Free Tissue Transfers and Replantation:

Reconstruction of Small-Sized Complex Defect on the Foot Dorsum Without Microsurgery: Intrinsic Adipofascial Flap

Dorsal foot defects are difficult to cover and often require major flap surgery by microsurgeons, even for defects of limited sizes. Intrinsic adipofascial flaps for small-sized complex defects are simple and do not require microsurgery; thus, a flap specialist is unnecessary. This study aimed to assess our institutional experience with this technique and define its role in dorsal foot reconstruction. Nine patients aged 48 to 86 years with soft tissue defects of the dorsal foot were treated with the intrinsic adipofascial flap by rotating the adjacent adipofascial tissues from May 2019 and January 2021 in our institution. Demographic, clinical, and followup data were evaluated. Primary outcomes include flap viability, flap bulkiness, ability to wear shoes, and donor site morbidity. The mean followup period was 24.5 months (range, 10-30 months) and the mean defect size was 6.4 cm2 (range, 3.0-9.0 cm2). Eight flaps survived providing an adequate contour and durable coverage with a thin flap. Among 8 cases of healed flaps, 6 required secondary skin grafts while the other 2 healed spontaneously without additional operation. One patient (defect size: 3.0 cm × 3.0 cm) with underlying diabetes mellitus and peripheral arterial occlusive disease encountered flap total necrosis. Revisional flap surgery was performed to cover the flap total necrosis. In conclusion, the intrinsic adipofascial flap is a relatively simple and suitable method for complex dorsal foot defect reconstruction because it provides minimal donor site morbidity. However, relatively large defect size and comorbidities, such as underlying diabetes mellitus and vascular occlusive disease could accompany a risk of flap necrosis.

Free Flap Failure and Contracture Recurrence in Delayed Burn Reconstruction: A Systematic Review and Meta-analysis

Background

Free tissue transfer is often considered a last resort in burn reconstruction due to its complexity and associated risks. A comprehensive review on free flap outcomes in delayed burn reconstruction is currently lacking. The study aimed to evaluate the available evidence on the failure and contracture recurrence rates in free flap delayed burn reconstruction.

Methods

A systematic review and meta-analysis was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The protocol was registered on PROSPERO (CRD42023404478). The following databases were accessed: Embase, PubMed, Web of Science, and Cochrane Library. The measured outcomes were free flap loss and contracture recurrence rate.

Results

Of the 1262 retrieved articles, 40 qualified for inclusion, reporting on 1026 free flaps performed in 928 patients. The mean age was 29.25 years [95% confidence interval (CI), 24.63-33.88]. Delayed burn reconstruction was performed at an average of 94.68 months [95% CI, - 9.34 to 198.70] after initial injury, with a follow-up period of 23.02 months [95% CI, 4.46-41.58]. Total flap loss rate was 3.80% [95% CI, 2.79-5.16] and partial flap loss rate was 5.95% [95% CI, 4.65-7.57]. Interestingly, burn contracture recurrence rate was 0.62% [95% CI, 0.20-1.90].

Conclusions

This systematic review provides a comprehensive evaluation of the free flap outcomes in delayed burn reconstruction. The flap loss rate was relatively low, given the complexity of the procedure and potential risks. Furthermore, burn contracture rate was found to be extremely low. This study demonstrates that free flaps are a safe and effective option for delayed burn reconstruction.

Outcomes of Muscle versus Fasciocutaneous Free Flap Reconstruction in Acute Burns: A Systematic Review and Meta-analysis

Background

Free flap reconstruction in acute burns is high risk but often required for limb salvage and coverage of vital structures. Prior studies have shown a flap loss rate up to 44%. This study aimed to compare the complications associated with muscle and fasciocutaneous free flaps in acute burn reconstruction.

Methods

A systematic review and meta-analysis was conducted according to PRISMA guidelines and registered on the PROSPERO database (CDR42023471088). The databases accessed were Embase, PubMed, Web of Science, and Cochrane Library. The primary outcome was free flap failure rate based on flap type. Secondary outcomes included venous congestion, arterial thrombosis, amputation, and need for reintervention.

Results

Twelve studies with 181 free flaps were included: 87 muscle flaps and 94 fasciocutaneous flaps. Muscle flaps had a higher risk ratio (RR) for total flap loss [RR: 2.32, 95% confidence interval (CI): 1.01-5.32, P = 0.04], arterial thrombosis (RR: 3.13, 95% CI: 1.17-8.42, P = 0.02), and amputations (RR: 8.89, 95% CI: 1.27-70.13, P = 0.03) compared with fasciocutaneous flaps. No significant differences were found in venous thrombosis (RR: 1.33, 95% CI: 0.37-4.78, P = 0.65) or need for reinterventions (RR: 1.34, 95% CI: 0.77-2.32, P = 0.29).

Conclusions

Muscle flaps in burn injuries are associated with higher risks of flap failure, arterial thrombosis, and amputations. Fasciocutaneous free flaps in acute burns seem to be safer with better outcomes, though further research is needed to confirm these findings.

