Durable Soft Tissue Coverage Research Articles

Scalp and Dural Reconstruction With a Tensor Fascia Lata Myofascial and Anterolateral Thigh Fasciocutaneous Chimeric Flap: A Case Report

Composite scalp and cranial defects present a challenge due to the unique elements that need to be reconstructed. The goals of reconstruction are to protect intracranial contents, prevent cerebrospinal fluid leak (CSF) and infection, and to provide durable soft tissue coverage. We present a case of an immunocompromised patient with history of craniotomy who developed osteomyelitis and a cranial abscess resulting in a composite defect with dural, bony, and soft tissue loss. To achieve vascularized watertight dural repair and durable soft tissue coverage for resolution of infection and eventual staged cranioplasty, we performed a free tensor fascia lata (TFL) myofascial and anterolateral thigh (ALT) fasciocutaneous chimeric flap. The patient healed well without CSF leak or infection at 5-month follow-up and cranioplasty is planned. Use of a chimeric TFL and ALT flap is effective in the treatment of large, composite cranial defects in the setting of active infection.

Multidisciplinary Treatment of Persistent Nontuberculous Mycobacterial Spinal Hardware Infection with a Pedicled Superior Gluteal Artery Perforator Flap.

Nontuberculous mycobacterial hardware infections are extremely challenging to treat. Multidisciplinary care involving removal of infected hardware, thorough debridement, and durable soft tissue coverage in conjunction with antibiotic therapy is essential for successful management. This case report presents a patient with chronic mycobacterial spinal hardware infection that underwent successful treatment with aggressive serial debridements and reconstruction with a large pedicled superior gluteal artery perforator flap coverage.

Functional Compatibility of Local Flaps for Coverage of Digital Skin Defects.

To determine if local flap coverage is functionally compatible of digital defects. Observational study. Department of Plastic and Reconstructive Surgery, Fauji Foundation Hospital, Rawalpindi, from January 2017 to June 2019. Patients with small and medium skin defects on digits were included. Data was collected for both independent and dependent variables, emphasising on functional outcome based on five parameters (adequate coverage of the defect, functional length of the digit, painless scar, finger-tip sensation, and inter-phalangeal joint motion). Follow-up was done for six months. Total number of patients included in the study was 96, with 45 male and 51 female patients. Mean age of study participants was 26.6 ± 16.9 years. Small to medium size defects were included in the study for coverage by local flaps like cross figure, lateral proximal phalanx, flag, thenar, homo-digital flaps etc. Results were studied in terms of functional outcomes. All the five parameters were achieved in 84 (87.5%) patients. Complications were observed in 10 (10.4%) patients. The most frequent complication was wound infection, which was observed in 2 (2.1%) patients. Local flaps for finger defects are a very effective way of providing durable soft tissue coverage. Key Words: Digital defects, Digital reconstruction, Local flaps for digits, Hand injuries.

A review of the Turned-down Onto Pericapsular-tissue Hemisectioned Amputated Toe (TOPHAT) flap for wound coverage during ray amputations of the toes

IntroductionExposure of the adjacent Metatarsal-Phalangeal Joint (MTPJ) commonly occurs after application of Topical Negative Pressure Wound Therapy (TNPWT) for a ray amputation wound. This is due to mechanical soft tissue erosion or trauma to the adjacent digital artery from direct pressure effect. This results in toe gangrene requiring a ray amputation and ultimately a larger wound bed. We describe the use of the Turned-down Onto Pericapsular-tissue Hemisectioned Amputated Toe (TOPHAT) flap – a filleted toe flap to protect the adjacent MTPJ capsule combined with a novel Negative Pressure Wound Therapy with instillation and dwell-time (NPWTi-d) dressing technique. The flap protects the adjacent joint capsule and reduces the wound burden whilst allowing the wound to benefit from TNPWT, thereby accelerating wound healing. Material and methodsA retrospective review was conducted of patients with toe gangrene requiring ray amputation that underwent the TOPHAT flap on in our institution from 2019 and 2020. Complications such as wound dehiscence, hematoma, flap necrosis and secondary infection were recorded. Other outcomes recorded were time taken to final skin grafting and time taken for complete wound epithelialization. Results9 patients underwent treatment with the TOPHAT flap. 2 patients had flap necrosis. 7 patients progressed to definitive skin coverage with skin grafting. One patient subsequently had progressive arterial disease despite successful skin grafting and required above knee amputation. The mean time to final skin grafting and complete wound epithelialization was 49.5 days and 107.5 days respectively. All patients were satisfied with the outcomes and were able to return to their pre-morbid function. ConclusionsThe TOPHAT flap has a consistent vascular supply that provides durable soft tissue coverage. It is a robust and easily reproducible technique to accelerate wound healing after ray amputations even in patients with peripheral vascular disease.

