Flap Congestion Research Articles

A Breast Sharing Technique using the pedicled IMAP flap for Delayed Breast Reconstruction and Contralateral Symmetrising Mammaplasty: A case series and evolution of the surgical technique in selected patients.

IntroductionThe ‘breast-sharing’ procedure uses the disposable tissue as a flap to reconstruct the post-mastectomy defect. This enables simultaneous breast reconstruction and contralateral symmetrisation without additional donor site morbidity. However, controversies related to the oncological safety of this procedure have prevented its widespread uptake. We aim to present this technique based on a pedicled internal mammary artery perforator (IMAP) flap and discuss its technical feasibility and oncological safety. Patients and methodsBetween April 2013 and May 2022, a series of 10 consecutive patients underwent a breast-sharing procedure using the pedicled IMAP flap for breast reconstruction. Clinical and surgical aspects of the breast-sharing procedure were analysed. ResultsIn all cases, the breast-sharing technique allowed for simultaneous breast reconstruction and contralateral breast symmetrisation. Immediate complications included two total venous congestions and one hematoma. Three flaps had distal flap congestion. One flap required debridement and local flap reconstruction. All flaps required fat grafting during the secondary procedures to improve breast symmetry. With an average follow-up of 5,6 years, there was no evidence of recurrent disease. All patients were satisfied to very satisfied with the aesthetic outcome of this reconstructive option. ConclusionsThe breast-sharing technique based on the IMAP flap combines breast reconstruction and contralateral symmetrisation with good aesthetic outcomes in selected patients. The flap has a high complication rate related to venous drainage. Flap design modification and using ICG imaging may reduce venous congestion. A secondary venous micro-anastomosis at the axilla is highly recommended for persistent flap congestion. The reported incidence of contralateral breast cancer is low and thus the residual tissue obtained from the contralateral breast mammaplasty can be safely used for breast reconstruction. Level of EvidenceLevel IV

A Comparison of Postoperative Outcomes Based on Muscle versus Fasciocutaneous Flaps in Scalp Reconstruction: A Systematic Review and Meta-analysis.

Scalp reconstruction in plastic and reconstructive surgery often necessitates the transfer of soft-tissue flaps to restore form and function. The critical decision lies in choosing between muscle-containing (MC) and fasciocutaneous (FC) flaps for scalp reconstruction, and while both variants have their merits, flap composition remains a subject of ongoing debate. This scientific discussion aims to explore this contentious issue through a comprehensive meta-analysis, shedding light on the rationale behind the choice of these flaps and the potential impact on clinical outcomes. A comprehensive systematic review was conducted following PRISMA-P guidelines, encompassing six prominent databases up to the year 2023. Data were collected from studies assessing outcomes of MC and FC flaps for scalp reconstruction. Quality evaluation was performed using ASPS criteria and the ROBINS-I tool. Statistical analysis included descriptive statistics, meta-analysis, sensitivity analysis, and assessment of bias using STATA software. The meta-analysis included 28 nonrandomized studies, totaling 594 flaps (MC: 380, FC: 214). MC flaps were significantly larger than FC flaps. There were no significant differences in flap loss, flap necrosis, or wound dehiscence between the two flap types. However, the incidence of venous congestion was significantly higher in FC flaps. Sensitivity analysis confirmed the robustness of results, and publication bias assessment showed no significant evidence of bias. While both MC and FC flaps offer viable options for scalp reconstruction, the choice should be tailored to individual patient characteristics and defect size. FC flaps may provide advantages such as shorter operative times and reduced morbidity, whereas MC flaps could be preferred for addressing larger defects. Future research should focus on prospective studies and strategies to mitigate venous congestion in FC flaps, enhancing their safety and efficacy in scalp reconstruction.

