Donor Site Defect Research Articles

In the Shave of Time: A Mineral Oil Skin Lubrication Substitute.

Lubricants such as mineral oil are commonly applied to the skin and dermatome before harvesting a split-thickness skin graft. Lubrication of the skin-device interface allows smoother glide of the dermatome and prevents skipping, resulting in obtaining a uniform and continuous skin graft. At our institution, mineral oil is the predominant lubricant used. Recently, during a complex lower extremity reconstruction involving a fasciocutaneous propeller flap for lateral ankle defect and skin grafting of the flap donor site, we were surprised to discover that our institution no longer carried mineral oil because of a national shortage. The procedure occurred during the coronavirus disease of 2019 pandemic, which may have affected the available supply. As normal saline did not appear to be an adequate mineral oil substitute,1 sterile water-soluble ultrasound lubricant was used at the skin-dermatome interface. The split-thickness skin graft was harvested without skipping or premature termination, and the donor site healed well. We used sterile ultrasound lubricant in two additional split-thickness skin graft procedures with similar excellent results. The nine characteristics of an ideal lubricant for split-thickness skin graft harvesting include cost-effectiveness, pain reduction, hemostasis, lubrication, solubility, no side effects, enhancement of wound healing, practicability, and antiseptic effect.2 Mineral oil, despite its frequent use, achieves very few of these ideal qualities and thus could be replaced with another lubricant with more optimal properties. Wettstein et al. demonstrated the effectiveness of saline irrigation as a lubricant in their series of 42 split-thickness skin grafts.1 Likewise, Engelhardt et al. noted that catheter gel lubricant with lidocaine and chlorhexidine additives was an effective agent that achieved all nine ideal qualities except for enhancement of wound healing.2 Ultrasound gel, similar to catheter lubricant, is cost-effective, water soluble, without known side effects, practical, and a lubricant. In the event that mineral oil is unavailable, as in our situation, sterile water-soluble ultrasound gel is an effective lubricant for split-thickness skin graft harvesting with which all surgeons should be familiar. ACKNOWLEDGMENT This study was deemed exempt by institutional board review. DISCLOSURE Neither author has a financial interest to declare in relation to the content of this article. No funding was received for this work. Matthew E. Braza, M.D.Spectrum Health/Michigan State UniversityCollege of Human Medicine Plastic Surgery Ewa Komorowska-Timek, M.D.Spectrum Health/Michigan State UniversityCollege of Human Medicine Plastic Surgery, and Advanced Plastic SurgeryGrand Rapids, Mich.

Use of Serial Flap Transfer Technique in En Bloc Reconstruction of Extensive Soft Tissue Defects in the Head and Neck.

En bloc reconstruction of extensive head and neck defects is feasible with matched tissue from the medial arm or chest. Nevertheless, the donor site faces significant morbidity following massive cutaneous flap harvesting. The serial flap transfer technique can increase the reconstructive ability of these flaps and minimize the donor site morbidity. A retrospective review was conducted from 2016 to 2020 on all patients who had undergone extensive head and neck reconstruction with the serial flap transfer technique. En bloc reconstruction of defects in the head and neck was performed using expanded perforator-plus flaps from the medial arm or chest; various flaps from the back were used to close the donor-site defects. Flap type, flap survival, complications, and revision procedures were assessed. This case series included 16 patients. The donor site of the chest or medial arm was successfully closed with the assistance of the thoracodorsal artery perforator flap, the latissimus dorsi myocutaneous flap, ortheparascapular flap. A medial arm flap with a width of 15 cm and a chest flap with a 16 cm width could be transferred with the primary closure of the donor sites. All flaps survived, except 1 had marginal necrosis. Complications occurred in 2 patients and were successfully managed nonsurgically. Both the recipient and donor sites were restored with good aesthetic results. Application of the serial flap transfer technique in extensive head and neck reconstruction decreases the donor site morbidity to a minimum and improves the overall outcomes.

