Coverage Of Defects Research Articles

Reconstruction of Moderately and Severely Atrophic Scalp-A Multicentric Experience in Surgical Treatment of Patients Irradiated for Tinea Capitis in Childhood and Surgical Algorithm.

Background and Objectives: Before the introduction of griseofluvin, the use of X-ray radiation was the treatment of choice for tinea capitis. More than half a century later various types of tumors have been found to be associated with childhood irradiation due to tinea capitis, most commonly cancers of the head and neck, as well as brain tumors. The often unusually aggressive and recurrent nature of these tumors necessitates the need for repeated surgeries, while the atrophic skin with an impaired vascular supply due to radiation often poses an additional challenge for defect reconstruction. We present our experience in the surgical treatment of such patients. Materials and Methods: This is a retrospective cohort study. In this study, 37 patients treated for acquired defects of the scalp with a history of irradiation therapy due to tinea capitis in childhood were included in this study, 24 male and 13 female patients. The mean age at the first appointment was 60.6 ± 7.8, with the youngest included patient being 46 and the oldest being 75 years old. Patients' characteristics, surgical treatment, and complications were analyzed and a reconstructive algorithm was developed. Results: Local flaps were used for reconstruction in 34 patients, direct sutures were used in 10 patients and 20 patients received split-thickness skin grafts for coverage of both primary and secondary defects for reconstruction of flap donor sites. One regional flap and one dermal substitute covered by an autologous skin graft were also used for reconstruction. Complications occurred in 43.2% of patients and were significantly associated with the presence of comorbidities (p = 0.001), aseptic bone necrosis (p = 0.001), as well as skin atrophy in frontal, occipital, and parietal region (p = 0.001, p = 0.042 and p = 0.001, respectively). A significant correlation between major complications and moderate skin atrophy was found only in the parietal region (p = 0.026). Conclusions: Unfortunately, many protocols developed for scalp reconstruction are not applicable in the setting of severe or diffuse scalp skin atrophy associated with high tumor recurrence rate and radiation-induced vascular impairment, such as in tinea capitis patients in Serbia. An algorithm has been developed based on the authors' experience in managing these patients.

Keystone design perforator island flap: our experience for coverage of lower limb defects

The fusion of concept of perforasome and trapezoid design made Keystone design Perforator Island flap (KDPIF). This flap was first introduced by Behan in 2003 and since then many modifications were done. Keeping the principles of KDPIF, two modifications were done in this study. Aims: to determine reliability and advantages of KDPIF for lower limb defect coverage. Materials and Methods:15 cases were done in Plastic surgery department of Rajshahi Medical College Hospital from October 2020 to September 2022. Results: The largest wound measuring 11X 10 cm2 on thigh defect following wide local excision of sarcoma was covered by the largest dimension flap measuring 16X 11 cm2. In most of the cases (7 cases), Type IIA KDPIF was done. With co-morbidities, 14 flaps survived without any complications. Range operating time was 35-110 minutes. Conclusion: Due to its reliable vascularity and easy execution and good outcomes, KDPIF is one of the best choices for lower limb defect coverage. Bangladesh Journal of Medical Science Vol. 22 No. 04 October’23 Page : 920-925

Transverse Eponychial Flap For Nail Lengthening And Fingertip Reconstruction

Introduction: Fingertip injuries are frequented with loss of pulp and nail complex. Most reconstructive procedures provide either the soft tissue defect coverage or lengthen the nail. Methods: Patients included were more than 10 years of age with fingertip injury of Allen type III and IV with intact eponychium. Transverse Eponychial Flap was used to lengthen the nail lost as well as provide defect coverage. Paired t test, chi square test and Pearson correlation and Mann Whitney test were used for statistical analysis. Results: Seventeen digits were analyzed. The average lengthening of the nail achieved was 142.4%. The average nail length during follow up was 59.1% of contralateral, with average final nail lengthening achieved was 31%. Reconstruction with Transverse Eponychial flap alone was performed in 58.8% of digits. Four patients (23.52%) had complete near normal nail. Sixteen digits had satisfactory and higher results. With Transverse Eponychial Flap alone it was possible to completely cover 10 fingertips (58.8%), requiring local flaps or skin graft for the remaining cases. Obliquely orientated injuries (76.47%) were more likely to undergo the procedure. Conclusion: The flap significantly lengthens the nail, and provides satisfactory results. We recommend the use of this flap in defects with Allen type III and IV fingertip injuries.