How to increase the success rate in microsurgical free and pedicled flap reconstructions with intraoperative multistep ICG imaging: A case series with 400 consecutive cases

BackgroundOver the last decade, microsurgical soft tissue transfer became the gold standard for a wide variety of reconstructions throughout the body. Continued improvement of instruments and surgical techniques allowed reaching a very high success rate, like the employment of intra-operative indocyanine green angiography (ICG-A). This study aims to assess and validate the role of a standard intraoperative ICG-A in free flap and pedicled flap surgery to improve the overall outcomes. Patients and MethodsFrom April 2018 and April 2023, four hundreds consecutive patients who underwent reconstruction using free flap and pedicled flap were enrolled. The ICG-A was always performed in free flap after elevation of the flap, after microsurgical anastomosis, immediately after the flap inset and after wound closure; in pedicled flap the sequential procedure was performed after elevation of the flap, after flap inset and after wound closure. ResultsAll four hundred patients who underwent flap reconstruction using intraoperative ICG angiography had an extremely low incidence of necrosis (0.75% partial necrosis among free flaps and pedicled flaps) and reoperation for perfusion-related complications (0.75% due to acute ischemia and 0.50% due to flap congestion). Minor complications like hematoma, seroma, wound dehiscence, and wound infections were managed with a second operation. No flaps were lost and all the patients were successfully treated. ConclusionsThe present report shows how the employment of systematic multiple-steps ICG angiography for intra-operative assessment of both free and pedicled flap’s perfusion can significantly reduce the complications rate, including flap loss and re-exploration surgeries, in a time- and cost-effective manner.

Principles and Clinical Application of Free-Style Capillary Perforator-Based Flap for Coverage of Facial Skin Cancer Defects.

This study introduces a free-style perforator based island flap (PBIF) for the reconstruction of skin defects. From March 2012 to December 2022, a retrospective investigation was conducted on patients who underwent reconstruction for facial defects due to skin cancer. Data on the patients' gender, age, anesthesia method, diagnosis, defect location, flap size, complications, and follow-up periods were collected. There are several principles for designing the PBIF: finger-pinching method, alignment with the direction of wrinkles, the smaller width and longer length of the flap, and proximal attachment to the muscle. A total of 32 patients were included, with an average age of 63.6 years. Surgeries were performed in various regions, such as the infraorbital area, nose, cheek, philtrum, and the anterior/posterior/inferior auricular regions, with an average flap size of 7.63 cm2. There were no complications, such as venous congestion or vascular insufficiency in the skin flaps, although one case required revisional closure due to flap disruption. The PBIF is a useful and effective method for the restoration of facial defects. This method can provide simple yet aesthetically satisfying results, showing stable outcomes without complex surgeries or complications. This study indicates the potential for this method to be more widely employed in reconstructive surgeries in the future.

Reliability of Early Detection of Venous Flap Congestion by Measuring Blood Glucose Level in Albino rat; Experimental study

Reliability of Early Detection of Venous Flap Congestion by Measuring Blood Glucose Level in Albino rat; Experimental study

Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study.

The efficacy and safety of perforator-based propeller flaps (PPF) versus free flaps (FF) in traumatic lower leg and foot reconstructions are debated. PPFs are perceived as simpler due to advantages like avoiding microsurgery, but concerns about complications, such as flap congestion and necrosis, persist. This study aimed to compare outcomes of PPF and FF in trauma-related distal lower extremity soft tissue reconstruction. We retrospectively studied 38 flaps in 33 patients who underwent lower leg and foot soft tissue reconstruction due to trauma at our hospital from 2015 until 2022. Flap-related outcomes and complications were compared between the PPF group (18 flaps in 15 patients) and the FF group (20 flaps in 18 patients). These included complete and partial flap necrosis, venous congestion, delayed osteomyelitis, and the coverage failure rate, defined as the need for secondary flaps due to flap necrosis. The coverage failure rate was 22% in the PPF group and 5% in the FF group, with complete necrosis observed in 11% of the PPF group and 5% of the FF group, and partial necrosis in 39% of the PPF group and 10% of the FF group, indicating no significant difference between the two groups. However, venous congestion was significantly higher in 72% of the PPF group compared to 10% of the FF group. Four PPFs and one FF required FF reconstruction due to implant/fracture exposure from necrosis. Additionally, four PPFs developed delayed osteomyelitis post-healing, requiring reconstruction using free vascularized bone graft in three out of four cases. Flap necrosis in traumatic lower-leg defects can lead to reconstructive failure, exposing implants or fractures and potentially causing catastrophic outcomes like osteomyelitis, jeopardizing limb salvage. Surgeons should be cautious about deeming PPFs as straightforward and microsurgery-free procedures, given the increased complication rates compared to FFs in traumatic reconstruction. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Distal Flap Heparinisation Versus Systemic Bolus of Low Molecular Weight Heparin for the Prevention of Vascular Congestion in Microvascular Free Flaps: A Randomised Clinical Trial

Distal Flap Heparinisation Versus Systemic Bolus of Low Molecular Weight Heparin for the Prevention of Vascular Congestion in Microvascular Free Flaps: A Randomised Clinical Trial

Distally based lateral supramalleolar flap for reconstructing distal foot defects in India: a prospective cohort study.

