Female ventral-onlay buccal mucosal graft urethroplasty supported with martius labial fat pad flap: early results

PURPOSE

There is a growing interest in reconstructive urology and female urethroplasty. We aimed to report our experience in ventral-onlay buccal mucosa graft (BMG) urethroplasty supported with Martius flap (MF) in treating female urethral stricture disease.

METHODS

We retrospectively evaluated data of 18 female patients (ages 35-78) who were diagnosed with urethral stricture disease and underwent ventral-onlay BMG urethroplasty supported with MF by single surgeon in a tertiary referral centre between February 2019 and October 2022. Detailed history, international prostate symptom score (IPSS), pelvic examination, urine flow rate (rate and pattern), post void residual (PVR), storage and voiding phase urodynamic study, and voiding cystourethrography were recorded. At the last visit; the number of urethral dilatations before urethroplasty, time from urethral dilation to urethroplasty, hospital stay, urethral catheterization time, postoperative IPSS, PVR and uroflowmetry values were recorded.

RESULTS

The presenting symptoms were obstructive voiding symptoms in 16 patients. While the mean number of urethral dilatation was 2.11 ± 1.93 (1-7), the mean time from dilatation to urethroplasty was 5.83 ± 5.00 (1-19 months) months. Maximum flow rate increased from 8.36 ± 3.26 ml/sec in preoperative uroflowmetry to 21.45 ± 5.27 ml/sec at the last follow-up (p < 0.001). Post-void residual urine (PVR) decreased from preoperative mean 116.66 ± 105.88 cc to 26.94 ± 22.69 cc postoperatively (p < 0.004). None of the patients developed stricture recurrence, incontinence or vaginal fistula until the last follow-up. The mean follow-up period was 17.28 ± 11.65 (1-35) months.

CONCLUSIONS

A ventral-onlay BMG urethroplasty supported with MF represents an effective and reproducible treatment option for FUS in the present study.

Detecting recurrent disease and surgical outcomes in patients with locally advanced tongue cancer after multimodal treatment using ¹⁸F-FDG-PET/CT

The purpose of this study was to evaluate the utility of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FPCT) parameters for detecting recurrent disease and the outcomes of salvage surgery in patients with locally advanced oral tongue squamous cell carcinoma (TSCC) after multimodal treatment. In total, 69 patients with locally advanced TSCC were treated with multimodal therapy. All patients underwent whole-body FPCT scans 4-10 months after the initial surgery. The analysis included FPCT parameters, such as maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG). Histological examination was used as the reference standard. Patients with recurrent TSCC underwent salvage surgery or surgery plus systemic treatment. This study included 69 patients: 36 in the recurrent TSCC group and 33 in the non-recurrent TSCC group. The SUVmax, MTV, and TLG in the recurrent TSCC group were 11.3 ± 3.6, 28.3 ± 15.6 cm3, and 113.2 ± 46.8 g, respectively; these values were 5.9 ± 3.6, 5.1 ± 2.2 cm3, and 13.4 ± 4.8 g, in the non-recurrent TSCC group respectively. The two groups had significant differences in terms of SUVmax, MTV, and TLG. In the recurrent TSCC group, 91.6 % of patients presented with local, locoregional, and regional disease and underwent salvage surgery plus systemic therapy, whereas 8.4 % had locoregional recurrence with distant metastases alone and underwent surgery plus systemic therapy. The patients were followed up for 12-60 months; 19 and 20 patients in the recurrent and non-recurrent TSCC groups showed no evidence of disease, whereas 11 and 8 were alive with the disease. Local recurrence or distant metastases led to the deaths of six patients in the recurrent TSCC group and five in the non-recurrent TSCC group. No significant differences in survival were observed between the two groups. FPCT parameters can detect the recurrence of locally advanced TSCC after multimodal treatment. Early salvage surgery can improve the treatment outcomes for recurrent TSCC.

First standardized assessment of perforators and perforasomes of the occipital artery - An anatomical study

BACKGROUND

Flaps have become an integral part of plastic and reconstructive surgery. The robust blood supply of such flaps is a prerequisite to reduce flap failure. Despite the reported versatility of the occipital flap, comprehensive anatomical studies on its perforators and perforasomes are lacking. Hence, we examined the perforators originating from the occipital artery and their associated perforasomes, aiming to fill this knowledge gap for reconstructive surgery techniques.

METHODS

39 of 40 occipital arteries of 20 fresh anatomical head specimens were dissected. Perforators with a least an outer diameter of 0.50 mm were identified and injected with dye to color their respective perforasomes. Location and size of the colored skin areas were determined as well as the location of their perforators were documented and analyzed.

RESULTS

In total, 183 perforators were found and described. The mean diameter of these vessels was 0.88 ± 0.27 mm (0.5-2.1 mm). The mean area of the perforasomes was 1288.26 ± 662.51 mm2 (144.60-3890.60 mm2). They were localized over the whole nuchal and occipital area. Lastly, perforator diameters were significantly associated with the size of their resulting perforasomes.

CONCLUSION

This study is the first comprehensive overview of perforators and associated perforasomes of the occipital artery on a respectable amount of specimen. The arterial supply of big portions of the occipital and nuchal area is provided solely by the perforators of the occipital artery. For flap surgery, perforator diameter is a crucial detail to be considered in the decision-making process.

More potential uses of specific perforator flaps in the calf - A cadaveric study on the subdermal vascular structure of the lower leg

BACKGROUND

The perforator flap has garnered significant interest since its inception due to its advantage of not needing a vascular network at the deep fascial level. Perforator flaps are commonly utilized in different flap transplant surgeries, and the thigh flap is presently the most widely used perforator flap. Is it possible for the calf to replace the thigh as a more suitable site for harvesting materials? Currently, there is a lack of relevant anatomical research. This study aims to address this question from an anatomical and imaging perspective.

METHODS

This study used cadavers to observe the branches and courses of perforators on the calf and the distribution of skin branches using microdissection techniques, digital X-ray photography, and micro-computed tomography techniques.

RESULTS

The perforators had three main branches: the vertical cutaneous branch, the oblique cutaneous branch, and the superficial fascial branch. The superficial fascial branch traveled in the superficial fascia and connected with the nearby perforators. The vertical and oblique cutaneous branches entered the subdermal layer and connected with each other to create the subdermal vascular network.

CONCLUSIONS

We observed an intact calf cutaneous branch chain between the cutaneous nerve and the perforator of the infrapopliteal main artery at the superficial vein site. Utilizing this anatomical structure, the calfskin branch has the potential to serve as a substitute for thigh skin flap transplantation and may be applied to perforator flap transplantation in more locations.

Constricted posterior fourchette deformities: Definition, classification and surgical treatment

BACKGROUND

Labiaplasty is one of the top cosmetic procedures patients are seeking in the past two years. However, treatment of disease in posterior fourchette caused by various etiological factors was less investigated and neglected.

METHODS

Three types of posterior fourchette deformity were proposed: (1) Redundant posterior fourchette, (2) Relaxed posterior fourchette, and (3) Constricted posterior fourchette. Local flap transfer technique was applied. Y-V-plasty and 5-Z-Flap-plasty were used to treat web type and tight type of the constricted posterior fourchette, respectively. Follow-ups were arranged on the Internet or at the outpatient clinic. Visual analogue scale (VAS) was utilized to evaluate sexual discomfort in the satisfaction questionnaires during follow-up.