Feet Salvage Using Anterolateral Thigh Flaps after Severe Frostbite Injury: A Case Report

BACKGROUND

Frostbite is a severe injury characterized by tissue damage due to exposure to freezing temperatures. It often necessitates prompt medical intervention to prevent further complications such as necrosis and amputation. This case report explores the successful use of bilateral anterolateral thigh (ALT) free flaps for feet salvage in a 19-year-old male refugee from Gambia who suffered severe frostbite injuries.

CASE REPORT

The patient, found after six days in freezing conditions, exhibited necrosis on multiple toes. Initial management included stabilization, intravenous fluids, and rewarming. Subsequent necrectomy and amputation revealed exposed metatarsal bones, necessitating a meticulous reconstructive strategy. Bilateral ALT flaps were chosen to preserve walking function, with a staged reconstruction involving multiple operations. The patient's progress, from inpatient care to outpatient follow-ups, is detailed, emphasizing the challenges and decisions in managing severe frostbite injuries.

RESULTS

The surgical intervention utilizing bilateral ALT flaps successfully salvaged the patient's feet. Throughout the postoperative period, wound care, rehabilitation, and outpatient monitoring contributed to positive outcomes. Despite challenges associated with the patient's ethnic background and nutritional status, the staged reconstruction facilitated effective healing and functional recovery. The use of ALT flaps provided a reliable solution with minimal donor site morbidity.

CONCLUSION

This case highlights the efficacy of bilateral ALT flap reconstruction in salvaging feet following severe frostbite injury. The successful restoration of foot function underscores the importance of early intervention and tailored reconstructive approaches in frostbite management. Despite patient-specific challenges, including nutritional status and limited healthcare resources, the use of ALT flaps facilitated optimal recovery and functional outcomes. Importantly, this report is unique as it describes a novel case of feet salvage using bilateral ALT flaps in severe frostbite injury, with only one similar case previously reported in the literature. This emphasizes the rarity and significance of this specific surgical approach in frostbite management.

Complications and management of excessive phallic turgor following gender-affirming phalloplasty

Gender-affirming phalloplasty involves flap tubularization, placing unique stresses on the vascularity of the flap. Tubularization renders the flap susceptible to postoperative edema that can lead to excessive turgor that, if left untreated, can compromise perfusion and threaten the viability of the phallic reconstruction. This phenomenon has not been formally described in our literature. We aim to define this entity, described here as "Excessive Phallic Turgor" (EPT), and to outline its incidence, frequency of its underlying etiologies, and sequelae. We conducted a single-center, retrospective review of all phalloplasty operations involving flap transfer performed from December 2016 to May 2023. All patients requiring emergent intervention (bedside suture release, reoperation, or both) due to excessive phallic swelling and impending flap compromise were considered to have EPT. Variables compared between groups included underlying etiology (categorized as congestion, hematoma or swelling), patient demographics, flap type and size, management, length of stay, and postoperative outcomes. Over the study period, 147 phalloplasty operations involving flap transfer for shaft creation were performed. Of those, 15% developed EPT. Age, BMI, flap length, flap circumference, flap surface area, single vs multistage operation, flap tubularization (shaft-only vs tube-within-tube), and flap donor site were not significantly different between the cohort that developed EPT and that which did not. Development of EPT was associated with higher rates of phallic hematoma, surgical site infection, shaft fistula requiring repair, and longer inpatient stays. When EPT develops, prompt diagnosis and alleviation of intraphallic pressure are paramount for mitigating short- and long-term morbidity.

[Emergency free flap in reconstruction of the lower limb: About 23 cases over 11 years]

OBJECTIVES

To study the coverage period influence and various parameters concerning the microsurgical act on the patient clinical outcomes.

METHODS

We report 23 cases of reconstruction of lower limb loss of substance by free flap operated from 2010 to 2021. Among them, 9 patients were operated on as an emergency versus 14 in the secondary or late phase of the trauma.

RESULTS

The average age of injured patients operated on emergency was 42 years (17-68 years) and 34 years for the patients who undergo deferred surgery (17-57 years). The sex ratio (female/male) was 22% in patients operated on urgently and 7% in patients operated on later. Regarding the type of free flap, it was Serratus anterior muscle flap in 10 cases, Latissismus dorsi flap in 9 cases, ALT flap in 3 cases and Gracilis muscle flap in 1 case. There were 2 failures of vascularized free transfer (8.7%) with complete necrosis of the flap and 3 revision surgeries on venous thrombosis which finally made it possible to obtain 3 flap successes. We analyze the results (complications/osteitis) according to the time to coverage.

CONCLUSIONS

In our study, we did not find any significant difference between the groups operated in emergency and at a distance concerning the rate of infection and failure of the flaps.

