Cutaneous Flap Research Articles

Dickkopf 2-Expressing Adenovirus Increases the Survival of Random-Pattern Flaps and Promotes Vasculogenesis in a Rat Model.

Dickkopf 2 (DKK2) has important roles in vertebrate development; it inhibits Wnt signaling-related processes, such as axial patterning, limb development, somitogenesis, and eye formation. However, DKK2 also acts as a Wnt signaling agonist. Dickkopf 2, induced during endothelial cell morphogenesis, promotes angiogenesis in cultured human endothelial cells. In this study, we explored the effect of DKK2-expressing adenovirus on random-pattern flaps using a rodent model. A DKK2-expressing (dE1-RGD/DKK2) adenovirus was generated and 20 Sprague-Dawley rats were randomly divided into 2 groups: a DKK2 group and a control group. Each group was intradermally injected with 1 × 10 plaque-forming units of DKK2-expressing adenovirus (DKK2 group) or control virus (control group) 48 hours before and immediately before surgery. Then, random-pattern dorsal cutaneous flaps of 3 × 9 cm were elevated. Flap survival rates and cutaneous blood flow were measured over time, and immunohistochemical staining was performed 10 days after surgery to detect CD31 and vascular endothelial growth factor (VEGF). Immunofluorescence staining confirmed the expression of DKK2 in the DKK2 group. The flap survival rate was higher in the DKK2 group (80.0 ± 4.49%) than in the control group (57.5 ± 4.21%; P < 0.05). Blood flow to the most distal compartment was higher in the DKK2 group than the control group during the early postoperative period. Although vascular density was greater in the DKK2 group, there was no difference in the VEGF concentration between groups. The findings of the present study suggest that the DKK2-expressing adenovirus increases the survival of the random-pattern cutaneous flap independently of VEGF. The administration of the DKK2-expressing adenovirus into elevated skin flaps increased the number of capillaries and blood flow, thereby improving skin flap survival.

Rhomboid Flap Reconstruction after Mastectomy for Locally Advanced Breast Cancer.

In patients undergoing mastectomy for locally advanced breast cancer (LABC), surgical skin flap reconstruction is sometimes required in order to cover large skin defects. This study assessed the efficacy of local, cutaneous (rhomboid) flap reconstruction after mastectomy by comparing data from patients with LABC requiring local flap reconstruction after mastectomy and those that underwent mastectomy alone. Data from 68 patients with LABC who underwent mastectomy were reviewed retrospectively; 14 underwent local (rhomboid) flap reconstruction after mastectomy (local flap group) and 54 underwent direct closure after mastectomy (direct closure group). A pinch test was performed to determine the closure method. Data on the operation, postoperative complications, and postoperative quality of life (QOL) were compared between groups. It was possible to close defects in the local flap group that were significantly larger than those in the direct closure group (p=0.0002). There was no significant difference in postoperative complications between groups. Although operative duration was significantly longer in the local flap group than in the direct closure group (p=0.016), the average difference was only 25 minutes. There was no significant difference in variables related to postoperative QOL. Rhomboid flap reconstruction was effective for covering large defects after mastectomy in patients with LABC.

“Closing the Gap” in Rural Greece: Foot Ulcer Reconstruction in an Octogenerian. Case Presentation with Literature Review

Foot ulcers of mixed aetiology are frequent in the elderly population. The majority of lower limb ulcerations are related to vascular disease. Diabetic foot ulcers constitute an outstanding paradigm of the coexistence of neurotrophic and vascular pathology. In this article, we present the case of an 89-year-old patient from a rural area of Greece. After total onychectomy for a subungual abscess of the hallux of the left lower limb, an ulcer developed on the tip of the hallux that prevented the nail from further growing. After surgical debridement of the ulcer, partial closure was achieved with a cutaneous advancement flap from the plantar surface of the distal phalanx. Strict adherence to simple but basic surgical principles is essential in dealing with minor surgical problems of daily practice in patients residing in rural areas of the country.

PROTECTIVE EFFECT OF LOW LEVEL LASER THERAPY ON DORSAL SKIN FLAPS SURVIVAL: RELEVANCE TO CYTOKINES SECRETION.