RESULTS

A total of 48 patients with constricted posterior fourchette deformity from May 2022 to May 2023 were reviewed in the study. Y-V-plasty could decrease VAS in patients with web-type deformity by 4.13 ± 1.46 (p＜0.001). 5-Z-Flap-plasty could decrease VAS in patients with tight-type deformity by 3.76 ± 1.53 (p＜0.05). Satisfaction rates of the web type and tight type were 93.1% (27/29) and 86.7% (13/15) respectively. Complications include two cases of hematoma, one case of persistent pain and two cases of dehiscence.

CONCLUSION

Constricted posterior fourchette seriously affects the quality of life. Y-V-plasty and 5-Z-Flap-plasty can be utilized to treat the two subtypes of constricted posterior fourchette, which can effectively reduce the pain score of patients with high satisfaction and few long-term complications.

Indocyanine green angiography guidance for vascular preservation in skin and nipple sparing mastectomy

PURPOSE

The skin and/or nipple-sparing approach has become an oncologically sound and desirable choice for women choosing mastectomy. Indocyanine green (ICG) perfusion imaging has been shown to reduce ischemic complications in mastectomy skin flaps. Immediate reconstruction requires a well-vascularized skin flap capable of tolerating full expansion. Identification of the perforating subcutaneous vessels to the skin envelope may allow for better and more consistent blood vessel preservation and flap perfusion.

METHODS

The authors conducted an institutional review board-approved prospective study with 41 patients to assess the feasibility of using ICG perfusion imaging to visualize, cutaneously map, and preserve the vessels that supply the skin flap and nipple-areolar complex. For each patient, the number of vessels initially mapped, the number of vessels preserved, the extent to which each vessel was preserved, and the proportion of the flap with adequate perfusion (as defined by the SPY-Q > 20% threshold) was recorded and analyzed.

RESULTS

Vessels were able to be identified and marked in a high majority of patients (90%). There was a moderate linear relationship between the number of vessels marked and the number preserved. Successful mapping of vessels was associated with lower rates of wound breakdown (p = 0.036). Mapping and preserving at least one vessel led to excellent flap perfusion (> 90%). No increase in complications was observed from utilizing ICG angiography preoperatively.

CONCLUSION

This prospective study using preoperative ICG perfusion mapping demonstrated safety, feasibility, and good prognostic outcomes.

LEVEL OF EVIDENCE

III.

Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery

Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multidatabase literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, 4 of which were comparative in nature and included both closures by PS and SS. Of these 4, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in 2 of the 4 (50%) studies (P = 0.014, P < 0.001) and radiation in 3 of the 4 (75%) studies (P < 0.001, P < 0.01, P < 0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.

Proximal toe wrap-around: a coverage technique for circumferential skin defects of the fingers

Circumferential skin defects of the fingers are a technical challenge. Although rare, their management should respect tissue organization and functional abilities. We report two cases of circumferential skin defect. Management used individually tailored "wrap-around" flaps taken from the hallux. The sample concerned the proximal cutaneous sheath of the first toe and the neurovascular pedicle of the first inter-metatarsal space. Nail and toe pad were spared. Both cases had complex circumferential skin defect of the finger, involving the neuro-vascular pedicle. Postoperative results were favorable, without functional limitation. The wrap-around technique provided skin coverage and also neurovascular pedicle reconstruction. Donor site damage was limited, with no functional consequences. This technique is a valuable option for management of circumferential skin defect of the finger.

The osteoplastic flap for pediatric temporal lobe epilepsy treatment: step-by-step guide and technical nuances

The osteoplastic flap is an under-utilized craniotomy approach in pediatric temporal lobe epilepsy treatment. By preserving the myofascial attachment of the temporalis muscle, the flap is allowed the remain vascularized while subdural and intracranial electrodes are in place. The process in which the flap is made and handled throughout this process can be complicated. We herein detail our surgical technique for the osteoplastic flap in the setting of pediatric temporal lobe epilepsy treatment, and highlight the surgical nuances specific to our 2-stage protocol in treating pediatric temporal lobe epilepsy.

Flap loss in head and neck reconstruction: Is there a singular cause for failure?

Despite the high success rates reported in head and neck reconstruction, free flap failures continue to persist. Understanding the factors associated with flap loss and improving overall success are paramount. This study aimed to comprehensively assess the factors influencing flap revision and free tissue transfer survival in head and neck reconstruction. The study included 70 patients with defects in the lower two-thirds of the head and neck region and underwent reconstruction using free flaps. Patient age, gender, smoking status, comorbidities and data on the location and aetiology of the defect, the specific type of flap employed, the recipient artery and vein chosen, instances of revision and the overall success of the flap were collected. The investigation aimed to establish correlations between these variables as well as flap success and revision rates. No statistically significant differences were observed in arterial and venous anastomosis revision rates, or flap survival, in relation to variables such as age, gender, flap type, smoking status, comorbidities, recipient artery or vein and the number of vein anastomoses. The malignant tumour group exhibited a lower requirement for arterial revision and a higher flap survival rate compared to the benign tumour group. This study underscores the comparable safety profiles of perforator-based and conventional flaps in head and neck reconstruction. Furthermore, it reveals that patient characteristics are not contraindications for free tissue transfer. Additionally, the quantity of the veins and choice of recipient vessels are flexible and do not significantly impact flap success. The higher rates of flap success in patients with malignant aetiology requires further investigation.

Functional donor-site morbidity following reconstruction with pectoralis major flaps: A systematic review

Background

Pectoralis major muscle/myocutaneous flaps (PMMFs) are commonly used in reconstructive surgery, but may result in shoulder disability on the donor side. A systematic review evaluating this morbidity could be beneficial for guiding patients and providers considering this procedure.

Methods

In October 2022, a systematic review of studies evaluating quantitative/qualitative measures of functional morbidity after PMMF was conducted. The results were categorized into PMMF's effect on range of motion (ROM), strength, and ability to complete shoulder-related activities/quality of life.

Results

Eleven studies were included for analysis, which analyzed standard PMMF and two PMMF variants that spared portions of the muscle. Three of five studies demonstrated reduced shoulder ROM for standard PMMF versus controls lasting at least 4 months after head and neck reconstruction. Two of five studies, including two prospective studies demonstrated reduced shoulder strength for standard PMMF versus controls lasting at least 3 months after surgery. Five of nine studies found significant impairment in the ability to conduct shoulder-related activities, including work, up to one year postoperatively for standard PMMF versus controls. Muscle-sparing PMMF variants exhibited more promising outcomes in some categories.

Conclusion

Standard PMMF results in prolonged reductions in shoulder ROM and strength, which may impair patients in shoulder-related activities. Other reconstructive options should be considered in patients who frequently participate in such activities. For patients requiring PMMF, muscle-sparing PMMF variants should be considered as alternatives to the standard PMMF.

L-Borneol promotes skin flap survival by regulating HIF-1α/NF-κB pathway

ETHNOPHARMACOLOGICAL RELEVANCE

The clinical application of skin flaps in surgical reconstruction is frequently impeded by the occurrence of distant necrosis. L-Borneol exhibits myogenic properties in traditional Chinese medicine and is used in clinical settings to promote wound healing and conditions such as stroke. Nevertheless, the precise mechanism by which borneol exerts its protective effects on skin flap survival remains unclear.

