Muscle Flap Research Articles

Combined resection of lung cancer and thoracic aortic wall with simultaneous thoracic aortic endografting: a case report

BackgroundCombined resection of lung cancer and the thoracic aortic wall with thoracic aortic endografting has been reported. However, whether the resection and endografting should be performed simultaneously or in two steps remains controversial.Case presentationA 68-year-old man was referred to our hospital because of left chest pain. Chest contrast-enhanced computed tomography revealed a huge tumor of the left lower lung lobe, and invasion to the aortic wall was suspected. Bronchoscopic examination was performed, revealing squamous cell carcinoma with a programmed death ligand 1 expression level of 90%. The clinical stage was T4N0M0 stage 3A. After neoadjuvant chemotherapy and radiotherapy, we performed one-stage surgery with the patient in the right lateral decubitus position and the left inguinal region exposed for femoral vessel isolation. Posterolateral thoracotomy was performed with making a latissimus dorsi muscle flap. The pulmonary artery, vein, and left lower bronchus were cut with a stapler. After hilar isolation, we evaluated the involvement of the descending aorta and marked the area of the involved aortic wall by a surgical clip. Using the left femoral artery approach, a GORE TAG conformable thoracic stent graft was delivered to the descending aorta. After thoracic aortic endografting, the involved aortic wall was resected and the left lower lobe of the lung and resected aortic wall were resected en bloc. The adventitial defect was covered by the latissimus dorsi muscle flap. The operating time was 474 min, and the blood loss volume was 330 mL. The postoperative pathological diagnosis was adenocarcinoma with an epidermal growth factor receptor mutation of exon 19 deletion. The residual viable tumor was 7 mm in diameter and close to the resected aortic wall. The patient’s postoperative course was uneventful. Five days after surgery, chest contrast-enhanced computed tomography revealed no endoleak or stent migration. Three months after surgery, he was alive with neither recurrence nor stent graft-related complications.ConclusionsOne-stage surgery involving combined resection of lung cancer and the thoracic aortic wall with simultaneous thoracic aortic endografting in the right lateral decubitus position with the left inguinal region exposed is safe and acceptable.

Sensory and pain outcomes of neurotized skin-grafted free gracilis muscle flaps for lower extremity reconstruction

BackgroundSkin-grafted free gracilis muscle flaps are commonly used for lower extremity reconstruction. However, the loss of sensory function may lead to increased patient morbidity. This study prospectively analyzed the sensory and neuropathic pain outcomes of neurotized skin-grafted free gracilis muscle flaps used for the reconstruction of lower extremity defects. MethodsPatients undergoing lower extremity reconstructions between 2020 and 2022 with neurotized skin-grafted free gracilis muscle flaps were prospectively enrolled. Sensation was assessed at 3, 6 and 12 months postoperatively using monofilaments, two-point discrimination, a vibration device, and cold and warm metal rods. Sensations were tested in the center and periphery of the flaps, as well as in the surrounding skin. The contralateral side served as the control. Patients completed the McGill pain questionnaire to evaluate patient-reported neuropathic pain. ResultsTen patients were included. At 12 months postoperatively, monofilament values improved by 44.5% compared to that of the control site, two-point discrimination, cold detection, warmth detection, and vibration detection improved by 36.2%, 48%, 50%, and 88.2%, respectively, at the reconstructed site compared to those at the control site. All sensory tests were significantly better than 3 and 6 months values (p < 0.05), but remained significantly poorer than the control site (p < 0.05). Sensation in the central flap areas were similar to peripheral flap areas throughout the follow-up period (p > 0.05). The surrounding skin reached values similar to the control site at 12 months (p > 0.05). Moreover, 50% of patients reported neuropathic pain at 3 months postoperatively, 40% at 6 months, and 0% at 12 months (p < 0.05). ConclusionMechanical detection, vibration detection, temperature detection, and two-point discrimination significantly improved over time but without reaching normal sensory function at 12 months postoperatively. Neuropathic pain resolved at 12 months.

Pedicled Peroneus Brevis Muscle Flaps as an Alternative to Fasciocutaneous Rotational Flaps for Lower-Extremity Soft Tissue Defects.