The loss of skin flaps (SF) due to tissue necrosis can be catastrophic, even with mortality, especially when there is exposure of large vessels or noble structures. This outcome occurs between 2 to 20% of the procedures performed. There is no currently adjuvant treatment that improves the survival of cutaneous flaps, without side effects or significant risks. Recent studies have sought to prove the efficiency of photobiomodulation (PBM) by means of Low Level Laser Therapy (LLLT) and present promising results for increased SF survival.OBJECTIVETo evaluate the effect of LLLT in dorsal skin flaps of mice in terms of tissue necrosis extent as well as biochemical analysis of pro and anti‐inflammatory cytokines.METHODSForty‐eighth Balb/C (20–25 g) male mice were randomly distributed into two groups with twenty‐four animals each; (1) control group that was not submitted to laser irradiation and (2) experimental group that was submitted to laser irradiation on the flap pedicle with a 660 nm wavelength, exposure radiant of 2.25 J/cm2 for a total time of 20 s/point. The treatment started immediately after performing the cranial base random skin flap (3× 1 cm dimension). The animals were euthanized after the evaluation of the percentage of necrosis area, blood and skin tissue was collected for analysis of cytokines and histology on 4th, 7th and 10th postoperative days. Results demonstrated that LLLT irradiation reduced the area of necrosis, significantly decreased IL‐1, IL‐6 and TNF‐α and increased IL‐10 cytokines compared to the non‐irradiated control group. In conclusion, LLLT may improve the healing of skin flaps by decreasing pro‐inflammatory cytokines and increasing the anti‐inflammatory IL‐10.Serum Interleukines after low level laser therapy (gray) versus control group (black). Significant decrease in pro‐inflamatories interleukines 1, 6 and tumor necrosis factor alfa and significant increase in anti‐inflamatory interleukin 10 after 4, 7 and 10 days post‐op.Figure 1

Alternative Methods to Local Flap Applications in Large Tissue Losses Caused by Gunshot Injuries in the Syrian War.

In gunshot injury (GSI), the distance, ballistic properties, and the site of injury of lead or scattering gain importance. The authors investigated alternative methods to local flap applications in large tissue losses on facial regions caused by GSI in the Syrian War at the light of our approaches and outcomes. The study was designed as a cross-sectional retrospective clinical cohort analyze. The authors analyzed data describing the distribution and comparisons of 187 Syrian patients who injured in the war due to GSI and transferred to our medical center from Jan 2011 and June 2018. The study included data of the patients with demographics, mechanisms of a war injury, clinical data, treatment, and outcomes. 131(70%) of all the patients were soldiers, while the rest 56 was civilians. 58% (n = 108) of the GSI was female while remaining was males (42%; n = 79). The rate for children was 32% in all the patients as the most common soft tissues of the face were around the maxilla-zygoma (38.4%), orbita-nose region (29.3%), mandibula-teeth (18.5%). The authors performed a fascio cutaneous transposition flap that was planned from the cervical region (58%), interpolation flap that was planned from the frontotemporal region (28%), and forehead rotation flap (14%). The authors did not lose any patients due to plastic reconstruction. The fasciocutaneous transposition flap, interpolation flap, and forehead rotation flap that The authors apply to these patients are extremely rare flaps today. These flap applications have achieved tremendous outcomes, even without any sign of necrosis in war surgery.

Study of the Effect of Hyperbaric Oxygen Therapy on the Viability of Dorsal Cutaneous Flaps in Tobacco-Exposed Rats.

Smoking causes a threefold increase in the risk of surgical complications in flaps. Hyperbaric oxygen therapy (HBOT) increases the viability of chronic wounds. However, there are few studies concerning the effects of HBOT on surgical flaps in patients who smoke. This study aimed to analyze the effect of HBOT on the viability of cutaneous flaps in tobacco-exposed rats. Twenty Wistar rats were exposed to tobacco smoke for two months. Following this period, all animals underwent a dorsal cutaneous flap (3 × 10cm) surgery and were divided into two groups: control (n = 10) and HBOT (n = 10). HBOT was performed in seven daily sessions (2 ATA, 90min). After seven days, the animals were euthanized. The outcomes were total area, viable area, viable area/total area rate, analysis of dermal appendages and angiogenesis (hematoxylin-eosin), and gene expression analysis of iNOS and VEGF-a biomarkers. The HBOT group showed an increase in viable area compared with the control group (84% versus 47%, p = 0.009, respectively). The HBOT group also showed an increase in appendage units (1.69 ± 0.54 versus 1.87 ± 0.58, p = 0.04) and angiogenesis density (1.29 ± 0.45 versus 1.82 ± 0.64, p < 0.001) compared to the control group. There was a difference between the control and HBOT groups in iNOS levels (0.926 ± 1.4 versus 0.04 ± 0.1 p = 0.002, respectively). However, this study did not show a difference between the groups concerning the gene expression of VEGF-a. The use of hyperbaric oxygen therapy increased the viability of cutaneous flaps in tobacco-exposed rats and decreased iNOS mRNA levels; however, it did not change VEGF-a levels. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

