494 DOI: 10.1016/j.burns.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/06/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Electrical injuries follow a specific pathophysiology and may progressively damage both skin and deeper tissues, frequently ending in amputations. Type and timing of soft tissue reconstruction after electrical burns is crucial for proper outcome. The aim of this study was to assess surgical management and outcome of patients with electrical injuries treated at the Zurich Burn Center over the last 15 years, with emphasis on risk factors for amputation and reconstructive strategy. METHODS Patient charts were reviewed retrospectively to identify cases admitted at the Zurich Burns Center (2005-2019). Patient characteristics and surgical management, with a special focus on amputations, reconstruction and outcome were analyzed and risk factors for amputation were assessed. RESULTS Eighty-nine patients were identified and a total of 522 operations were performed. Escharotomy and fasciotomies were performed in 40.5% and 24.7% of cases, respectively, mainly at admission. The total amputation rate was 13.5% (23 amputations, 12 patients). Development of compartment syndrome, rhabdomyolysis, high myoglobin and CK blood levels, kidney failure, sepsis and respiratory complications during the course were related to higher risk of amputation (p < 0.001). Sixty-six flap-based reconstructions were performed (25% cases): 49 loco-regional flaps, 3 distant pedicled flaps, 14 free flaps. Two flaps were lost (flap failure rate 14%). Both flap losses occurred in cases of early reconstruction (within 5-21 days). CONCLUSIONS Electrical injuries are still cause of elevated morbidity and mortality, with high amputation rate. Predictors for amputation can support physicians in the surgical care and decision-making. Reconstruction remains challenging in this type of injury: the surgical management with early decompression, serial necrectomies and delayed early reconstruction remains the procedure of choice at our unit.
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Brewin MP, Hijazi Y, Pope-Jones S, Exton RJ, Khan MS. Free tissue transfer for burns reconstruction: A single-site experience. Burns 2020; 46:1660-1667. [PMID: 32451129 DOI: 10.1016/j.burns.2020.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 11/15/2022]
Abstract
This study reviews free tissue transfer (FTT) surgery for both acute wound and reconstructive scar management of burn injuries at a UK burns unit over a 10-year period. Thirty eight patients underwent 46 FTTs, or free flaps, as part of their burn injury pathway. For the cohort of patients, there was one flap failure, which occurred for a secondary scar reconstruction. It is noted that FTT was successful for all seven acute or primary interventions. Anterolateral thigh flap was the most frequently performed (57%); followed by parascapular flaps (22%) of which 43% were pre-expanded. A method of pre-expansion for neck contractures and a novel technique of anchoring this flap to the pre-tracheal fascia are described here. This can provide the patient with good neck contouring by using the capsule to hitch the flap into a good position. It is clear that further work is required to study the prevention of hypertrophic scarring that can occur at the interface between flap and adjacent skin, where occurrence rate in this cohort was 17%. It is proposed that FTT now provides a viable solution both to the coverage of complex burn wounds and to the revision of scar contractures. Consensus over an FTT protocol for the primary management of open burn wounds is seen as the logical next step for this surgical intervention.
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Affiliation(s)
- M P Brewin
- Department of Plastic and Reconstructive and Burns Surgery, Salisbury NHS Foundation Trust, Odstock Road, Salisbury SP2 8BJ, United Kingdom.