To report our experience using a peroneus brevis flap (PBF) for soft tissue defects of the distal third of the tibia, ankle, and hindfoot in resource-challenged environments. Retrospective review. Rural outpatient surgical facility in Honduras. Patients who sustained tibia, ankle, or hindfoot fractures or traumatic degloving, with critical-sized soft tissue defects treated with either a proximally based or distally based pedicled PBF to achieve coverage of the middle and distal third of the leg, ankle, and/or hindfoot. Flap healing, complications, and reoperations. Twenty-three patients, 4 with proximally based and 19 with distally based PBF flaps were included. The mean patient age was 37.3 (SD = 18.3; range 18-75 years). Duration of follow-up averaged 14.7 months (SD = 11.4; range 4-46). The PBF successfully covered the defect without the need for additional unplanned surgical flap coverage in all but 2 patients. Thirty percent of the PBFs received a split thickness skin graft, while the remainder granulated successfully without skin graft. Four flaps were partially debrided without additional flap mobilization, while 1 flap was lost completely. Ten patients had successful re-elevation of their flaps for secondary procedures such as implant removal, spacer exchange, deep debridements, and bone grafting. All donor site incisions healed without complication. The pedicled PBF allows coverage of distal leg, ankle, and hindfoot wounds using muscle in patients who may otherwise require free tissue flaps or transfer to another institution for coverage. PBFs can be learned and implemented without the use of microvascular techniques. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Diagnosis and Management of Esophageal Fistulas After Lung Transplantation: A Case Series.

Lung transplantations are highly complex procedures, often conducted in frail patients. Through the addition of immunosuppressants, healing can be compromised, primarily leading to the development of bronchopleural fistulas. Although esophageal fistulas (EFs) after lung transplantation remain rare, they are associated with significant morbidity. We aimed to investigate the clinical presentation, diagnostic approaches, and treatment strategies of EF after lung transplantation. All patients who developed EF after lung transplantation at the University Hospitals Leuven between January 2019 and March 2022 were retrospectively reviewed and the clinical presentations, diagnostic approaches, and treatment strategies were summarized. Among 212 lung transplantation patients, 5 patients (2.4%) developed EF. Three patients were male and median age was 39 y (range, 34-63). Intraoperative circulatory support was required in 3 patients, with 2 needing continued support postoperatively. Bipolar energy devices were consistently used for mediastinal hemostasis. All EFs were right-sided. Median time to diagnosis was 28 d (range, 12-48) and 80% of EFs presented as recurrent respiratory infections or empyema. Diagnosis was made through computed tomography (n = 3) or esophagogastroscopy (n = 2). Surgical repair with muscle flap covering achieved an 80% success rate. All patients achieved complete resolution, with only 1 patient experiencing a fatal outcome during a complicated EF-related recovery. Although EF after lung transplantation remains rare, vigilance is crucial, particularly in cases of right-sided intrathoracic infection. Moreover, caution must be exercised when applying thermal energy in the mediastinal area to prevent EF development and mitigate the risk of major morbidity. Timely diagnosis and surgical intervention can yield favorable outcomes.

Costal cartilage as a promising technique for large bronchial fistula closure in fistulous empyema: a case report

BackgroundThere is no high level of evidence for the treatment of fistulous empyema. We report here a promising technique for closure of a bronchopleural fistula using costal cartilage as a bronchial embolus.Case presentationThe patient is a 79-year-old man. A computed tomography scan diagnosed a fistulous empyema associated with perforation of lung abscess of right middle lobe. After thoracoscopic curettage of the right empyema cavity, right middle lung resection and intercostal muscle flap coverage over the bronchial stump were performed. Seven months after the surgery, a bronchopleural fistula developed. Bronchoscopy revealed fistulas in the middle lobe bronchus and B3b. After the open window thoracostomy, the empyema cavity was cleaned up. The empyema cavity remained from the anterior to the lateral thoracic region of the second to fourth ribs. A part of the second through fourth ribs that formed the ceiling of the pleural empyema cavity was removed to create space for skin and thickened parietal pleura to fill the cavity. The costal cartilage obtained from the rib resection was trimmed and harvested to fit into the diameter of the bronchopleural fistula. The free costal cartilage was sutured and fixed with five stitches with 3-0 PDS. The visceral pleura was covered with the thickened parietal pleura and skin and fixed airtight. To maintain a tight seal, a Blake® silicone drain was inserted between the visceral pleura and the thickened parietal pleura, and a suction reservoir was utilized to sustain negative pressure. The drain was removed on the 21st day. As of 21 months postoperatively, the skin and thickened parietal pleura flap has maintained its integrity, and there has been no evidence of pus or recurrence of air leaks.ConclusionIn the case of a fistulous empyema extending anteriorly, costal cartilage can be easily harvested, making it a promising option as a lid for fistula closure.