One-year follow-up after urethroplasty, with the focus on both lower urinary tract and erectile function

Background: Urethral stricture disease (USD) represents a complex urological problem. Urethroplasty is considered the gold standard for the treatment of USD. Most available studies report outcome data obtained from retrograde urethrography and uroflowmetry. Only a limited number of papers describe the effect of urethroplasty on erectile function and their results are inconsistent. The goal of this prospective study was to evaluate the effect of urethroplasty on both lower urinary tract and erectile function using objective parameters and standardized patient-reported outcome measurement tools.Materials and Methods: A total of 55 consecutive patients with USD were enrolled into the study. Patients underwent ventral onlay urethroplasty, urethroplasty according to the Asopa technique, dorsal onlay urethroplasty, cutaneous flap urethroplasty using the Orandi technique or anastomotic repair. All patients were evaluated using uroflowmetry, urethrography, the PROM-USS questionnaire and the International Index of Erectile Function-5 questionnaire (IIEF-5) pre-operatively and consequently post-op, in 3-month intervals. This study presents the comparison of baseline pre-op parameters and parameters 12 months after the surgery using the Wilcoxon signed rank test, Wilcoxon rank sum test and the Kruskal-Wallis one-way analysis of variance.Results: A significant improvement in uroflowmetry parameters, all domains of the PROM-USS questionnaire, as well as the overall score of the IIEF-5 was observed. No statistically significant differences between sub-groups were found when comparing treatment results in patients with short versus long strictures and patients with penile urethra stricture versus bulbar or membranous urethra stricture.Conclusions: Urethroplasty yielded very good functional results with respect to both lower urinary tract and erectile functions.

Application of free anterolateral thigh tissue flap in repairation of tissue defects in total or near-total glossectomy

Objective To evaluate the functional outcomes of the flaps repaired with free anterolateral thigh tissue flap in patients who had total or near-total glossectomy. Methods From March, 2015 to May, 2018, 15 patients with tongue cancer were treated by total or near total tongue resection. The free anterolateral thigh tissue flaps were used to repair the defects of tongues after radical tumor resection. The size of 15 flaps were 6 cm×10 cm to 8 cm×15 cm. Patient data were retrospectively analyzed. Patients were requested to conduct the postoperative reviews. Results All 15 flaps survived, while 1 occurred vascular crisis which was survived after the exploration and corresponding treatment. As the results of 12 to 48 (average 30) months followed-up by clinic visits, the mouth and chewing function recovered well after 6 months, while the swallowing and pronouncing function were poor. The motion of thigh donor area was good, without numbness, pain and discomfort. Conclusion The defect being left after total or near-total tongue resection is repaired and reconstructed with anterior lateral cutaneous tissue flap, which is able to partially restore the functions and shape of the tongue. Key words: Tongue cancer; Anteriolateral thigh tissue flap; Reconstruction; Microsurgical technique

Abstract P1-20-16: Immediate implant-based breast reconstruction using a titanium-coated polypropylene mesh (TiLOOP Bra): Complication rates and risk factors in a single-institution experience