AIM OF THE STUDY

To explore the potential of L-borneol to promote skin flap survival and elucidate the underlying mechanisms.

MATERIALS AND METHODS

Thirty-six male Sprague-Dawley rats were randomly divided into three groups: a high-dose (200 mg/kg L-borneol per day), a low-dose (50 mg/kg/day), and control group (same volume of solvent). In each rat, a modified rectangular McFarlane flap model measuring 3 × 9 cm was constructed. Daily intragastric administration of L-borneol or solvent was performed. The flap was divided into three square sections of equal size, namely Zone I (the proximal zone), Zone II (the intermediate zone), and Zone III (the distal zone). The survival rate was quantified, and the histological state of each flap was evaluated on the seventh day following the surgical procedure. The assessment of angiogenesis was conducted using lead oxide/gelatin angiography, whereas the evaluation of blood flow in the free flap was performed using laser Doppler flow imaging. Superoxide dismutase activity was detected using the water-soluble tetrazolium salt-8 method. The quantities of vascular endothelial growth factor, interleukin (IL)-1β, IL-6, and tumour necrosis factor-α were determined using immunohistochemistry. The levels of nuclear transcription factor-κB, hypoxia-inducible factor-1, B-cell lymphoma-2 (BCL-2), and BCL-2-associated X (BAX) were determined by Western blotting technique.

RESULTS

Flap survival rate significantly improved and neutrophil recruitment and release were enhanced after treatment with the compound. Angiogenesis was promoted. L-borneol protected against oxidative stress by increasing superoxide dismutase activity and decreasing malondialdehyde content. It downregulated the hypoxia-inducible factor nuclear transcription factor-κB pathway, leading to the inhibition of several inflammatory factors. Simultaneously, it facilitated the expression of vascular endothelial growth factor and BCL-2.

CONCLUSION

The study shows that L-borneol may promote skin flap survival by inhibiting HIF-1α/NF-κB pathway.

Efficiency of Middle Vault Reconstruction with Dorsal Septal T Flap in Achieving Ideal Dorsal Aesthetic Lines and Regularity

BACKGROUND

Dorsal aesthetic lines and irregularities are the most critical points that can be manipulated in rhinoplasty operations. Although spreader grafts and flaps have been used for this purpose in the reconstruction of the keystone area for a long time, dorsal irregularity is often inevitable. This study aims to evaluate the effectiveness of dorsal septal T flap and nasal dorsum reconstruction in achieving ideal dorsal aesthetic lines and regularity.

METHODS

Thirty-four patients (30 women, 4 men) who underwent closed technique rhinoplasty between 2019 and 2021 were included in the study. The mean age of the patients was 25.4 years. Patients with crooked nose, severe deviation, and severe dorsal hump were also excluded. All patients included in the study underwent Rhinoplasty Outcome Evaluation (ROE) questionnaires preoperative and postoperative 1st year.

RESULTS

The mean age of the patients was 25.4 years (range 18-40 years). A total of 34 patients, including 30 women and four men, were operated. The mean follow-up period was 13.2 months, ranging from 12 to 14 months. In the physical examinations performed at the control visits, no functional problem was encountered in any patients. Preoperative and postoperative mean ROE scores were 60.9 and 92.7, respectively.

CONCLUSIONS

With the technique described in the study, dorsal hump recurrence is minimized compared to other preservation techniques. Since the keystone area transition can be fine-tuned, continuity is ensured, and ideal dorsal aesthetic lines are created. The stability of the upper lateral cartilages is provided, thus eliminating the need for spreader grafts.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Linear Scalp Incision in Brain Tumor Surgery: Intraoperative and Postoperative Considerations

BACKGROUND

Although the linear scalp incision is commonly used in neurosurgical practice, a systematic study elucidating its pros and cons in a specific surgical setting is lacking. Herein, we analyzed our experience with linear scalp incision in brain tumor surgery and the impact on intraoperative variables and postoperative complications.

METHODS

Patients undergoing brain tumor surgery (January 2014-December 2021) at 2 neurosurgical departments were included and divided into 2 groups: linear or flap scalp incision. Patients' demographics characteristics, surgical variables, and wound-related complications were analyzed.

RESULTS

More than a total of 1036 craniotomies, linear incision (mean length 6cm) was adopted in 282 procedures (27.2%). Mean maximum diameter of the craniotomy was 5.25 cm, with no statistical difference between the 2 groups. In emergency surgery (36 cases), the linear and flap incisions were used indifferently. Linear incision was predominant in supratentorial and suboccipital lesions. Flap incision was significantly more frequent among meningiomas (P < 0.01). Neuronavigation, operative microscope, and subgaleal drain were more frequently used in the flap scalp incision group (P = 0.01). Overall complication rate was comparable to flap scalp opening (P = 0.40).

CONCLUSIONS

The use of the linear incision was broadly applied for the removal of supratentorial and suboccipital tumors granting adequate surgical exposure with a low rate of postoperative complications. Tumors skull base localization resulted the only factor hindering the use of the linear incision. The choice of 1 incision over another didn't show to have any impact on intraoperative and postoperative variables, and it remains mainly based on surgeon expertise/preference.

Management of urosymphyseal fistula and pubic bone osteomyelitis: Description of a new surgical technique by cystectomy, urinary diversion and pelvic filling flap by unilateral pedicled myocutaneous vertical rectus abdominus muscle flap

Pubic bone osteomyelitis is a rare infection, mostly related to urinary fistula. The published data about the medical or surgical management of this type of infection is relatively poor. In this case study of three patients, we describe our surgical technique for the management of urosymphyseal fistula complicated with pubic bone infection using pelvic filling flap by unilateral pedicled myocutaneous vertical rectus abdominus muscle flap. The first patient had the pelvic space filled with omentum flap. Unfortunately, the patient presented, postoperatively, an enteric fistula resulting from intestine incarceration on the resected bone. Considering this failure, the next two cases, have benefited from a Taylor flap to protect the peritoneal cavity by covering the residual pubic bone. Early complications were pyelonephritis and anemia (Clavien-Dindo 2), but no repeat surgery was required afterwards. The hospital stay for both cases were 26- and 12-days contrary to the first case who was hospitalized for 180-days. In conclusion, despite our limited experience in managing complicated urosymphyseal fistula, Taylor's flap, mainly used for gynecological or rectal surgery, might be a good reproducible solution for the surgical management of this kind of fistula with pubic debridement. It allows to protect the peritoneal cavity with fewer postoperative complications.

Clinical Evaluation of Coronally Advanced Flap with or without a Platelet-Rich Fibrin Membrane for the Root Coverage

Aim

To evaluate "coronally advanced flap" with or without "a platelet-rich fibrin membrane for the root coverage."

Materials and Methods

All the clinical parameters were assessed at different time intervals (at baseline, 1, 3, and 6 months) in both experimental and control group. Following "clinical parameters" were recorded using "UNC-15" "Probe-Plaque Index (PI)" (Silness and Loe, 1964), "Gingival Index" (GI) (Loe and Silness, 1963), "Recession depth (RD)," "Recession width (RW)," "Clinical attachment level (CAL)," and "Width of keratinized gingiva (WKG)".

