Flap Surgery Research Articles

Enhancing Skin Flap Survival with Preoperative Carbon Dioxide Fractional Laser Treatment: A Novel Approach in Reconstructive Surgery

Background: Skin flap necrosis remains a significant challenge in reconstructive surgery, predominantly due to insufficient blood supply. Traditional methods like the surgical delay procedure, while effective, are invasive and associated with considerable patient discomfort and health care costs. This study explores the efficacy of Carbon Dioxide Fractional Laser (CDFL) treatment as a novel, less invasive alternative to enhance skin flap survival. Methods: Twenty-nine adult male Sprague-Dawley rats were divided into 2 groups: a CDFL treatment group (n=14) and a control group (n=15). The CDFL group received laser pretreatment 1 week before flap surgery, whereas the control group underwent flap surgery without pretreatment. Flap survival was assessed 7 days postsurgery using indocyanine green fluorescence angiography. In addition, histological analysis was conducted to evaluate tissue integrity, capillary density, and VEGF expression. Results: The CDFL-treated flaps showed significantly increased survival areas compared with controls (P<0.01). Histological evaluation revealed enhanced capillary dilation and increased VEGF expression in the CDFL group (P<0.05). Although capillary density was higher in the CDFL group, it did not reach statistical significance (P=0.052). Conclusion: CDFL pretreatment significantly improves skin flap survival in rats, suggesting potential as a minimally invasive alternative to traditional surgical delay techniques. This approach could offer substantial benefits in reconstructive surgery, reducing patient morbidity and associated costs. Further studies are warranted to confirm these findings in clinical settings.

Accessory Abductor Pollicis Longus: An Anatomical Case Report

An accessory abductor pollicis longus (APL) tendon is present in more than 80% of people, but a separate muscle belly is present in only 20% of people. The present article documented the atypical anatomical variation of APL found during routine dissection. The muscle had three bellies and three tendons with unique bifurcation and attachments in the right upper limb of a 52-year-old male cadaver. The variation of APL is clinically important for surgeons doing flap surgeries, tendon transfer, for surgeons dealing with De Quervain’s tenosynovitis, and in any operative procedure involving the forearm and hand. Multiple APL tendons can be regarded as a functional advantage since injured tendons can be compensated by healthy ones. In addition, knowledge of the anatomy of the area is essential for treating this condition surgically by performing a tendon release after conservative treatment has failed.

Flap Versus Flapless Implant Placement in Immediate Functional Loading: A Comparative Study

ABSTRACT Background: Dental implants are now the typical tooth replacement method. Because it speeds up therapy, quick functional loading—attaching prosthetic restorations to implants following surgery—has become popular. Flapless implant implantation reduces surgical stress and expedites recovery. Methods: A prospective comparative study of 100 flap and flapless dental implant patients was done. Patient-reported outcomes, implant survival, peri-implant parameters, and surgical complications were assessed. Statistical analysis compared the two groups’ results. Results: Both flap and flapless methods exhibited good implant survival and similar peri-implant characteristics. Patients reported equal postoperative comfort and satisfaction in both groups. Surgical complications were similar for flap and flapless surgeries. Conclusion: In immediate functional loading, flap and flapless implant insertion are equally effective and safe. Both methods yield dependable implant survival, peri-implant health, patient comfort, and surgical safety. Dental professionals should evaluate patient variables and anatomical aspects while choosing an implant implantation surgery. Implant dentistry needs further study on long-term results and treatment regimens.

Comparative evaluation of healing after periodontal flap surgery using EPIGLUE and silk suture: A split mouth clinical study

Comparative evaluation of healing after periodontal flap surgery using EPIGLUE and silk suture: A split mouth clinical study

Robotic nipple sparing mastectomy and immediate breast reconstruction: significant attempts with the latissimus dorsi muscle without island flap.

This study presents preliminary results of robot-assisted nipple-sparing immediate breast reconstruction (R-NSMIBR) with gel implant combined with latissimus dorsi muscle flap without island flap and validation of the safety and utility of this novel surgical modality. Records pertinent to R-NSMIBR with gel implants combined with latissimus dorsi muscle flap surgery for breast reconstruction between September 2022 and May 2023 were examined. A total of 13 patients who underwent R-NSMIBR were analyzed, nine of which were performed without skin island. We divided the patients with and without skin islands into two groups and recorded the operation time and bleeding respectively. The mean total operative time for R-NSMIBR was 436.5±56.88 minutes and 355.75±69.68 minutes. As experience in learning increased, time required to create the operating space and position the robotic arm decreased significantly. Not creating an island of skin also saves a great deal of surgical time. Average total blood loss was 37.5±6.45 mL and 26.25±7.5 mL. No cases of nipple-areolar complex necrosis or perioperative complications or no local recurrences were reported. There were no local recurrences or deaths that occurred during a mean follow-up period of 3±1 months. All the patients expressed satisfaction with the aesthetic outcome following surgery. There were no significant differences between two groups. This surgical method shows promise for future promotion in the field.