Abstract Background: Immediate implant reconstruction after a skin sparing or a nipple sparing mastectomy is an attractive option made easier by the use of mesh to cover the lower implant pole. Acellular dermal matrices (ADM) have been widely used and described in the literature. A titanium-coated polypropylene mesh (TCPM) is an alternative to ADM but only few clinical data have been published. Methods: 209 patients who underwent single or bilateral immediate implant breast reconstruction after conservative mastectomies using TCPM were retrospectively evaluated accounting for 260 procedures. We analyzed short-term outcomes and surgical complications. Univariate and multivariable logistic regression analyses were performed to evaluate the predictive character of patients and procedure-related characteristics on postoperative complications. Major complications were defined as implant loss and implant replacement by an expander. Results: Among 260 mastectomies, 170 were skin-sparing mastectomies, 66 nipple-sparing mastectomies and 24 skin-reducing mastectomies with an inferior deepithelialized dermal flap associated with TCPM. The median age was 52.5 years (range: 25-84), 26.3% of patients were smokers and 21.3% had previously received radiotherapy. The overall complication rate was 34.6% and major complications occurred in 8.9% of cases. Implant infection occurred in 8.8%, delayed wound healing in 20.8% and skin or nipple areola complex necrosis in 2.7% of cases. In univariate analyses, smoking, a high breast weight and implant infection occurrences were associated with major complications. Risk factors for implant infection were high body mass index (BMI), smoking, a high breast and implant weight and long drainage duration. Risk factors for delayed wound healing were smoking, a high breast and implant weight and skin reducing mastectomies. Cutaneous abdominal flap was reported as a protective factor for delayed wound healing and implant infection probably allowed by a tension-free closure. In multivariable analysis, smoking and a high breast weight were independently correlated with postoperative complication occurrence. Major complications were associated with smoking and implant infection while an inferior deepithelialized dermal flap associated with TCPM was reported as a protective factor. Conclusion: Titanium-coated polypropylene mesh (TCPM) in immediate breast reconstruction reported acceptable complication rates. Cutaneous abdominal flap and an inferior deepithelialized dermal flap associated with TCPM may help reducing the complication rate particularly when complication risk factors are present. Tension-free closure and careful handle of the cutaneous flap during mastectomy could help reducing the complication rate. Citation Format: Laure Delmond, Flavie Sire, Simon Thezenas, Philippe Rouanet, Pierre-Emmanuel Colombo, Anne Mourregot, Marian Gutowski. Immediate implant-based breast reconstruction using a titanium-coated polypropylene mesh (TiLOOP Bra): Complication rates and risk factors in a single-institution experience [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-16.

Inferiorly Based Preauricular Flap for Anterior Ear Reconstruction.

The anterior aspect of the auricle is a complex 3-dimensional structure. Each anatomical component in this region has an essential role in the aesthetic appearance of the ear and face. The reconstruction of defects in this region is challenging because of the lack of mobile, excess skin for primary closure, and the inability to skin graft overexposed cartilage. The aim of the study was to present the planning and surgical technique of a simple, reproducible, 1-stage flap, for the reconstruction of the anterior aspect of the auricle. A series of 11 patients, who underwent reconstruction of the anterior aspect of the auricle with 1-stage, inferiorly based, preauricular, cutaneous flap. All reconstructions were conducted under local anesthesia, and the defects were mainly due to tumor resections or skin necrosis after otoplasty. The average defect size was 1.5 cm. The flap was applied to different sites of the anterior auricle. All flaps survived except one, where there was partial flap loss. The aesthetic results were excellent, with no auricular deformity. The inferiorly based, preauricular flap is a versatile flap for a safe, simple, and reproducible, 1-stage reconstruction for almost every region of anterior ear defect, with excellent aesthetic results.

Surgical Sphincter Saving Approach and Topical Nifedipine for Chronic Anal Fissure with Hypertonic Internal Anal Sphincter.

The role of augmented internal anal sphincter (IAS) tone in the genesis of posterior chronic anal fissure (CAPF) is still unknown. Lateral internal sphincterotomy is the most employed surgical procedure, nevertheless it is burdened by high risk post-operative anal incontinence. The aim of our study is to evaluate results of sphincter saving procedure with post-operative pharmacological sphincterotomy for patients affected by CAPF with IAS hypertonia. Methods: We enrolled 30 patients, undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement; all patients received topical administration of nifedipine 0.3% and lidocaine 1.5% ointment-based therapy before and for 15 days after surgery. The primary goal was patient's complete healing and the evaluation of incontinence and recurrence rate; the secondary goal included the evaluation of manometry parameters, symptom relief and complications related to nifedipine and lidocaine administration. Results: All wounds healed within 40 days after surgery. We didn't observe any de novo postoperative anal incontinence case. We reported 2 cases of recurrences, healed after conservative therapy. We didn't report any local complications related to the administration of the ointment therapy; with whom all patients reported a good compliance. Conclusions: Fissurectomy and anoplasty with V-Y cutaneous advancement flap and topical administration of nifedipine and lidocaine, is an effective treatment for CAPF with IAS hypertonia.

