Adequate Tissue Coverage Research Articles

Tissue Expander Followed by Autogenous Bone Graft Versus Autogenous Bone Graft Alone for Mandibular Reconstruction: Quantitative Assessment.

The use of a tissue expander in maxillofacial intraoral tissue reconstruction is a developing approach, which provide adequate tissue coverage and aesthetics. The purpose of this study was to quantitatively compare the use of a soft tissue expander in conjunction with autogenous bone graft with bone graft alone for the repair of the mandible's anterior region. The study comprised 24 patients with bone defects in the anterior mandibular region. Patients were divided into 2 groups at random. In group I, expander with bone graft was used, whereas in group II, bone graft was used alone. Volumetric measures of the grafted area was performed using CBCT, and cephalometric evaluations of the anteroposterior and vertical skeletal relationship, as well as the soft tissue profile were recoded. A comparison was made between the 2 groups 6 and 24 months after surgery with P ≤ 0.05 considered significant. The mean difference in grafted bone volume between the 2 groups was 1.95cm 3 , indicating a significant difference between the 2 groups ( P = 0.05) with superior group I results. The soft tissue profile of group I demonstrated a considerable improvement and stability of the lower lip, the labiomental sulcus, and the thickness of the soft tissue Pogonion compared with group II. The use of a tissue expander in conjunction with a bone graft resulted in a better soft tissue profile, making it a favored approach in maxillofacial reconstruction.

Bilobed PMMC in Females: Our Challenging yet Meritorious Experience.

The gold standard reconstructive options for full-thickness defect of the oral cavity after resection of malignant lesions are the free flaps. But in developing nations due to resource constraints, it cannot be offered to all. Hence, pectoralis major myocutaneous (PMMC) flap as bilobed flaps is most commonly used. Bilobed flaps are technically demanding, and in females, it is more challenging due to higher complication rates especially in large breasts. There has been no major reported data evaluating outcomes of bilobed PMMC in females. This is a retrospective evaluation of outcomes of patients who underwent the bilobed PMMC flap reconstruction for full-thickness defect of the oral cavity after resection of malignant lesions from June 2018 to December 2019. Out of 80 patients, all patients ultimately had adequate tissue coverage for the defect with acceptable facial aesthetics. Functional outcomes with regards to oral continence, speech and swallowing were encouraging. Our study had 33.75% flap-related complications. Fifteen percent of patients developed varying degrees of flap loss, of which only 3.75% had total flap loss and 11.25% had partial flap loss which was managed accordingly. Our study concludes that with careful planning, raising of flap based on sound anatomic concepts and applying oncoplastic techniques, shortcomings of bilobed female PMMC can be addressed and still used as suitable alternatives for free flap for full-thickness oral cavity defects in limited resource settings.

Case report: Severe index finger open fracture. Surgical rescue with homodigital vascularized adipofascial reverse flap

BACKGROUND: Hand trauma has a high incidence worldwide, it accounts nearly 30% of all trauma and medical visits to emergency rooms, fingertip injuries are the most common among hand trauma. The initial management and the proper choice of treatment are important, the main objective is to achieve adequate tissue coverage, in order to avoid unnecessary amputation, prevent complications and functionality loss. CASE REPORT: A 32-year-old male patient presented with crush trauma on right hand resulting in injuries with tissue loss on the fingertips of the second and third finger and traumatic partial amputation of the distal phalanx of the second finger. EVOLUTION: Surgical technique of homodigital vascularized adipofascial reverse flap was performed in second finger and the fracture was managed conservatively, without complications. A weekly follow up was carried out for 2 months with favorable functional, biological and aesthetic results. The third finger was treated with surgical irrigation and debridement and placement of a sub-occlusive bandage, with favorable outcome. CONCLUSION: Homodigital adipofascial reverse dorsal flap has advantages over other types of conventional flaps; it is a simpler, safe and reliable technique, with good postsurgical outcomes in terms of functionality, aesthetics and recovery, needing only one intervention and offering the appropriate coverage to exposed bone and soft tissue, with minimal repercussions on the donor site.