Microvascular Muscle vs. Fascio-Cutaneous Free Flaps for Reconstruction of Plantar Load-Bearing Foot Defects-An International Survey.

Background: The reconstruction of plantar load-bearing foot defects faces many plastic surgeons with a major challenge. The optimal patient- and defect-oriented reconstructive strategy must be selected. Methods: To analyze the current trends and recommendations in reconstruction of plantar load-bearing foot defects, we conducted an international survey among plastic surgeons querying them about their recommendations and experiences. Results: The survey revealed that the most common strategies for reconstruction of the foot sole are locoregional and microvascular free flaps, emphasizing the relevance of plastic surgery. Among microvascular free flaps, muscle and fascio-cutaneous free flaps are by far the most frequently used. The target qualities of the reconstructed tissue to be considered are manifold, with adherence being the most frequently mentioned. We observed a noteworthy correlation between the utilization of muscle flaps and a preference for adherence. In addition, we identified a substantial correlation between the usage of fascio-cutaneous free flaps and further target qualities, such as good skin quality and sensitivity. Conclusions: Our findings provide insights into the clinical reality and highlight important aspects that must be considered in reconstruction of the weight-bearing areas of the foot providing support in the selection of the appropriate therapy.

Demographic review of aesthetic surgery for patients with facial palsy.

This study analyzed the demographic characteristics of patients with facial palsy who were treated using either dynamic or static procedures. This study aimed to compare the frequency of procedure implementation and age distribution between the two groups. This study retrospectively analyzed the medical records of patients treated for facial palsy at a single institution from 2014 to 2022. Among cases included in our study, dynamic procedures involved cross-facial nerve graft and latissimus dorsi or gracilis muscle flap transfer. Static procedures included gold weight insertion, canthopexy, browlift, and thread lift/static slings. Among the 31 patients included in our study, eight (25.8%) incorporated dynamic techniques, and the average age of patients was 44.75 years (range, 24-68 years) with a male to female ratio of 1:4. The remaining 23 patients (74.2%) underwent a static procedure, of which the average age was 59.17 years (range, 23-81 years) which was statistically significantly higher than the average age of 44.75 of dynamic patients (p= 0.013). Regarding the timing of treatment after diagnosis, no patient underwent dynamic procedures more than 20 years after initial diagnosis. A greater diversity in the timing of treatment was observed in the static group. All patients who underwent dynamic procedures were treated using static procedures during the study period. Because aesthetics-based static techniques are typically quick outpatient procedures that can be performed under local anesthesia, our study shows that these are often preferred treatments for all age groups, especially for debilitated or older patients. Further research is required to investigate the long-term functional outcomes of these surgical techniques in a wider population of patients.

Single Surgeon Comparison of Midline Versus Overlapping Locoregional Flap Closure Following Spinal Instrumentation

BackgroundTwo techniques for paraspinous muscle flap closure of spine surgeries have been described: one with tension-free mobilization of the muscle flaps approximated at the midline and one with perforators more aggressively dissected to allow for overlapping of the flaps. We seek to compare the surgical outcomes in patients who underwent either type of complex spinal closure as no investigation has yet evaluated a superior technique. MethodsAn IRB-approved retrospective analysis was conducted on all patients who underwent spine surgery followed by locoregional muscle flap complex closure performed by a single plastic surgeon between January 2016 and July 2021. Patients were divided into two groups based on which closure method was employed. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed by multivariable logistic regression with Firth’s correction. Results110 patients with similar baseline demographics were included. There were significantly more smokers (15% vs. 0%, p = 0.02) and a significantly greater rate of post-operative radiation (40% vs. 17%, p = 0.009) in the overlapping group. After controlling for smoking and post-operative radiation, the incidence of surgical site infection, skin necrosis, dehiscence, hematoma, and seroma did not differ between the groups. The procedure length per centimeter of closure was shorter in the midline approximation group, although this data fell just short of significance (3.2 vs. 3.8 minutes/cm, p = 0.08). ConclusionThe present study demonstrates that both the overlapping and midline approximation of muscle flaps are equally safe and effective strategies for locoregional closure of spinal wounds.