Reconceiving the closed approach in unilateral cleft lip rhinoplasty: An objective evaluation of 64 consecutive cases

Introduction: The cleft lip nose has been the classical case of an unsolved mystery in the history of plastic surgery. As Kernahan aptly stated, “a repaired cleft is revealed more by the associated nasal deformity than by the repair line.” Cleft lip nasal deformity becomes a surgical challenge due to various reasons: 1. Wide variation in clinical presentation, requiring a host of surgical techniques. 2. Deformity may be quite asymmetric, making correction difficult. 3. Patients might have undergone several previous operations, which lead to scarring. Aim: We aim to assess the surgical outcome of the closed approach of unilateral cleft lip nose deformity correction. Methodology: We perform the cleft lip nose correction with the primary cleft repair as well as a secondary rhinoplasty in preschool age group and adults depending on the esthetic concerns. Our approach is the closed (endonasal) rhinoplasty technique to dissect the slumped alar cartilage of its soft-tissue attachments and cutaneous skin flap and reshape and reposition it with the help of sutures inserted percutaneously. Results: We have evaluated our results by comparing the pre- and post-operative photographs in standard views and represented the correction of several esthetic nasal parameters with a simple numerical rating. We have compiled the overall result by taking into account the collective numerical ratings at 6 months of follow-up. Our results of primary rhinoplasty ranked in the “good” or “excellent” category in 85% of the cases while it was “fair” or “good” in 82% of the secondary rhinoplasties. Conclusion: We conclude that the closed rhinoplasty is less invasive, takes less surgical time, avoids tedious dissection, gives better on table predictability of the outcome, and shortens postoperative recovery and tissue healing, providing a stable and acceptable result.

Phalloplasty: understanding the chaos

Wide variation in overall strategies and surgical specifics for masculinizing genital surgery has created a “phalloplasty chaos” that is confusing to both surgeons and patients seeking gender confirming surgery. The purpose of this article is to review masculinizing genital confirming surgery, or “phalloplasty”, focusing on specific goals and categorizing each component of the surgical process. Experienced surgeons from several high-volume centers review and categorize the commonly employed strategies and techniques for gender confirming phalloplasty, including the permutations of approaches to cutaneous flap for phallic construction, the sequence and staging of procedures, and strategies for urethral construction. There is no clear advantage or reduction in complications associated with particular sequences of urethral and phallic reconstruction. Because no single technique or staging strategy has proven superior for gender confirming genital surgery, it is paramount that surgeons are knowledgeable of all available options and the associated advantages, disadvantages, and risks.

Reconstruction of composite leg defects post-war injury.

In a high conflict region, war injuries to the distal lower extremity are a major source of large composite defects involving bone and soft tissues. These defects are at the edge between using a single free flap [osteo-(+/-myo) cutaneous] vs double free flap reconstruction (bone and soft tissue). In this paper, we present our experience and outcomes in treating patients with leg war injury reconstructed using a single free fibula flap. Fifteen patients with distal leg composite defects secondary to war injuries were treated between January 2015 and March 2016. All patients were reconstructed using single barrel free fibula osteo-(+/-myo)cutaneous flap where single or double skin paddles were used according to the soft tissue defect requiring coverage. There were no cases of total or partial flap loss. Complications were limited to three cases including traumatic fibula fracture, venous congestion with negative findings, and residual soft tissue defect requiring coverage. There were no cases of wound dehiscence or infection. Mean follow-up time was 418.8 days. Mean bone healing time was nine months after which patients were allowed full weight bearing. A single barrel free fibula osteo-(+/-myo)cutaneous flap is a valid and reliable tool for reconstruction composite lower extremity defects post-war injury. Adequate planning of fibula flap soft tissue components (skin, muscle) rearrangement is essential for success in such challenging reconstructions.

Use of the transverse branch of the superficial circumflex iliac artery as a landmark facilitating identification and dissection of the deep branch of the superficial circumflex iliac artery for free flap pedicle: Anatomical study and clinical applications.