Role of the Gastrocnemius Musculocutaneous with a Propeller Style Skin Flap in Knee Region Reconstruction: Indications and Pitfalls.

Background Soft tissue reconstruction around the knee area is still an open question, particularly in persistent infections and multiple reoperations scenario. Flap coverage should guarantee joint mobility and protection, even when foreign materials are implanted. The chimeric harvesting of the musculocutaneous gastrocnemius flap, based on the sural artery perforators, can extend its applicability in soft tissue reconstruction of the upper leg, overcoming the drawbacks of the alternative pedicled flaps. Methods A multicenter retrospective study was conducted enrolling patients who underwent to a pedicled, chimeric gastrocnemius musculocutaneous-medial sural artery perforator (GM-MSAP) or lateral sural artery perforator (GM-LSAP) flap for knee coverage in total knee arthroplasty (TKA) recurrent infections and oncological or traumatic defects of the upper leg from 2018 to 2021. Outcomes evaluated were the successful soft tissue reconstruction and flap complications. Surgical timing, reconstruction planning, technique, and rehabilitation protocols were discussed. Results Twenty-one patients were included in the study. Nineteen GM-MSAPs and 2 GM-LSAPs were performed (soft tissue reconstruction in infected TKA [12], in infected hardware [4], and in oncological patients [5]). Donor site was closed primarily in 9 cases, whereas a skin graft was required in 12. Flap wound dehiscence (1), distal flap necrosis (1), distal necrosis of the skin paddle (1), and donor site infection (1) were the encountered complications. Flap reraise associated to implant exchange or extensive debridement was successful without requiring any further flap surgery. Conclusion The propeller-perforator GM-MSAP offers qualitative defect coverage and easiness of multiple flap reraise due to skin availability and its laxity.

Finger defect reconstruction using the radial artery superficial palmar branch free flap

Purpose: The radial artery superficial palmar branch (RASP) free flap is accepted as a surgical technique for the reconstruction of finger defects. This study revisited the RASP free flap and evaluated its reliability and usefulness in a variety of finger defects. Methods: From January 2017 to December 2022, multiple surgeons at a single institution performed a total of 315 RASP free flap reconstructions. Basic patient demographics and information on the finger defect and flap were assessed, and immediate postoperative flap and donor site-related complications were also studied. Data regarding long-term outcomes, such as the thumb joint range of motion and static two-point discrimination (S2PD), were collected and evaluated to identify statistically significant differences from the unaffected or non-innervated side. Results: The mean postoperative follow-up was 14.8 months. The total flap survival rate was approximately 91.4%. There was no statistically significant difference in mean postoperative palmar abduction and radial abduction between the affected and unaffected thumbs in both groups. In the single-digit group, there was a statistically significant difference in S2PD between the innervated flap and unaffected side. A statistically significant difference was also found between innervated and non-innervated flaps in the multiple-digits group. Conclusion: The RASP free flap is a valuable surgical option in reconstructing finger defects. It has already been proven to be safe and useful in coverage of single and tip defects. Stability should be ensured when there are multiple defects. Finally, the donor site morbidity is minimal and the recovery of sensation, once the flap is reinnervated, could be promising.

The use of Integra Dermal Regeneration Template in the surgical management of revision penile inversion vaginoplasty: A case series

