Decreased Donor Site Morbidity Research Articles

Forehead Flap - A Salvage Option for Failed Anterolateral Thigh Flap in Buccal Mucosa Carcinoma Reconstruction

Introduction: Pedicled lateral forehead flap could be a valuable option for reconstruction in the floor of the orbit and floor of the mouth in the absence of other resources available. Case presentation: A-57-year-old male with multiple comorbidities, underwent partial maxillectomy, hemi mandibulectomy and hemiglossectomy with infratemporal fossa clearance due to a rapidly spreading buccal mucosa carcinoma on the left side. The last resort was the pedicled lateral forehead flap after unsuccessful reconstructive attempts with an anterolateral thigh flap. Discussion: The pedicled forehead flap which has rich vascularity, decreased donor site morbidity and reliable anatomy made it a favorable locoregional flap for oral reconstruction. Conclusion: Flaps should be chosen considering the patient’s condition and resources available. Forehead flap due to its proximity is an ideal option for reconstruction of oral cavity defects.

Forehead Flap - A Salvage Option for Failed Anterolateral Thigh Flap in Buccal Mucosa Carcinoma Reconstruction

Introduction: Pedicled lateral forehead flap could be a valuable option for reconstruction in the floor of the orbit and floor of the mouth in the absence of other resources available. Case presentation: A-57-year-old male with multiple comorbidities, underwent partial maxillectomy, hemi mandibulectomy and hemiglossectomy with infratemporal fossa clearance due to a rapidly spreading buccal mucosa carcinoma on the left side. The last resort was the pedicled lateral forehead flap after unsuccessful reconstructive attempts with an anterolateral thigh flap. Discussion: The pedicled forehead flap which has rich vascularity, decreased donor site morbidity and reliable anatomy made it a favorable locoregional flap for oral reconstruction. Conclusion: Flaps should be chosen considering the patient’s condition and resources available. Forehead flap due to its proximity is an ideal option for reconstruction of oral cavity defects.

Revisiting Scalp Tissue Expander In Indonesia: Restoration Of Cicatricial Alopecia

Background: Scalp alopecia from burn injuries significantly impacts physical appearance and psychological well-being, often leading to social phobia. Tissue expanders have been effective in reconstructive surgeries, offering advantages in restoring hair-bearing scalp areas with excellent color and texture match. However, comprehensive algorithms for their use, particularly in Indonesia, are lacking. Case Presentation: A 10-year-old girl with cicatricial alopecia on the right lateral, frontal, and vertex of the scalp from a burn injury sought reconstructive surgery due to teasing from peers. A 400 mL round silicone expander was implanted and gradually expanded over five weeks. Reconstruction surgery advanced the expanded flap towards the frontal area, improving her hairline. Despite minor necrosis at the flap’s distal margin, which healed by secondary intention, the outcome was favorable. Discussion: This case demonstrates the effectiveness of tissue expanders in scalp reconstruction. Benefits include improved cosmetic outcomes and decreased donor site morbidity, though complications such as infection and alopecia in the expanded tissue require careful management. The underutilization of tissue expanders in Indonesia may be due to lack of insurance coverage and limited local availability. Conclusion: Scalp tissue expansion is a beneficial technique for reconstructing scalp defects, especially in burn-induced alopecia. Wider adoption in regions with limited advanced modalities could significantly benefit patients.

For Your Consideration: Bridge Enhanced ACL Restoration (BEAR): Why, How, and When

Reconstruction of the anterior cruciate ligament (ACL) has been the gold standard for complete rupture for nearly 40 years. During this journey, variations on technique, rehab, and graft selection have been points of discussion. With the explosion of biologic augments currently seen in orthopedics, a paradigm shift of reconstruction to potential repair and/or restoration has begun. The bridge enhanced ACL restoration (BEAR) procedure provides the ability to perform primary repair of the acutely torn ACL’s via utilization of a proprietary protein based scaffold. Many promising benefits have been shown from early clinical data, including potentially decreasing risk of osteoarthritis, decreased donor site morbidity, and higher success rates in the subset of patients that fail ACL restoration verses those that fail ACL reconstruction. Nevertheless, restoration has potential drawbacks and requires proper patient identification. As the implant has moved from research to commercialization, many questions still exist regarding why, how, and when to use the BEAR implant for injured patients. This manuscript aims to provide a broad overview of these questions and provide clarity based upon initial experiences.