The primary prevention of pancreatic fistula using a vascularised rectus abdominis muscle flap – A porcine model

A pancreatic fistula is one of the most devastating complications following a Whipple's procedure. Fistula rates remain high despite various modifications to surgical techniques. We propose the use of a vascularised muscle flap in the primary prevention of pancreatic fistulas. A distal pancreatectomy was performed on 5 pigs in our porcine model. A pancreaticojejunal (PJ) anastomotic leak was simulated. The pigs were divided into treatment (4 pigs) and control groups (1 pig). A left pedicled rectus abdominis flap was wrapped around the PJ anastomosis for the treatment group and omitted for the control group. Serum and drain amylase levels were recorded. The PJ-rectus abdominis flap complex was evaluated histologically. There was no biochemical evidence of anastomotic leak in the treatment group. The drain-serum amylase ratio was less than 1.5 in the treatment group (p=0.006). Microscopically, the muscle adjacent to the anastomotic leak showed mild necrotic changes with an affected muscle depth of less than 10%. The vascularised rectus abdominis muscle is a durable flap to withstand proteolytic pancreatic enzymes. It is able to provide a water-tight seal around the PJ anastomosis and mitigate intraperitoneal haemorrhage and infection caused by erosion from the pancreatic fistula.

Outcomes of Free Flap Transfer in Facial Reanimation: A Review.

Free functional muscle transfer is is an option for reanimating the face in chronic facial nerve paralysis. The optimal outcome in these patients is the ability to restore a spontaneous smile in response to emotion. We discuss the role of free functional muscle transfer in facial paralysis treatment, the choices of nerve used in reconstruction surgery, and the application of different types of muscle flaps in facial reanimation. In this paper, we review the relevant and up-to-date academic literature regarding the outcomes of free functional muscle flap transfer in facial paralysis patients.

Robotic harvest of the free gracilis muscle flap

The conventional approach to harvest of the gracilis muscle flap necessitates a medial thigh incision that is often related to several donor site complications. In this report we describe the robotic harvest of the free gracilis muscle flap in order to reduce the morbidity associated with the open incision. Through three ports, the robotic system (Da Vinci Xi, Intuitive Surgical) enables precise dissection of the gracilis muscle, the vascular pedicle, and the obturator nerve; thus, enhancing surgical control, optimizing visualization through magnification, aiding in detailed vascular pedicle dissection and minimizing human error. We believe that the technique of totally robotic harvest of the free gracilis muscle flap, herein introduced, is a feasible and effective approach, and confers specific advantages over traditional harvest technique.

Mentalis Muscle Reconstruction: An Innovative Technique.

The mentalis muscle is a significant component of the lower lip; its injury could impair appearance and function. This study presents a surgical strategy for treating mentalis muscle rupture to restore muscle tension and improve function. Medical records and photographs of 2 patients with mentalis muscle rupture were reviewed. After physical examinations, 3-dimensional computed topographies were conducted to evaluate chin appearance further. The surgical strategy was designed according to individual malformations and requests. Both patients injured their mentalis muscles in childhood and presented to our clinic with a concave deformity at the center of the chin and impaired mentalis muscle function. The surgical procedure involved the reconstruction of the mentalis muscle by reassembling the muscle flaps and releasing the scarred soft tissue. Both patients were satisfied with the outcome. Mentalis muscle rupture requires surgical correction. The study proposes an innovative approach that enables patients to achieve a more harmonious appearance and improve function.