Exophytic Squamous Cell Carcinoma of the Scalp: A Case Report

Squamous cell carcinoma (SCC) is the second-most common clinical presentation of non-melanoma skin cancer. Despite its prevalence, the rate of growth and development of SCC lesions is low. We present a case report of an exophytic SCC of the midline scalp. Over approximately 18 months, the exophytic portion of this lesion grew to a size of 8.5 x 7 cm due to the fact that the patient did not seek medical attention. The patient suffered from many predisposing factors including active smoking status, type II diabetes, and significant previous sun exposure. In addition to these predisposing factors, the patient did not have comprehensive health insurance to cover outpatient medical care. This case highlights the importance of early intervention in the management of head and neck skin cancers and the negative impact of delayed treatment.

Regulated extravascular microenvironment via reversible thermosensitive hydrogel for inhibiting calcium influx and vasospasm

Arterial vasospasm after microsurgery can cause severe obstruction of blood flow manifested as low tissue temperature, leading to tissue necrosis. The timely discovery and synchronized treatment become pivotal. In this study, a reversible, intelligent, responsive thermosensitive hydrogel system is constructed employing both the gel–sol transition and the sol–gel transition. The “reversible thermosensitive (RTS)” hydrogel loaded with verapamil hydrochloride is designed to dynamically and continuously regulate the extravascular microenvironment by inhibiting extracellular calcium influx. After accurate implantation and following in situ gelation, the RTS hydrogel reverses to the sol state causing massive drug release to inhibit vasospasm when the tissue temperature drops to the predetermined transition temperature. Subsequent restoration of the blood supply alleviates further tissue injury. Before the temperature drops, the RTS hydrogel maintains the gel state as a sustained-release reservoir to prevent vasospasm. The inhibition of calcium influx and vasospasm in vitro and in vivo is demonstrated using vascular smooth muscle cells, mice mesenteric arterial rings, and vascular ultrasonic Doppler detection. Subsequent animal experiments demonstrate that RTS hydrogel can promote tissue survival and alleviate tissue injury responding to temperature change. Therefore, this RTS hydrogel holds therapeutic potential for diseases requiring timely detection of temperature change.

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Proposing a new strategy for the discovery and treatment for diseases requiring timely detection of temperature change.

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Applying both the gel–sol transition and the sol–gel transition of PEG/PLGA triblock polymers.

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Realizing the dynamical and continuous regulation of the extravascular microenvironment.

Clinical application of an expanded reverse-island flap with two dorsal metacarpal arteries and dorsal metacarpal nerves in index- and middle-finger-degloving injury repair and amputation reconstruction

The dorsal metacarpal artery flap (DMAF) is irrefutable as an effective way of repairing long finger defects, and hand surgeons might consider using it for long finger reconstruction or degloved injury repair. Unfortunately, the DMAF containing a single dorsal metacarpal artery (DMA) hinders the treatment effect. The sensory restoration of long fingers and the reconstruction of phalangeal joints and tendon grafts are unsolved challenges as well. We reported our experience in reconstructing the index and middle finger by a reverse-island flap with two DMAs and dorsal metacarpal nerves (DMNs) with blood supply. We reviewed ten patients with finger-crush injuries affecting eight index fingers and two middle fingers. Degloving injuries occurred in two patients, and finger amputations occurred in eight others. Two patients received simple flap reconstruction, and eight received finger reconstruction, including seven from abandoned phalangeal joints and tendon grafts of the severed finger and one from the iliac crest bone graft. All patients underwent finger reconstruction by an expanded reverse-island flap consisting of two DMAs and DMNs up to a maximal size of 9 × 8 cm². Postoperative follow-up evaluation showed a satisfactory appearance and functional recovery of the reconstructed fingers. We posit that the expanded reverse-island flap involving two DMAs and DMNs constitutes a feasible and safe option for restoring a severely damaged index or middle finger, particularly for patients who are unwilling to undergo toe-to-finger transplantation to reconstruct the injured long fingers.

Aspirin, heparin and ischemia time in microvascular free flap surgery - their influence and an optimal anticoagulation protocol

BACKGROUND

Microvascular surgery has become a standardized technique for reconstruction of large tissue defects in Head and Neck Reconstructive Surgery. However, the main dreaded complications are thrombosis of blood vessels or major bleeding after surgery. Several different anticoagulation protocols have been established in the last decades to overcome these problems with varying degrees of success.

METHODS

Over a period of six years, a standardized anticoagulation protocol including acetylsalicylic acid (ASA) and unfractionated heparin (UFH) for direct intraoperative and postoperative administration was established, optimized and compared to a previously used non-standardized protocol. A total of 178 flap surgeries were included in the development and optimization process of the protocol.

RESULTS

ASA significantly increased the risk of complications when used for longer than 72 h (OR = 2.52; p = 0.002; 95% CI 1.39-4.59). Administration of UFH reduced flap loss (bolus: OR 0.68; p = 0.47; 95% CI 0.24-1.93; continuous UFH administration: OR = 0.61; p = 0.33; 95% CI 0.22-1.66), however doses greater than 500 IU/ h of UFH as continuous infusion increased the risk of complications. Reduction in ischemia time had no effect on the occurrence of complications.