Bone filling decreases donor site morbidity after anterior cruciate ligament reconstruction with bone-patellar tendon-bone autografts.

Bone-patellar tendon-bone (BTB) autograft remains the most widely used graft source for anterior cruciate ligament reconstruction (ACLR). The drawback associated with BTB is increased donor-site morbidity, such as anterior knee pain. The purpose of this study was to evaluate and compare anterior knee pain after refilling the patella bony defect with bone substitute. This is a retrospective analysis of consecutive patients who underwent BTB ACLR at a single institution between January 2015 and December 2020. The cohort was divided into two groups; one in which the patellar bony defect was refilled with bone substitute (Bone Graft group) and another in which this the bony defects were not treated (No Bone Graft group). Demographic variables, reported anterior knee pain, visual analog scale (VAS) score, complications, re-operation, and patient reported outcome measures, such as the IKDC, LYSHOLM and SF-12 scores, were compared between groups. A total of 286 patients who underwent BTB ACLR were included. The No Bone Graft group included 88 (30.7%) patients and the Bone Graft group included 198 (69.3%) patients. The Bone Graft group had less anterior knee pain at last clinic follow up (33.3% vs. 51.1% p = 0.004) as well as lower VAS anterior knee pain scores (2.18 vs. 3.13, p = 0.004). The Bone Graft group had lower complications rates (21.7% vs 34.1, p = 0.027). No differences were found in the LYSHOLM, IKDC, and SF-12 scores. Bone refilling in BTB ACLR significantly reduces prevalence and severity of anterior knee pain. Larger randomized trials are needed to confirm the benefits of bone refilling in ACLR patients. Retrospective study-III.

Analysis of 461 Consecutive Patients' Donor Site Morbidity following Abdominal Tissue-Based Breast Reconstruction without Fascia Reinforcement Graft.

Despite the popularity of breast reconstruction with abdominal flap, the integrity of the abdominal wall gets compromised after the operation. To decrease donor site morbidity, researchers have developed various inlay or onlay graft materials. However, the indications of use are unclear and dependent on the subjective decision of the surgeons. In this study, we have investigated donor site morbidities in breast reconstruction with free abdominal flap surgery in which graft materials were not used. We reviewed 461 consecutive cases for the preoperative characteristics of patients, intraoperative details, and postoperative donor site complications from May 2013 to March 2019. While 386 patients underwent deep inferior epigastric perforators (83.7%), muscle sparing type 2 transverse rectus abdominis musculocutaneous flaps were performed in 75 patients (16.3%). Bilateral dissection of the pedicle was performed in 162 patients, compared to unilateral dissection in 299 patients. The mean follow-up duration was 22.7 months. The overall complication rate in the donor site was 7.2%. The flap height was significantly associated with the overall complication. While majority of them were delayed wound healing (n = 28, 6.1%), there were four cases of hematoma (0.9%). There were two cases of bulging (0.4%), which occurred in patients receiving bipedicle dissection; however, there was no case of hernia. Conclusions. Breast reconstruction with an abdominal free flap can be safely performed without fascia reinforcement graft even with bilateral dissection of the pedicle. With complete preservation of fascia and zigzag fascial incision, a low incidence of abdominal bulging can be obtained even with bilateral harvesting of the flap.