Defects involving the ankle and foot are often the result of road traffic accidents. Many such defects are composite and require a flap for coverage, which is a significant challenge for reconstructive surgeons. Various locoregional options, such as reverse sural artery, reverse peroneal artery, peroneus brevis muscle, perforator-based, and fasciocutaneous flaps, have been used, but each flap type has limitations. In this study, we used the distally based lateral supramalleolar flap to reconstruct distal dorsal defects of the foot. The aim of this study was to analyze the efficacy of the flap in reconstructing distal dorsal defects of the foot. The specific objectives were to study the adequacy, reach, and utility of the lateral supramalleolar flap for distal defects of the dorsum of the foot; to observe various complications encountered with the flap; and to study the functional outcomes of reconstruction. The distal dorsal foot defects of 10 patients were reconstructed with distal lateral supramalleolar flaps over a period of 6 months at a tertiary care center, and the results were analyzed. We were able to effectively cover distal foot defects in all 10 cases. Flap congestion was observed in two cases, and minor graft loss was seen in two cases. The distally based lateral supramalleolar flap is a good pedicled locoregional flap for the coverage of distal dorsal foot and ankle defects of moderate size, with relatively few complications and little morbidity. It can be used as a lifeboat or even substitute for a free flap.

Outcomes of omega variant keystone flap in conjunction with single fraction radiotherapy for helical keloids: A comprehensive one-year follow-up study

Achieving esthetically pleasing results for helical keloids can be challenging. This study aims to share the results of a treatment approach for helical keloids, which involves complete excision and reconstruction using an omega variant keystone flap, followed by a single fractional radiotherapy. The current study is a retrospective review of 25 helical keloids in 21 patients from May 2021 to March 2023. All keloid cases were excised entirely. We covered the defect with an omega variant keystone flap followed by a single fraction of 9.5 or 10Gy radiotherapy within 24h after surgery. The mean follow-up period was 12 months. The primary outcome was recorded as recurrence versus non-recurrence. The secondary outcome was scores assessed by the Patient and Observer Scar Assessment Scale. All 25 keloids in 21 patients completed the treatment protocol, with a follow-up interval of 12 months. Of these patients, 100% had successful treatment of their keloids without any keloid recurrence. The postoperative course was uneventful except for one case of early postoperative flap congestion, which was spontaneously healed without any interventions. Scores obtained from the Patient and Observer Scar Assessment Scale showed that pain, itchiness, color, stiffness, thickness, irregularity, vascularity, pigmentation, thickness, relief, and pliability significantly improved. (p<0.001). We successfully reconstructed helical keloids using an omega variant keystone flap after keloid removal followed by 9.5 or 10Gy single fractional radiotherapy without any keloid recurrence in one-year follow-ups.

Superficial outside-flap shunt (SOS) is associated with a low incidence of postoperative DIEP flap venous congestion: A single-institution retrospective cross-sectional study

Venous congestion burdens up to 15% of deep inferior epigastric artery perforator (DIEP) flap breast reconstructions. For these cases, venous augmentation by superficial outside shunt (SOS) is associated with 100% success in secondary salvage surgeries. Intraoperative venous augmentation using other techniques yields a 0.3% rate of return to theater due to venous congestion, but there is no evidence assessing the effectiveness of the SOS technique applied preventively. Comparing this preventive approach to data prior to its implementation, we expect to find a reduced number of venous congested flaps with reduced flap losses and revision surgeries. This retrospective cross-sectional study involved DIEP flap breast reconstructions performed between 2011 and 2020. The control group included patients receiving additional venous anastomosis as a secondary salvage procedure. The "preventive SOS group" included patients who received preventive SOS during the main surgery. Age, body mass index (BMI), pregnancies, perioperative treatments (neoadjuvant or adjuvant chemo or radiotherapy), follow-up complications (arterial ischemia, venous congestion, hematomas, partial/total flap loss), and revision surgeries (breast debridement, flap remodeling) were recorded and compared. Within 695 flaps performed, 397 flaps were included in the control group, and 298 flaps were included in the preventive SOS group. The groups were homogeneous for age (p=0.418), BMI (p=0.747), and flap weight (p=0.064). Fifty-one flaps (12.8%) in the control group compared to zero (0.0%) in the preventive SOS group required return to theater (p<0.001). We reported encouraging preliminary results for SOS to prevent DIEP flap venous congestion. These results must be validated prospectively.