Simple reconstruction of the skin and soft-tissue defect following Fournier’s gangrene

Fournier’s gangrene (FG) is a form of severe necrotizing fasciitis over the external genitalia, perineal, and perianal region with vessel thrombosis, sepsis, and multiorgan failure. Mortality and morbidity are high, treatment includes intensive resuscitation, emergency debridement, and parenteral antibiotics. The defects are closed later using negative pressure, skin grafting, muscle flaps, primary closure, thigh pockets, or a combination. The below case series included four patients who presented with FG involving the perineum and external genitalia, underwent serial debridement of the necrotic scrotal tissue exposing the testes, and once the wound was clean, a local cover for the testes either primary closure by mobilization of healthy skin around the scrotum, or by medial thigh pockets was done. The advantages of utilizing the local skin are reduced friction, good cosmesis, decreased infection, ensured functionality, easier to perform surgically, have reduced hospital stay; as compared to grafting, which leads to contractures with healing, decreased lubrication, and higher patient dissatisfaction. Utilizing the local skin around the scrotum and perineum can act as an efficient means of satisfactory restorative cosmesis and function in FG.

Macedo ileal catheterizable reservoir adding the scissors maneuver of channel continence: Long term follow-up

The Macedo ileal catheterizable channel was published in 2000 and consists of an enterocystoplasty with a catheterizable channel that precludes the need of the appendix for the efferent channel. After 25 years of experience with this technique, we decided to review our experience in a select subgroup of cases performed and followed exclusively by the author in a non-teaching hospital facility after the latest modifications of the procedure. Since 2008, we have refined our technique with the following modifications: small skin transverse incision instead of longitudinal one, with a semicircular flap for further stoma creation in the midline and importantly the scissors maneuver. This maneuver consists of crossing two 2cm rectus abdominis muscle flaps in the midline to create a neosphincter over the catheterizable channel. Follow-up was defined as the interval between the date of surgery and last visit to the clinic. We defined stoma continence if the dry interval between catheterization was 4hs. Early and late complications were reported as well as the reintervention rate. Additional procedures in association with bladder augmentation were also appointed. We have treated 49 patients. Indications were spinal dysraphism (71.4%), mainly myelomeningocele (65.3%), and others (PUV, exstrophy, anorectal anomalies). Urodynamic evaluation showed bladder pressure of high risk for upper urinary tract involvement (66%), urinary incontinence (24.5%), conversion of incontinent urinary diversion (3.8%), one exstrophy patient not considered (1.9%). Mean age at surgery was 88 months (7.3 years), 21 patients had additional surgeries in addition to Macedo ileal catheterizable channel: Macedo-Malone LACE procedure in 21 patients and bladder neck surgery to improve continence in 5 patients. Urinary stoma continence was 93.9% (46/49) after first surgery, one patient had a serous line valve revised, two patients still leak after 2h and await revision. Overall enterocystoplasty complications rate was 12.24% and consisted of urinary leakage in 3 cases and channel/stoma stricture in 3 cases. All patients treated for sphincteric deficiency associated with bladder reconstruction are continent per urethra. Urinary stoma revision for stricture was done in 2 cases and consisted on suprafascial approach and reanastomosis, one patient resolved with dilatation of the channel to the stoma. Mean follow up is 100 months (8.3 years). We confirmed in a long term follow-up based on face-to-face visits with 8.3 years mean follow-up that the Macedo procedure associated with the scissors maneuver is associated with 93.9% continence of the stoma. Overall complications rate was 12.24%. The cosmetic aspect with a small transverse incision and a midline stoma is another strength of the technique.

Interposing Rectus and Gracilis Muscle Flaps for Pelvic Reconstruction in Bladder Exstrophy after Bladder Neck Closure.