Bilaminate Synthetic Dermal Matrix versus Free Fascial Flaps: A Cost-Effectiveness Analysis for Full-Thickness Hand Reconstruction.

Full-thickness injuries to the hand require durable soft tissue coverage to preserve tendon gliding and hand motion. We aim to investigate the cost effectiveness of hand resurfacing comparing free fascial flap reconstruction versus bilaminate synthetic dermal matrices. Cost effectiveness was modeled using decision tree analysis with the rollback method. Total active range of motion was modeled as the common outcome variable based on systematic literature review. Costing was performed from a payer perspective using national Medicare reimbursements. The willingness to pay threshold was determined by average worker's compensation for hand disability. Probabilistic sensitivity analysis was conducted for range of motion outcomes and the costs using 10,000 Monte Carlo simulations. The average cost of free fascial flap reconstruction was $14,201.24 compared with $13,674.20 for Integra, yielding an incremental cost difference of $527.04. Incremental range of motion improvement was 18.0 degrees with free fascial flaps, yielding an incremental cost effectiveness ratio of $29.30/degree of motion. Assuming willingness to pay thresholds of $557.00/degree of motion, free-fascial flaps were highly cost effective. On probabilistic sensitivity analysis, free fascial flaps were dominant in 25.5% of simulations and cost effective in 32.1% of simulations. Thus, microsurgical reconstruction was the economically sound technique in 57.5% of scenarios. Free fascial flap reconstruction of complex hand wounds was marginally more expensive than synthetic dermal matrix and yielded incrementally better outcomes. Both dermal matrix and microsurgical techniques were cost effective in the base case and in sensitivity analysis. In choosing between dermal matrix and microsurgical reconstruction of complex hand wounds, neither technique has a clear economic advantage.

Revisiting Gillies' "Cocked Hat" Reconstruction for Thumb Reconstruction.

A technique for reconstructing a thumb following amputation through the metacarpal phalangeal joint is described. This technique was first described by Gillies and involves bony augmentation with iliac crest bone graft to lengthen the first ray and a random pattern flap to cover and provide durable sensate soft tissue coverage. As opposed to more commonly performed procedures, this technique does not involve microsurgery or any specialized equipment. There are several limitations to this technique, but it remains a good option where resources do not allow more modern reconstructive procedures. We present our use of the technique, which was performed at a forward operating base for a coalition service member.

A Review of Local Soft Tissue Coverage Options for Oncologic Defects of the Distal Lower Extremity

Abstract The distal third of the lower extremity has historically been a challenging anatomic region to provide durable soft tissue coverage following significant trauma or oncologic resection. This is due to the paucity of locoregional tissue. At times, wound coverage is the rate limiting factor in attempts at limb salvage, and the pendulum has swung from amputation to utilization of free tissue transfer as these techniques have developed over the years. The most recent published novel techniques in reconstruction of this area have instead utilized local tissue options rather than their free flap counterparts. The potential benefits of choosing these alternatives in the appropriate patient selection include less donor site morbidity, less operative time, ability of more healthcare facilities to provide reconstruction if not equipped for free flaps, and preservation of other sites if they are needed for in the setting of disease progression. This provides a review of the most common and reliable locoregional options for the distal leg, ankle, and foot.