Complex reconstruction following traumatic forequarter amputation

Interscapulothoracic amputation is a radical and morbid procedure used for the management of upper extremity trauma and more commonly for resection of solid tumors. Traumatic forequarter amputation poses a unique challenge for achieving adequate tissue coverage depending on the condition of the muscle and soft tissue of the ipsilateral extremity. We present a case of a 38-year-old construction worker who suffered an almost complete forequarter amputation of his right upper extremity secondary to blunt force trauma from a crane pulley that fell from 60 ft. This is a unique mechanism of injury, as most traumatic forequarter amputations occur as a result of traction injury. Details of the case report including the unique challenges, techniques for tissue salvage, fillet flaps, and chest wall reconstruction are presented.

Treatment of Periprosthetic Knee Infection With Concurrent Rotational Muscle Flap Coverage Is Associated With High Failure Rates

BackgroundSoft-tissue deficiency is a potentially devastating complication of the infected total knee arthroplasty (TKA). Rotational muscle flaps are commonly used to address these defects. However, reported success rates vary widely. MethodsWe reviewed 26 consecutive patients who underwent rotational muscle flap surgery for full-thickness anterior soft-tissue defect during treatment of an infected TKA. Twenty-four cases used a medial gastrocnemius rotational flap, 1 used a lateral gastrocnemius flap, and 1 used a rectus femoris-vastus intermedius flap. Implant survival, recurrence of infection, and limb survival were reported. Patient and procedural characteristics were tested for association with failure using χ2 and Student t-test. Kaplan-Meier analysis was used to estimate the failure-free survival function. ResultsMean follow-up time was 3.3 years. Eighteen of 26 patients (69.2%) experienced recurrent infection requiring an average of 5.3 additional operations (range, 1-20). Five (19.2%) required arthrodesis while 6 (23.1%) eventually underwent above-the-knee amputation. Two patients (7.7%) died due to complications of revision surgery or persistent infection. Eleven patients (42.3%) were infection free with a retained prosthesis after treatment at a mean follow-up of 5.3 years (range, 0.7-18.0 years). ConclusionRotational muscle flap coverage of soft-tissue defects in the setting of the infected TKA remains a viable salvage option. However, despite adequate tissue coverage, many patients experience recurrent infection requiring additional surgical treatment. Patients and surgeons should be aware of the potential high failure rates observed when treating these complex problems.

Outcomes after retroflexed gracilis muscle flap for vascular infections in the groin

Multiple catheterizations and procedures on the femoral arteries can increase the risk of infection and eventual destruction of the overlying skin and subcutaneous tissue. Without adequate tissue coverage, vascular structures are exposed and, thus, vulnerable to disruption. This can lead to loss of limb and/or life and carries a significant mortality. We hypothesized that gracilis muscle flap (GMF) was a reliable adjunct in providing healthy tissue coverage for a complex surgical problem. Retrospective review of charts was performed on all patients who had undergone GMF for groin infections at a tertiary care medical center. From 1997 to 2012, GMF was performed in 68 limbs (64 patients) by vascular surgeons for infectious etiology to cover the common femoral artery. At the time the GMF was placed, the femoral artery had synthetic graft/patch in 14 limbs, whereas 54 limbs had procedures with autologous conduit. Complete healing was achieved in 58 (85%) limbs. Treatment was deemed not successful in 10 limbs where patients continued to have persistent infection. Six out of 10 limbs had anastomosis disruption requiring emergent ligation of the common femoral artery. Nine patients died during the perioperative period (30-day). There were a total of 13 amputations in 12 patients. Limb salvage was achieved in 55 limbs (81%). Univariate analysis suggested that patients that had revascularization procedures with synthetic graft had a higher complication rate compared with autologous/vein reconstruction (24% vs 5%; P= .021). This group also has a higher rate of persistent infection compared with the autologous group (24% vs 2%; P= .006). Patients older than 75years at the time of GMF had a higher incidence of GMF-related complications (57% vs 5%; P= .04). Multivariate analysis confirmed that presence of prosthesis led to higher incidence treatment failures and muscle flap complications at the surgical site (odds ratio, 6.6; P= .04; and odds ratio, 13.3; P= .03, respectively). GMF is technically simple to perform and provides durable soft tissue coverage with a high rate of healing for complex groin wounds even in the presence of synthetic conduit.

A practical approach for the correction of iatrogenic penile skin loss in children: Scrotal embedding technique.