Development of an Automated Free Flap Monitoring System Based on Artificial Intelligence

Meticulous postoperative flap monitoring is essential for preventing flap failure and achieving optimal results in free flap operations, for which physical examination has remained the criterion standard. Despite the high reliability of physical examination, the requirement of excessive use of clinician time has been considered a main drawback. To develop an automated free flap monitoring system using artificial intelligence (AI), minimizing human involvement while maintaining efficiency. In this prognostic study, the designed system involves a smartphone camera installed in a location with optimal flap visibility to capture photographs at regular intervals. The automated program identifies the flap area, checks for notable abnormalities in its appearance, and notifies medical staff if abnormalities are detected. Implementation requires 2 AI-based models: a segmentation model for automatic flap recognition in photographs and a grading model for evaluating the perfusion status of the identified flap. To develop this system, flap photographs captured for monitoring were collected from patients who underwent free flap-based reconstruction from March 1, 2020, to August 31, 2023. After the 2 models were developed, they were integrated to construct the system, which was applied in a clinical setting in November 2023. Conducting the developed automated AI-based flap monitoring system. Accuracy of the developed models and feasibility of clinical application of the system. Photographs were obtained from 305 patients (median age, 62 years [range, 8-86 years]; 178 [58.4%] were male). Based on 2068 photographs, the FS-net program (a customized model) was developed for flap segmentation, demonstrating a mean (SD) Dice similarity coefficient of 0.970 (0.001) with 5-fold cross-validation. For the flap grading system, 11 112 photographs from the 305 patients were used, encompassing 10 115 photographs with normal features and 997 with abnormal features. Tested on 5506 photographs, the DenseNet121 model demonstrated the highest performance with an area under the receiver operating characteristic curve of 0.960 (95% CI, 0.951-0.969). The sensitivity for detecting venous insufficiency was 97.5% and for arterial insufficiency was 92.8%. When applied to 10 patients, the system successfully conducted 143 automated monitoring sessions without significant issues. The findings of this study suggest that a novel automated system may enable efficient flap monitoring with minimal use of clinician time. It may be anticipated to serve as an effective surveillance tool for postoperative free flap monitoring. Further studies are required to verify its reliability.

A Classic and Effective Approach for Managing Totally Implantable Venous-Access Port Site Dehiscence in Patients with Cancer: The Limberg Flap

Background: Totally implantable venous-access ports (TIVAPs) are essential for long-term intravenous treatment in cancer patients, but TIVAP site dehiscence remains a significant issue. This study aims to investigate how Limberg flap transposition compares to primary repair and other local flap techniques in managing TIVAP site dehiscence.Methods: A retrospective study was conducted on patients who underwent repair operations, without TIVAP removal, for right subclavicular area TIVAP site dehiscence between May 2016 and March 2023. Outcomes of primary repair, Limberg flap transposition and other local flap surgeries were analyzed, focusing on incisional integrity and dehiscence recurrence rate.Results: Nine patients and 3,204 catheter days were included in the study, with a total of 15 surgical repair procedures performed for dehiscence, including cases of recurrence. Among them, Limberg flap transposition demonstrated the longest period of incisional integrity, with a mean of 231.4 days, surpassing primary repair (74.25 days) and other local flap techniques (29.5 days). Additionally, the Limberg flap exhibited the lowest recurrence rate, with 0.86 events per 1,000 catheter days, compared to primary repair (10.10 events per 1,000 catheter days) and other local flap approaches (16.95 events per 1,000 catheter days).Conclusion: Limberg flap transposition is considered as an effective solution for TIVAP site dehiscence, showing reduced complications and recurrence rates compared to primary repair and other local flap techniques. This study suggests Limberg flap transposition should be considered the preferred option for managing TIVAP dehiscence in cancer patients, thereby improving patient care and outcomes.