Keystone flap: a safe coverage option in the handling of salvage for myelomeningocele

Myelomeningocele (MMC) is the most common and severe pathology of open spina bifida compatible with life. Its early closure is an urgent therapeutic objective to reduce the morbidity and mortality of neonates, being a surgical challenge with two major objectives: (1) achieve closure of the dural cerebrum-spinal fluid fistula and (2) ensure a stable and durable soft tissue coverage. The use of fasciocutaneous flaps in keystone design is shown as a safe and stable surgical option with excellent aesthetic results in patients with MMC and who presented failed primary closures. Two clinical cases of fasciocutaneous flaps in keystone design were described as a coverage option in patients with lumbosacral MMC, in whom the primary closure was unsuccessful and required a safe coverage as a priority. Successful coverage of the lumbosacral defect was performed using keystone flaps in neonatal patients with MMC and previous manipulation of the soft tissues when attempting primary closure, but they have had dehiscence of the wound, with a large area of lumbosacral defect and sizeable defect/back ratio. The use of keystone flaps is a useful, accessible, and versatile technique as a management option for lumbosacral coverage defects in MMC, achieving a stable and safe covering of the meninges, without cerebrum-spinal fluid fistulas, which also allows the primary closure of the soft tissues in the donor area. The safety of this type of flap when used as salvage in lumbosacral defects with previously handled and raised tissues could infer that it is reliable enough to be considered as a first surgical option in the initial management of MMC.

Free Serratus Fascia Flap for Reconstruction of Soft Tissue Defects Involving the Distal Upper and Lower Extremity.

Free fascial flaps are widely used for the reconstruction of defects located on the distal extremities as they provide thin yet durable soft tissue coverage. The serratus anterior fascia flap stands out from other fascial flap alternatives as it has optimal anatomical properties that can provide ideal coverage in a wide range of reconstructive challenges. The purpose of this study was to present our experience with the serratus anterior fascia flap in a variety of complex soft tissue defects. A retrospective review was conducted on patients who underwent reconstruction with the free serratus anterior fascia flap for complex soft tissue defects involving the distal extremities. Complex soft tissue defects of 13 patients were reconstructed using the free serratus fascia flap. No major postoperative complications such as flap loss, dehiscence, infection, or hematoma were encountered in any of the patients. All of the patients demonstrated durable and harmonious long-term flap coverage that facilitated movement without any signs of scar contractures and tendon adhesions at the site of reconstruction. The serratus anterior fascia flap demonstrates versatility and stability for the closure of complex distal extremity defects. It creates thin yet durable coverage that facilitates underlying tendon gliding while providing harmony with the natural contours of these anatomic areas and has low donor site morbidity, making it a primary choice in the reconstruction complex soft tissue defects involving the hands and feet.

Reconstruction of Deep Burn Wounds Around the Ankle With Free Fascia Flaps Transfer and Split-Thickness Skin Graft.

We aimed to introduce a technique by combining free fascia flaps transfer with split-thickness skin graft for the reconstruction of deep burn wounds at the ankle. Fifteen patients from 2009 to 2016 were enrolled in this study. Patients in this series suffered from a deep burn injury around the ankle, which was accompanied with exposure of tendon and medial or lateral malleolus exposure due to severe soft-tissue defects (N = 15). All the 15 wounds were repaired combining free fascia flaps with split-thickness skin graft operations, including nine anterolateral thigh fascia lata flaps (ATFL flaps) and six superficial temporal fascia flaps (STF flaps). All the fascia flaps completely survived. Two patients showed partial grafting skin necrosis due to either wound infection or subcutaneous hematoma infection, and this was eventually healed satisfactorily after conventional dressing change. All patients achieved esthetic outcome and acceptable functionality without further revisions needed. Our present study reports a useful method that involves using free fascia flaps in combination with split-thickness skin graft to repair deep burn wounds around the ankle. This method provided reliable and durable soft-tissue coverage with good outcomes.