Results

At final evaluation (i.e., mean change from baseline to 6 months), "the decrease in Plaque Index was 2.5% higher in Group B (66.0%) as compared to Group A (63.5%). The decrease in Gingival Index was 6.1% higher in Group B (91.4%) as compared to Group A (85.3%), and the decrease in recession width was 4.0% higher in Group B (75.2%) as compared to Group A (71.2%). The decrease in clinical attachment level was 4.4% higher in Group B (53.2%) as compared to Group A (48.4%). The increase in width of keratinized gingiva was 1.9% higher in Group A (28.8%) as compared to Group B (26.9%)."

Conclusion

The controlled, randomized, split mouth design showed that CAF surgery, either by alone or in combination with PRF, is an efficient treatment method for covering denuded roots. "This design was used to treat bilateral isolated Miller's class I and II recessions in gingival part. When compared to the CAF approach, the results from a combination of CAF and PRF after a 6-month period showed additional advantages in addition to mean root coverage in the treatment of Miller's classes I and II recessions in gingival part."

IGF-PLGA microspheres promote angiogenesis and accelerate skin flap repair and healing by inhibiting oxidative stress and regulating the Ang 1/Tie 2 signaling pathway

Random flaps are widely used in the treatment of injuries, tumors, congenital malformations, and other diseases. However, postoperative skin flaps are prone to ischemic necrosis, leading to surgical failure. Insulin-like growth factor- 1(IGF-1) belongs to the IGF family and exerts its growth-promoting effects in various tissues through autocrine or paracrine mechanisms. Its application in skin flaps and other traumatic diseases is relatively limited. Poly (lactic-co-glycolic acid) (PLGA) is a degradable high-molecular-weight organic compound commonly used in biomaterials. This study prepared IGF-PLGA sustained-release microspheres to explore their impact on the survival rate of flaps both in vitro and in vivo, as well as the mechanisms involved. The research results demonstrate that IGF-PLGA has a good sustained-release effect. At the cellular level, it can promote 3T3 cell proliferation by inhibiting oxidative stress, inhibit apoptosis, and enhance the tube formation ability of human umbilical vein endothelial cells (HUVEC) . At the animal level, it accelerates flap healing by promoting vascularization through the inhibition of oxidative stress. Furthermore, this study reveals the role of IGF-PLGA in activating the Angiopoietin-1(Ang1)/Tie2 signaling pathway in promoting flap vascularization, providing a strong theoretical basis and therapeutic target for the application of IGF-1 in flaps and other traumatic diseases.

A randomized clinical trial comparing buccinator flap and Bardach two-flap palatoplasty

The study aimed to assess the efficacy of buccinator myomucosal flap (BMF) compared to Bardach two-flap use in primary cleft palatoplasty on palatal length and fistulation rate. Palatal length in relation to the pharynx is a critical factor regarding velopharyngeal function. The goal was to predict the risk of velopharyngeal insufficiency by comparing the potential of two different techniques in lengthening the palate and to decrease the fistulation rate. A total of 46 patients with complete wide cleft palate were randomly divided into two equal groups: a study group, in which the cleft palate defect was repaired by BMF; and a control group, in which patients' clefts were repaired by Bardach (two-flap) palatoplasty during primary repair. All patients were evaluated at 1-, 3- and 6-month intervals to detect the fistulation rate and to measure the palatal length by taking impressions, pouring casts to measure the palatal length from anterior reference point (incisive foramen) to the posterior reference point(uvula) and calculating the change of palatal length. There was a significant increase in the palatal length measurements in the study (BMF) group (immediate postoperatively and at 3 and 6 months) compared to the control group (p < 0.001). Regarding the fistulation rate, there was no statistically significant difference (p = 0.346). The use of the buccinator flap during primary repair of cleft palate decreased the fistulation rate.

Preoperative sleep-disordered breathing and craniofacial abnormalities are risk factors for postoperative sleep-disordered breathing in patients undergoing skin-flap oropharyngeal reconstruction surgery for oral cavity cancer: a prospective case-control study

PURPOSE

After oropharyngeal reconstruction surgery, excessive flap volume within the oral cavity may increase the risk of pharyngeal obstruction during sleep. This prospective observational study aimed to test a hypothesis that the skin-flap oropharyngeal reconstructive surgery increases nocturnal apnea-hypopnea index (nAHI, primary variable) after surgery.

METHODS

Adult patients undergoing oropharyngeal reconstruction surgery participated in this study. The hypothesis was tested by comparing the results of portable type 4 sleep study and craniofacial assessments with lateral head and neck computed tomography scout image before and after surgery. Multiple linear regression analyses were performed to identify predictors for nAHI increase after the surgery.

RESULTS

In 15 patients, a postoperative sleep study was performed at 41 (27, 59) (median (IQR)) days after the surgery. nAHI did not increase after the surgery (mean (95% CI), 13.0 (7.2 to 18.7) to 18.4 (10.2 to 26.6) events.hour-1, p = 0.277), while apnea index significantly increased after the surgery (p = 0.026). Use of the pedicle flap for the oropharyngeal reconstruction (p = 0.051), small mandible (p = 0.008), longer lower face (0.005), and larger tongue size (p = 0.008) were independent predictors for worsening of nAHI after surgery. Hospital stay was significantly longer in patients with the pedicle flap (n = 8) than in those with the free flap (n = 7) (p = 0.014), and the period of hospital stay was directly associated with increase of nAHI after surgery (r = 0.788, p < 0.001, n = 15).

CONCLUSIONS

Oropharyngeal reconstruction surgery worsens sleep-disordered breathing in some patients with craniofacial and surgical risk factors.

TRIAL REGISTRATION

UMIN Clinical Trial Registry (UMIN000036260, March 22, 2019), https://rctportal.niph.go.jp/s/detail/um?trial_id=UMIN000036260.

Functional outcomes of soft palate reconstruction after oncologic surgery: a systematic review and meta-analysis

OBJECTIVE

The aim of this study is to analyze functional outcomes of soft palate reconstruction after oncologic surgery.

METHODS

This study was conducted in conformity with the PRISMA statement. A single arm meta-analysis was performed for feeding tube dependence (FTD) (primary outcome), velopharyngeal insufficiency (VPI) and hypernasality (HN) (secondary outcomes) incidences.

RESULTS

A total of 510 patients (males: 77.75%, n = 353/454) with a median age of 58 years (n = 480/510; 95% CI 57.0-61.0) who underwent soft palate surgical resection with primary reconstruction were included. Overall, the cumulative FTD rate was 1.55% (n = 28/510; 95% CI 0.24-3.96%), the VPI rate was 22.18% (n = 119/379; 95% CI 12.99-33.02%), and the HN rate was 33.01% (n = 88/234; 95% CI 19.03-46.61%).

CONCLUSIONS

Soft palate reconstruction results in a low incidence of FTD, and most patients resume a full oral diet. Both obturators, primary closure, local and free flaps seem good reconstructive options. Nevertheless, more specific postoperative functional deficiencies like VPI and HN owns higher incidences, potentially affecting the quality of the swallowing and speaking function and the patient's quality of life.