Since its initial design and use for the temporary coverage of severe full-thickness burn defects, Integra® (Integra LifeSciences) Dermal Regeneration Template has been increasingly used all over the body, yielding successful results in coverage of wound beds with insufficient vascularity and suboptimal conditions for proper healing. In this study, we report an institutional case series and outcomes of gender-affirming vaginoplasty revision for vaginal lengthening or reopening of the canal via placement of Integra® to assist in optimizing the wound bed for subsequent skin grafting when wound conditions were deemed to be suboptimal. A retrospective chart review was conducted in patients who underwent this technique by a single surgeon (JM) at the authors' institution. Demographics, vaginal depth, and complications were recorded and compared. Our patient population thus far includes 178 primary vaginoplasties, of which 9 of those needing revision were treated with this approach. The age at revision mean was 47±13.5 years, and the body mass index mean was 31±4.1. All patients had comorbidities and five were former smokers. Eight patients had prior revision conducted without Integra®, with a mean of 1.89±1.76 and the time to first revision mean was 15.89±14.2 months. No long-term complications after Integra® reported and most of the patients did not require further revision. The follow-up mean was 8.48±8.66 months. A mean of 6.77±5.35cm was gained after the Integra® revision (4.92±4.1cm before versus 12.54±3.07cm after). The final depth after Integra® + full-thickness skin graft mean was 13.34±4.65cm. Overall, the depth gain mean was 7.48±5.77cm; in total, seven patients gained depth after revision with an average of 78% skin graft take. Overall, Integra® presents an alternative option for revision vaginoplasty with complicated wound beds potentially aiding in the healing process before grafting.

Latissimus dorsi flap for breast reconstruction: a large single-institution evaluation of surgical outcome and complications

PurposeThe use of autologous tissues is considered gold standard for patients undergoing breast reconstruction and is the preferred method in the post-radiation setting. Although the latissimus dorsi flap (LDF) has been replaced by abdominal flaps as technique of choice, it remains a valuable option in several specific clinical situations and its use has been regaining popularity in recent years. In this work, we present an 18-year retrospective analysis of a single-institution single-surgeon experience with LDF-based reconstruction with focus on early complications and reconstructive failures.MethodsHospital records of all patients undergoing breast surgery for any reason in the Certified Breast Cancer Center, Regio Klinikum Pinneberg, Germany between April, 1st 2005 and October, 31st 2022 were reviewed. 142 consecutive LDF-based reconstructive procedures were identified. Detailed information was gathered on patient characteristics, treatment-related factors, and complications.ResultsOne hundred forty patients (139 female, 1 male) received 142 LDF-based surgeries. The flap was used mainly for immediate breast reconstruction with or without implant (83% of patients), followed by defect coverage after removal of a large tumor (7%), implant-to-flap conversion with or without placement of a new implant (6%), and delayed post-mastectomy reconstruction (4%). The use of LDF decreased between 2005 and 2020 (2005: 17, 2006: 13, 2007: 14, 2008: 16, 2009: 5, 2010: 9, 2011: 8, 2012: 3, 2013: 10, 2014: 8, 2015: 8, 2016: 7, 2017: 7, 2018: 4, 2019: 4, 2020: 2, 2021: 6, 2022: 4). Surgery was performed for invasive breast cancer in 78%, ductal carcinoma in situ in 20% and other reasons such as genetic mutation in 1% of patients. Ipsilateral radiation therapy was received by 12% of patients prior to LDF surgery and by 37% after the surgery. 25% of patients were smokers. The median duration of surgery, including all procedures conducted simultaneously such as e.g., mastectomy, axillary surgery, or implant placement, was 117 min (range 56–205). Patients stayed in the hospital for a median of 7 days (range 2–23 days). The most common complication was seroma (26%), followed by wound dehiscence (8%), surgical site infection (7%), partial skin and/or nipple necrosis of any size (7%) and hematoma requiring surgical evacuation (2%). 19% of all patients required seroma aspiration or drainage, mostly at the donor site and performed under ultrasound guidance in the ambulatory setting. Flap loss due to necrosis occurred in 2% of patients.ConclusionsLatissimus dorsi flap is a well-established surgical technique commonly used for immediate breast reconstruction as well as defect coverage in locally advanced breast cancer. To the best of our knowledge, this is one of the largest single-surgeon analyses of early complications in patients receiving LDF. As expected, seroma was the most common complication observed in nearly one third of patients and requiring a therapeutic intervention in every fifth patient. Serious adverse events occurred rarely, and flap loss rate was very low.

Reuse of Nasoseptal Flaps for Endoscopic Endonasal Skull Base Reconstruction.