Correction to: Auricular cartilage regeneration on donor site defect with one-sided perichondrial cartilage graft in an experimental rabbit model

Auricular cartilage is considered the source for cartilage grafts with good esthetic results and is often used in augmentation rhinoplasty. Most revision procedures require grafting, and the auricular cartilage can be the source for secondary rhinoplasty. Due to limited donor locations, donor site optimization of graft material is very important. We aimed to evaluate the healing process from the donor site, including the regeneration of cartilage from the donor site in an experimental animal model. Six New Zealand white rabbits were used for the investigation of cartilage regeneration from donor defects with one-sided perichondrium. Cartilage defect measuring 0.5 × 3 cm was made in rabbit ears. Two trial groups with 12 ears in each group were formed (one-sided perichondrium vs without perichondrium). Macroscopic and microscopic evaluation examinations were performed at week 4. The gap and thickness of the donor defect were measured with a centimeter grinder for macroscopic evaluation. While macroscopic evaluation of wound thickness and the gap was not significant between groups (p = 1.00, p = 0.053, respectively), microscopic evaluation showed immature cartilage formation at week 4 of the donor defect with one-sided perichondrium (p = 0.004). The donor defect with one-sided perichondrium showed new cartilage formation within the area of the perichondrium. These findings showed the regeneration of cartilage was developed at the donor defects with one-sided perichondrium in the fourth week. Level of evidence: Not ratable

Closure of the radial forearm free flap donor site with split-thickness skin graft or amniotic membrane: A prospective randomized clinical study

The purpose of this study was to compare the clinical, aesthetic, and functional outcomes between amniotic membrane (test group) and split-thickness skin grafts (control group) used for radial forearm free flap defect closure.The primary outcome measurement for both groups was assessment of the defect closure healing process. In addition, aesthetic (Vancouver Scar Scale) and functional outcomes (skin sensitivity, hand/wrist functionality, grip strength) were evaluated.Fifty eligible patients with radial forearm free flap donor site defects were randomly assigned to two groups receiving either amniotic membrane (test group; n = 25) or split-thickness skin graft (control group; n = 25) for defect covering. Forty-seven of the 50 patients (n = 47) were able to be followed up for 6 months and showed a significantly longer healing process (p < 0.001) with amniotic membrane (64.5 ± 38.4 days; n = 24) than with split-thickness skin grafts (29.2 ± 8.9 days; n = 23); however, there were no differences in the prevalence of healing defects/dehiscence and/or wound infections. Forty-two of the 47 patients (21 in each group) were able to be continually followed up for 12 months, and showed no differences in terms of clinical outcome as well as the subjective and objective aesthetic and functional results evaluated.With regard to the clinical, aesthetic, and functional outcomes evaluated for radial forearm free flap defects, coverage with amniotic membrane offers an excellent alternative treatment approach, avoiding secondary induced donor site morbidity.

“Wing-Shaped Skin Component of Latissimus Dorsi Myocutaneous Flap Design for Breast Reconstruction—Useful Innovation”

We describe a pedicled latissimus dorsi myocutaneous (LDMC) flap with a wing-shaped skin paddle to cover large breast defects. It allows primary closure of the donor site with the added advantage of some flap projection. This is performed utilising the principles of M-plasty and the anatomy of thoracodorsal musculocutaneous perforators, which would not be possible with the conventional flap design. Analysis of a series of 23 patients who underwent breast reconstruction using wing shaped skin component LDMC technique between 2011 and 2019 in a breast unit of a Tertiary Care Hospital is presented here. Patient characteristics, technical details, and outcomes were analysed. Mean patient age was 41 (SD 10.9) years. The mean defect dimensions were 13.5 (SD 3.4) cm and 10.5 (SD 2.6) cm in length and width, respectively. The mean flap area was 147 (SD 67.2 cm2).The donor site defect was closed primarily in all the cases. The average length of inhospital stay was 4.9 (SD 1.5) days (range 3–9 days). One patient (4.3%) had marginal necrosis of the flap, three patients (13%) had donor site seroma, and two patients (8.7%) suffered donor site wound dehiscence. None of the complications entailed re-surgery or delay the onset of adjuvant therapy. At a mean follow-up of 37.5 (SD 33.9) months, none of the patients reported tumour recurrence or donor site morbidity. Wing-shaped skin component of latissimus dorsi myocutaneous flap offers a simple and reliable pedicled flap to cover large breast defects with minimal donor site morbidity. It creates a mild breast mound and may avoid the use of implants and its associated complications in small-breasted patients. It can be conveniently performed in non-microsurgical setups.