The deep branch of the superficial circumflex iliac artery (SCIA) should be included when a large superficial circumflex iliac artery perforator (SCIP) flap is necessary, or when anatomical structures perfused by the deep branch are procured. The aim of this study was first to describe the anatomical features of the "transverse branch" of the deep branch of the SCIA in cadavers, and then to assess the efficacy of its use as a landmark for identification and dissection of the deep branch of the SCIA through clinical applications. Twenty groin regions from 10 cadavers were dissected. The course and the takeoff point of the transverse branch were documented. With the transverse branch used as a landmark for pedicle dissection, 27 patients (16 males and 11 females) with an average age of 51.7 years underwent reconstructions that used vascularized structures nourished by the deep branch of the SCIA. Aside from the skin paddle, an iliac bone flap was used in 10 cases, a lateral femoral cutaneous nerve flap in four cases, and a sartorius muscle flap in three cases. The defect locations included the head (seven cases), the foot (six cases), the hand (six cases), the arm (five cases), and the leg (three cases). The causes of reconstruction were tumors in 13 patients, trauma in six patients, infection in four patients, surgical procedures in three patients, and refractory ulcer in one patient. In all specimens, the transverse branch was found underneath the deep fascia caudal to the anterior superior iliac spine (ASIS). The average distance from the ASIS to the transverse branch was 25.5 ± 13.0 mm (range, 5-50 mm). The average dimension of the flap was 13.1 × 5.9 cm2 . All the flaps survived completely after the surgery; lymphorrhea was seen in one patient at the donor site. The average follow-up period was 12.9 months (range, from 2 to 42 months), and all patients had good functional recovery with satisfactory esthetic results. The transverse branch was found in all specimens, branching from the deep branch of the SCIA. Successful results were achieved by using it as the landmark for identification and dissection of the deep branch of the SCIA. This method allows safe elevation of a large SCIP flap or a chimeric SCIP flap.

The composite extensor retinaculum cutaneous flap: an anatomical cadaveric study

Background: Complex digital extensor tendon injuries are difficult to manage when adhesion formation and stiffness prevail. Vascularised tissue to reconstruct the skin and extensor defect would be the ideal reconstruction in both the acute and delayed settings. This anatomical study evaluates vascular supply to a suitable composite flap comprising skin, subcutaneous tissue and extensor retinaculum.Methods: An anatomical study of 18 cadaveric upper limbs was conducted to investigate the technical feasibility of a composite flap prior to its clinical application. The anterior (n = 9) or posterior (n = 9) interosseous artery was exposed and selectively injected with a coloured dye. Specimens were then dissected to raise the proposed composite flap of extensor retinaculum and the overlying integument. Specimens were subsequently assessed by digital subtraction angiography to evaluate the corresponding microvascular supply to the composite flap. Results: The anterior and posterior interosseous arteries supplied the extensor retinaculum through a dense network of vessels with choke anastomoses. The skin overlying the extensor retinaculum was predictably supplied by either artery through the perforator vessels between the fourth and fifth extensor tendon compartments.Conclusion: A composite unit of skin and extensor retinaculum can be harvested on either the anterior or posterior interosseous arteries. It can be employed for simultaneous vascularised tendon and skin reconstruction.

Acquired Full-Thickness Nasal Ala Defects: General Principles and Reconstruction Options

The article presents the data of scholarly publications on the general principles and organizational solutions for nasal ala reconstruction of full-thickness defects. The reconstruction of the full-thickness nasal ala defect includes restoration of the external skin and internal covering epithelium, formation of support structures to achieve a stabile shape and position of the alar subunit. With this end in view, plastic material in the form of composite grafts from the auricle is applied, and each tissue layer is formed separately in the region of the defect. The external skin is most often reconstructed with medial cheek cutaneous flaps. The support structures are formed with cartilage autografts. The reconstruction of the internal lining defect is performed with local mucosal or skin flaps, more rarely mucosal or skin grafts. The limiting factors are: risk for ischemic complications, surgical trauma, and secondary surgical correction. The agenda do not only include achievement of acceptable anatomical and functional results but also the quality of perioperative life, shorter time and duration of the surgical intervention and minimum changes in the donor site.