The aim of this particular study is to determine the efficacy of scrotal embedding technique in children with overly deficient penile shaft skin, which takes advantage of the rich vascular supply of the scrotal layers and provides adequate tissue coverage. We give the operative and clinical details of two consecutive cases for which we preferred scrotal embedding technique to replace deficient penile skin. The mean operative time for the first and second stages was 72.5 and 52.5 min, respectively. Intraoperative and postoperative courses and convalescences were uneventful. The patients were hospitalized for a mean duration of 2 days. After a mean follow-up of 29 months, cosmetic and functional results were satisfactory. Scrotal embedding technique should be considered as a feasible surgical alternative while reconstructing the penile shaft in iatrogenic cases with overly deficient shaft skin.

A Rare Association of Congenital Lumbar Hernia and Giant Congenital Nevus

Conclusion The association of congenital lumbar hernia and giant nevus has not been reported till date and ours is the first such case. Hence, this patient posed a management dilemma. Operating for both conditions in the same setting produced less than satisfactory cosmetic result. Thus, it is concluded that when such cases are encountered, proper preoperative studies to evaluate the hernia and planning for adequate tissue coverage should be done. Transperitoneal laparoscopic mesh hernioplasty with use of tissue expanders would have produced better results. Cosmetic results of nevus excision have been better if managed separately.

The Pedicled Subpectoral Fascia Flap for Expander Coverage in Postmastectomy Breast Reconstruction: A Novel Technique

In expander-based breast reconstruction, providing adequate tissue coverage of the prosthesis is necessary to prevent complications. The authors have previously described the use of the serratus anterior fascia for this purpose-but when this fascia is unavailable or inadequate, the subpectoral fascia can be used. This study describes the anatomy of the subpectoral fascia, the surgical technique for harvesting it, and an algorithm for choosing between the serratus and subpectoral fascia flaps. Clinical and functional outcomes following use of the subpectoral fascia in expander-based breast reconstruction are reported. Thirteen patients (17 breasts) were included in the study. After approval by the institutional review board, retrospective case note analysis was performed for demographic and perioperative factors. Postoperative complications including capsular contracture, seroma, hematoma, wound dehiscence, and infection were recorded. Cadaver studies involving 10 hemichests were undertaken. The subpectoral fascia for each hemichest was dissected and measured for length and width. At a mean follow-up of 589 days (range, 115 to 960 days), seroma occurred in one breast, wound infection occurred in one breast, and minor wound dehiscence occurred in one breast. There were no incidences of capsular contracture or hematoma. The mean +/- SD length of cadaver subpectoral fascia was 148 +/- 26.6 mm and the mean width was 83 +/- 32.1 mm. The subpectoral fascia flap is a novel and safe option for providing vascularized lateral or inferior coverage of prosthesis in expander-based breast reconstruction. Its harvest and use are not associated with adverse clinical outcomes.

Complications of Hydroxyapatite Use for Transnasal Closure of Cerebrospinal Fluid Leaks

Hydroxyapatite cement (HAC) was first introduced in the 1980s as a new method for bone replacement. However, it has not been recommended for use in areas exposed to air. Despite this, surgeries have been performed using HAC to close nasal/sinus cerebrospinal fluid (CSF) leaks or in the treatment of encephaloceles. This study retrospectively documented four patients in whom HAC was used for closure of ethmoid and sphenoid sinus CSF leaks. This study showed that exposed hydroxyapatite could be extremely problematic resulting in scarring, chronic granulation, infection, and prolonged healing. Oftentimes, revision surgery was necessary to help control the reaction to hydroxyapatite. Because of the frequent complications occurring with use of hydroxyapatite in the paranasal sinuses, its use should be limited to selected individuals in whom difficulty in achieving closure of the CFS leak could be anticipated and in whom adequate tissue coverage could be provided.

Vascular anatomy of the brachioradialis rotational musculocutaneous flap.