CONCLUSION

Anticoagulation regimes in microvascular surgery can influence the postoperative complication rate. The optimal protocol should consist of a combination of ASA and UFH for the intraoperative and direct postoperative phase. Prolonged administration of ASA as well as doses >500 IU/ h of UFH are to be avoided due to the increased complication rate.

Evaluation of the Suprafascial Thin ALT Flap in Foot and Ankle Reconstruction

BACKGROUND

 Distal lower extremity reconstruction can be challenging in terms of flap design. Bulky flaps result in limited mobility accompanied with the need of customized footwear. Raising the ALT-flap in a superficial fascial plane (thin ALT-flap) can be beneficial. This study evaluates thin ALT-flaps for lower distal extremity reconstruction.

METHODS

 In a retrospective study, patients that underwent microvascular extremity reconstruction at the level of the ankle and dorsal foot at the University of Freiburg from 2008-2018 were reviewed.

RESULTS

 95 patients could be included in the study (35 perforator flaps, 8 fascia flaps and 54 muscle flaps).Among the perforator flaps, 21 ALT-flaps were elevated conventionally and 14 in the superficial fascial plane (thin ALT-flap). Among the conventional ALT-flaps, there was one flap loss (5%) and one successful revision (5%). 5(24%) flaps received secondary thinning. 57%(n = 12) were able to wear conventional footwear. There were 2(15%) successful revisions of thin ALT-flaps. 100% of thin ALT-flaps survived and 85%(n = 11) of the patients wore ordinary footwear after defect coverage.Among fascial flaps, 50%(n = 4) had to be revised with 2(25%) complete and 1 (13%) partial flap loss. All patients achieved mobility in ordinary shoes (n = 8).In muscle flaps, there were 7(13%) revisions and 5(9%) flap losses. 5(9%) flaps received secondary thinning. Only 33%(n = 18) were mobile in ordinary footwear.

CONCLUSION

 The thin ALT-flap is a save one-stage evolution for lower distal extremity reconstruction with a favorable flap survival rate. Compared with conventional ALT-flaps it might be beneficial in reducing the need for expensive custom fitted shoes and secondary thinning procedures.

Watching the Vessels Grow: Establishment of Intravital Microscopy in the Arteriovenous Loop Rat Model

Tissue engineering in reconstructive surgery seeks to generate bioartificial tissue substitutes. The arteriovenous (AV) loop allows the generation of axially vascularized tissue constructs. Cellular mechanisms of this vascularization process are largely unclear. In this study, we developed two different chamber models for intravital microscopy and imaging of the AV loop in the rat. Multiple design variations were implanted and the stability of the chamber and AV loop patency was tested in vivo. Our novel chamber facilitates repetitive observation of the AV loop using fluorescence-enhanced intravital microscopy. This technique can be used for daily evaluation of leukocyte-endothelial cell interactions, vascularization, and tissue formation in the AV loop model on 14 consecutive days. Therefore, our newly developed model for intravital microscopy will provide better understanding of cellular and molecular processes in tissue engineering in the AV loop. Moreover, it supports initiation of the novel approaches for therapeutic applications. Impact statement In the Arteriovenous (AV) loop, axially vascularized tissue can be generated and modified using different tissue engineering approaches. Cellular mechanisms of this vascularization process are largely unclear. We managed to develop an intravital microscopy model for long-term observation of intravascular and perivascular events in the AV loop. Leukocyte-endothelial cell interactions, vascularization, and tissue formation in the AV loop can now be evaluated on a day-to-day basis. This will provide better understanding of cellular and molecular processes happening during tissue engineering within the AV loop.

Reconstruction of traumatic and non-traumatic lower extremity defects with local or free flaps

Background

Despite continuous surgical advances, reconstruction of complex lower extremity wounds remains challenging. The indication of local flaps or microsurgical free tissue transfer depends on the anatomical location and size of the defect, as well as the comorbidities and general condition of the patient. In this study, local and free flap reconstruction of distal lower extremity defects was assessed, and postoperative complications and limb salvage were analyzed.

Methods

A total of 34 patients were included in this retrospective study. Distal lower extremity defects were of traumatic (29%) and non-traumatic (71%) etiologies. Patient characteristics, flap selection, postoperative complications, and limb preservation within the first 12 months were assessed and compared by reconstructive treatment concept. Statistical analysis included parametric and non-parametric tests. The two-sided alpha was set at 5% for all statistical tests.

Results

While 21 patients were treated with local flaps, 13 patients underwent microsurgical free flap reconstruction. The most common comorbidities were peripheral vascular disease and diabetes. Local flaps included the gastrocnemius muscle flap, soleus flap, sural flap, and plantaris medialis flap. The most commonly used free flaps for soft tissue reconstruction were latissimus dorsi and gracilis muscle flaps. The overall lower extremity preservation rate was 94.1%. There was one case of below-knee amputation 1 month after free flap reconstruction, and one case of first-ray amputation of the foot after local flap coverage.