Turbocharging of Deep to Superficial Venous System for Vessel Depleted Neck in Radial Forearm Free Flap: A Case Report of One Neck Vein for Drainage of Both Venous Systems

Dual venous anastomosis in radial forearm free flap surgery increases chances of flap survival as compared to anastomosing only the superficial system. A 48-year-old male patient who had received three previous microsurgical reconstructions and radiotherapy presented with recurrent oral cavity carcinoma. Two of these reconstructions were anastomosed to the left side neck vessels. The recurrence was in the left half of the soft palate. The left neck and underlying vessels were severely scarred and fibrotic, and only 2 cm of the left internal jugular vein (IJV) could be circumferentially mobilized for anastomosis, allowing for only one venous anastomosis. The radial forearm free flap was harvested and a tributary of the cephalic vein was preserved in the proximal part to act as a conduit for drainage of one of the venae comitantes. The cephalic vein was anastomosed end-to-side to the IJV and one venae comitantes to the preserved tributary in end-to-end fashion. The flap survived and the patient was discharged in a week. This novel method helps to drain both venous systems through one available neck vein.

Variations in the Termination of the Popliteal Artery: A Multidetector Computed Tomography Angiography (CTA)-Based Retrospective Study.

Comprehension of the intrucate anatomy and variations in the termination of the popliteal artery (PA) is increasingly essential for endovascular interventionists, plastic surgeons, vascular surgeons, and orthopedic surgeons, due to the rise in procedures like embolectomy, vascular grafting, free fibular flap surgery, and high-tibial osteotomy. Few studies from India have reported on the variant anatomy of PA termination, and none have used 128-slice tomography. This study aimed to observe the terminal branching pattern of the PA and the morphology of its terminal branches using 128-slice computed tomography angiography (CTA) and to analyze its relation to gender and laterality. A retrospective review of CTA images of 181 lower extremities from 100 patients (137 males and 44 females), aged five to 75 years, was conducted. The usual type I-A pattern was found in 75.69% of cases, while 24.31% exhibited variant patterns. Type III was the most common variation observed (19.34%), with type III-A being the most prevalent (11.05%). Types II-B and II-C were not observed. Among 84 bilaterally examined cases, 19.05% had unilateral variations and 15.48% had bilateral variations, with 8.33% showing bilaterally similar variations and 7.14% dissimilar variations. No significant difference in branching patterns was found between genders or sides. The mean length of the tibial-peroneal trunk (TPT) in the type I-A pattern was 3.00 ± 0.99 cm (right side: 3.21 ± 1.02 cm; left side: 2.82 ± 0.93 cm; males: 2.9 ± 1.00 cm; females: 3.37 ± 0.85 cm), with statistically significant differences between sides and genders. In the type II-A pattern, the mean TPT length was 7.16 ± 3.75 cm. An exceptionally long TPT (12.97 cm) was noted in one case of the III-B pattern. There is a high prevalence of variation in the termination pattern of the PA. Knowledge of these variations is crucial for any interventions in this region to avoid postoperative vascular complications and reduce patient suffering.

Scalp Flap Surgery - an Efficient Way to Save the Cranial Bone Flaps

Brain surgery often requires wide ecisions to ensure the radicality of the surgical intervention. In this contet, the role of the plastic surgeon becomes essential in the reconstructive stage where outstanding soft tissue defects following life-saving neurosurgical interventions often require creation of large local flaps. By effectively covering the defects with quality tissues, the rapid healing of patients is ensured, as well as obtaining stable results over time. This paper presents the salvage surgical approach in the case of a patient operated for the recurrence of a brain tumor, the rotation scalp flap being the optimal choice for this case.

Clinical efficacy and pain control of diode laser-assisted flap surgery in the treatment of chronic periodontitis:A systematic review and meta-analysis