The exstrophy-epispadias complex is a spectrum of ventral wall malformations including classic bladder exstrophy and cloacal exstrophy (CE). Patients undergo multiple soft-tissue procedures to achieve urinary continence. If unsuccessful bladder neck closure (BNC) is performed, muscle flaps may be used to reinforce BNC or afterward for fistula reconstruction. In this study, patients reconstructed using a rectus abdominis or gracilis muscle flap were reviewed. A retrospective cohort study of patients with exstrophy-epispadias complex who underwent BNC and had a muscle flap was performed. Indication for flap use; surgical technique; and risks for BNC failure, including mucosal violations (MVs), were reviewed. MVs were previous bladder mucosa manipulation for exstrophy closure, repeat closures, and bladder neck reconstruction. Success was defined as BNC without fistula development. Thirty-four patients underwent reconstruction. Indications included fistula prophylaxis during BNC ( n = 13), fistula closure after BNC ( n = 17), fistula prophylaxis after BNC during open cystolithotomy ( n = 1), or fistula closure after open cystolithotomy ( n = 3). A vesicourethral fistula developed most frequently in classic bladder exstrophy (88.9%) and vesicoperineal fistula in CE (87.5%). Thirty-three rectus flaps and 3 gracilis flaps were used, with success achieved in 97.1% and 66.7%, respectively. All 34 patients achieved success, and 2 patients with CE required a second flap. The rectus flap is preferred as it covers the anteroinferior bladder and pelvic floor to prevent urethral, cutaneous, and perineal fistula formation. The gracilis flap only reaches the pelvic floor to prevent urethral and perineal fistula development. Increased MVs increase the risk of fistula formation and may influence the need for prophylactic flaps. Therapeutic, IV.

Salvage treatment of acute respiratory failure after autogenous tissue flap transplantation for chronic empyema with chest wall sinus: a case report and literature review

BackgroundChronic empyema with chest wall sinus is a difficult and complex disease caused by multiple causative factors. It is difficult to control local infection due to its possible combination of bronchopleural fistula (BPF) and residual bone.The relevant literature emphasizes some risk factors for empyema progression after pneumonectomy, while the correlation between empyema and BPF after pneumonectomy increases mortality by infecting the remaining lungs. After pneumonectomy, the lung function of the contralateral side is particularly important.Case presentationThis paper reports a 62-year-old male patient who underwent right pneumonectomy for squamous cell carcinoma of the lung 12 years ago and began to develop empyema with anterior chest wall sinus 3 years ago. After admission, chest computed tomography (CT) showed right pleural effusion and formation of chest wall sinus. According to his clinical symptoms and imaging examination, he was diagnosed as chronic empyema with chest wall sinus.Due to the huge residual cavity of the patient,the clinical effect of using free vastus lateralis myocutaneous flap combined with pedicled pectoralis major muscle flap to fill the abscess cavity was satisfactory,but acute respiratory failure occurred due to left lung aspiration pneumonia after operation.ConclusionsAfter a series of treatment measures such as tracheal cannula, tracheotomy, anti-infection, maintenance of circulatory stability, and rehabilitation training, the patient was ultimately rescued and cured. Postoperative follow-up showed that the muscle flaps survived and empyema was eliminated.

Post-Intubation Tracheoesophageal Fistula: Surgical Management by Complete Cervical Tracheal Transection.

We report successful surgical management of post-intubation tracheoesophageal fistula (TEF) in an adult patient requiring long-term mechanical ventilation. A complete tracheal transection without tracheal resection, via an anterior cervical approach, followed by direct closure of tracheal and esophageal defect, and interposition of muscle flap between the suture lines and tracheal reconstruction was performed. In selected cases, this surgical procedure may be a viable alternative to traditional techniques used to treat post-intubation TEF via the anterior or lateral cervical approach.

Pectoralis Major Muscle Flap Utilization in Salvage Esophagectomy Including Great Vessel Resection Reconstructed by Prosthetic Grafts.

Salvage surgery is a therapeutic option for recurrent or residual esophageal cancer after definitive chemoradiation therapy. This report aimed to describe the procedure of reconstruction after salvage esophagectomy involving great vessel resection using prosthetic grafts, a pectoralis major muscle (PM) flap, and free jejunal transfer, if required. To the best of our knowledge, no previous report has described the reconstruction of the defect after combined esophageal and great vessel resection. From January 2017 to December 2022, 4 patients underwent salvage esophagectomy with excision of the great vessels and reconstruction with prosthetic grafts, as well as a PM flap placement in a single center. We retrospectively investigated the patients' clinical data. The patients were all men, with a median age of 70 (range, 67-77) years. Regarding neoadjuvant therapy, 2 patients received chemoradiation therapy, 1 patient received radiotherapy only due to drug-induced pneumonia, and 1 patient received chemotherapy with adjuvant radiotherapy. Alimentary tract reconstruction was performed by free jejunal transfer in 2 cases, direct suture in 1 case, and stomach roll in 1 case. In all cases, a vascular bypass was established before tumor resection. We created mediastinal tracheostoma in 2 cases. A PM flap was inserted to cover the prosthetic grafts and approximate the tracheal mucosa. With regard to major complications, leakage from the jejunal esophageal anastomotic site was observed in 2 cases. The leakage improved with conservative treatment without graft removal or replacement in both cases. In cases of locally recurrent or residual tumors after definitive chemoradiation therapy, salvage esophagectomy along with great vessel resection, followed by reconstruction using prosthetic grafts, PM flaps, and free jejunal transfer, if necessary, is a useful option.