Conclusion

Reconstruction of lower extremity defects can be achieved by local or free flap reconstruction. Flap selection is influenced by anatomical location, defect size, and patient factors.

Soft-tissue reconstruction after soft-tissue sarcoma resection: the clinical outcomes of 24 patients

PURPOSE

Pedicle or free-flap reconstruction is important in surgical sarcoma management. Free flaps are indicated only when pedicle flaps are considered inadequate; however, they are associated with a higher risk of flap failure, longer surgical times, and technical difficulty. To determine the skin defect size that can be covered by a pedicle flap, we investigated the clinical outcomes and complications of reconstruction using pedicle flaps vs. free flaps after sarcoma resection.

METHODS

We retrospectively studied the medical records of 24 patients with soft-tissue sarcomas who underwent reconstruction using a pedicle (n = 20) or free flap (n = 4) following wide tumour resection.

RESULTS

All skin defects of the knee, lower leg, and ankle were reconstructed using a pedicle flap. Skin defects of the knee, lower leg, and ankle were covered by up to 525 cm², 325 cm², and 234 cm², respectively. The amount of blood loss was significantly greater in the free-flap group than in the pedicle flap group (p = 0.011). Surgical time was significantly shorter in the pedicle flap group than in the free-flap group (p = 0.006). Total necrosis was observed in one (25%) patient in the free-flap group; no case of total necrosis was observed in the pedicle flap group.

CONCLUSION

Less blood loss, shorter surgical time, and lower risk of total flap necrosis are notable advantages of pedicle flaps over free flaps. Most skin defects, even large ones, of the lower extremities following sarcoma resection can be covered using a single pedicle flap or multiple pedicle flaps.

The Anterolateral Thigh Perforator Flap: Its Expanding Role in Lower Extremity Reconstruction

The anterolateral thigh (ALT) flap is a popular flap for lower extremity reconstruction despite its varied pedicle anatomy. Beyond its use for soft tissue coverage, using the chimeric flap concept, the ALT flap is useful for tendon and ligament reconstruction and the creation of a gliding surface with the fascia lata component. The vastus lateralis muscle can be included for dead-space obliteration. The main pedicle is long and is a similar size match for major artery reconstruction. If several perforators are available, a split flap could be fashioned into a multitude of shapes all arising from the same pedicle.

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

BACKGROUND

Distal one - third trauma of the lower limb is a complex condition to treat. The reverse sural flap is a time tested procedure for reconstruction of such defects especially in patients where free flaps are ruled out due to comorbidities. The purpose of this study is to compare the two modifications of the classical technique of reverse sural flap (adipofascial and fasciocutaneous) which is lacking in the literature.

MATERIAL & METHODS

In this study, the authors conducted a retrospective analysis of 67 patients with lower one-third leg defects reconstructed with either adipofascial reverse sural flap (Group A, n = 37) or two-staged fasciocutaneous reverse sural flap (Group B, n = 30) in a tertiary care hospital in North India between 2015 and 2019. An evaluation of the different flap characteristics of the two variants of the reverse sural flap was done and compared. Mean follow up period was 12 months.

RESULTS

The adipofascial group showed shorter operative time, was a single-stage and with better reach and aesthetic outcome. The complications did not differ except that for the adipofascial group was associated with unstable skin graft over the flap initially which did not require any treatment.

DISCUSSION

Lower one-third defect of the lower limb has been a challenge for reconstructive surgeons all over the world. The goal of reconstruction is a functional lower limb. Although free tissue transfer is the preferred modality of treatment of such cases but it may not be possible in all cases due to various reasons. Reverse sural flap is a very lucrative local option for such reconstructions as it is easy to perform, reliable, low profile and bulk, require minimal facilities with less operative time. Adipofascial flaps represent an extremely useful modification of the reverse sural flap which is quick to perform with minimal donor site morbidity.

CONCLUSION

Adipofascial reverse sural artery flap is a good option for patients with lower limb trauma with the added advantage of being single-stage and with better donor site cosmesis as compared to the fasciocutaneous reverse sural artery flap.

Reconstruction of Upper Extremity Defects by Random Pedicle Abdominal Flaps: Is It Still a Valid Option?

Traumatic soft tissue defects of the hand and upper extremities are common and may be challenging to the reconstructive surgeon. Several reconstructive procedures such as use of local, regional, distant, and free flaps have been described. This study aimed to report the techniques, outcomes, and complications of pedicle abdominal flaps in reconstructing hand and upper extremity defects.