137 Maximal Harvest Density of Full-Thickness Skin Columns in Skin Replacement Therapy

Abstract Introduction Split-thickness skin grafts (STSGs) are the mainstay of skin replacement therapy but fail to adequately reproduce basic skin functions and subject patients to new, open wounds that can cause significant pain and scarring. Full-thickness skin grafts (FTSGs) have improved cosmetic outcomes and better recapitulate skin functions, but few sites can serve as donors and requirement for “take” is greater. Prior research has shown that full-thickness skin column (FTSC) harvest results in improved healing of the injured site and decreased morbidity of the donor site at 10% harvest density. This study aims to determine the maximal harvest density of FTSC donor sites. Methods Ten donor sites were created on the dorsum of anesthetized swine (Sus scrofa domestica). STSG donor sites were harvested with a dermatome (12/1000 inch) and compared to FTSC donor sites with the highest possible harvest ratio of sixteen 1.5mm-diameter skin columns/1cm2 (28% harvest density). Donor site morbidity was assessed via re-epithelialization, contraction, pigmentation, number of hair follicles, and scar thickness on post-burn day (PBD) 7, 14, 21, 28, 60, and 90. Results There were no significant differences in re-epithelialization or contraction between FTSC and STSG donor sites. STSG donor site pigmentation was significantly decreased as compared to control on all assessment days (p=0.0161, 0.0003, 0.0031, 0.0095, 0.0244, respectively), and remained significantly hypopigmented as compared to FTSC starting at PBD 14 (p< 0.0001). Pigmentation was decreased for FTSC donor sites at PBD 14 (p=0.0204) but significance was lost by PBD 21. Both FTSC and STSG donor sites showed significantly fewer hair follicles as compared to control at PBD 7 (p=0.0011, 0.0003, respectively). On PBD 21, STSG had significantly less hair follicles as compared to FTSC donor sites (p=0.0010). This resolved by PBD 28. FTSC scars were significantly thicker than both control and STSG at PBD 28 (p=0.0348, 0.0038, respectively) and PBD 60 (p=0.0174, 0.0329, respectively). This significance was lost by PBD 90. Conclusions No statistically significant differences were seen in re-epithelialization and contraction between FTSC and STSG donor sites. STSG were hypopigmented as compared to FTSC donor sites and had significantly less hair follicles at day 21. FTSC donor site scars were significantly thicker than STSG. Although decreased donor site morbidity has been observed at lower harvest densities (10%), these results were not seen at 28%, which likely exceeds the optimal harvest density.

Minimally Invasive Quad Harvest Featuring Endoscopic Closure and Preparation With Adjustable Suspensory Fixation Device Incorporated With Braided Suture

The quad tendon has increasingly became a very common option for anterior cruciate ligament reconstruction. Minimally invasive approaches are one of the many advantages to the quad tendon graft. One of the issues with a small incision is assuring appropriate proximal closure. In this technique, we use the arthroscope to view proximally and a Scorpion (Arthrex) device to close our proximal quad harvest. We also describe the updated preparation of the quad tendon with FiberTag TightRope (Arthrex) and FiberTag ABS (Arthrex). These implants have FiberTag incorporated to the suspensory devices that creates a stable construct that is faster to incorporate into the quad with the slotted clamp. Together, these updates to the preparation and harvest should make the construct more reproducible and decrease donor-site morbidity respectively.

Determining clinically meaningful thresholds for innovative burn care products to reduce autograft: A US burn surgeon Delphi panel

Reducing the amount of donor skin needed for definitive wound closure can improve outcomes in patients with severe burns. This Delphi Consensus Panel (DCP) aimed to achieve expert consensus on the percentage reduction in donor skin for autograft that constitutes a clinically meaningful benefit. A two-round DCP of fifteen US burn surgeons was conducted via a web-based survey platform. Fourteen panelists (93.3%) completed both rounds. In Round 2, consensus, defined as ≥70% agreement, was achieved for five of the seven consensus statements. All panelists agreed that a clinically meaningful reduction in the amount of donor skin required would facilitate wound management and decrease donor site morbidity experienced by patients. Furthermore, based on three treatment scenarios, consensus was achieved for a clinically meaningful reduction in the amount of donor skin required for autograft for the adult population in deep partial-thickness and full-thickness burns. Findings from this DCP indicate that an innovative cellular and/or tissue product that would reduce the needed amount of donor skin, by the identified thresholds, has the potential to improve the outcomes for patients with severe burn injuries in a meaningful way.