Introduction Pedicled nasoseptal flap (NSF) placement is a critical component of skull base reconstruction after endoscopic endonasal approaches (EEAs). The effectiveness of NSF reuse has not been thoroughly studied. Prior reports using flaps harvested at one center and reused at another may have technical variability bias. Methods We identified patients who underwent both their initial and NSF-reused surgeries at Weill Cornell Medical College from 2004 to 2022 using a prospective database of all EEAs. Surgical pathology, intraoperative leak grade, use of cerebrospinal fluid (CSF) diversion and skull base coverage were examined. The primary outcome measure was occurrence of CSF leak. Results Fourteen patients (six women, eight men) underwent 14 first time and 14 revision operations with median age of 36.6 years (interquartile range [IQR]: 23.9-61.3) at the time of the NSF reuse. The median interval between the first NSF use and reuse was 70.6 months (IQR: 16.6-87). Eight patients were operated on for pituitary adenoma. Nonadenomas included three craniopharyngiomas and one case each of epidermoid, ependymoma, and chordoma. There were 16 high-flow, 8 low-flow intraoperative leaks, and 4 with no leak. CSF diversion was used in 24 operations. There were three postoperative leaks, one after a first operation and two after NSF reuse. All postoperative CSF leaks, whether first or second operations, occurred in cases with both high-flow intraoperative CSF leak and incomplete NSF coverage ( p = 0.006). Conclusion NSF reuse is effective at preventing postoperative CSF leak. The primary predictors of leak are high-flow intraoperative leak and inadequate defect coverage with NSF, regardless of the operation number.

Bipedicle flaps - A Simple & Effective Mode of Coverage of Defects in the Leg and Foot: A Retrospective Case Study

Bipedicle flaps - A Simple & Effective Mode of Coverage of Defects in the Leg and Foot: A Retrospective Case Study

In vivo efficacy proof of concept of a large-size bioprinted dermo-epidermal substitute for permanent wound coverage.

Introduction: An autologous split-thickness skin graft (STSG) is a standard treatment for coverage of full-thickness skin defects. However, this technique has two major drawbacks: the use of general anesthesia for skin harvesting and scar sequelae on the donor site. In order to reduce morbidity associated with STSG harvesting, researchers have developed autologous dermo-epidermal substitutes (DESs) using cell culture, tissue engineering, and, more recently, bioprinting approaches. This study assessed the manufacturing reliability and in vivo efficacy of a large-size good manufacturing practice (GMP)-compatible bio-printed human DES, named Poieskin®, for acute wound healing treatment. Methods: Two batches (40cm2 each) of Poieskin® were produced, and their reliability and homogeneity were assessed using histological scoring. Immunosuppressed mice received either samples of Poieskin® (n = 8) or human STSG (n = 8) immediately after longitudinal acute full-thickness excision of size 1 × 1.5cm, applied on the skeletal muscle plane. The engraftment rate was assessed through standardized photographs on day 16 of the follow-up. Moreover, wound contraction, superficial vascularization, and local inflammation were evaluated via standardized photographs, laser Doppler imaging, and PET imaging, respectively. Histological analysis was finally performed after euthanasia. Results: Histological scoring reached 75% ± 8% and 73% ± 12%, respectively, displaying a robust and homogeneous construct. Engraftment was comparable for both groups: 91.8% (SD = 0.1152) for the Poieskin® group versus 100% (SD = 0) for the human STSG group. We did not record differences in either graft perfusion, PET imaging, or histological scoring on day 16. Conclusion: Poieskin® presents consistent bioengineering manufacturing characteristics to treat full-thickness cutaneous defects as an alternative to STSG in clinical applications. Manufacturing of Poieskin® is reliable and homogeneous, leading to a clinically satisfying rate of graft take compared to the reference human STSG in a mouse model. These results encourage the use of Poieskin® in phase I clinical trials as its manufacturing procedure is compatible with pharmaceutical guidelines.