Ultrathin Free Flaps to the Foot and Ankle: New Options for Optimal Soft Tissue Coverage and Functional Contour

Soft tissue defects and chronic wounds around the foot and ankle can prove difficult to reconstruct using conventional techniques. Traditional flaps used for coverage in this region can result in the need for future debulking, shoe gear modifications, donor site morbidity, decreased function, and scarring. Successful reports of ultrathin free flaps harvested along suprafascial planes have yet to be described in the foot and ankle literature. We present 2 cases of ultrathin flaps used for foot and ankle defects that provide optimal contour while not limiting anatomic function. The resultant functional outcomes and contour shown by both flaps underscore the benefit of a thin and pliable flap in this region.

Flap Coverage of Dysvascular Digits Including Venous Flow-Through Flaps

A dysvascular digit is defined as a threatened circulatory condition of a digit caused owing to multiple reasons, such as medical illness or trauma. A dysvascular digit always needs surgical manipulation of the vessel in trauma cases. The revascularization of the digit is a priority in such conditions, after which reconstruction of the defect is performed. In this article, the authors present and discuss the venous free flap, thenar free flap, toe plantar free flap, free style perforator flap, hypothenar free flap, and anconeus muscle free flap.

Hand, Wrist, Forearm, and Arm Replantation

Level of injury plays a significant role in decisions to perform replantation, with improved function, nerve regeneration, and decreased rate of reperfusion injury for injuries at the distal forearm or wrist compared with proximal injuries. The principles of a functional and sensate outcome dictate replantable parts, whereas patient comorbidity, expectations, and safety dictate patient candidacy. Vascular grafts are an expected part of the operation, and the contralateral arm or a lower extremity should be prepped into the surgical field. Despite diminished function, patient satisfaction and independence remain high after a major upper extremity replantation.

Phalloplasty Flap-Related Complication

This article focuses on flap-related complications after creation of a neophallus for transgender individuals. It outlines the most frequently used flaps for this procedure and how flap-related complications can affect the overall outcome of the phalloplasty. With surgeons staging the procedure in different stages, it is important to understand the different strategies and the implication a flap-related complication can have on the end result and how it may be prevented.

Versatility of Free Cutaneous Flaps for Upper Extremity Soft Tissue Reconstruction

The goals of upper extremity soft tissue reconstruction should go well beyond providing coverage and restoring function. As the field of reconstructive microsurgery has evolved, free cutaneous flaps (FCFs) are gaining wider application. The advantages of FCF include minimizing donor-site morbidity by preserving the muscle and fascia, improving versatility of flap design, and superior aesthetic results. This review highlights the application of anterolateral thigh, superficial circumflex iliac artery, deep inferior epigastric perforator, superficial inferior epigastric artery, and flow-through flaps for reconstruction of upper extremity defects. These flaps share several qualities in common: well-concealed donor sites, preservation of major arteries responsible of providing inflow to distal extremity, and potential for a two-team approach (donor and recipient sites). While the choice of flaps should be decided based on individual patient and defect characteristics, FCF should be considered as excellent options to achieve the goals of upper extremity reconstruction.

The value of postoperative anticoagulants to improve flap survival in the free radial forearm flap: a systematic review and retrospective multicentre analysis

BACKGROUND

Free radial forearm flap (FRFF) reconstruction is a valuable technique in head and neck surgery, which allows closure of large defects while striving to maintain functionality. Anticoagulative drugs are often administered to improve flap survival, although evidence regarding effectiveness is lacking.

OBJECTIVE OF REVIEW

To investigate the effectiveness of postoperative anticoagulants to improve survival of the FRFF in head and neck reconstruction.

TYPE OF REVIEW

Systematic review and multicentre, individual patient data meta-analysis.

SEARCH STRATEGY

MEDLINE, EMBASE, Web of Science and CINAHL were searched for synonyms of 'anticoagulants' and 'free flap reconstruction'.

EVALUATION METHOD

Studies were critically appraised for directness of evidence and risk of bias. Authors of the highest quality publications were invited to submit their original data for meta-analysis.

RESULTS

Five studies were of adequate quality, and data from four studies (80%) were available for meta-analysis, describing 759 FRFF procedures. Anticoagulants used were as follows: aspirin (12%), low molecular weight dextran (18.3%), unfractioned heparin (28.1%), low molecular weight heparin (49%) and prostaglandin-E1 (2.1%). Thirty-one per cent did not receive anticoagulants. Flap failure occurred in 40 of 759 patients (5.3%) On univariate analysis, use of unfractioned heparin was associated with a higher rate of flap failure. However, these regimens were often administered to patients who had revision surgery of the anastomosis. In multivariate logistic regression analysis, anticoagulant use was not associated with improved flap survival or flap-related complications.

CONCLUSIONS

The studied anticoagulative drugs did not improve FRFF survival or lower the rate of flap-related complications. In addition, some anticoagulants may cause systemic complications.

Neo-digit functional reconstruction of mutilating hand injury using transplantation of multiple composite tissue flaps

PURPOSE

Functional reconstruction of mutilating hand injuries poses a challenge to the surgeon. We present our experience with use of multiple composite tissue flaps transplant for functional reconstruction of hand in patients with mutilating hand injuries. The associated merits and demerits of these surgical approaches are briefly discussed.