Comparisons of fascio‐cutaneous anterolateral thigh and sandwich fascial ALT free flap in the distal extremity reconstruction

The anterolateral thigh (ALT) flap is considered a workhorse reconstructive option; however, it is encumbered by its bulkiness that can result in poor final outcome and need for revision surgery. The aim of the present study was to compare the standard cutaneous ALT free flap and sandwich fascial ALT (SALT) free flap, raised harvesting between the Scarpa's fascia and the crural fascia, for distal extremity soft tissue reconstruction, including pre- intra- and post-operative considerations and outcomes. A retrospective review of medical records from 2013 to 2018 of 24 patients who underwent distal extremity reconstruction with standard fascio-cutaneous ALT flap (13 patients) and SALT flap (11 patients) was performed. The mean defect dimensions were 12 × 6.5 cm in group 1 and 12 × 6 in group 2. Surgical outcomes and quality of life were assessed (through the upper extremity functional scale and the lower extremity functional scale questionnaires. The mean flap dimensions were 13.1 × 7.1 in group 1 and 14.1 × 7.8 in group 2, the overall flap success rate was 100% (one microvascular venous thrombosis occurred in group 1), no statistically significant difference was recorded regarding microvascular thrombosis (one patient in group p = .369) and infections (one patient in group 1, p = .36) while a statistically significant difference was presence regarding the number of secondary/debulking procedures (6 patients vs. 0) (p = .0076) and the quality of life perception showed an overall better perception in group 2 with statistical significant difference (p = .03). The SALT flap represents a valid option, as showed through our preliminary data, when a thin and robust reconstruction is required when dealing with distal extremities soft tissue reconstruction.

Anatomical study of the perforator flap based on the acromial branch of the thoraco-acromial artery (abTAA flap): a cadaveric study.

The aim of this anatomical study was to describe a local perforator flap, for covering shoulder defects, by determining the features of the acromial branch of the thoraco-acromial artery (abTAA), and the supplied cutaneous area. Thirteen fresh cadaveric thoraxes were dissected bilaterally. A precise and reproducible protocol was performed. For each abTAA flap cadaveric dissection, the following parameters were measured after arterial injection: distances between the origin of the perforator artery on the abTAA and the sternum, the acromion, the clavicle, diameter of the perforator artery of the abTAA, length of the perforator pedicle course through major pectoralis muscle, and rotation arc. We also calculated the surface of the injected skin paddle. These measurements were related to morphometric parameters evaluated through the distance between sternum and acromion. The mean distances measured from the origin of the perforator artery on the abTAA were 14.25cm to the sternum, 3.45cm to the acromion, 5.65cm to the clavicle. The mean diameter of the abTAA was 1.20mm ± 0.2. The arc of rotation was 180°, and the length of the perforator pedicle could be extended to 7.46cm ± 1.15. We observed an colored elliptical cutaneous paddle with a longer radius 18cm and a small radius 15cm. Our results suggest that this type of flap could be useful in clinical practice for reconstruction and covering of the acromial area with a thin cutaneous flap with low sequelae on the donor site.

Two-staged reverse sural flap: a versatile flap with consistent results in the soft tissue reconstruction of distal leg and heel defects—an institutional experience

Reverse sural flap (RSF) is commonly used for soft tissue reconstruction of distal leg and heel defects. The classic method of flap transfer is the single-staged cutaneous islanded reverse sural flap (SS-RSF). This method is associated with variable flap complications notably the venous congestion. The other form of flap transfer is the two-stage reverse sural flap (TS-RSF), in which the pedicle of the flap is exteriorized in the first stage. Flap division and re-inset are done in the second stage. The aim of this paper is to review the flap outcomes and complications among the SS-RSF and TS-RSF reconstruction of soft tissue defects in the distal leg and heel. This is a retrospective chart review of RSF being operated in a tertiary care hospital. The duration of study was 1.5years. Twelve RSFs (6 SS-RSF, 6 TS-RSF) were done for soft tissue defects in the distal leg and heel. Wounds of various etiologies (traumatic, chronic, non-healing ulcers) were reviewed. Trauma was the most common etiology with 8 out of 12 (66.7%) patients. Large wounds, donor site damage and patients with peripheral vascular disease were excluded from the study. Five out of six (83.3%) of TS-RSF healed uneventfully. However, 3 out of 6 (50%) of SS-RSF had partial flap necrosis. All complicated flaps healed well subsequently. No donor site complication was found in any of our patients. Pedicle exteriorization in TS-RSF eliminates the element of venous congestion and eventually flaps necrosis. Less technical expertise and minimal morbidity are additional advantages of TS-RSF. Level IV, therapeutic study.