Comparative evaluation of platelet rich fibrin matrix (PRFM) membrane and platelet rich fibrin (PRF) membrane using the vestibular incision subperiosteal tunnel access (VISTA) approach technique for the treatment of multiple gingival recession in humans: A double-blind, parallel-group, randomized controlled clinical trial

Background: In this evolutionary era of dentistry, newer techniques have evolved for complete coverage of multiple recession defects (MRDs). Since 2012, MRDs have been treated using the vestibular incision subperiosteal tunnel access (VISTA) approach and a variety of regenerating membranes with varying degrees of success. Platelet‑rich fibrin matrix (PRFM) membrane has shown a robust release of growth factors and was known to enhance the healing process. Thus, in this study we have evaluated the effectiveness of platelet-rich fibrin matrix (PRFM) with that of platelet-rich fibrin (PRF) membrane using the vestibular incision subperiosteal tunnel access (VISTA) technique in Miller Class I and II multiple gingival recession defects. Methods: This randomized, parallel designed, controlled, clinical study was conducted in 20 subjects (10 male and 10 female) having class I/II MGR defects either buccally or labially. The test group was treated with VISTA and PRFM membrane while the control group was treated with VISTA and PRF membrane. The clinical measurements such as plaque index, papillary bleeding index, probing pocket depth, relative attachment level (RAL) and relative gingival marginal level (R-GML), width of keratinized gingiva (WKG), gingival recession (REC) and gingival thickness (GT) were measured at baseline, three and six months. A Student’s paired t-test was utilized to analyse data from the day of surgery to six months. Results: Ten patients in the test group (89.23±15.04) and 10 patients in the control group (85.06±17.71) showed marked root coverage compared to baseline. Conclusions: Both test and control groups showed statistically significant enhancement in root coverage. However, no statistically significant difference was found when a comparison was made between the two groups in terms of PD, relative RAL, R-GML and REC reduction, gain in WKG, and increase in GT. Trial registration: CTRI/2021/07/035240, registered 29 July 2021.

Transorbital transposition of the temporoparietal fascia flap to reconstruct the skull base defects: A preclinical study with comparison to the transpterygoid transposition.

Transpterygoid transposition of the temporoparietal fascia flap (TPFF) is a feasible selection for ventral skull base defect (VSBD) reconstruction, but not anterior skull base defect (ASBD) reconstruction, after expanded endoscopic endonasal approach (EEEA). The goal of this study is to introduce the transorbital transposition of the TPFF for skull base defects reconstruction after EEEA, and make quantitative comparison between the transpterygoid transposition and transorbital transposition. Cadaveric dissections were performed in five adult cadaveric heads with creating three transporting corridors bilaterally, encompassing superior transorbital corridor, inferior transorbital corridor, and transpterygoid corridor. For each transporting corridor, the minimum necessary length of the TPFF for skull base defects reconstruction was measured. The areas of ASBD and VSBD were 1019.63 ± 176.32 mm2 and 572.99 ± 126.21 mm2 . The length of the harvested TPFF was 149.38 ± 6.21 mm. In contrast to the transpterygoid transposition with incomplete coverage, transorbital transposition of the TPFF allowed full coverage of ASBD with a minimum necessary length of 109.75 ± 8.31 mm. For VSBD reconstruction, transorbital transposition of the TPFF needs shorter minimum necessary length (123.88 ± 4.49 mm) than transpterygoid transposition (138.00 ± 6.28 mm). Transorbital corridor is a novel pathway for transporting the TPFF into the sinonasal cavity for skull base defects reconstruction after EEEA. In comparison with transpterygoid transposition, transorbital transposition provides wider coverage of skull base defects with a fixed length of the TPFF.

Single-Stage Extensor Digitorium Tendon Reconstruction, Including Overlying Soft Tissue Defects of the Foot Dorsum with a Composite-Free Anterolateral Thigh Flap