ObjectiveTo assess the diode laser-assisted periodontal flap surgery's clinical effectiveness and postoperative pain management in treating chronic periodontitis, and to offer evidence-based medical justification for the procedure's clinical use. Data sources and study selectionIn this study, a computer combined with manual search was used to search for articles on diode laser-assisted periodontal flap surgery for the treatment of chronic periodontitis published from the establishment of the database to September 2023. The databases searched included China Academic Journal Full Text Database (CNKI), China Biomedical Literature Database (CBM), Chinese Science and Technology Journal Database (VIP), Wanfang Database, PubMed, Web of science, Cochrane Library, Embase, and Scopus. Two researchers independently performed the screening and study selection, following the inclusion and exclusion standards to extract basic information and required data. Meta-analysis of the included literature was performed using Revman V5.4 software. ResultThirteen articles were analyzed. Meta-analysis showed that the use of the diode laser was effective in reducing patients' probing pocket depth (PPD) at 3 and 6 months postoperatively (3 months: MD = −0.46, 95 % CI = [−0.89, −0.03], P = 0.04; 6 months: MD = −0.35, 95 % CI = [−0.63, −0.06], P = 0.02), was able to effectively improve 3 month clinical attachment level (CAL) (MD = −0.36, 95 % CI = [−0.66, −0.06], P = 0.02), and was able to promote wound healing and reduce patients' early postoperative pain (MD = 0.67, 95 % CI = [0.01, 1.32], P = 0.05; MD = −1.67, 95 % CI = [−2.23, −1.00], and P < 0. 001), while for gingival index (GI), the use of diode laser did not have a significant effect. ConclusionsThe available evidence suggests that the use of a diode laser adjunct is effective in reducing PPD, improving CAL, promoting wound healing, and reducing early postoperative pain in patients compared with flap application alone; however, for GI, diode lasers did not show any improvements. Clinical significancePeriodontal flap surgery fails to eliminate microorganisms from the soft tissue wall, potentially leading to recolonization, reinfection, and accompanying side effects such as pain and swelling. The use of a diode laser reduces PPD, improves CAL, and relieves early postoperative pain.

Interrupted time series analysis of chronic periodontitis-related procedures before and after the scaling reimbursement policy in Korea.

To study the use of a quasi-experimental design to assess the effects of scaling reimbursement policies on the incidence of chronic-periodontitis procedures. Interrupted time series analysis was used to compare the effects before and after policy implementation using data on the number of periodontitis-related procedures from the Korean National Health Insurance Service-National Sample Cohort (n = 740,467) and the Health Screening Cohort (n = 337,904). Periodontitis-related procedures with diagnosis codes were categorized into basic (scaling or root planing), intermediate (subgingival curettage) and advanced (tooth extraction, periodontal flap surgery, bone grafting for alveolar bone defects or guided tissue regeneration). Subjects' demographics and comorbidities were considered. The incidence rate of immediate changes and gradual effects before and after policy implementation was assessed. Following the policy implementation from July 2013, an immediate increase was observed in total and basic procedures. No significant changes were noted in intermediate and advanced procedures initially. A decrease in the slope of intermediate procedures was observed in both databases. Advanced procedures showed varied trends, with no change in the National Sample Cohort but an increase in the Health Screening Cohort, particularly among subjects with comorbidities. Following the new policy implementation, the number of intermediate procedures decreased while the number of advanced procedures increased, especially among patients with comorbidities. These findings offer valuable insights on policy evaluation.

Early Dangling Protocol Post Lower Extremity Free Flap Surgery: An Evidence-based Case Report

Background: Free flap is tissue transplantation by including its feeding artery from one body part to another. Intravascular thrombosis is the main obstacle commonly faced in the anastomosed part. Yet, postoperative extremity mobilization has widely become the main question related to flap failure. Only a few studies explained the best time to perform lower extremity mobilization post free flap surgery to maintain adequate flap viability. This study aimed to find the effectiveness of the dangling protocol in reducing lower extremity free flap surgery complications. Methods: A literature search was conducted through PubMed, Cochrane, and Embase in March 2022 using “Free tissue flap” or “free flap” AND “dangling protocol” or “early ambulation” AND “postoperative complication” keywords. Title and abstract screening, full-text reading, and eligibility assessment were performed to find related evidence regarding our clinical question. Results: The two relevant articles are a systematic review and a clinical trial study. Both studies showed 94-100% flap viability after applying early dangling protocol as early as three days post lower leg free flap surgery with level evidence of IIB up to IV without any incidence of flap necrosis. Conclusion: Early dangling protocol can be implemented safely after free flap surgery of the lower extremity without postoperative complications such as total or partial necrosis.