Use of soleus musculocutaneous perforator-based propeller flap for lower extremity wound coverage after osteocutaneous fibula free flap harvest.

Osteocutaneous fibula free flap (OCFFF) donor sites are often covered with skin grafts, with an additional donor site, more postoperative care, and increased cost. The authors examine posterior tibial artery (PTA) based pedicled propeller flaps (PPF) as an alternative for OCFFF donor site coverage. Retrospective review of 16 consecutive patients from 30 to 79 years old, who underwent OCFFF reconstruction of head and neck defects (11 mandibular, 5 maxillary), with the closure of donor site with PPF based on a perforator from PTA. Mean donor site defect measured 12.9 × 5.1 cm, PPF was an elliptical design, and rotated 180 degrees in a propeller fashion, to cover donor site defect. Visual analog scale (VAS) was used to assess esthetic results, functional outcomes assessed using mobility and range of motion (ROM), and secondary complications including infections, hematomas, and seromas were recorded. Follow-up period was noted in months postoperatively. Other information collected included underlying head and neck pathology. Average dimension of PPF measured 13.9 × 4.1 cm. Successful closure of donor site defects in 14 of 16 patients, with two flaps having partial necrosis, one requiring a secondary skin graft. Follow-up was 6 to 10 months, esthetic results with mean VAS 8.8 of 10, full ROM, and mobility noted. No secondary complications were observed. The most common pathology noted was squamous cell carcinoma (6 of 16 patients). PPFs based on the soleus branch of the PTA represent an excellent alternative to skin grafts for the closure of OCFFF donor site defects.

Repair of Donor Site Defects After Forearm Free Flap Harvest With Dual Triangular Flaps and in Situ Small Full-thickness Skin Flaps.

The aim of this study was to introduce a method for repairing donor site defects after harvesting forearm free flaps with dual triangular flaps combined with in situ small full-thickness skin flaps. Free forearm skin flaps were applied to repair defects after tumor resection in 25 patients with oral squamous cell carcinoma. Although forearm free flaps were prepared, dual triangular flaps and adjacent full-thickness skin flaps were designed and fabricated to repair donor site defects in situ. Twenty-five cases of forearm donor site defects were successfully repaired with dual triangular flaps combined with in situ small full-thickness skin grafts. All adjacent full-thickness skin grafts used to close the donor site defect of the forearm survived, and the wound healed well without delayed wound rupture or serious complications at the donor site. The movement of the elbow and wrist joint on the side of the flap was normal, the blood supply in the palm was normal, and the skin color at the donor site of the forearm skin flap was similar to that of the surrounding tissue. There was no dent deformity or contracture deformity. Moreover, there was no significant difference in swelling and wrist movement between the adjacent forearm skin grafting group and the abdominal skin grafting group, but the former technique reduced the risk of scar infection and tendon exposure and greatly improved the esthetics of the surgical site on the forearm. Modified donor dual triangular flaps combined with adjacent full-thickness skin grafts can reduce the recovery time during and after surgery and avoid trauma at a third surgical site. This method is worthy of practical application in the preparation of forearm skin flaps for oral and maxillofacial surgery.

Superficial peroneal nerve accessory artery (SPNAA) flap for head and neck reconstruction: A cadaveric anatomical study and retrospective case series review

Several different flaps can reconstruct intraoral defects or lower limb deficits after free fibula osteo-cutaneous flap harvesting for jaw reconstructions. However, commonly used options may not be available for various reasons and can be associated with significant morbidity. We hypothesized that flaps supplied by the superficial peroneal nerve accessory artery (SPNAA) could be a viable alternative reconstructive option. We describe the SPNAA's anatomy using 20 human cadaveric leg dissections and report eight cases involving SPNAA-based perforator flap reconstructions (six propeller flaps and two free flaps) in a retrospective case series. Patient-specific baseline variables and intraoperative and postoperative outcomes are described. Cadaveric dissection suggests that the location of the SPNAA is reliable but its origin varies, with 40% (N = 8) of SPNAAs being of type I origin, 20% type II (N = 4), and 40% (N = 8) type III in our series. All reconstructions were successful. No intraoperative complications occurred during propeller or free-flap reconstructions. No flap failures occurred. One propeller reconstruction showed distal superficial skin necrosis and one donor site wound dehisced; both were successfully managed conservatively. No other short-term or long-term complications occurred. Flaps based on SPNAA perforators appear effective, reliable, and safe reconstructive methods for covering fibula osteocutaneous donor site defects and for intraoral reconstructions. Controlled trials are required to compare its effectiveness and safety with other reconstructive methods.