| | - Y Hijazi
- Department of Plastic and Reconstructive and Burns Surgery, Salisbury NHS Foundation Trust, Odstock Road, Salisbury SP2 8BJ, United Kingdom
| | - S Pope-Jones
- Department of Plastic and Reconstructive and Burns Surgery, Salisbury NHS Foundation Trust, Odstock Road, Salisbury SP2 8BJ, United Kingdom
| | - R J Exton
- Department of Plastic and Reconstructive and Burns Surgery, Salisbury NHS Foundation Trust, Odstock Road, Salisbury SP2 8BJ, United Kingdom
| | - M S Khan
- Department of Plastic and Reconstructive and Burns Surgery, Salisbury NHS Foundation Trust, Odstock Road, Salisbury SP2 8BJ, United Kingdom
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Castro JC, Coltro PS, Millan LS, Corrêa FB, Farina Junior JA. Early Application of Microsurgical Flaps in the Electric Burns of Extremities: A Two Institutional Case Series. J Burn Care Res 2018; 39:1037-1042. [PMID: 29931152 DOI: 10.1093/jbcr/irx010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Some groups have avoided early microsurgical flaps in electrical burns under the pretext of injury to the microvasculature, which could increase vascular thrombosis. However, this option frequently results in amputation of the extremity. This study aims to evaluate the early application of microsurgical flaps for the treatment of electrical burns of extremities. A case series was retrospectively evaluated including patients with electrical trauma in extremities undergoing early microsurgical reconstruction. Data were obtained from medical charts, including age, trauma location, flap type and microvascular anastomosis, the need for other procedures, postoperative complications, the length of hospital stay after the flap surgery, and patient outcomes. Five microsurgical flaps were performed in less than 30 days to trauma, one anterolateral thigh flap to cover skin failure in upper limb, and four radial forearm flaps to cover failure in feet. The patient ages had a mean of 25.8 years (from 12 to 42 years). The microsurgical procedure occurred from 21 to 27 days after the burn, with a mean of 24.2 days. Hospital discharge had a mean of 26.6 days (from 19 to 35 days after the surgery). Only one patient required reintervention for re-anastomosis. All patients had a good flap viability, avoiding amputation of the affected extremity and with a proper preservation of function. The early application of microsurgical flaps for patients with electrical burns of extremities may provide adequate, sturdy, and stable skin coverage, contributing to the treatment of noble structures exposed and avoiding amputation of the extremities.
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Affiliation(s)
- Júlio C Castro
- Division of Plastic Surgery, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Pedro S Coltro
- Division of Plastic Surgery, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Lincoln S Millan
- Plastic Surgery Service, Institute of Medical Assistance of the State Public Servant, São Paulo, Brazil
| | - Fernanda B Corrêa
- Division of Plastic Surgery, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Jayme A Farina Junior
- Division of Plastic Surgery, Ribeirão Preto Medical School, University of São Paulo, Brazil
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Serror K, Chaouat M, Romano G, Schmidt M, Blet A, Mimoun M, Boccara D. Free-style puzzle flap as a cross-leg pedicled flap: the concept of re-using a flap in acute burns, a case report. BURNS & TRAUMA 2018; 6:2. [PMID: 30009190 PMCID: PMC6040606 DOI: 10.1186/s41038-018-0107-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/05/2018] [Indexed: 11/23/2022]
Abstract
Background In well-selected cases, flaps can play a pivotal role in optimizing outcomes in the acute phase of burns. A previous redundant flap could be reused or recycled as a donor site from which a new flap could be raised. Case presentation We report the case of a patient with full thickness burns on both legs, leading to the exposure of joints of the right ankle and the right foot and left patellar tendon. The right lower extremity was covered with a free musculo-cutaneous latissimus dorsi flap. Then, a musculo-cutaneous cross-leg flap pedicled on the anterior branch and centered on a perforator was harvested from the previous redundant flap to cover the controlateral knee. Conclusion Sequential flap coverage can be considered in cases of extensive soft tissue defects and particularly in burns. This case illustrates that re-using a redundant part of a previous flap to cover another defect is a safe and interesting alternative in the event of a lack of donor sites or to save donor sites for later reconstruction of contracted burn scars.