(135) DYSORGASMIA IN A FEMALE PATIENT FOLLOWING TRAM RECONSTRUCTIVE SURGERY

Abstract Introduction Many women struggle with sexual dysfunction, either in desire, arousal, orgasm, and/or pain. Despite the incidence of dysorgasmia in the general population, there is a paucity of literature focusing on its causes and treatment, especially when attributed to medical conditions and surgery. Objective This case report describes an unusual presentation of post-orgasmic pain following breast reconstruction surgery using abdominal tissue. Methods A 73-year old woman presented with chronic orgasmic pain in the deep pelvic area following transverse rectus abdominal muscle (TRAM) flap reconstruction for a mastectomy in the setting of breast cancer treatment. The patient was diagnosed with ductal carcinoma breast cancer in 2011, where she received a lumpectomy with radiation. After 2 years, in 2013, she was diagnosed with a recurrence of breast cancer. She underwent a mastectomy with no complications, with a transverse rectus abdominal muscle flap reconstruction surgery conducted five days later. Following the TRAM reconstruction, the patient consistently began to observe pain with orgasm. Results Prior to this surgery, the patient had experienced normal sexual intercourse and orgasm throughout her life. The patient describes pain with orgasm associated with self-stimulation, manual stimulation, oral stimulation, and vaginal penetration. The patient describes the pain associated with orgasm as a “deep, dull pain” causing nausea and is often associated with abdominal spasms. The pain lasts 2-3 minutes following orgasm and is rated as a 5-6/10 on the pain scale. The pain is not associated with urinary incontinence, urinary fullness, or bowel dysfunction. Physical exam revealed a tense abdominal wall consistent with TRAM reconstruction, well healed incisions, a normal clitoris in terms of appearance and sensation and normal pelvic floor muscles. Conclusions An orgasm is a complex process which involves interplays between the clitoris, the glans pubis, and the sympathetic activation system. A four-phase model for orgasm has been explored, which separates the orgasm response into: desire (the urge to participate in sexual activities), arousal (increased genital blood flow and clitorial erection), orgasm (after the threshold for stimulation has been reached), and resolution. Dysorgasmia can be multifactorial, and while still unclear, etiologies include pelvic floor dysfunction and/or spasm. While the pathophysiology of how the pelvic floor is connected to orgasm is not exactly understood, it is theorized to be due to dysregulated coordination of pelvic floor muscles. A transverse rectus abdominis muscle (TRAM) flap is a common breast reconstructive procedure following mastectomy. The most common complications of a TRAM flap surgery are hernias/abdominal bulges, fat necrosis, and loco-regional occurance. Interestingly, TRAM surgeries have previously been associated with pelvic floor dysfunction in women due to an increase in abdominal pressure. Since the pelvic floor is tightly connected to the mechanism of an orgasm, it is possible that disruptions to the pelvic floor may lead to painful spasms during orgasms. This is also consistent with the patient’s sensation of abdominal “spasms” during/after orgasm. While not all TRAM surgeries cause dysorgasmia, this patient’s dysorgasmia may be postulated to be secondary to pelvic floor dysfunction. Disclosure No.

Investigation on the influence of the skin tone on hyperspectral imaging for free flap surgery

Hyperspectral imaging (HSI) is a new emerging modality useful for the noncontact assessment of free flap perfusion. This measurement technique relies on the optical properties within the tissue. Since the optical properties of hemoglobin (Hb) and melanin overlap, the results of the perfusion assessment and other tissue-specific parameters are likely to be distorted by the melanin, especially at higher melanin concentrations. Many spectroscopic devices have been shown to struggle with a melanin related bias, which results in a clinical need to improve non-invasive perfusion assessment, especially for a more pigmented population. This study investigated the influence of skin tones on tissue indices measurements using HSI. In addition, other factors that might affect HSI, such as age, body mass index (BMI), sex or smoking habits, were also considered. Therefore, a prospective feasibility study was conducted, including 101 volunteers from whom tissue indices measurements were performed on 16 different body sites. Skin tone classification was performed using the Fitzpatrick skin type classification questionnaire, and the individual typology angle (ITA) acquired from the RGB images was calculated simultaneously with the measurements. Tissue indices provided by the used HSI-device were correlated to the possible influencing factors. The results show that a dark skin tone and, therefore, higher levels of pigmentation influence the HSI-derived tissue indices. In addition, possible physiological factors influencing the HSI-measurements were found. In conclusion, the HSI-based tissue indices can be used for perfusion assessment for people with lighter skin tone levels but show limitations in people with darker skin tones. Furthermore, it could be used for a more individual perfusion assessment if different physiological influencing factors are respected.