Donorsite defect of medial femoral condyle corticoperiostal flap in the treatment of lower limb infected nonunions.

Chronic osteomyelitis is a major challenge in orthopaedic surgery; it is the result of open fracture, periprosthetic infection and septic arthritis. Osteomyelitis leads to fracture nonunion. The treatment of bone infection and infected nonunion consists primarily of the complete removal of infected and avascular bone and soft tissue from the surgical site, followed by local and systemic pathogen-specific antibiotic therapy and temporary stabilisation, but may lead to massive skeletal and soft tissue defects. The use of free or pedicled vascularised bone transfers and callus distraction techniques (bone transport) has been recommended for large bone defects. The aim of this study is to evaluate the results of patients affected by infected non-unions of the lower limbs, treated with a corticoperiosteal flap from the medial femoral condyle and to investigate the donor site morbidity of this flap. The patients were 11 males (average age of 45.6 years), who presented a nonunion of the tibial diaphysis in 7 cases and non-union of femoral diaphysis in 4 cases, treated with free or pedicled corticoperiosteal flap. In all patients, surgical debridement was performed before the flap of infected bone and soft tissues that would not contribute to wound healing. Clinical and radiographic evaluations of the recipient site were performed. Preoperative and postoperative X-ray and MRI scans after the 3-year follow-up of the donor site were performed, in order to observe possible bone restoration and any complications. The patients reported complete clinical and radiographic bone healing in 90.9 % of cases. As regards donor site, there were no differences between the medial femoral donor condyle compared to the contralateral site, due to complete regeneration of donor site bone. MRI investigation showed complete restoration of the donor site with vascularised bone in all patients. Our results suggest that the use of bone flaps for the treatment of infected non-unions is an effective procedure, that must be performed after accurate debridement of the non-union site. The corticoperiosteal flap seems to have few morbidities on the donor site and a high percentage of successful bone healing.

A Novel Technique for Reconstruction of a Congenitally Absent Earlobe.

Congenital anomalies of the external ear may present a reconstructive challenge, particularly when normal chondrocutaneous components of the auricle fail to develop. Our goal was to develop a novel technique for lobule reconstruction of a congenitally absent earlobe with photographic documentation of the technique. Informed consent for perioperative photography and publication of case details was obtained. A postauricular, turnover flap with ipsilateral conchal cartilage grafting was performed to reconstruct the lobule, and a superiorly based, postauricular, rotation advancement flap was used to close the donor site defect. Perioperative photographs are included demonstrating technique and cosmetic results. Malformations rarely involve the lobule or lower third of the ear primarily. Literature regarding lobule reconstruction for congenital malformations is scarce. We present a novel technique for lobule reconstruction of a congenitally absent earlobe performed in a single stage that avoids a visible neck scar and allows for simultaneous conchal cartilage harvest. The technique demonstrated satisfactory cosmesis regarding contour and overall appearance and these results remained stable at 1-year follow up.