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Affiliation(s)
- Kevin Serror
- Department of Plastic Reconstructive Surgery, Burn Center, Hôpital Saint Louis, AP-HP 1 Avenue Claude Vellefaux, 75010 Paris, France
| | - Marc Chaouat
- Department of Plastic Reconstructive Surgery, Burn Center, Hôpital Saint Louis, AP-HP 1 Avenue Claude Vellefaux, 75010 Paris, France
| | - Golda Romano
- Department of Plastic Reconstructive Surgery, Burn Center, Hôpital Saint Louis, AP-HP 1 Avenue Claude Vellefaux, 75010 Paris, France
| | - Magali Schmidt
- Department of Plastic Reconstructive Surgery, Burn Center, Hôpital Saint Louis, AP-HP 1 Avenue Claude Vellefaux, 75010 Paris, France
| | - Alice Blet
- Department of Plastic Reconstructive Surgery, Burn Center, Hôpital Saint Louis, AP-HP 1 Avenue Claude Vellefaux, 75010 Paris, France
| | - Maurice Mimoun
- Department of Plastic Reconstructive Surgery, Burn Center, Hôpital Saint Louis, AP-HP 1 Avenue Claude Vellefaux, 75010 Paris, France
| | - David Boccara
- Department of Plastic Reconstructive Surgery, Burn Center, Hôpital Saint Louis, AP-HP 1 Avenue Claude Vellefaux, 75010 Paris, France
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Irthum C, Fossat S, Bey E, Duhamel P, Braye F, Mojallal A. Place du lambeau libre antérolatéral de cuisse dans la reconstruction des pertes de substance distales des membres inférieurs. ANN CHIR PLAST ESTH 2017; 62:224-231. [DOI: 10.1016/j.anplas.2016.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 07/21/2016] [Indexed: 11/30/2022]
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Jabir S, Frew Q, Magdum A, El-Muttardi N, Philp B, Dziewulski P. Microvascular free tissue transfer in acute and secondary burn reconstruction. Injury 2015; 46:1821-7. [PMID: 25983220 DOI: 10.1016/j.injury.2015.04.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 04/24/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The mainstay of operative treatment in burns is split skin grafting with free tissue transfer being indicated in a minority of cases. However, free tissue transfer faces a number of challenges in the burns patient. These include; overall cardiovascular and respiratory stability of the patient, availability of suitable vessels for anastomosis, sufficient debridement of devitalised tissue and a potentially increased risk of infection. We carried out a retrospective study in order to determine the indications, timing, principles of flap selection, complications, outcomes and methods of promoting flap survival when free tissue transfer was utilised for burn reconstruction in our unit. MATERIALS AND METHODS All patients who underwent soft tissue reconstruction for burn injuries with microvascular free tissue transfer between May 2002 and September 2014 were identified from our burns database. The records of these patients were then retrospectively reviewed. Data extracted included, age, gender, type of injury, total body surface area involved, indications for free tissue transfer, anatomical location, timing of reconstruction, complications and flap survival. RESULTS Out of a total of 8776 patients admitted for operative treatment over a 12-year period, 23 patients required 26 free flaps for reconstruction. Out of 26 free flaps, 23 were utilised for acute burn reconstruction while only 3 free flaps were utilised for secondary burn reconstruction. All 26 free flaps survived regardless of timing or burn injury mechanism. Complications included haematomas in 2 flaps and tip necrosis in 4 flaps. Two flaps required debridement and drainage of pus, 1 flap required redo of the venous anastomosis while 1 required redo of the arterial anastomosis with a vein graft. CONCLUSIONS Free tissue transfer has a small but definite role within acute and secondary burn reconstruction surgery. Despite the complexity of the burn defects involved, free flaps appear to have a high success rate within this cohort of patients. This appears to be the case as long as the appropriate patient and flap is selected, care is taken to debride all devitalised tissue and due diligence paid to the vascular anastomosis by performing it away from the zone of injury.
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Affiliation(s)
- Shehab Jabir
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, United Kingdom.
| | - Quentin Frew
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, United Kingdom
| | - Ashish Magdum
- Castle Hill Hospital, Cottingham, Hull HU16 5JQ, United Kingdom
| | - Naguib El-Muttardi
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, United Kingdom
| | - Bruce Philp
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, United Kingdom
| | - Peter Dziewulski
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, United Kingdom
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Abstract
BACKGROUND The treatment of bone-exposed wounds with artificial dermis is not widely accepted in burn patients because of uncertain clinical results. This article aimed to review our clinical experience with this technique. METHODS We implanted artificial dermis in 11 bone-exposed burns. Implantation was directly performed on bones with periosteum, whereas bones without periosteum were trephinated or burred before implantation. All wounds were closed by secondary skin grafting. RESULTS The mean patient age was 49 years. Lower extremity is the most common site of bone exposure. The mean bone exposed area was 55.6 cm, whereas the mean Integra-implanted area was 86.7 cm. The overall implant take rate was 91%, and the skin grafting success rate was 80%. No secondary breakdown was noted after a 2-year follow-up. CONCLUSIONS This study confirms that artificial dermis can be an alternative treatment tool for burns with exposed bones, especially in patients with limited donor sites.
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Bibliography—Editors’ selection of current world literature. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e31828aa74c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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