Modified Mustardé and Superolateral Periosteal Flaps for Full-Thickness Defects of Medial and Central Lower Eyelid: A Case Series.

Reconstructing full-thickness defects involving 50% to 75% of the horizontal length of the lower eyelid after medial and central full-thickness block resection can be challenging. As a disadvanatge, 1-stage reconstructions may require a free graft reconstruction of the posterior lamella. In addition, 2-stage reconstructions are associated with several complications, including erythema, and the eye must be temporarily closed after surgery. The present study describes a single-surgeon retrospective case series. Five patients diagnosed with basal cell carcinoma underwent wide full-thickness block resection with optimal excision margins (3-5 mm). Subsequently, 1-stage reconstruction was performed using the modified Mustardé flap, incised using the transconjunctival approach. This flap comprised the skin, muscle, tarsus, and conjunctival flap raised from the lateral canthus through a lateral cantholysis procedure, and then extended to the lateral cheek. The flap was medially transposed to cover the medial and central lower eyelid defect. The superolateral periosteal flap was harvested from the superolateral orbital rim attached to the lateral border of the tarsus of the modified Mustardé flap. The lateral forniceal conjunctiva was released from the retractor and advanced superiorly to cover the inner surface. The study included 3 men and 2 women, with a mean age of 71 years (range, 62-90 years). Histological evaluations confirmed tumor-free margins in all cases. The average follow-up duration was 20 months (6-60 months), with no tumor recurrence. None of the patients developed long-term complications, such as ectropion, entropion, lagophthalmos, trichiasis, symblepharon, erythema, wound dehiscence, or flap necrosis. All patients had minimal scarring, and no secondary surgical interventions were necessary. This case series demonstrates the efficacy of the combined modified Mustardé and superolateral periosteal flaps in 1-stage reconstruction of full-thickness defects involving 50% to 75% of the horizontal length of the medial and central lower eyelid without compromising functional and aesthetic outcomes.

Mid-term Clinical Outcome of Microvascular Gracilis Muscle Flaps for Defects of the Hand

Purpose: Gracilis muscle flaps are useful to cover defects of the hand. However, there are currently no studies describing outcome measurements after covering soft tissue defects using free flaps in the hand. Aim: To analyze mid-term results of gracilis muscle flap coverage for defects on the hand, with regard to functional and esthetic integrity. Methods: 16 patients aged 44.3 (range 20–70) years were re-examined after a mean follow-up of 23.6 (range 2–77) months. Mean defect size was 124 (range 52–300) cm2 located palmar (n = 9), dorsal (n = 6), or radial (n = 1). All flaps were performed as microvascular muscle flaps, covered by split thickness skin graft. Results: Flaps survived in 15 patients. 6 patients required reoperations. Reasons for revisions were venous anastomosis failure with total flap loss (n = 1) requiring a second gracilis muscle flap; necrosis at the tip of the flap (n = 1) with renewed split thickness skin cover. A surplus of the flap (n = 2) required flap thinning and scar corrections were performed in 2 patients. Mean grip strength was 25% (range 33.3–96.4%) compared to the contralateral side and mean patient-reported satisfaction 1.4 (range 1–3) (1 = excellent; 4 = poor). Conclusions: Gracilis muscle flaps showed a survival rate of 94%. Patients showed good clinical outcomes with acceptable wrist movements and grip strength as well as high reported satisfaction rates. Compared to fasciocutaneous free flaps, pliability and thinness especially on the palmar aspect of the hand are advantageous. Hence, covering large defects of the hand with a gracilis muscle flap can be a very satisfactory procedure.Level of evidence: IV observational.