The Role of Reversed Homodigital Island Flap in Digital Reconstruction

Background: Fingertip injuries are very common. Reconstructionof extensive distal phalangeal defects with exposureof tendon, bone, or joint can be particularly a difficult problem.Options are local, regional and free flaps. SSG on bone andtendon is unsuccessful and nondurable. The primary goals ofdigital reconstruction are to preserve digital length and maintainfull mobility of the digit with providing adequate protectivecover of the deeper vital structures with soft tissue and skinof good quality. Homodigital artery island flap has been foundto be very useful and is commonly used for the recon‌structionof fingertip amputations.Patients and Methods: We used the reversed homodigitalartery island flap to reconstruct fingertip injuries in 8 patientsat Minia University Hospital and private sector in the periodbetween January to December 2017. We retrospectivelyanalyzed patients for: Age, sex, mechanism of injury, locationof defect, flap survival, sensory recovery and donor sitecoverage.Results: Five patients were males and 3 females. Agefrom 18 to 42 years mean (27.3 years). Six patients hadcomplete flap survival and two patients suffered venouscongestion that resolved completely by conservative measures.Donor site closure was directly closed in all cases. Nearnormal sensory recovery was noted.Conclusion: The reverse homodigital island flap is a safemethod for distal phalangeal reconstruction offering multipleadvantages over other local, regional and free flaps with analmost negligible donor site defect. Venous congestion andinability to reconstruct proximal finger defects are drawbacks

"Point line anterograde dissection" for the safe preparation of supraclavicular flap

Objective: To investigate the application in the preparation of supraclavicular island flap by "point line anterograde dissection (PLAD) ". Methods: A retrospective analysis was performed on 45 flaps of 43 patients treated with supraclavicular artery island flap from the Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital Affiliated to Capital Medical University from January 2013 to June 2019. The patients were all male, aged 35-72 years old. There were 26 cases of hypopharyngeal cancer, 4 cases of recurrent laryngeal cancer, 2 cases of cervical esophageal cancer, 1 case of tonsillar cancer, 1 case of parotid gland cancer, 3 cases of postoperative pharyngeal fistula after hypopharyngeal cancer, 2 cases of esophageal fistula after trauma, 2 cases of esophageal stricture after hypopharyngeal carcinoma operation, 1 case of autoimmune laryngeal stenosis, and 1 case of cheek defect after maxillary sinus cancer operation."Point" was the origin of the supraclavicular artery in the transverse carotid artery. "Line" was an extension line made along the starting point of the supraclavicular vessel for anterograde anatomy of 1-2 cm and the direction of the blood vessel. The extension line was used as the central axis of the designed island flap. Characteristics of flap blood supply, the time of flap preparation, flap survival, donor area recovery and clinical follow-up were recorded. Results: The arterial blood supply of the flap was constant, and the venous reflux was variable. The area of the prepared flap was (4-8) cm×(10-18) cm, and the preparation time was 30-60 min, with a median of 42 min. Skin flap survival rate was 100%. Partial necrosis of skin flap occurred in 1 patient and postoperative pharyngeal fistula occurred in 5 patients, all of whom were cured by dressing change. The donor site defects were closed and sutured directly. 3 patients had partial incision dehiscence and healed after dressing change. During the follow-up, 1 patient was lost, and the remaining 42 patients were followed up for 8 to 55 months.40 patients involved swallowing function, all of them returned to regular diet or soft fluid after operation.40 patients involved malignant tumors and local tumor recurrence in 3 patients among whom, there were 2 cases of lymph node recurrence, and 2 cases of distant metastasis, including 1 case of lung metastasis and 1 case of bone metastasis. Conclusion: PLAD is a simple, safe and efficient method for the preparation of supraclavicular island flap.

Superficial Peroneal Neurocutaneous Flap for Coverage of Donor Site Defect After the Combined Transfer of Toe and Dorsal Foot Flap.

Reconstruction of digital loss with soft tissue defects remains a tough challenge. Although a combined flap of toe and dorsal foot skin provides a good option for "like-for-like" hand reconstruction, the disappointed donor site morbidity prevents it from popularity. In this study, we presented experiences of the superficial peroneal neurocutaneous (SPNC) flap for donor site closure after the combined toe and dorsal foot flap transfer. Superficial peroneal neurocutaneous flaps were used to cover foot donor site defects in 9 patients. The flaps harvested from feet including 3 cases of wrap-around flap with dorsal foot flap, 4 cases of 2nd toe flap with dorsal foot flap, 2 cases of 2nd and 3rd toe flap with dorsal foot flap. The flap size, operation time, and complications were documented, and the donor sites were evaluated by the subjective outcome measure, the foot evaluation questionnaire, and the Vancouver Scar Scale. All flaps but one survived completely without complications. Marginal necrosis occurred in the distal part of the flap in one case, which was treated by daily dressings. The skin grafts on the lower leg healed uneventfully. The average operation time of flap transfer was 40 minutes. Follow-up ranged from 9 to 16 months, and patients were content with the results of the foot donor site according to the outcome measures. All the patients were able to wear normal shoes walking and running with a normal gait, and none sustained complications of skin erosion or ulceration. Protective sensibility was obtained in all the flaps. Two patients complained of cold intolerance and 2 could not wear a thong sandal. The donor site scars on the lower leg were measured 3.2 on average on the Vancouver Scar Scale. The SPNC flap is a practical procedure for donor site closure on the foot, especially when extra dorsal foot skin is elevated with a toe flap for hand reconstruction.