Outcomes after retroflexed gracilis muscle flap for vascular infections in the groin

Multiple catheterizations and procedures on the femoral arteries can increase the risk of infection and eventual destruction of the overlying skin and subcutaneous tissue. Without adequate tissue coverage, vascular structures are exposed and, thus, vulnerable to disruption. This can lead to loss of limb and/or life and carries a significant mortality. We hypothesized that gracilis muscle flap (GMF) was a reliable adjunct in providing healthy tissue coverage for a complex surgical problem. Retrospective review of charts was performed on all patients who had undergone GMF for groin infections at a tertiary care medical center. From 1997 to 2012, GMF was performed in 68 limbs (64 patients) by vascular surgeons for infectious etiology to cover the common femoral artery. At the time the GMF was placed, the femoral artery had synthetic graft/patch in 14 limbs, whereas 54 limbs had procedures with autologous conduit. Complete healing was achieved in 58 (85%) limbs. Treatment was deemed not successful in 10 limbs where patients continued to have persistent infection. Six out of 10 limbs had anastomosis disruption requiring emergent ligation of the common femoral artery. Nine patients died during the perioperative period (30-day). There were a total of 13 amputations in 12 patients. Limb salvage was achieved in 55 limbs (81%). Univariate analysis suggested that patients that had revascularization procedures with synthetic graft had a higher complication rate compared with autologous/vein reconstruction (24% vs 5%; P= .021). This group also has a higher rate of persistent infection compared with the autologous group (24% vs 2%; P= .006). Patients older than 75years at the time of GMF had a higher incidence of GMF-related complications (57% vs 5%; P= .04). Multivariate analysis confirmed that presence of prosthesis led to higher incidence treatment failures and muscle flap complications at the surgical site (odds ratio, 6.6; P= .04; and odds ratio, 13.3; P= .03, respectively). GMF is technically simple to perform and provides durable soft tissue coverage with a high rate of healing for complex groin wounds even in the presence of synthetic conduit.

Functional and Clinical Outcomes of Upper Extremity Amputation.

Upper extremity amputation is an uncommon but often necessary procedure. It can be required as a result of trauma, infection, or malignancy. Amputation is a life-changing procedure. Careful planning for it must not only include the level of amputation and assurance of durable soft-tissue coverage of the amputation site, but it must also consider patients' goals and occupations, as well as social factors affecting amputees. The choice of prosthesis is an individual matter, but new technology permits lighter and more multifunctional prostheses. Targeted muscle reinnervation can be used to achieve improved myoelectric signaling and possibly decrease limb pain following amputation. Rehabilitation is crucial to achieving favorable results.

Microsurgical Lower Extremity Reconstruction in the Subacute Period: A Safe Alternative.

Background:Microsurgical reconstruction of the lower extremity is an integral part of the limb salvage algorithm. Success is defined by a pain-free functional extremity, with a healed fracture and sufficient durable soft tissue coverage. Although early flap coverage of lower extremity fractures is an important goal, it is not always feasible because of multiple factors. Between the years 2000 and 2010, approximately 50% of patients at Los Angeles County and University of Southern California Medical Center requiring microsurgical reconstruction did not receive soft tissue coverage until more than 15 days postinjury secondary to primary trauma, physiologic instability, patient comorbidities, or orthopedic and plastic surgery operative backlog. The objective of our study was to evaluate outcomes in patients who underwent microsurgical reconstruction of the lower extremity, in relation to the timing of reconstruction.Methods:A retrospective chart review was performed for patients requiring immediate lower extremity reconstruction from January 2000 to December 2009 at LAC + USC.Results:Fifty-one patients were identified in this study. The most common mechanisms of injury were motorcycle, motor vehicle, and fall accidents. Eighty-six percent of injuries were open and 74% were comminuted. The distal 1/3 of the tibia, including the tibial pilon, was the most common location of injury. When comparing patients reconstructed in less than 15 days versus greater than or equal to 15 days, there was no significant difference in rates of flap failure, osteomyelitis, bony union, or ambulation.Conclusion:Microsurgical reconstruction of the lower extremity in the subacute period is a safe alternative.

Digital Fillet Flaps: A Systematic Review.