Reconstruction of medium and large nasal defects.

Objective: The aim of this study is to share our experience with nasal reconstruction and to give a standardized algorithm for nasal reconstruction. Study Design: Descriptive cross sectional. Setting: Burns and Plastic Surgery Center, Peshawar. Period: January 2019 to December 2022. Material &amp; Methods: Data was obtained from patient records after approval from IREB. Patients with multiple co-morbidities and small defects (&lt;1.5cm) were excluded from this study. Defects were classified based on anatomic areas of radix, dorsum, sidewall, alar and lower third nasal defects. Cases were cross tabulated regarding site for the reconstructive options to generate the treatment algorithm. Results: A total of 51 cases were included in the study including 30 (58.8%) male patients. Mean age of patients was 48.12+21.89SD. Skin malignancies were the most common (n=35, 68.6%). Nasal ala was the most common site reconstructed in our study (25.5%) followed by nasal dorsum and sidewalls. Medium size (41.2%) was the most common. In 64.8% (n=33) cases, forehead based flaps were used to reconstruct the nasal defects (Table-I). In 5.9% cases we observed flap congestion. In 19 (37.25%) cases, patients presented with additional soft tissue defects which needed reconstruction (Table-II). Reconstructive options are presented as an algorithm based on the defect site (Figure-1). Conclusion: In this study we shared our experience with the readers regarding reconstruction of the nasal detects. We have formulated an algorithm for reconstruction of these defects that will simplify reconstruction in such cases.

FREE VASCULARIZED FIBULA GRAFTING AS MANAGEMENT FOR LARGE SKELETAL DEFECTS IN HUMERAL OSTEOMYELITIS IN NORTHERN IRELAND

IntroductionThe purpose of this study is to evaluate the radiological and clinical outcomes in Northern Ireland of free vascularised fibular bone grafting for the treatment of humeral bone loss secondary to osteomyelitis. Upper limb skeletal bone loss due to osteomyelitis is a devastating and challenging complication to manage for both surgeon and patient. Patients can be left with life altering disability and functional impairment. This limb threatening complication raises the question of salvage versus amputation and the associated risk and benefits of each. Free vascularised fibula grafting is a recognised treatment option for large skeletal defects in long bones but is not without significant risk. The benefit of vascularised over non-vascularised fibula grafts include preservation of blood supply lending itself to improved remodeling and osteointegration.Materials &amp; MethodsSixteen patients in Northern Ireland had free vascularised fibula grafting. Inclusion criteria included grafting to humeral defects secondary to osteomyelitis. Six patients were included in this study. Patients were contacted to complete DASH (Disabilities of the Arm, Shoulder and Hand) questionnaires as our primary outcome measure. Secondary outcome measures included radiological evaluation of osteointegration and associated operative complications. Complications were assessed via review of Electronic Care Record outpatient and in-patient documents.ResultsSix patients in Northern Ireland have been treated with free fibula grafting for humeral defects secondary to osteomyelitis. Regarding aetiology of osteomyelitis, five patients had sustained humeral fractures which were initially managed with open reduction internal fixation and complicated by infected non-union. These cases required removal of metalwork, segmental resection and placement of cement spacer with prolonged antibiotic therapy before return to theatre for vascularised fibula grafting. One patient developed native humeral osteomyelitis, the exact cause of which was unclear. Four patients were contactable for outcome score completion. The average DASH score was 45.5. (range 11.1 – 70.4). The median score was 50.2. With regard to post-operative complications, four of the six patients required return to theatre. Reasons were flap congestion, failure of metalwork at three months, donor site skin grafting for delayed healing and external fixation of graft fracture following trauma. Three patients experienced donor site morbidity in the form of delayed healing or infection requiring admission for intravenous antibiotics. One patient died due to cerebrovascular accident (CVA) within one month of return to theatre for a graft related complication - radiographic osteointegration was not assessed for this patient. At the time of this study, three of the remaining five patients have achieved graft osteointegration. Two patients are within 6 months of grafting procedure therefore too early to comment on radiographic osteoingreration. Radiographs to date are encouraging.ConclusionsFree vascularised fibula grafting for humeral shaft bone defects is a viable option for limb salvage but carries significant risk of complications. Our study highlights the need for proper informed consent regarding risk for this uncommon complex procedure which should only be undertaken by a multidisciplinary team in a specialist orthoplastic unit. This procedure is performed infrequently and our study has given us more information on risk and clinical outcomes to provide full and informed consent for patients in the future.