Decreasing donor site morbidity after groin vascularized lymph node transfer with lessons learned from a 12-year experience and review of the literature

Donor site morbidity related to vascularized lymph node transfer (VLNT) remains a cause of worry among surgeons. As such, our study explores donor site morbidity after VLNT with or without concomitant deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Furthermore, we evaluate our surgical approach to ascertain whether it reduces the morbidity rate. A retrospective chart review of donor site complications and surgical techniques was performed from 2006 to 2018. The patients' medical histories and demographic data were analyzed for risk factors. Patients were contacted by telephone for a long-term follow-up questionnaire. A literature review was implemented to evaluate the reported donor site complications and surgical strategies in literature. Complications were evaluated with and without concomitant autologous breast reconstruction (DIEP flap). Eighty-nine patients were included in our case series. Sixty-five cases (73%) were combined with DIEP flap breast reconstruction. Seroma rate diminished from 60% in the first 39 cases to 18% in the last five years (50 cases) (p<0,001). Lymphedema of the afferent lower limb is described in the literature but did not occur in our series. Seroma formation is the most common donor site morbidity after groin VLNT flap harvest, particularly when combined with DIEP flap breast reconstruction. This paper contains the largest reported series of combined VLNT + DIEP flaps and describes surgical strategies on how to decrease seroma formation and avoid iatrogenic lymphedema of the lower limb.

Inferior Meatus Mucosal Flap for Septal Reconstruction and Resurfacing After Nasoseptal Flap Harvest.

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Medial Sural Artery Perforator Flap for Leg and Knee Coverage: Extended Skin Paddle With 2 Perforators.

For soft-tissue defect coverage in the lower leg and around the knee joint, the gastrocnemius muscle flap is the most commonly used. Having constant anatomy, a long pedicle, and decreased donor site morbidity, the medial sural artery perforator (MSAP) flap may represent a good reconstructive alternative. The aim of this report was to present the experience of using a dual perforator MSAP pedicled flap. Nineteen patients underwent soft-tissue reconstruction by MSAP flap in the one third of the lower leg and around the knee joint. Eleven patients were injured in traffic accidents. Exposure of a knee prosthesis required flap coverage in 4 cases. The other defect etiologies were a gunshot wound, bone abscess due to a sickle cell anemia, bone exposure due to a full thickness burn, and sarcoma resection. Defect dimensions ranged from 7 × 5 cm to 15 × 8 cm. Seventeen flaps were harvested with 2 perforators. Donor sites were closed primary in 16 of the 19 cases. The sizes of the MSAP flaps ranged from 7 to 22 cm × 5 to 8 cm. The procedure was uneventful in 17 cases. The 2 unsuccessful flaps developed a distal necrosis, for which an excision with direct suture was made secondary. Complete healing was achieved in all cases. The pedicled MSAP flap represents a versatile option in soft-tissue defect coverage of the lower leg and around the knee joint. Inclusion of 2 perforators could render the flap safer and increase its skin paddle, making it suitable for larger defects.

Quadriceps Tendon Autograft in Anterior Cruciate Ligament Reconstruction.

Quadriceps tendon (QT) autograft in anterior cruciate ligament reconstruction has received increased attention, as more studies compare clinical outcomes between QT, bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) autografts. Biomechanically, QT has similar properties to BPTB and to HT. QT has shown equivalent stability, patient-reported outcome measures, strength and graft failure rates, and decreased donor site morbidity compared with BPTB and HT. All three autografts have excellent clinical outcomes. Ultimately, anterior cruciate ligament graft selection should be a discussion between a physician and their patient while considering a patient's age, activity level, and occupation.

Propeller Flaps for Reconstructing Leg and Foot Defects: The Relation between Flap Length and the Incidence of Ischemia