The purpose of this 2-part vascular injection study was to (1) determine the sources of blood supply to the brachioradialis muscle and the distance around which the brachioradialis muscle flap may be rotated for local soft tissue reconstruction and (2) determine the fasciocutaneous vascular perfusion territory associated with the vascular pedicle of the brachioradialis muscle flap. Lead oxide injections were administered in 16 fresh frozen human upper extremity amputation specimens to determine the contribution of the isolated radial recurrent artery (RRA) and subsequent 3- and 6-cm segments of radial artery (RA) to a rotational brachioradialis muscle flap. The RRA perfused an average of 41% (range, 20% to 60%) of the brachioradialis muscle length. Selective injection of the RRA and the proximal 3-cm segment of the RA perfused 80% (range, 59% to 100%) of the muscle length, corresponding to more than 90% of muscle volume. Flap rotation consistently provided adequate tissue coverage to the antecubital fossa, the lateral elbow, and the proximal one-third volar forearm. Based on these findings, the fasciocutaneous perfusion territory of the isolated vascular pedicle was quantified by selective India ink injection studies in 10 fresh frozen cadaveric specimens. Consistent fasciocutaneous perfusion occurred directly over the muscle belly. No specimen, however, was perfused greater than approximately 1 cm distal to the musculocutaneous junction. This 2-part study defines the vascular anatomy and local utility of the brachioradialis rotational musculocutaneous flap.

Effects of mesh modification on the structure of a mandrel‐grown biosynthetic vascular prosthesis

Mandrel-grown, mesh-reinforced vascular prostheses require adequate tissue coverage of the mesh for effective clinical function, particularly in low blood flow situations. Development of the ovine collagen-based Omniflow™ vascular prosthesis has shown that the extent of this tissue cover is dependent on the interactions of the mandrel and the mesh with the sheep host. In the present study, the effects of chemical changes to the mesh have been examined. These data indicate that certain treatments of the mesh, particularly collagen or heparin, lead to increased tissue coverage while the number of sheep cells present and the ultrastructure of the resulting vessel remain unchanged. © 1999 John Wiley & Sons, Inc. J Biomed Mater Res, 47, 309–315, 1999.

Effects of mesh modification on the structure of a mandrel-grown biosynthetic vascular prosthesis.

Mandrel-grown, mesh-reinforced vascular prostheses require adequate tissue coverage of the mesh for effective clinical function, particularly in low blood flow situations. Development of the ovine collagen-based Omniflowtrade mark vascular prosthesis has shown that the extent of this tissue cover is dependent on the interactions of the mandrel and the mesh with the sheep host. In the present study, the effects of chemical changes to the mesh have been examined. These data indicate that certain treatments of the mesh, particularly collagen or heparin, lead to increased tissue coverage while the number of sheep cells present and the ultrastructure of the resulting vessel remain unchanged.

Vascular Craft Selection

Twenty to thirty per cent of patients with arterial injuries and some patients with venous injuries require interpositional grafting. The first choice of grafting material for both arterial and venous injuries is autogenous vein. Injuries to large vessels such as the aorta and superior vena cava may necessitate synthetic prostheses. Synthetic aortic prostheses have excellent long-term patency rates, but the same materials are much less likely to remain patent in the vena cava. Panel or spiral grafts constructed from saphenous vein appear to be the best replacement for this vessel. Autogenous veins are present in different diameters ranging from a mean of 6.4 mm in the saphenous vein to a mean of 1.8 cm in the internal jugular vein. The thickest autogenous vein is the saphenous vein, and thus it is preferred for medium-sized and small arteries. The authors prefer the larger 7.5-mm cephalic vein for replacement of medium-sized veins. In the absence of suitable saphenous vein, the cephalic vein is also the choice for arterial interposition grafts. Although there are few reports of the use of arterial autografts in vascular trauma, the surgeon should be aware that autografts may be ideal for vascular injuries in children and for isolated injuries with severe contamination. Finally, the use of synthetic grafts in injuries where adequate tissue coverage is not possible may result in immediate limb salvage, but the incidence of limb loss in this situation will be extremely high.

Amputations after vascular trauma in civilians.

In a ten-year retrospective study of 233 patients who sustained a vascular injury to an extremity, eight (3.4%) extremities were amputated. Factors that affect the incidence of amputation after peripheral vascular trauma include early operation, fasciotomy, preoperative antibiotics, appropriate vascular reconstruction with adequate tissue coverage, use of arteriography during and after reconstruction, and early reoperation for postoperative complications. Some patients benefit psychologically and physically from early definitive amputation.