Are hand biomechanics affected following radial forearm flap harvest? A systematic review and meta-analysis

Donor site morbidity following radial forearm flap (RFF) harvest remains a controversial issue. The aim of this meta-analysis was to answer the question “Are the range of wrist movements (range of motion, ROM) and hand strength affected after RFF harvesting?” The PubMed, Embase, Scopus, and Cochrane Library electronic databases were systematically searched (to December 2019). Self-controlled studies evaluating hand biomechanics after RFF harvest were included. Weighted mean differences with 95% confidence intervals were calculated using the random-effects model. The outcome variables were ROM, forearm movements, grip, and pinch strengths. Thirteen studies involving a total of 335 patients were included. With the exception of grip strength and supination, which showed statistically significant reductions of about 2.40 kg and 2.86° (P < 0.05), all other ROM, forearm movements, and pinch strengths showed an insignificant difference when the operated hand was compared to the non-operated hand (P > 0.05). Regression analysis showed that the method of donor site closure and size of the donor site defect had an insignificant impact on hand biomechanics. This study confirms the lack of discernible biomechanical morbidity after RFF transfer. The minimal reduction in hand biomechanics after RFF is considered to be clinically negligible.

Estimated birth prevalence of Menkes disease and ATP7A-related disorders based on the Genome Aggregation Database (gnomAD)

BackgroundPrevious estimates of the prevalence of Menkes disease, a lethal X-linked recessive disorder of copper metabolism, were based on confirmed clinical cases ascertained from specific populations and varied from 1 in 40,000 to 1 in 354,507. With newly available population-based allelic frequencies of DNA sequence variants, the expected birth prevalence of Menkes disease and other ATP7A-related phenotypes can be reconsidered using Hardy-Weinberg theoretical principles. MethodsWe reviewed the canonical ATP7A transcript in the current version of gnomAD (v2.1.1) to evaluate frequency of complete loss-of-function alleles in a diverse normal control population. As a comparator, we used the DMD locus, associated with Duchenne and Becker Muscular Dystrophy, another X-linked recessive trait. We applied Hardy-Weinberg theory and PolyPhen-2 in silico plus REVEL and CADD ensemble analyses to calculate estimated frequencies of normal and predicted deleterious ATP7A alleles. ResultsWe identified 1106 total ATP7A variants out of 205,523 alleles in gnomAD, with missense variants most common (43.4%). Complete loss-of-function variants were found in four ATP7A alleles (frequency = 0.0000194), including three frameshift/nonsense mutations and one canonical splice donor site defect. Assuming Hardy-Weinberg equilibrium, this frequency of pathogenic alleles predicts 1 in 34,810 live male births with Menkes disease or other ATP7A-related disorders each year in the US. The same analysis for DMD loss-of-function variants predicted 1 in 7246 newborn males with Duchenne (or Becker) muscular dystrophy. We also identified nine ATP7A missense variants in gnomAD predicted as deleterious by PolyPhen-2 and stringent REVEL/CADD criteria, comprising 12 more disease-causing alleles and raising the estimated birth prevalence to 1 in 8664 and predicting 225 newborns with Menkes disease or other ATP7A-related disorders per year in the US alone. ConclusionsAssuming Hardy-Weinberg equilibrium, the allelic frequency of deleterious ATP7A variants in a genomic database from a large diverse population predicts a birth prevalence of Menkes disease or ATP7A-related disorders as high as 1 in 8664 live male births. This genome-driven ascertainment of deleterious ATP7A alleles in the population implies a higher birth prevalence of Menkes disease and ATP7A-related conditions than previously appreciated. A population-based newborn screening pilot study for Menkes disease will be instrumental in confirming the prediction.