Abstract Background Loss of the extensor tendon with overlying soft tissue remains a complex reconstructive challenge. Successful reconstruction combines tendon repair with defect coverage by soft tissue flaps, meets the goals of approaching functionality, and achieves an esthetic result. Patients and Methods From June 2016 to June 2022, our center submitted six patients to a one-stage procedure correcting the extensor tendon and skin defect using a composite-free anterolateral thigh (ALT) flap with fascia lata (FL). Results The ALT skin paddle was from 10 × 8 cm to 26 × 13 cm, and all flaps included vascularized FL with an average of 12 × 9.5 cm, which was split and folded to reconstruct as a tendon. The extensor digitorium brevis tendon defects were reconstructed by fascia sheets in all patients. One patient had additional reconstruction of the extensor hallucis longus tendon. All the flaps survived completely, and no complication was reported. All patients received rehabilitation therapy starting in the third week postoperatively. The mean follow-up was 33.67 months (range, 10–60). The mean arc of ankle rotation between dorsiflexion and plantar flexion was 49.20 degrees (range, 40–55 degrees). After reconstruction, our patients showed good functional results, and these patients could walk, climb stairs, tiptoe again without support, and regular footwear could be worn. Conclusion A composite-free ALT flap with vascularized FL is a reasonable option for coverage of the extensor tendon and overlying soft tissue defects. It helps reduce the surgical risk and hospitalization time and provokes faster recovery and rehabilitation. Level of Clinical Evidence Case studies, Level 4.

The Utility of Flap Coverage for Limb Salvage in Patients With Severe Prosthetic Joint Infections of the Knee Requiring Implant Exchange.

Prosthetic joint infection (PJI) is a challenging complication of knee arthroplasty, which can require amputation in severe cases. This study analyzes the utility of flap reconstruction in PJIs requiring hardware removal and extensive soft tissue debridement. This was a retrospective analysis of patients who were treated according to a multistage extremity salvage protocol between 2018 and 2022. The protocol involved at least 3 planned surgeries including (1) hardware removal with antibiotic spacer placement and soft tissue debridement, (2) spacer exchange with flap coverage, and (3) hardware reimplantation with simultaneous or delayed extensor mechanism reconstruction. All patients had large periprosthetic tissue defects that would necessitate an amputation if not reconstructed. Primary outcomes were extremity salvage and successful defect coverage. Fifty-two patients (25 female) underwent 62 reconstructions (52 primary, 10 salvage). Flap techniques included pedicled muscular (n = 32), fasciocutaneous (n = 4), combined muscular and fasciocutaneous (n = 2), and free flaps (n = 24). Overall rate of successful defect coverage was 95% (98% in primary and 80% in salvage reconstructions). At a median follow-up of 11 months, 41 patients completed the treatment protocol with a 68% (n = 28) extremity salvage rate (reimplantation arthroplasty, n = 15; permanent knee fusion, n = 13). On the multivariate model including demographic factors, defect size, and flap type, no single factor independently predicted limb salvage. Alongside intensive orthopedic surgical treatment, flap coverage may aid in extremity salvage in severe knee PJIs by reestablishing healthy soft tissue coverage and allowing reimplantation arthroplasty. We recommend a multispecialty approach including plastic surgeons for this challenging condition.

Reconstruction of Upper and Lower Limb Defects with Medial Sural Artery Perforator Flaps: Is Aesthetics Worth the Effort? A Retrospective Analysis

Abstract Background One of the most essential goals in managing complex limb defects is obtaining adequate soft tissue coverage with excellent functional and aesthetic outcomes. Free perforator skin flaps represent an optimal option for such defects. Therefore, our intention was to reconstruct these kinds of defects with thin fasciocutaneous flaps without the need for debulking. Herein, we define the legitimate use of the medial sural artery perforator (MSAP) flaps for small-moderate size defect coverage of the hand and foot. Patients and Methods Seven patients received MSAP flaps for reconstruction of different hand and foot defects, of which the majority were males (4/7). Age, sex, flap size, location, number of perforators, recipient vessel, type of anastomosis, technique of donor site closure, and postoperative morbidity were recorded. Patients' age ranged from 48 to 84 years. Results Single-stage debridement followed by reconstruction was performed. Flap sizes ranged from 6 to 18 cm in length and 4 to 10 cm in width. The pedicles of 6 flaps were anastomosed to the tibial artery system (three posterior tibial artery, three dorsalis pedis artery) and one to the ulnar artery. Conclusion MSAP flap can be a versatile option for single-stage reconstruction of small-moderate size defects of the extremities, where thin, soft tissue envelope is required. This flap has lower donor site morbidity, more tedious elevation process, and has a good reconstructive and aesthetic result without the need for debulking in the future.