Perforator-Based Propeller Flap with Additional Venous Pedicle for Lower Limb Reconstruction.

Propeller flaps are effective reconstructive tools for small-to-medium sized defects of the lower limb and a reasonable alternative to free flaps. A major vessel of the lower limb remains undisturbed while raising the flap and the flap donor and recipient areas are addressed in the same operative field. Perforator-based propeller flaps are based on single perforator arising from a major vessel and during rotation of the larger paddle there is a possibility of kink in the venous component leading to congestion of flap. In our modification, one superficial vein of the lower limb namely the great saphenous or short saphenous vein was included in the flap territory to enhance the retrograde or antegrade venous drainage of the flap. We observed, no flap congestion or necrosis in the postoperative period. Also, the patency of the incorporated vein was confirmed using handheld and color Doppler.

Quantization of extraoral free flap monitoring for venous congestion with deep learning integrated iOS applications on smartphones: a diagnostic study.

Free flap monitoring is essential for postmicrosurgical management and outcomes but traditionally relies on human observers; the process is subjective and qualitative and imposes a heavy burden on staffing. To scientifically monitor and quantify the condition of free flaps in a clinical scenario, we developed and validated a successful clinical transitional deep learning (DL) model integrated application. Patients from a single microsurgical intensive care unit between 1 April 2021 and 31 March 2022, were retrospectively analyzed for DL model development, validation, clinical transition, and quantification of free flap monitoring. An iOS application that predicted the probability of flap congestion based on computer vision was developed. The application calculated probability distribution that indicates the flap congestion risks. Accuracy, discrimination, and calibration tests were assessed for model performance evaluations. From a total of 1761 photographs of 642 patients, 122 patients were included during the clinical application period. Development (photographs =328), external validation (photographs =512), and clinical application (photographs =921) cohorts were assigned to corresponding time periods. The performance measurements of the DL model indicate a 92.2% training and a 92.3% validation accuracy. The discrimination (area under the receiver operating characteristic curve) was 0.99 (95% CI: 0.98-1.0) during internal validation and 0.98 (95% CI: 0.97-0.99) under external validation. Among clinical application periods, the application demonstrates 95.3% accuracy, 95.2% sensitivity, and 95.3% specificity. The probabilities of flap congestion were significantly higher in the congested group than in the normal group (78.3 (17.1)% versus 13.2 (18.1)%; 0.8%; 95% CI, P <0.001). The DL integrated smartphone application can accurately reflect and quantify flap condition; it is a convenient, accurate, and economical device that can improve patient safety and management and assist in monitoring flap physiology.

Intraoral anastomosis for primary microsurgical reconstruction in patients of oral cavity malignancies: Retrospective analysis of 30 cases from a tertiary care center in India