Submandibular Gland Excision with Facial Artery Preservation: The Argument for Changing the Established Norms

To evaluate the difference in average operating time and intraoperative blood loss in transcervical submandibular gland excision for isolated benign submandibular diseases, while preserving the facial artery and ligating the facial artery. A prospective study was conducted in our institute for a duration of 6 months from January 2022 to June 2022. 30 patients undergoing excision of the submandibular gland as an isolated procedure were included. They were randomly divided into 2 groups of 15, Group "A" where the facial artery was preserved, and "B" where the artery was ligated. The operating time in minutes and intra operative blood loss was compared. The mean operating time was 48.26 min in Group A, and 46.2 min in Group B. The p value between the two groups was 0.189586, which was not significant. The mean blood loss in group A was 44.6 ml, and 45.8 ml in group B. The p value was not significant at 0.331254. Preserving the facial artery in benign tumours while excising the gland neither increases operating time nor intraoperative bleeding. This will not only retain the anatomy, but provide a second option for flap reconstruction in case needed later.

The clasp and rubber bands technique to close large skin-soft tissue defect: A case report

This article discusses the use of the skin-stretching technique (SST) to manage large soft tissue defects resulting from various causes. The other surgical techniques for closing such defects, such as pedicle flaps and free tissue flaps, are often associated with significant morbidity and cost. The SST involves progressively stretching soft tissue using an external device to reduce defect size or complete wound coverage. The article describes a simple, inexpensive, and readily available method for managing large wound defects using clasps and rubber bands. The article also highlights the potential complications associated with SST such as skin necrosis, pin site infection, wound dehiscence, infection, and pain. Overall, SST is a promising alternative for the management of large soft tissue defects that are not amenable to direct suturing.

Anatomic feasibility study of osteocutaneous free flap from the proximal ulna

OBJECTIVE

The present anatomic study aimed to assess the feasibility of an osteocutaneous free flap harvested from the proximal ulna for reconstruction after complex hand trauma.

METHOD

Nineteen upper limb specimens free of scarring in the elbow region were injected in the brachial artery. After S-shaped incision centered on the medial epicondyle, a systematic approach to the epitrochlear-olecranal groove exposed the superior ulnar collateral artery and ulnar nerve. Bone and skin perforators were screened for during dissection and their emergence with respect to the medial epicondyle was assessed. Pedicle length was also assessed. The skin paddle was harvested in the distal part of the S incision and the operative site was closed by local skin plasticity.

RESULTS

Bone and skin perforators from the superior ulnar collateral artery were found in all 19 specimens. Mean pedicle length from the artery was greater than 9cm in all cases. The skin perforator emerged at a mean 19mm distally from the medial epicondyle, and the bone perforator at a mean 40mm.

DISCUSSION

An osteocutaneous free flap can be harvested from the proximal ulna and medial side of the elbow. As bone and skin perforators were found in all 19 cases, this flap can be used routinely. Harvesting, however, systematically involves ulnar nerve release and anterior transposition. This osteocutaneous free flap harvested from the proximal ulna offers an alternative for osteocutaneous defects in the hand, with harvesting from the same limb.

CONCLUSION

In this anatomic series, an osteocutaneous free flap could in all cases be harvested from the posterior ulnar recurrent artery via a medial elbow approach. Safety and efficacy remain to be demonstrated in in vivo reconstruction.

LEVEL OF EVIDENCE

III.

Surgical management of axillary hidradenitis suppurativa with latissimus dorsi flap on a 24-year-old patient: A case report

INTRODUCTION

Hidradenitis suppurativa (HS) is a chronic inflammatory disorder with distinct characteristics: chronic nature, morphology, and location. It originates from occluded and ruptured follicles, releasing keratin and bacteria into the nearby dermis. This causes an inflammatory reaction, leading to the formation of abscesses and the destruction of the pilosebaceous junction.

CASE PRESENTATION

We present the case 24-year-old female with a severe, stage III case of HS who had a lesion (approx. 10 × 15 cm) on her right axilla spanning 4 years. Despite some response to medical treatment, she experienced recurrent symptoms, due to this, surgical intervention was decided, using a latissimus dorsi thoracodorsal artery perforator (TDAP) flap. The lesion was successfully removed, and the flap was placed, leading to proper postoperative healing, cicatrization, and sensitivity in the patient.

DISCUSSION

HS poses a challenge due to its recurring course. Treatment involves pharmacological and surgical approaches, with the former suited for mild to moderate cases and the latter for severe instances. Surgical options, like TDAP flaps, show lower recurrence rates than skin grafts. TDAP flaps also offer advantages such as reduced bulkiness and favorable aesthetic and functional outcomes compared to other latissimus dorsi flaps.

CONCLUSION

HS represents an obstacle in terms of systemic effects and aesthetic concerns. Lattisimus dorsi flaps have emerged as an effective treatment method due to the reliable vascular supply and adequate volume to the recipient site as demonstrated by our case, where the patient showed appropriate evolution with no morbidity associated with the procedure as well as adequate aesthetic results.

The Pacman Flap and Its Modifications for Reconstruction of Skin Cancer Surgical Wounds on the Scalp and Other Body Areas: A Review of 23 Cases

BACKGROUND

The Pacman flap is a modified V-Y advancement flap that showed to be versatile in repairing surgical and non-surgical wounds. Indeed, this flap has been used in any anatomical localization, except for the scalp, where its use has not been reported. Moreover, the versatility of the Pacman flap can be enhanced by applying simple modifications to its original design.

MATERIALS AND METHODS

A case-series of 23 patients whose surgical breaches were repaired using standard or modified Pacman flap were included in this retrospective study.

RESULTS

Most patients were male (65.2%) with a median age of 75.7 years. Squamous cell carcinoma was the tumor most commonly removed (60.9%), while scalp and face were the most frequent localizations (30.4%). Although 18 flaps were sculpted in the traditional Pacman shape, 5 were modified to fit the defect and localization. Complications occurred in 30% of flaps, but all of them were minor except for 1 extended necrosis.

CONCLUSIONS

The Pacman flap can be used to repair surgical wounds localized in any body area, including the scalp. Three modifications can enhance the versatility of the flap and offer new repair options to dermatologic surgeons.

The Pacman Flap and Its Modifications for Reconstruction of Skin Cancer Surgical Wounds on the Scalp and Other Body Areas: A Review of 23 Cases

BACKGROUND

The Pacman flap is a modified V-Y advancement flap that showed to be versatile in repairing surgical and non-surgical wounds. Indeed, this flap has been used in any anatomical localization, except for the scalp, where its use has not been reported. Moreover, the versatility of the Pacman flap can be enhanced by applying simple modifications to its original design.

MATERIALS AND METHODS

A case-series of 23 patients whose surgical breaches were repaired using standard or modified Pacman flap were included in this retrospective study.

RESULTS

Most patients were male (65.2%) with a median age of 75.7 years. Squamous cell carcinoma was the tumor most commonly removed (60.9%), while scalp and face were the most frequent localizations (30.4%). Although 18 flaps were sculpted in the traditional Pacman shape, 5 were modified to fit the defect and localization. Complications occurred in 30% of flaps, but all of them were minor except for 1 extended necrosis.

CONCLUSIONS

The Pacman flap can be used to repair surgical wounds localized in any body area, including the scalp. Three modifications can enhance the versatility of the flap and offer new repair options to dermatologic surgeons.