Soft tissue coverage of a total gluteal defect with a combination of perforator‐based flaps: A case report

Soft tissue defects in the buttock area are often related to decubitus ulcers, which are usually small to medium-large size and can be regularly treated with local flaps. However, when the defects have bigger size, such as those involving the whole gluteal region, the coverage can become more challenging, since this specific area needs both a good resistance to pressure and an acceptable functional result. The most common solution for similar cases is the use of multiple local flaps, or, in extreme situations, a free flap. In particular, local flaps based on perforator vessels are, in selected cases, a consolidated alternative to free flap allowing an efficient reconstruction of soft tissue defects using adjacent similar tissues, providing the benefit of "like with like" coverage. Here we present a case of a large mycosis fungoides nidus of the gluteal region measuring 25 cm × 18 cm reconstructed using two large perforator flaps adjacent to the defect combined with a remote one for coverage of the donor site. The cranial flap was designed based on a perforator arising from the superior gluteal artery and transferred into the defect by means of a V-Y advancement, while the two caudal propeller flaps in the posterior thigh were both based on perforators of the profunda femoris artery and rotated 180°, respectively. To obtain a tension-free cover of the donor site defect we applied the concept of "sequential" propeller flaps. Post-operative course was uneventful and the patient was ambulatory with assistive devices after 1 week. At 6 months follow-up, wounds were completely healed without complications and a good functional result was obtained. This report showed the great coverage potential of multiple perforator-based local flaps when properly combined allowing primary closure of the donor site. In particular, we managed to reconstruct a total gluteal defect using just ipsilateral side tissue, reducing morbidity, and obtaining a stable result.

Factors associated with skin graft take in fibula and radial forearm free flap donor sites.

Identify factors associated with skin graft take in fibula free flaps (FFF) and radial forearm free flaps (RFFF) donor sites. To determine which factors are associated with decreased skin graft take at the donor site in FFF and RFFF in head and neck patients. Retrospective Chart Review Case Series. Multicenter Tertiary Care. A multicenter retrospective review was performed at three institutions identifying patients who underwent free tissue transfer, specifically either FFF or RFFF, between 2007 and 2017. Patient demographics, medical history, and social history were examined including age, gender, BMI, smoking status, diabetes and preoperative anticoagulation use. Preoperative, intraoperative data, and postoperative data were also examined including tourniquet use, type of flap, area of skin graft, if the skin graft had a donor site or if it was taken from the flap, wound NPWT use, cast use, use of physical therapy, DVT prophylaxis, limb ischemia, heparin drip, and postoperative aspirin use. Statistical analysis was used to determine which factors were significantly associated with skin graft take. 1415 patients underwent a forearm or fibula flap and 938 patients underwent split-thickness skin graft. Of these, 592 patients had sufficient information and were included in the final analysis. There were 371 males and 220 females. The average age was 55.7. Complete skin graft take was seen in 480 patients (81.1%). On univariate analysis, patients with diabetes (p=.003), type of flap (fibula p<.001), skin graft area (p=.006), tourniquet use (p=.003), DVT prophylaxis (p=.008) and casting (p=.003) were significantly associated with decreased skin graft take rate. In a multivariate analysis, diabetes (OR 2.17 (95%CI 1.16-3.98)), fibula flaps (OR 2.86 (95%CI 1.79-4.76)), an increase in skin graft area (OR 1.01 (95%CI 1.01-1.01)), post-operative aspirin (OR 2.63 (95%CI 1.15-5.88), and casting (OR 2.94 (95%CI 1.22-7.14)) were associated with poor rates of skin graft take. Several factors affect skin graft take rate and should be considered when performing a skin graft for a donor site defect.

Combined use of a petal flap and V-Y advancement flap for reconstruction of presacral defects following rectal resection.