METHODS

From August 2004 to October 2014, functional reconstruction of hand with transplantation of multiple composite tissue flaps was performed in 8 patients. These included the toe with dorsal pedis artery flap, the reverse posterior interosseous artery flap, and the anterolateral thigh flap. Mean interval from injury to functional reconstruction was 10.6 days.

RESULTS

All transplanted skin flaps and reconstructed neofingers survived completely. Only 1 patient developed wound infection at the recipient site (hand), which resolved without any debridement or revision surgery. At the donor site (foot), partial skin necrosis was observed in 1 patient, which healed with local wound care. In other patients, all wounds healed without any complications. The average range of movement at the neofinger metacarpophalangeal and interphalangeal joints was 38° and 73°, respectively. None of the patients required revision surgery.

CONCLUSION

Use of negative pressure wound therapy and multiple composite tissue flap transplantation appears to be an effective strategy for hand functional reconstruction in patients with mutilating hand injuries. Among the multiple composite tissue flaps, use of toe transplantation combined with reverse posterior interosseous artery flap appears to be the best option.

Breast free flap complications related to haematoma formation - do the risks of multiple antithrombotics outweigh the benefits today?

Background Free flap reconstruction is today a common operation for many breast cancer patients, but local protocols for microsurgery still predict the use of antithrombotic agents. Reduced operation times and complication rates together with faster mobilisation, after introduction of perforator flaps, call for less comprehensive antithrombotic regimens. It was hypothesised that multiple antithrombotics was a risk factor for bleeding-related flap complications. Methods A retrospective cohort study was conducted to study the association between reoperation for haematoma and flap-related complications after free flap breast reconstruction. A combination of heparin, low-molecular-weight heparin and dextran were used as antithrombotics. A sub-analysis was performed to compare non-dextran to dextran treated patients. Results One hundred and thirty-nine patients were identified, reconstructed with 150 consecutive perforator free flaps to the breast. Reoperation for breast haematoma (13%) was associated with concomitant re-operation for venous congestion (8.6%) (p < 0.001), but also for flap thrombosis (2.9%) (p = 0.007), highlighting haematoma as a risk factor for flap-related complications. An increased rate of haematoma re-operations of the breast was noted among the flap-related complications in the dextran (n = 79), compared to the non-dextran group (p = 0.011). Conclusion The current study highlights the use of multiple antithrombotics as a risk factor for haematoma reoperation. Liberal use of drains and evacuation of breast haematomas are, therefore, indicated together with limitation of antithrombotic agents. The highly variable use of antithrombotic agents worldwide call for evidence-based guidelines in standardised free flap breast reconstruction.

Advancing biomaterials of human origin for tissue engineering

Biomaterials have played an increasingly prominent role in the success of biomedical devices and in the development of tissue engineering, which seeks to unlock the regenerative potential innate to human tissues/organs in a state of deterioration and to restore or reestablish normal bodily function. Advances in our understanding of regenerative biomaterials and their roles in new tissue formation can potentially open a new frontier in the fast-growing field of regenerative medicine. Taking inspiration from the role and multi-component construction of native extracellular matrices (ECMs) for cell accommodation, the synthetic biomaterials produced today routinely incorporate biologically active components to define an artificial in vivo milieu with complex and dynamic interactions that foster and regulate stem cells, similar to the events occurring in a natural cellular microenvironment. The range and degree of biomaterial sophistication have also dramatically increased as more knowledge has accumulated through materials science, matrix biology and tissue engineering. However, achieving clinical translation and commercial success requires regenerative biomaterials to be not only efficacious and safe but also cost-effective and convenient for use and production. Utilizing biomaterials of human origin as building blocks for therapeutic purposes has provided a facilitated approach that closely mimics the critical aspects of natural tissue with regard to its physical and chemical properties for the orchestration of wound healing and tissue regeneration. In addition to directly using tissue transfers and transplants for repair, new applications of human-derived biomaterials are now focusing on the use of naturally occurring biomacromolecules, decellularized ECM scaffolds and autologous preparations rich in growth factors/non-expanded stem cells to either target acceleration/magnification of the body's own repair capacity or use nature's paradigms to create new tissues for restoration. In particular, there is increasing interest in separating ECMs into simplified functional domains and/or biopolymeric assemblies so that these components/constituents can be discretely exploited and manipulated for the production of bioscaffolds and new biomimetic biomaterials. Here, following an overview of tissue auto-/allo-transplantation, we discuss the recent trends and advances as well as the challenges and future directions in the evolution and application of human-derived biomaterials for reconstructive surgery and tissue engineering. In particular, we focus on an exploration of the structural, mechanical, biochemical and biological information present in native human tissue for bioengineering applications and to provide inspiration for the design of future biomaterials.