Approach to Tendinopathies of the Upper Limb: What Works

Tendinopathies are some of the most common diagnoses treated by hand surgeons. Diagnoses such as trigger digit, de Quervain tenosynovitis, extensor carpi ulnaris tendinitis, and epicondylitis often resolve with nonoperative treatment and/or a single ambulatory procedure. When symptoms persist or worsen after surgery, patients are disappointed and treatment can be challenging. This article reviews practical points in evaluation of such cases, and surgical options that work in revision scenarios.

Vascularized lymph node flaps can survive on venous blood without an arterial inflow: an experimental model describing the dynamics of venous flow using indocyanine green angiography (With video)

Background

Several surgeons have described studies of free-tissue transfers using veins instead of arteries. These innovative microsurgical techniques can offer several advantages, such as an easier dissection during flap harvesting, and represent an alternative during an accidental surgical mistake or development of new surgical procedures. The purpose of this study was to describe and explore different constructs of vascularized lymph node transfer (VLNT) only based on venous blood flow in a mouse model, evaluate their blood flow microcirculation through indocyanine green (ICG) angiography and investigate the lymphatic drainage function and the lymph nodes' structures.

Methods

Five types of venous lymph node flaps (LNF) were created and investigated: Types IA, IB, IC, IIA and IIB were developed by ICG intraoperatively (with videos in the article). Seven weeks later, by applying methylene blue, the recanalization of the lymphatic vessels between the LNF and the recipient site was detected. Lymph nodes were collected at the same time and their structures were analyzed by hematoxylin and eosin staining analysis.

Results

All of the venous LNFs developed except Type IC. Seven weeks later, methylene blue flowed into Types IA, IB, IIA and IIB from recipient sites. When comparing with arteriovenous lymph node, the medullary sinus was diffusely distributed in venous lymph nodes. The proportion of cells was significantly reduced (p < 0.05). The artery diameters were significantly smaller (p < 0.05). The veins diameters and lymphatic vessels output in Types IA, IB, IIA and IIB were more dilated (p < 0.05).

Conclusions

This research demonstrated that Type IA, IB, IIA and IIB venous LNFs can retrogradely receive venous blood supply; they can survive, produce a lymphatic recanalization and integrate with the surrounding tissue, despite lymph node structural changes. Our results will improve the understanding of the survival mechanism of venous LNFs and will help researchers to design new studies or lymphatic models and eventually find an alternative procedure for the surgical treatment of lymphedema.

[Necrotizing fasciitis of the posterior neck. A rare clinical form of head and neck cellulitis: a case report from Togo]

We report the case of a 75-year-old diabetic patient who presented with posterior cervical necrotizing fasciitis complicating cellulitis. Medical management in intensive care and surgical drainage were undertaken; sequential excision of the necrotic tissue left a large loss of substance of the nuchal region for which we opted for directed healing in the first instance. The definitive coverage of this loss of substance by locoregional rotation flap or by thin skin grafting was discussed. However, it was refused by the patient.

Bilaterally parallel elliptic flap versus Karydakis flap in primary pilonidal sinus disease: a randomized controlled trial

PURPOSE

Pilonidal sinus disease is a disease that especially affects the young population and causes loss of workforce. Although many treatment methods have been defined, there is still no "gold standard" treatment method. Our objective was to evaluate the postoperative results of bilateral parallel elliptical flap and Karydakis flap in the surgical treatment of pilonidal sinus.

METHODS

This study was conducted at the Colorectal Surgery Department of Ankara Numune Training and Research Hospital. It designed a prospective randomized controlled study. Patients that underwent surgery due to pilonidal sinus were included in the study. The patients were randomly divided into two groups. Surgery was performed with the bilateral parallel elliptical flap (BPEF) technique in one group and the Karydakis flap (KF) technique in the other group. Postoperative pain, length of hospital stay, wound complications, time taken to return to work/school, and recurrence incidence were evaluated.

RESULTS

A total of 102 patients were included in the study, 49 in the BPEF group and 53 in the KF group. The length of hospital stay was similar in the BPEF and KF groups (1.41 ± 0.81 and 1.45 ± 0.84, respectively; p > 0.05). There was less postoperative pain in the BPEF group (2.47 ± 1.02 vs 3.57 ± 1.10, p < 0.05). Wound complications were observed in nine patients in the BPEF group (18.2%) and 14 patients in the KF group (26.2%). The time to return to work/school was shorter in the BPEF group (21.06 ± 6.37 vs 27.04 ± 7.45; p < 0.05). Recurrence developed in two (4%) patients in the BPEF group and three (5.6%) patients in the KF group (p > 0.05).

CONCLUSIONS

The patients who underwent surgery with the bilateral parallel elliptical flap technique had less pain and a shorter time to return to work/school after the operation. The postoperative complication and recurrence rates were similar in both groups.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT05851690. (5/11/2023) (retrospectively registered).

Recurrent labial adhesion and vaginal destruction treatment with ileal vaginoplasty and labia major flap: A rare case report

Labial adhesion (LA) and vaginal destruction are very rare conditions in women. We report a 40-year-old woman with severe LA and distal vaginal stenosis after a radical hysterectomy at the age of 35. Completely destruction of vaginal epithelium, severe recurrent LA, voiding symptoms, and chronic pelvic pain occurs for her due to the repeated vaginal dilatation and low estrogen level. A combination of ileal vaginoplasty (IV) and labia majora flap was used in two surgical stages for treatment. After surgery, the patient's urinary symptoms and pelvic pain were relieved and she was able to have sex with her partner.

Inverted ILM Flap Technique in Optic Disc Pit Maculopathy

Purpose

To present the outcome of optic disc pit maculopathy (ODPM) managed successfully with an inverted internal limiting membrane (ILM) flap over the optic disc. A narrative review of ODPM pathogenesis and surgical management techniques are also provided.

Case Report

This prospective interventional case series included three eyes of three adult patients (25-39 years old) with unilateral ODPM and a mean duration of unilaterally decreased visual acuity of 7.33 ± 2.40 months (4-12 months). The pars plana vitrectomy with posterior vitreous detachment induction was performed on eyes, followed by an inverted ILM flap insertion over the optic disc and gas tamponade. Patients were followed for 7-16 weeks postoperatively; best-corrected visual acuity (BCVA) improved dramatically in one patient from 2/200 to 20/25. BCVA in other patients improved two and three lines - to 20/50 and 20/30, respectively. A significant anatomical improvement was achieved in all three eyes, and no complication was detected throughout the follow-up period.

Conclusion

Vitrectomy with inverted ILM flap insertion over the optic disc is safe and can yield favorable anatomical improvement in patients with ODPM.

One-sized bilobed flap does not fit all standing cones: a mathematical analysis of the standing cone in bilobed flap dynamics

The bilobed flap (BLF) is a workhorse for nasal repair. Alterations to the length and orientation of the BLF's standing cutaneous deformity (SCD) have been suggested as a means of preventing Z-plasty-induced flap lengthening and consequent ipsilateral alar depression. To investigate the effect of design variations of the SCD on bilobed flap mechanics. Geometric analysis of the BLF was performed using commercially available graphing software. BLFs were designed with a SCD equal to one radius (rBLF) and one diameter (dBLF) of the primary defect as well as with a more superiorly-oriented one diameter SCD (soBLF). Lengths from the pivot point to the distal edges of the primary defect and primary lobe were measured and compared. Elongation or a more superior orientation of the SCD without changes to the rest of the flap design forms a primary lobe along a shorter arc resulting in insufficient flap length to resurface the primary defect. The insufficient length requires secondary motion to complete the repair and possible unintended alar displacement. Modification of the size and orientation of the SCD alters the location of the pivot point, which is a key determinant of BLF mechanics. Therefore, changes to the SCD require alterations to the remainder of the flap design to ensure aesthetic and functional success.