Background: Reconstruction of soft tissue defects in theleg and the foot remains challenging. Anatomical constraintslimit the options available for reconstructing complex defectsespecially lower third of leg. Perforator propeller flaps areraising interest in reconstructive surgery of the limbs. Wepresent our experience with perforator propeller flaps forreconstruction of soft tissue defects in leg and foot with anemphasis on the safe limit of a perforator flap in the lowerlimb.Methods: The study was carried prospectively and 32patients with leg or foot defects treated with various perforatorpropeller flaps (both elective as well as emergency) wereincluded in the study. A hand-held ultrasound Doppler wasused pre-operatively and intraoperatively to detect the perforatorvessels.Results: Out of the 32 cases, we witnessed total flap lossin one and distal necrosis in 6 cases. In 4 of them the flapslengths were more than one third of the limb length. 8 patientshad minor complications which included congestion, infectionor graft loss.Conclusion: Perforator flaps may represent a good alternativeto the free flaps in the areas were other local reconstructiveprocedures are not possible. This is a versatiletechnique and with decreased donor site morbidity limited toa single body area. There is a specific like to like soft tissuereplacement leading to a better cosmetic and reconstructiveoutcome. The main drawback of the perforator flaps howeveris the higher risk of venous congestion. The incidence of distalnecrosis increases with flap length more than one third of thelimb provided other factors affecting flap vitality are constant.

Free Style Perforator Flaps for Aesthetic Facial Reconstruction.

BACKGROUNDFunctional and cosmetic outcomes affect reconstruction of the face more than any region of the body. To use a predetermined perforator flap freely designed allowing a wide range of movement and manipulation can give us an optimum outcome. We present our clinical experience with free style facial perforator flaps, surgical technique, and complications. METHODSThirty patients with post-tumor resection of the face were reconstructed with free style local perforator flaps between January 2014 and November 2016. Doppler was used to identify the perforator vessels preoperatively. RESULTSTwenty-two clinical cases had no complications. Four had venous congestion that resolved spontaneously, three had a distal 1/3 superficial necrosis, and one suffered from hematoma. CONCLUSIONFreestyle perforator flaps were applied to get better cosmetic facial reconstruction, allowing one stage procedure and decreasing donor site morbidity. Modern anatomical understanding, good planning, and meticulous surgical technique can affect clinical results.

Augmented Reality Microsurgical Planning with a Smartphone (ARM-PS): A dissection route map in your pocket

Perioperative microsurgical planning increases the likelihood of successful results. Augmented reality (AR) is the addition of artificial information to allow the user to perform tasks more efficiently. The aim of our study is to report the use of AR for microsurgical planning with a smartphone (ARM-PS) as a dissection route map. AR was used for superficial circumflex iliac artery perforator (SCIP) flap planning. Three-dimensional (3D) reconstruction images of the inguinal and lower abdomen vascular anatomy were obtained by computed tomography angiography. These 3D images were imported to a smartphone and an AR app was used to superimpose them with the camera. The drawings performed with ARM-PS were correlated with handheld Doppler and intraoperative findings. The correlation of ARM-PS drawings with handheld Doppler results was 100% for superficial inferior epigastric artery (SIEA) and superficial and deep branches of SCIP in 60 inguinal areas studied. Intraoperative findings matched perfectly in all 30 cases with ARM-PS drawings for the location of the mentioned vessels and lymph nodes. Flap harvest time decreased in 20% compared with our traditional timing. ARM-PS is an easy, noninvasive, and accurate method that provides a dissection route map, thereby standardizing flap harvesting, and shows a perfect correlation with intraoperative findings. It reduces operating time and may improve operative results, thus decreasing donor site morbidity.

Virtual surgical planning and intraoperative navigation for mandibular reconstruction: from accurate to minimal invasive

Simultaneous restoration of function and appearance should be performed in mandibular reconstruction. Option of reconstructive techniques is determined by cause, location, extent, and classification of the mandibular defects. Vascularize bone graft is one of the most popular technique in current clinical practice of mandibular reconstruction. Fibula is the most common donor site for mandibular reconstruction. The disadvantage of low height of neo-mandible reconstructed by single fibular segment can be solved by vascularized double barrel fibula graft. Using virtual surgical planning and intraoperative navigation for mandibular reconstruction leads to simplify surgical procedure, reduce operating time and injury, and decrease donor site morbidity so that accurate mandibular reconstruction could be completed. Direction of minimal invasive surgery for mandibular reconstruction will be developed by intraoral approach and intraoral anastomosis.