In patients undergoing either robotic neck dissection or no neck dissection, the neck recipient vessels for the free flaps remain unexposed. Intraoral vessels have been successfully used as microvascular recipients but their use in intraoral malignancies is uncommon. We describe our initial experience of using intraoral recipients in 30 patients with oral cavity malignancies. For this retrospective observational study, the hospital records of all patients who underwent microvascular reconstruction using intraoral recipient vessels over a 14-month period at a tertiary care hospital in India were studied. Patient demographics, disease profile, details of oncosurgical resection, reconstructive procedure details, and postoperative recovery data were analyzed. Intraoral anastomosis was successfully performed in 30 patients. The average patient was middle-aged (mean age 54 years) and male (26/30). Location of the postexcision defect was the buccal mucosa in 16/30 and the tongue in 12/30 patients. Anterolateral thigh flap (ALT) was used in 28/30 patients. Recipient vessels were facial vessels in 24/30 patients and lingual vessels in 6/30 patients. Venous anastomotic coupler was used in 27/30 patients. Three patients underwent re-exploration for flap congestion with loss of flap in 2/30 patients. The intraoral approach offers consistent vascular anatomy and can be performed without any external incision and oro-cervical tunneling. Being technically challenging, it has an initial learning phase. Adequate mouth opening and preservation of recipient vessels during excision and neck dissection are important prerequisites. This approach can offer a scarless reconstruction, which can improve the psycho-social rehabilitation of the patients.

Utility of the intraflap perfusion procedure for abdominal free flap in unilateral breast reconstruction

Heparin prophylaxis for venous thromboembolism can be used in microsurgery. If vein anastomosis is performed before the artery, heparin irrigation into the artery can be performed locally without systematic effect. This study aimed to introduce this "intraflap perfusion procedure" in autologous breast reconstruction. Among the 220 patients with unilateral breast cancer who had received the free abdominal flap, we retrospectively compared those that had undergone the intraflap perfusion procedure (n = 108) and those who did not (n = 112). A 10 mL injection of heparinized physiological saline solution (100 units/mL) was administered into the deep inferior epigastric artery. Intraflap perfusion was performed before, during, and after vein anastomosis, without the vessel clip of the vein. Artery anastomosis was performed without the use of a vein clamp. Further, vein anastomosis was performed tightly to prevent leakage from the vein anastomosis site during artery anastomosis. The rates of superficial inferior epigastric vein (SIEV) superdrainage (18.5% vs. 42.0%, P < 0.001), and intraoperative flap congestion (0.9% vs. 8.0%, P = 0.01) were significantly lower in patients undergoing this procedure. There were no significant differences regarding other factors (age, BMI, laterality, comorbidities, and other operative details). Intraflap perfusion prevented long-term stasis at the venous anastomosis site and capillary level. It could reduce flap congestion. SIEV superdrainage was performed to manage flap congestion, particularly in patients who did not undergo this procedure. Consequently, it can be inferred that this procedure reduces the rate of superdrainage.

Latissimus dorsi myocutaneous flap for cover of post mastectomy defects: Experience of a single surgeon in regional cancer centre Telangana, India

The majority of oncological operations for breast tumors need substantial excision of locally advanced breast tumors, as well as high volume flaps for defect repair. The function of the latissimus dorsi myocutaneous flap (LDMF) in oncoplastic replenishment of major soft tissue lesions involving the breast, as well as the rate of success and complications of the flap, were investigated in this series. all patients in this study were operated by single faculty at a regional cancer centre in Telangana, India. During the period from 2018- may, to 2020 December. This series includes 33 cases of LDMF repair done at our center. The patients ranged in age from 30 to 70 years old, with a 6-month follow-up period. The main problem was immediately repaired in all of the patients. In our group of 33 patients, the flap had healed mainly without flap congestion in 27 of them. Wound infection with skin bride necrosis in one patient, flap marginal necrosis in four cases, and seroma development at the defect location in four patients were all mild postoperative problems. In autologous reconstruction, LDMF can offer tissue volume as well as a stable vascular pedicle. When compared to the TRAM flap, DIEP flap, and other breast reconstructive methods, the percentage of postoperative problems is acceptable. LDMF should be used more frequently since it is a technically simple technique that gives appropriate coverage of a wide range of abnormalities, acceptable aesthetic results, and few postoperative problems.

Hirudotherapy for limb ischemia in the pediatric intensive care unit: A retrospective observational cohort.