A novel modified Winograd surgical tricks and tips with a "bird flap" for the treatment of ingrown toenails

BACKGROUND

The Winograd technique is the most commonly used surgical treatment for ingrown toenails. We describe a novel modified approach, more effective and simpler to perform with a better cosmetic outcome.

METHODS

We retrospectively included 45 and 39 patients with 67 and 58 ingrown toenails who underwent our modified Winograd technique and the Winograd technique, respectively, from July 2017 to June 2020, and obtained data after 3, 6, and 12 months of follow-up.

RESULTS

No significant differences in the postoperative time taken to return to regular activities in the modified Winograd and traditional Winograd groups (p = 0.103) and regarding the recurrence in both groups (p = 0.055) were found. The extent of proximal germinal matrix exposure with the modified Winograd technique was significantly more clearly revealed than in the traditional Winograd method contextually (p < 0.05). The postoperative appearance satisfaction rate was significantly higher in the modified Winograd group than in the traditional Winograd group (p = 0.029).

CONCLUSION

The modified Winograd technique is effective in treating ingrown toenails.

Nagging Pain and Foot Ulcers Can be Treated into Remission

Lower extremity ulcerations are very common in patients with diabetes. These wounds lead to amputation in a surprisingly large percentage of patients with diabetes. The mortality rate following amputation in a patient with diabetes is alarmingly high. Preventive treatment is pivotal to avoid the numerous complications associated with diabetic ulcerations. However, at the onset of ulceration, early treatment under the supervision and guidance of a specialist can result in remission. Diabetic peripheral neuropathy is also a life-altering and debilitating disease. Although some patients experience numbness, some experience pain that can be sharp, shooting, and tingling. Although treatment is challenging and often requires medication, newer modalities, such as stimulation and physical therapy, have shown promise in reversing the devastating effects of peripheral neuropathy.

The Free Medial Sural Artery Perforator Flap (MSAPF): An Indispensable Tool for Head and Neck Reconstruction

Background

Modern head and neck surgery is characterized by its emphasis on three important objectives of reconstructive and rehabilitative procedures-cosmesis, function and coverage of vital structures. Reconstruction with free flaps is a necessity when the defects become too large for more simple reconstruction options such as skin grafting and local flaps. The medial sural artery perforator flap (MSAPF) is a thin flap with a long pedicle. It has tremendous potential for applications in small-to-moderate soft tissue defects. Furthermore, chimeric MSAPF includes a skin paddle and a separated piece of medial gastrocnemius muscle, allows more freedom for flap insetting especially in 3-D reconstruction.

Purpose

The aim was to study the assessment of feasibility of MSAPF for head and neck reconstruction.

Method

Prospective case study from January 2019 to December 2019 was carried out in oral cancer patients with squamous cell carcinoma of the tongue, buccal mucosa and floor of the mouth which was reconstructed using MSAPF after oncologic resection.

Results

We reconstructed 20 patients using MSAPF. It was designed according to the size and site of the defect. Donor site was primarily closed in all cases. Great results were obtained. Out of 20 MSAP, 19 flaps survived. Flap failed in one case due to venous thrombosis. The thickness of the flap ranged from 4-9 mm, pedicle length ranged from 8-13mm, number of perforators ranged from 1-2, arterial diameter ranged from 1.5-2 mm and venous diameter ranged from 1-3mm.

Conclusion

MSAPF is a good alternative for head and neck reconstruction with the advantages of thin and pliable skin, a long and reliable vascular pedicle, straightforward intramuscular dissection, the possibility of chimeric flap design and minimal donor site morbidity.

Flap management of groin wounds following vascular procedures: A review of 270 flaps for vascular salvage

BACKGROUND

Groin dehiscence following vascular procedures results in morbidity for patients with peripheral vascular disease. Controversy exists around the indications for flap coverage. We present an institutional experience with flap reconstruction of groin wounds after vascular procedures to identify predictors of beneficial outcomes.

PATIENTS AND METHODS

A retrospective review of patients who had flap coverage for infected/nonhealing groin wounds following a vascular procedure between 1998 and 2021 was performed. Demographics and clinical characteristics, including flap and vascular graft type, were collected along with major complications. Univariate and multivariable logistic regression analyses were performed to assess the associations between procedures and major complications.

RESULTS

A total of 270 flaps were transferred to 237 patients. Thirty-three patients had bilateral wounds. The mean age and BMI were 67 ± 11 years and 27.9 ± 6.3 kg/m², respectively. Flaps included rectus femoris (n = 142), sartorius (n = 118), rectus abdominis (n = 7), and gracilis (n = 3). Covered vascular grafts included prosthetic materials (n = 200) and autografts (n = 70). The median length of hospital stay after surgery was 10 days (interquartile range=12), and the mean follow-up was 29.1 ± 39.2 months. The major complication rate was 38.5% with wound infection being the most common. Flaps successfully prevented the infection-related removal of the grafts in 98.9% of cases. Multivariable analysis revealed no significant associations between variables and having a major complication.

CONCLUSIONS

Flap coverage of the inguinal vessels can be performed safely with favorable limb salvage. Wound complications were high, but graft salvage was excellent. Rectus femoris and sartorius muscle flaps were the most common flaps, yielding comparable outcomes.

Epidermoid Cyst of Orbit Requiring Cranialization of Frontal Sinus

How often do intracranial epidermoid cysts occur?Is a coronary incision necessary?What are the steps of the procedure, difficulties encountered, and process for circumventing those difficulties?What is the follow-up protocol and outcome?

Open lower extremity fractures in the geriatric population

INTRODUCTION

Open fractures in the elderly are distinct compared to younger populations. The purpose of this study is to follow a series of open fractures of the lower extremity in the geriatric population to better prognosticate outcomes.

METHODS

We performed a retrospective chart review of patients over the age of 65 years old who were treated for an open, lower extremity fracture across two level I trauma medical systems. Patients were included if they had documented wound healing problems in the postoperative period, or 6 months of follow-up, or if they had a definitive radiographic outcome. Sixty-four patients were included of an average age of 76.23, of whom 73.4% were female.

RESULTS

The fracture types were midshaft femur in 3, distal femur in 9, patella in 2, proximal tibia in 3, proximal fibula in 1, midshaft tibia in 14, distil tibia in 8, ankle in 23, and talar neck/calcaneus in 1. Forty-two fractures were the result of low energy mechanism and 22 fractures were from high energy mechanism. Fourteen fractures were type 1, 32 were type 2, 11 were type 3A, 6 were type 3B, and 1 was type 3C. At final follow-up, 13 wounds were well healed, 39 wounds were healed following a delay of more than 6 weeks to achieve healing, 3 were infected, 3 had been treated with amputation, 2 had chronic ulceration, 2 with active draining, and 2 had draining sinuses.

DISCUSSION

Open lower extremity fractures are serious injuries with high rates of morbidity. Such risks are even higher in the geriatric population, particularly with regard to wound healing. This study provides important prognostic information in counseling geriatric patient with an open lower extremity fracture, as well as informs treatment in terms of wound surveillance and care in the postoperative period.