The Reverse Superficial Sural Artery Flap Revisited for Complex Lower Extremity and Foot Reconstruction

Background:

Soft-tissue defects of the distal lower extremity and foot present significant challenges to the reconstructive surgeon. The reverse superficial sural artery flap (RSSAF) is a popular option for many of these difficult wounds. Our initial experience with this flap at multiple institutions resulted in a 50% failure rate, mostly because of critical venous congestion. To overcome this, we have modified our operative technique, which has produced a more reliable flap.

Methods:

All patients reconstructed with an RSSAF between May 2002 and September 2013 were retrospectively reviewed. In response to a high rate of venous congestion in an early group of patients, we adopted a uniform change in operative technique for a late group of patients. A key modification was an increase in pedicle width to at least 4 cm. Outcomes of interest included postoperative complications and limb salvage rate.

Results:

Twenty-seven patients were reconstructed with an RSSAF (n = 12 for early group, n = 15 for late group). Salvage rate in the early group was 50% compared with 93% in the late group (P = 0.02). Postoperative complications (75% vs. 67%, P = 0.70) were similar between groups. Venous congestion that required leech therapy was 42% in the early group (n = 5) and 0% in the late group (P = 0.01).

Conclusions:

Venous congestion greatly impairs the survival of the RSSAF. A pedicle width of at least 4 cm is recommended to maintain venous drainage and preserve flap viability.

Effect of heparin on prevention of flap loss in microsurgical free flap transfer: a meta-analysis

The effectiveness of heparin for thromboprophylaxis during microvascular free flap transfer is uncertain. The purpose of this meta-analysis was to determine the effect of heparin on the prevention of flap loss in microsurgical free flap transfer.A search of PubMed, Cochrane databases, and Google Scholar using combinations of the search terms heparin, free flap, flap loss, free tissue transfer was conducted on March 15, 2013. Inclusion criteria were: 1) Prospective randomized trials. 2) Retrospective, non-randomized studies. 3) Patients received free tissue transfer. Flap loss rate was used to evaluate treatment efficacy. Odds ratios (ORs) with 95% confidence intervals (CI) were calculated and compared between therapies. Four studies meet the criteria for analysis and were included. Two studiescompared aspirin and heparin, and the ORs of the 2 studies were 1.688 and 2.087. The combined OR of 2.003 (95% CI 0.976–4.109, p = 0.058) did not indicate any significant difference between heparin and aspirin therapies. Two studiescompared high and low doses of dalteparin/heparin therapies, and the ORs of the 2 studies were 4.691 and 11.00. The combined OR of 7.810 (95% CI 1.859–32.808, p = 0.005) revealed a significant difference indicating that high dose dalteparin or heparin therapy is associated with a greater flap loss rate than low dose therapy. Heparin and aspirin prophylaxis are associated with similar flap loss rates after free flap transfer, and high dose dalteparin or heparin therapy is associated with a greater flap loss rate than low dose therapy.

Ischaemia-related cell damage in extracorporeal preserved tissue - new findings with a novel perfusion model

Tissue undergoing free transfer in transplant or reconstructive surgery always is at high risk of ischaemia-related cell damage. This study aims at assessing different procedures using an extracorporeal perfusion and oxygenation system to investigate the expression of hypoxia inducible factor (HIF)-1-α as marker for hypoxia and of the pro-apoptotic protein Caspase-3 in skeletal muscle to elucidate potential improvements in tissue conservation. Twenty-four porcine rectus abdominis muscles were assigned to five different groups and examined after they had been extracorporeally preserved for 60 min. time. Group I was left untreated (control), group II was perfused with a cardioplegic solution, group III was flushed with 10 ml of a cardioplegic solution and then left untreated. Group IV and V were perfused and oxygenated with either an isotone crystalloid solution or a cardioplegic solution. Among others, immunohistochemistry (Caspase-3 and HIF-1-α) of muscle samples was performed. Furthermore, oxygen partial pressure in the perfusate at the arterial and venous branch was measured. Expression of Caspase-3 after 60 min. was reduced in all groups compared to the control group. Furthermore, all groups (except group III) expressed less HIF-1-α than the control group. Oxygenation leads to higher oxygen levels at the venous branch compared to groups without oxygenation. Using an extracorporeal perfusion and oxygenation system cell damage could be reduced as indicated by stabilized expressions of Caspase-3 and HIF-1-α for 60 min. of tissue preservation. Complete depletion of oxygen at the venous branch can be prevented by oxygenation of the perfusate with ambient air.

Biological extremity reconstruction after sarcoma resection: past, present, and future

In sarcoma surgery besides a wide local resection, limb salvage became more and more important. Reconstruction of bone and soft tissue defects after sarcoma resection poses a major challenge for surgeons. Nowadays a broad range of reconstructive methods exist to deal with bony defects. Among these are prostheses, bone autografts, or bone allografts. Furthermore a variety of plastic reconstructive techniques exist that allow soft tissue reconstruction or coverage after sarcoma resection. Here we discuss the historical highlights, the present role, and possible future options for biological reconstruction.