Soleus Muscle Flap for Coverage of Soft Tissue Defect of Leg

Background: Open tibia fracture with soft tissue loss at the fracture site is and always a challenging problem for orthopedic surgeons to deal with. Soleus flap is an important option for such defects out of many other options. Methods: Retrospective descriptive study in which twenty-one patients with open tibia fracture with soft tissue defect at fracture site requiring flap coverage were included in the study. In all 21 patients, the soleus muscle flap was done. Results: Out of 21 patients, in 16 patients medial hemisoleus flap was done and in five composite soleus muscle flap was done. The average age of the patients was 37.8 years, and the right leg was more involved. In all patients, bone coverage was achieved. Three patients required debridement and mobilization of flap due to infective necrosis at the margin. The mean follow-up was 12 months. Conclusion: Soleus muscle flap is a good and versatile flap for the coverage of soft tissue defects of the leg exposing bone or fracture.

Reconstruction with an Anterolateral Thigh Free Flap Following a Skin Graft from the Same Donor Site for Tissue Use Efficacy: Two Case Reports

The coverage of extensive soft tissue defects requires several considerations, such as limited donor sites, reconstruction methods, and the outcome of functional recovery. In the cases described herein, when a significant soft tissue defect was present on an extremity, we opted for staged reconstruction. We first performed a split-thickness skin graft (STSG) to reduce the soft tissue defect, using the anterolateral thigh (ALT) as the donor site. In the second stage, the remaining soft tissue defect was reconstructed with an ALT free flap, utilizing the same lateral thigh area that had previously served as the STSG donor site. After the free flap procedure, we encountered several challenges in monitoring the ALT flap; however, all flaps ultimately survived. To the best of our knowledge, this is the first report of using an ALT free flap following STSG from the same donor site, demonstrating efficient tissue utilization. We believe this approach is beneficial for reconstructing extensive soft tissue defects, as it maximizes tissue use efficiency and reduces donor site morbidity when donor options are limited.

Gluteal Propeller Perforator Flaps: A Paradigm Shift in Abdominoperineal Amputation Reconstruction.

Abdominoperineal amputation (AAP) is a gold standard procedure treating advanced abdominal and pelvic cancers. The defect resulting from this extensive surgery must be reconstructed to avoid complications, such as infection, dehiscence, delayed healing, or even death. Several approaches can be chosen depending on the patient. Muscle-based reconstructions are a reliable solution but are responsible for additional morbidity for these fragile patients. We present and discuss our experience in AAP reconstruction using gluteal-artery-based propeller perforator flaps (G-PPF) in a case series. Between January 2017 and March 2021, 20 patients received G-PPF reconstruction in two centers. Either superior gluteal artery (SGAP)- or inferior artery (IGAP)-based perforator flaps were performed depending on the best configuration. Preoperative, intraoperative, and postoperative data were collected. A total of 23 G-PPF were performed-12 SGAP and 11 IGAP flaps. Final defect coverage was achieved in 100% of cases. Eleven patients experienced at least one complication (55%), amongst whom six patients (30%) had delayed healing, and three patients (15%) had at least one flap complication. One patient underwent a new surgery at 4 months for a perineal abscess under the flap, and three patients died from disease recurrence. Gluteal-artery-based propeller perforator flaps are an effective and modern surgical procedure for AAP reconstruction. Their mechanic properties, in addition to their low morbidity, make them an optimal technique for this purpose; however, technical skills are needed, and closer surveillance with patient compliance is critical to ensure success. G-PPF should be widely used in specialized centers and considered a modern alternative to muscle-based reconstructions.