Lymphatic flow through (LyFT) ALT flap: an original solution to reconstruct soft tissue loss with lymphatic leakage or lower limb lymphedema

INTRODUCTION

The lympho-venous shunt using the distal vein of ALT flap pedicle allowed at the same time the coverage of the inguinal defects and to perform lymphovenous shunt into a run-in vein of the descending branch of the lateral circumflex femoral pedicle, draining the lymph through the flap pedicle. Surgical technique, complications and final outcomes (both clinical and lymphoscintigraphic) are reported.

METHODS

Five patients (45.8 y.o.[22-70]) with groin soft tissue loss with lymphatic leakage or lower limb lymphedema, benefited of the described technique. The ALT flap was used to cover the defect and, at the same time, we could perform a lymphovenous shunt between afferent lymphatics to the thigh and the descending branch of the lateral circumflex femoral pedicle, distal to the perforator nourishing the flap. Clinical and lymphoscintigraphic assessment of the limbs, cease of lymphorrhea or cellulitis/lymphangitis episodes, eventual downstaging of physiologic/physical therapy were recorded. LYMphatic Quality Of Life in leg (LYMQoLLeg) and patient satisfaction were evaluated.

RESULTS

Average flap size was 88.8cm² (range 84-126). The mean number of multi-lymphovenous anastomosis (MLVA) performed was 1.8 (range 1-3) per patient with 1-3 lymphatics shunted into each vein. Only one hemato-seroma requiring surgical revision. Mean improvement of perometer values was 48.2% (range 27.7-67.7) with an average follow-up of 13.6 months (range 12-17). Lymphoscintigraphy showed disappearing of the lymphatic leak and lymphedema with a high satisfaction of LYMQoL score.

DISCUSSION

The combination of pedicle flap with lympho-venous bypass as lymphatic derivation concept, improving the chronic morbidity scenarios of lymphatic complications.

Vascularized osseous flaps for head and neck reconstruction: Comparative analysis focused on complications and salvage options

OBJECTIVES

This study aimed to compare the clinical outcomes of fibular (FFF group) and scapular (SFF group) osseous free flaps for reconstructing head and neck defects for primary surgery and salvage options.

METHODS

We analyzed 156 cases of osseous free flaps in 138 patients from a retrospective review of a single institutional database between January 1996 and January 2020 (FFF, 114 cases in 99 patients; SFF, 42 cases in 39 patients). Clinical profiles such as age, sex, primary tumor site, and defect type were investigated in the two groups. In addition, the incidences and types of perioperative complications, flap compromise, and salvage management were compared between the two groups.

RESULTS

FFF was used mostly for oromandibular defects, whereas SFF was preferred for maxillary defect reconstruction. The length of hospital stay was longer in the FFF group than in the SFF group. The flap compromise rate was not significantly different between the two groups; however, donor-site complications were not observed in the SFF group as compared to 7.9% in the FFF group. A regional or free (musculo) cutaneous flap was used as a salvage procedure in partial flap compromise. Contralateral SFF was available to replace a completely compromised SFF, whereas it was not feasible in a completely compromised FFF. Cox proportional hazards analysis showed no significant prognostic factors for flap-related complications.

CONCLUSION

The two osseous free flaps showed differences in defect type, flap donor complications, and options for compromised flap salvage. These findings must be considered carefully in the preoperative planning stage to guarantee early recovery and timely administration of postoperative adjuvant treatment if necessary.

Tarsoconjunctival flap for scleromalacia related to treatments for conjunctival melanoma

Purpose

To describe the use of a tarsoconjunctival pedicle flap for the repair of scleral melt secondary to treatment of conjunctival melanoma.

Observation

A 67-year-old woman developed progressive scleromalacia after multiple treatments for an American Joint Committee on Cancer cT2d category conjunctival melanoma. Prior to referral, she underwent synchronous topical chemotherapy (interferon, 5-fluorouracil, mitomycin). Then, incomplete tumor regression led to excision with adjuvant cryotherapy. Lastly, systemic metastasis treated with systemic immunotherapy provided durable remission. However, her multiple treatments (e.g., topical chemotherapy, resection, cryotherapy) were associated with progressive nasal bulbar scleromalacia treated by conjunctival advancement and amniotic membrane grafts. Sclera reinforcement was achieved after a tarsoconjunctival flap was affixed to the eye to cover, and thus vascularize the scleral defect. The tarsoconjunctival flap provided 5 years of tectonic support.

Conclusions and Importance

Tarsoconjunctival pedicle flaps can provide scleral integrity for a patient with progressive scleral melting.

Local Flap Reconstruction of Burn Contractures in Extremities and Neck: A Nine-Year Experience with Long-Term Outcome Evaluation in Southwestern Iran

Background

Treating burn scar contractures remains challenging for reconstructive surgeons; no clear guidelines declare the optimal and most effective technique. We evaluated the efficacy of local flaps in treating patients with post-burn contractures.

Methods

This retrospective study included 243 patients with post-burn contractures referred to Taleghani Hospital (Khuzestan, southwest Iran) for local flap reconstruction from 2011 to 2020. Patients' demographic data, detailed descriptions of scars, surgical procedures, and flap outcomes were assessed. A plastic surgeon conducted all surgical procedures, the goals of which were to release the scar and cover the defect. Joint range of motion (ROM) (according to goniometric measurements), complications, need for second-stage surgery, and patient satisfaction were assessed.

Results

After scar release, 70.4% of joints were covered with a Z-plasty and similar local flaps, 26.1% with a Z-plasty plus skin grafts, and 3.5% with only skin grafts. The outcome after one year revealed a significant improvement in mean ROM (by 45.80% of the normal ROM; P< 0.001). The mean functional and aesthetic satisfaction scores were 9.45 and 7.61 out of 10, respectively. The complication rate was 10.82%: re-contracture occurred in 3.82%, flap tip necrosis in 1.27%, and partial flap necrosis in 0.31%.

Conclusion

Simple local flaps such as the Z-plasty are safe and effective in covering the joint following post-burn contracture release. Due to the feasibility, minimal need for facilities, steep learning curve, acceptable functional and aesthetic outcomes, and low complication rate, we strongly recommend the Z-plasty for reconstructing burn contractures, particularly in LMICs.

Corpus spongiosum flap: a unique technique in the management of urosymphyseal fistula

Urosymphseal fistulas are a debilitating but treatable consequence of the combination of radiotherapy and endoscopic interventions in prostate cancer patients. Treatment includes fistula excision with a tissue flap to prevent communication of involved structures and provide structural and vascular support. We introduce a unique surgical approach of mobilizing and utilizing a corpus spongiosum flap in urosymphyseal fistula repair. A retrospective study identified two patients who underwent repair with a pedicled corpus spongiosum flap at our institution. The corpus spongiosum had adequate length and vascularization and limited the need for extra-pelvic muscle flaps, thus maintaining muscle integrity in the abdomen and thighs. Following extirpative surgery, both patients had durable fistula closure, decreased pelvic pain, and resolution of lower urinary tract symptoms and osteomyelitis. These cases highlight the potential of the corpus spongiosum to be a reasonable alternative interpositional flap in genitourinary reconstruction.