Acute limb ischemia due to microvascular malperfusion may be refractory to initial therapies. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and reconstructive surgery to improve venous congestion in ischemic flaps; however, there are minimal reports related to ischemia secondary to arterial malperfusion. We evaluated a pediatric cohort from an academic intensive care unit with refractory limb ischemia in whom hirudotherapy was attempted to elucidate its use and outcomes. Institutional patient database was queried to identify pediatric patients (<18 years) who received hirudotherapy in the pediatric critical care unit and met inclusion/exclusion criteria. Patient charts were evaluated for indices including demographics, primary disease, coagulative status, vascular access, vasoactive medication dosing, bleeding, leech use, limb and mortality outcomes. Data was evaluated to identify trends or suspected impact on outcomes. Hirudotherapy was used in 7 patients for limb ischemia, 5 with congenital heart disease, and 2 others with viremic shock. Time to leech application following recognition of ischemia averaged 3 days, with duration of use averaging 3.9 days. Five patients discontinued therapy due to bleeding. Mortality rate was 57%, all secondary to multiorgan failure. In 3 surviving patients, 4 of 5 treated limbs resulted in at minimum partial amputation. Vasoactive-inotropic score tended higher prior to leech application, suggesting a vasoconstrictive pathway for arterial malperfusion. No identifiable trends appeared associated with salvaged limb or adverse effects. Blood loss predictably increased with leech application, as did total transfusion requirement. This case series establishes baseline data for use of hirudotherapy in critically ill children with acute limb ischemia caused by arterial malperfusion. Based on this retrospective cohort, we cannot recommend routine use of hirudotherapy for acute limb ischemia from arterial malperfusion in the pediatric intensive care unit. Application of leeches should be aligned with a protocol defining start and stop parameters, standardized leech utilization, and monitoring for adverse outcomes. Future study would benefit from consensus definitions of study outcomes, including perfusion recovery, tissue/limb salvage and bleeding manifestations. Additional prospective studies are needed prior to any standard or systematic recommendations for use.

Staggered Setting of Latissimus Dorsi and Serratus Anterior Flaps for the Treatment of Scalp Avulsions: A Retrospective Study.

Although the incidence of scalp avulsion has decreased in recent years, it remains a major concern among plastic surgeons. We therefore aimed to introduce an improved free flap technique for repairing scalp avulsion with less tissue from the donor site. This method can achieve maximum primary closure of the donor site and improve its appearance and function as well as reduce the donor-site morbidity by ensuring that a smaller free flap can completely cover the scalp defect. Eight patients with scalp avulsion who had undergone staggered placement of the free flaps were evaluated. Data on the age, cause of scalp avulsion, scalp defect size, degree of avulsion, postoperative complications, and follow-up duration were analyzed. The postoperative evaluation criteria were donor-site sensation, latissimus dorsi muscle strength, upper extremity function, and quality of life. Patients' mean age was 38.7 years. The main cause of scalp avulsion was occupation-related accidents. The mean scalp defect size and postoperative follow-up duration were 26 cm × 20.4 cm and 41.5 months, respectively. One patient developed flap congestion postoperatively. The wounds at the recipient site healed well in all patients. There was no significant difference in the sensation between the surgical and nonsurgical sides. However, the latissimus dorsi muscle strength significantly differed between both sides. The mental component score, which was used to assess quality of life, did not significantly differ between the patients and healthy population, whereas the physical component score significantly differed between the two groups. None of the included patients had severe upper extremity functional limitation. Staggered placement of free flaps achieved maximum primary closure of the donor site and greater scalp avulsion defect coverage with less tissue excised from the donor site. Importantly, donor-site appearance improved and some donor-site functions were preserved postoperatively.

Medicinal Leech Therapy in Veterinary Medicine: A Retrospective Study.

The objective of this study was to report the clinical indications, outcomes, and complications associated with medicinal leech therapy (MLT) in dogs and cats. Medical records (2012-2016) of client-owned dogs (n = 9) and cats (n = 3) treated with MLT at one institution were retrospectively reviewed. Retrieved data included the signalment, indications, physical examination findings, laboratory results, methods of leeching, outcomes, and complications associated with MLT. Following MLT sessions, nine patients (75%) visibly showed clear improvement of the affected tissue. One patient (8%) was euthanized before complete healing owing to pulmonary parenchymal disease. Improvement or appearance of tissue following MLT was not recorded in two patients (17%). Results suggest that MLT may be a safe and effective treatment modality for venous congestion and necrosis in compromised skin flaps and wounds with success in resolving 75% of the lesions in this study. This study is suggestive of the value of MLT when more conventional treatment methods fail in dogs and cats. A data collection form was created for veterinarians to use with the goal of obtaining standardized, objective MLT data for future studies.