The aim of this study was to evaluate the efficacy of a combination of flaps for the reconstruction of presacral defects following abdominoperineal resections: a paramedian vertically oriented caudally based lotus petal flap for presacral defects combined with a horizontal V-Y advancement flap for closure of the superficial donor site defect. A retrospective study was conducted on patients with a residual defect following an abdominoperineal resection between 2010 and 2017 in the Noordwest Ziekenhuisgroep. The primary endpoint was complications related to the reconstruction. Twelve patients were included, all reconstructions healed well. Three patients had a grade I or II complication (Clavien Dindo classification). Use of a petal flap and V-Y advancement flap for reconstruction of presacral defects was found to be safe and simple, and should, therefore, be considered in the management of such problems.

Outcome of Dorsolateral OnlAy OMG Urethroplasty for Anterior Urethral Stricture

Objective: To determine the feasibility, safety, efficacy and short term outcome of using new surgical technique for repair of anterior urethral stricture Introduction: The conventional approach for management of long segment anterior urethral stricture is a two stage Johansons repair along with the use of free grafts if required. Now a days the preferred management of urethral stricture involving long segments of anterior urethra is dorsal only oral mucosa Augmentation urethroplasty which requires circumferential mobilization of urthera that might cause ischaemia of urethra in addition of chordee. For that we adopted new technique (kulkarnis) of dorsolateral onlay buccal mucosal graft one sided anterior urethroplasty in which only unilateral urethral mobilization done through perineal approach. Materials and Methods: A total of 50 patients underwent urethroplasty for anterior urethral strictures using dorsolateral onlay BMG from April 2010 to December 2012 at NIKDU, JBFH, BSMMU and BDM Hospital. We selected 16 to 70 years old male (mean age 39 years) underwent a one-sided dorsolateral oral mucosal graft urethroplasty. The mean (range) stricture length was 6.5 (4.5-9) cm in patients with single bulbar urethral involvement and 10.5 (8.5–15.0) cm in patients with panurethral strictures. Free graft was taken from oral mucosa either lower lip or cheeks. Follow up was done by uroflowmetry at 3rd week, after removal of penile catheter and repeat at 3rd and at 6th month. In addition to uroflometry – RGU &amp; MCU was done at 3rd month and Urethrocystoscopy was done at 6th month follow up. The results were classified into the following outcomes. Success was defined as a maximum flow rate of &gt;10 ml/sec, normal RGU, and/or urethroscopy (with a 19 Fr. sheath). Failure was defined as the presence of obstructive urinary tract symptoms, Qmax &lt;10 ml/sec, stricture diagnosed on retrograde urethrogram/ urethroscopy, and the need for any postoperative urethral intervention. Result: The overall follow up was 12-30 months. Of the 50 patients 45 (90%) had a successful outcome and 5(12%) had failure. 3 failure treated by OIU and 2 by meatal dilatation. No significant donor site defect was observed. Bangladesh Journal of Urology, Vol. 16, No. 2, July 2013 p.37-42

Improving the Versatility of the Latissimus Dorsi Myocutaneous Flap Using the Perforator Propeller Flap Concept.

The latissimus dorsi myocutaneous flap is widely used in reconstructive surgery; however, primary donor-site closure remains challenging when a wide flap is harvested. A large latissimus dorsi myocutaneous flap was elevated and transferred to repair defects. Perforators adjacent to the donor site of the myocutaneous flap were explored using an ultrasound Doppler probe or a technique of extensive exploration along the margins of the donor site wound. A single or multiple perforator propeller flaps based on these perforators were used to close the donor site defect. From June 2012 to April 2018, this method was used to restore posttraumatic and oncologic defects of the chest wall in 14 cases, upper extremity in 6 cases, and lower extremity in 1 case. The size and width of the latissimus dorsi myocutaneous flaps ranged from 16 × 11 cm to 33 × 17 cm (mean area, 335.6 cm) and 9 cm to 20 cm (mean width, 14 cm), respectively. The donor site defect was closed primarily by using a single flap in 11 cases, dual flap in 9, and triple flap in one. Donor site breakdown was not observed in any of the cases. The perforator propeller flap could be used to reconstruct a latissimus dorsi myocutaneous flap donor site defect, ensuring not only the harvesting of a wide flap but also achieving primary donor site closure, thus greatly improving the versatility and capability of the latissimus dorsi myocutaneous flap in the reconstruction of large-sized defects.