Digital fillet flaps have a consistent vascular supply and provide durable soft-tissue coverage. Despite their readily available nature, their use in the foot remains limited. This systematic review was undertaken to determine the size defect that could be covered, the potential postoperative complications, and the durability of a digital fillet flap. Studies were eligible for inclusion if they involved use of the entire digit for soft-tissue coverage of defects of any etiology, reported complications, and had any length of follow-up time. A total of 9 studies met all the inclusion criteria, for a total of 34 patients with a combined mean age of 47.1 years and a combined mean follow-up time of 9.3 months. Complications consisted of continued infection and partial or total necrosis of the flap. Digital fillet flaps were able to cover defects up to a combined mean size of 15.6 cm2. Coverage was found to be best for forefoot ulcerations. The flaps had limited donor site morbidity and provided full coverage of exposed vital and osseous structures that was able to withstand forces applied during weight bearing, The procedure is simple and straightforward, reducing operating time and the need for more complex soft-tissue reconstructive procedures. Therapeutic, Level IV: Systematic review.

Use of a Continuous External Tissue Expander in the Conversion of a Type IIIB Fracture to a Type IIIA Fracture

Various methods have been used for soft tissue coverage of Gustilo-Anderson type IIIB open fractures. These injuries are often contaminated and, by definition, are associated with extensive periosteal stripping and inadequate soft tissue coverage. These characteristics predispose the patient to infection, delayed union, nonunion, and the likelihood of multiple surgeries to achieve durable soft tissue coverage. Although free tissue transfer and rotational flap coverage are the mainstay of treatment for Gustilo-Anderson type IIIB fractures, these procedures typically require additional modalities, such as local wound care, negative-pressure wound therapy, and skin grafting, to expedite wound coverage. Numerous undesirable aspects of these tissue coverage techniques exist, including the requirement for repeated application, potential anesthesia complications, near-constant surveillance, patient compliance, graft failure, and cost. External tissue expanders offer the surgeon a device that can rapidly facilitate closure of full-thickness soft tissue defects. This technique offers the benefit of a 1-time application that is easy to apply and cost-effective and can significantly improve fracture coverage options with a cosmetically acceptable result. Although this technique has been previously described for fasciotomy and ulcer coverage, to the authors' knowledge, continuous external expansion has never been reported in open fracture wound management, specifically in converting type IIIB to type IIIA open fractures. The authors' early success with this method indicates that it may be a valuable tool in the management of Gustilo-Anderson type IIIB open fractures.

Total Patellar Skin Loss From Cryotherapy After Total Knee Arthroplasty

The use of cryotherapy after total knee arthroplasty is a very common therapeutic adjunct accepted as routine postoperative care. We present 2 cases of total patellar skin loss due to cryotherapy after total knee arthroplasty. Substantial soft tissue defects were created after the initial debridement of the necrotic tissue. Both patients were evaluated for frostbite, and the wounds were sharply debrided. Application of an advanced wound management technique involves the use of a collagen-glycosaminoglycan biodegradable bilayer matrix, silver impregnated antimicrobial dressing, and low-pressure vacuum device, followed by delayed split thickness skin grafting and low-pressure vacuum device. We find that this technique provided durable soft tissue coverage for necrotic wounds of the knee that do not involve the joint capsule.

Freier Latissimus-dorsi-Transfer zur Rekonstruktion von Weichteildefekten der unteren Extremität

Sustainable and durable soft tissue coverage at the lower extremity following trauma, tumor resections, sequelae of radiation therapy or osteomyelitis using free latissimus dorsi muscle transfer is provided by a free latissimus dorsi muscle flap. Soft tissue defects at the lower extremity following trauma, tumor resections, and sequelae of radiation therapy or osteomyelitis. Thoracotomy with incision of the latissimus dorsi muscle; a relative contraindication in wheelchair drivers as well as in overhead athletes due to potential diminished strength and shoulder proprioception following latissimus dorsi muscle transplantation. Under general anesthesia the patient is positioned laterally, and a substantial and meticulous debridement of the defect is performed, as is the identification and preparation of the target vessel, which is preferentially the posterior tibial artery at the calf, or more proximally the popliteal or femoral artery from the medial side as well as concomitant veins/the great saphenous vein. A tailored latissimus dorsi musculocutaneous flap is harvested with subsequent microsurgical anastomosis to the target vessel with preferential end-to-side anastomosis of the artery and end-to-end anastomosis of one or two veins. A 24-h intermediate care unit, clinical flap monitoring for at least 5-7days, dangling of the flap using an elastic bandage for an initial 3 times 5min starting on POD7, compression stockings for at least 6months subsequently. From 2001-2007 75 free latissimus dorsi flaps were performed (53 ± 17years) for soft tissue coverage at the lower extremity. In 58% the target vessel was the posterior tibial artery, in 11% the femoral artery, in 8% the anterior tibial artery and in 8% the popliteal artery. In 15% an arteriovenous (AV) loop was applied. Overall free flap survival was 95%. We encountered four total flap losses, exclusively in complex reconstructions with AV-loop situations.