Current trends in local flaps of the hand

Soft-tissue coverage of the hand remains a difficult surgical challenge. Local flaps provide thin, pliable, durable options for coverage of defects. Functional and aesthetic outcomes are optimized by restoring defects with similar tissue. Local flaps have been used for coverage of soft-tissue defects of the hand for decades; however, recent advances in detailed anatomic neurovascular knowledge and microsurgical techniques allow for accurate vascular pedicle and nerve dissection. This has prompted the emergence of new flaps and modifications to previously described operations. Research evaluating and comparing outcomes and complications between reconstructive alternatives have become essential to enabling surgeons to offer the most suitable options to patients. The purpose of this article is to briefly describe the most important advances in the recent literature regarding local flaps in the hand. Current trends include efforts to decrease donor site morbidity, improve functional outcomes (often through the reestablishment of sensation through nerve coaptation), optimize aesthetic outcomes, and minimize complications.

TYPE II HYPOPHARYNGEAL DEFECT RECONSTRUCTION - A SINGLE INSTITUTION EXPERIENCE.

SUMMARY – There are several options for hypopharyngeal reconstruction depending on defect size. Reconstructive options include primary closure, local flaps, regional axial flaps or regional intestinal flaps, and free flap transfer with skin or intestinal free flaps. The preferred method of reconstruction should minimize early postoperative complications that prolong hospital stay and/or become life threatening, ensure early restoration of function and decrease donor site morbidity. The purpose of this study was to evaluate functional outcomes of different flap reconstruction methods in type II hypopharyngeal defects. In this non-randomized retrospective cohort study, data on 31 (27 male and four female) patients were collected over a 10-year period of single institution type II hypopharyngeal defect reconstructions. The following measures of functional outcome were extracted from patient medical histories: postoperative complications (flap failure, fistula formation, donor site related complications), hospital stay in days and swallowing function after 14 days, 1 month and 6 months. There were nine patients in the radial forearm free flap (RFFF) reconstruction group, seven in the jejunum reconstruction group, and 15 in the gastric tube reconstruction group. In the RFFF group, three patients experienced flap failure; in the jejunal transfer group, no donor site morbidity was observed; whereas three patients from the gastric tube reconstruction group had minor abdominal skin wound dehiscence. Out of the 3 different reconstructive methods, RFFF was most likely to fail. The mean duration of hospital stay was 22.6 days, being shortest in the RFFF group. There were no significant differences in early postoperative swallowing function among the groups. The choice of flap used for hypopharynx reconstruction should be driven by donor site factors and functional outcomes. When assessing type II hypopharyngeal defect reconstruction results, the findings of this study suggest that free jejunal flaps and gastric tubes offer superior functional results in comparison with RFFFs.

Functional and radiological outcomes of acromioclavicular joint reconstruction in type iii disruption without allograft with synthetic materials

Introduction: Effectiveness of surgery for complete Acromio-clavicular Joint (ACJ) dislocation is controversial. We analyzed the long-term Functional and radiological outcome after in on Acromio-clavicular ligament reconstruction by modified Mazzocca technique for Type 3 dislocations. Aim: To study the functional and radiological outcomes of acromioclavicular joint reconstruction in type III disruption without allograft with synthetic materials Method: Retrospective analysis of case records and patient reviewed to assess the long-term functional and radiological outcome by patient satisfaction, UCLA shoulder rating score and coracoclavicular distances. Results: We had 38 cases of Type 3 Acromio-clavicular dislocations over a period of 5 years. Mean age of the entire group was 42.1 years (26 to 57). Among them, 32 are males and six females. Three patients were lost their follow-up during the post-op rehabilitation period; among them, two were presented with infection, one with shoulder stiffness. Long-term functional and radiological outcomes were regarding UCLA shoulder rating score, patient satisfaction and coracoclavicular distances compared with the uninjured shoulder. Conclusions: More aggressive management of acromioclavicular dislocation needed to avoid poor results with chronic injuries, and we have moved toward without graft and earlier surgical intervention. We recommend modified Mazzocca technique used in the management of Grade 3 Acromio-clavicular joint dislocation for the following reasons (A). Better short-term functional and radiological outcome and low risk of complications (B). No need graft harvesting surgery and decreased donor site morbidity.