The Subchondral Bone Condition During Microfracture Affects the Repair of the Osteochondral Unit in the Cartilage Defect in the Rat Model

Background: Microfracture (MF) is frequently performed as a first-line treatment for articular cartilage defects. Although good clinical outcomes are often obtained in the short term, poor clinical outcomes sometimes occur because of subchondral bone deterioration. The condition of the subchondral bone treated with MF may affect the repair of the osteochondral unit. Purpose: To analyze histological findings of the osteochondral unit after performing MF on subchondral bone in different states—normal, absorption, and sclerosis—in a rat model. Study Design: Controlled laboratory study. Methods: Full-thickness cartilage defects (5.0 × 3.0 mm) were created in the weightbearing area of the medial femoral condyle in both knees of 47 Sprague-Dawley rats. Five MF holes were created within the cartilage defect using a 0.55-mm needle to a depth of 1 mm at 0 weeks (normal group), 2 weeks (absorption group), and 4 weeks (sclerosis group) after the cartilage defect was created. In the left knee, MF holes were filled with β-tricalcium phosphate (β-TCP). At 2 and 4 weeks after MF, knee joints were harvested and histologically analyzed. Results: MF holes were enlarged at 2 weeks and further enlarged at 4 weeks in all groups. In the absorption group, osteoclast accumulation around the MF holes and cyst formation were observed. The trabecular bone surrounding the MF holes was thickened in the sclerosis group. The diameter of the MF hole was largest in the absorption group at 2 and 4 weeks after MF compared with the other groups. No subchondral bone cysts were observed after β-TCP implantation. Pineda scores in all groups were significantly better with β-TCP implantation than without β-TCP implantation at 2 and 4 weeks. Conclusion: MF for subchondral bone with bone absorption induced enlargement of the MF holes, cyst formation, and delay of cartilage defect coverage. Implantation of β-TCP into the MF holes enhanced remodeling of the MF holes and improved repair of the osteochondral unit compared with MF only. Therefore, the condition of the subchondral bone treated with MF affects repair of the osteochondral unit in a cartilage defect.

Efficacité de la fixation interne précoce associée à un lambeau libre pour le traitement des fractures ouvertes de l’avant-bras Gustilo IIIB

IntroductionGustilo IIIB open forearm fractures are severe injuries often associated with extensive bone and soft tissue injuries. The treatment of Gustilo IIIB open forearm fractures remains a challenging problem, with a high morbidity rate such as infection, nonunion, even amputation. External fixation is preferred for open lower limb fractures. However, there are significant differences between open bone injuries of the upper and lower extremity in terms of treatment plans. Use of internal fixation methods for open fractures is a controversial issue, as it requires early coverage of skin and soft tissue defects after radical debridement and irrigation. The optimal approach for open forearm fractures remains to be determined. The present study evaluated whether early internal fixation combined with free flap placement is effective for the treatment of Gustilo IIIB open forearm fracture. HypothesisEarly internal fixation combined with the free flap technique in the treatment of Gustilo IIIB open forearm fracture provides good consolidation results. Material and methodsFrom January 2015 to January 2020, 20 patients with Gustilo IIIB open forearm fracture treated with early internal fixation combined with free skin flap placement were retrospectively analyzed. There were 9 males and 11 females, with an average age of 40years. In all cases, the injuries were classified as Gustilo type IIIB. The area of the wounds ranged from 9×3cm to 27×10cm. Fist-stage plate fixation was adopted in 16 cases. Four patients presenting with major contamination received first-stage fixation with Kirschner wires and external fixation, and the second-stage surgery of surgical treatment included flap placement and internal fixation within 10days. The rates of limb salvage and complications were recorded. The Anderson scoring system was utilized to assess limb function. ResultsLimb salvage was successful in all 20 cases. The average length of hospital was 19 days (range, 7–28days). Four patients developed superficial infections. After debridement, the wounds were covered with skin grafts. No deep infections or osteomyelitis occurred. Three patients developed nonunion, and bone grafts achieved bone healing later. The donor skin flaps healed well, with partial pigmentation. No complete necrosis of the flaps occurred. Only the distal part of flaps became necrotic in two cases, which were then successfully treated by debridement and skin grafting. The average follow-up duration was 14.7months (range, 8–24months). According to the Anderson scoring system, 7 cases were graded as excellent, 6 cases as good, 5 cases as fair, and 2 cases as poor. ConclusionFor Gustilo IIIB type injuries, early and thorough debridement along with early internal fixation and skin flap coverage of the wound can achieve satisfactory clinical results, shorten the treatment cycle, and maximize limb function recovery. Level of evidenceIV; retrospective study without control group.