Anterolateral Thigh Flap–Based Reconstruction for Oncologic Vulvar Defects

Vulvar defects after tumor extirpation always require immediate reconstruction. Transferring a skin flap from a distant region may be required for large defects. Although the anterolateral thigh flap has gained popularity in other types of oncoplastic surgery, it has rarely been reported for vulvar reconstruction. The aims of this retrospective study were to evaluate the outcome of anterolateral thigh flap-based vulvar reconstruction and to develop an operative strategy. Eleven patients with vulvar carcinoma underwent resection and immediate reconstruction with the anterolateral thigh flap between 2005 and 2009. Based on defect type and local soft-tissue quality, four types of anterolateral thigh flap-based reconstructions were performed: unilateral anterolateral thigh flap, ipsilateral anterolateral thigh flap combined with contralateral advancement flap or local flap, fenestrated anterolateral thigh flap, and split anterolateral thigh flap. Postoperative complications were recorded and clinical outcomes were evaluated. Partial flap necrosis occurred in one patient with a fenestrated anterolateral thigh flap for bilateral reconstruction. One wound dehiscence occurred in the contralateral local flap. Two patients had prolonged serous drainage. Mean follow-up was 8 months. One patient developed stricture of the urethral meatus and another had regional metastasis. With careful design, the anterolateral thigh flap may provide reliable and durable soft-tissue coverage for various vulvar defects with good outcomes and minimal donor-site morbidity.

Reversed turnover latissimus dorsi muscle flap for closure of large myelomeningocele defects

Soft-tissue coverage of large myelomeningocele defects is a major surgical challenge that requires close co-operation between neurosurgeons and plastic surgeons to achieve adequate, durable and tension-free coverage of the neural tube. This study was conducted in Zagazig university hospitals on 11 infants, born with large thoracolumbar myelomeningocele defects, presented from June 2004 to February 2007. These defects were reconstructed by using reversed turnover latissimus dorsi muscle flap covered by split-thickness skin graft. The infants were between the ages of 2 and 5 days at the time of surgery and were followed up for 6-12 months postoperatively. All patients tolerated the procedure without major complications. This method provides a tension-free, stable and durable soft-tissue coverage with well-vascularised tissue over the dural repair.

Gaenslen's split-heel incision for calcaneal osteomyelitis—Case report

Background The purpose of the report was to present a 45-year-old lady who had a chronic osteomyelitis right calcaneum with a large non-healing ulcer and discharging sinus, treated by split-heel incision of Gaenslen. Objectives Patients who have a recurrent ulcer of the heel often have a below-the-knee amputation because durable soft tissue coverage cannot be obtained over the calcaneus. Often, even if the ulcer heals satisfactorily or the area appears to be revascularized as a result of a peripheral vascular procedure, the resulting surface is not durable and the ulcer recurs. Gaenslen's technique is recommended for refractory cases or patients with a draining sinus centrally located on the plantar aspect of the heel. An excellent functional result can be obtained. Method Calcaneum was divided from posterior to anterior with a broad osteotome and split into two halves to expose the interior of the bone. Sequestra, infected material, necrotic slough damaged cortex were removed. The wound was closed loosely with a drain in situ. Result The pressure sore and the surgical wound healing were remarkable at the end of 6 weeks. The heel had a deeply situated surgical scar and over which the surrounding tissues were laid, thus forming thick cushions. Conclusions Split-heel incision of Gaenslen removed all sequestra, obviously infected matter and did little damage to the cortex. The resultant scar was painless and was so deeply situated that the tissues on either side curl inward to form ‘cushions’.