Treatment of gum recession by the method of a coronally displaced flap and application of phytoextract

BACKGROUND: Owing to the widespread prevalence of gum recession in the morbidity structure of the population, the search for optimal treatment tactics for patients with this pathology is crucial in dentistry. AIM: To evaluate the effectiveness of treatment of patients with gum recession using the coronally displaced flap method and application of a phytoextract. MATERIALS AND METHODS: Overall, 123 patients diagnosed with gum recession were clinically examined. During examination, all patients revealed a defect such as exposed roots in the area of the frontal group of teeth. Moreover, the size of the defect was measured, and the Miller class was determined. Then, complex treatment was performed, including conservative treatment and, if required, surgical intervention, as well as orthopedic treatment. RESULTS: In the surgical treatment of gum recession, flap operations were performed. On postoperative day 2, to achieve the best healing and regeneration of the gums, a phytoextract was applied. Over a 3-year period after treatment of patients with gum recession, the effectiveness of treatment was monitored, and relapses of the disease were detected. The following complications were identified after treatment of patients diagnosed with gum recession: transition from class I to II to Miller, 15% of cases; class II to III according to Miller, 19.5%; temporomandibular joint diseases during recession, 16.5%; and occlusal deformation during recession, 19.8%. Stabilization in class I recession occurred in 45.0% of patients, class II in 33.4%, and class III in 8.5%. CONCLUSION: The etiology and pathogenesis of gum recession requires long term treatment and observation and early diagnosis and an integrated approach. Therefore, new treatment methods that will be most effective and can be used in all age groups are required. One of these methods is the method developed by the authors for the treatment of gum recession using a coronally displaced flap and the application of a phytoextract, which has shown high effectiveness in the long term.

The Efficacy of Vibhithaki Ksharasutra in the Management of Nadivrana w.s.r Pilonidal Sinus

Pilonidal sinus (PNS) is a chronic disorder that occurs in the space between the buttocks (natal cleft). Men are more susceptible (because they have more hair) to pilonidal sinus than women. Excision, primary closure and reconstructive flap surgery are the most commonly used surgical techniques for this disease. However, there is a high risk of recurrence or wound infection after surgery. In addition, the patient needs a longer hospital stay, and the procedure is expensive. Acharya Susrutha (800 BC) considered this disease under Nadivrana (Shalyaja) and advocated a minimally invasive para surgical treatment namely the Kshara Sutra procedure. Susrutha mentioned Kshara dravyas like Apamarga, Palasha, Vasa, Vibhithaki, etc used in the preparation of the Ksharasutra. Here we selected Vibhitaki to prepare Kshara and Ksharasutra. Vibhithiki is cost-effective as it is easily available and the properties of this plant are favourable to Kshara qualities. The present case study deals with the efficacy of Vibhitaki Ksharasutra in the management of Nadivrana (pilonidal sinus).

Staged treatment with arterial reconstruction and flap transplantation for ischemic mangled extremity: An observational study.

Patients with traumatic ischemic mangled extremities first undergo arterial reconstruction using autogenous vein grafts, followed by flap transplantation as a staged treatment for soft tissue reconstruction. This study aimed to report the outcomes of such a staged treatment. Thirteen patients underwent arterial reconstruction between February 2015 and April 2017 due to damage to the major blood vessels by the traumatic mangled extremities. Of them, 6 patients (5 males and 1 female with a mean age of 51 years, age range: 36-60 years) who underwent soft tissue reconstruction due to necrosis were retrospectively analyzed. The average Mangled Extremity Severity Score was 7.2 (range, 6-8). Injuries were found in the lower leg (4 cases), foot (1 case), and wrist and hand (1 case). Arterial reconstruction was performed using autologous venous grafts. The reconstructed arteries included the posterior tibial artery (3 cases), anterior tibial artery (1 case), dorsalis pedis artery (1 case), and radial artery (1 case). The blood circulation status of the reconstructed blood vessels was assessed using computed tomography angiography at an average of 5 weeks (range, 4-6 weeks) after arterial reconstruction. For some necrotic soft tissues, debridement and flap transplantation were performed an average of 7 weeks (range, 6-8 weeks) after arterial reconstruction. Soft tissue reconstruction was performed with an anterolateral thigh free flap in 4 cases, a local flap in 1 case, and a muscle flap in 1 case. In 5 out of 6 cases, blood circulation was maintained in the reconstructed blood vessels, resulting in the salvaging of the extremities. All the patients who underwent flap surgery survived. Notably, there were no special complications during a follow-up visit conducted at an average of 19 months post-reconstruction. To treat an ischemic mangled extremity, the limbs should first be salvaged with arterial reconstruction, followed by subsequent appropriate flap surgery when soft tissue necrosis occurs at the mangled site as a staged treatment.

Experimental study of slow-released Angiogenin by silicon micro-needle in improving blood support to multiple-territory perforator flaps in rats.

This research aimed to investigate the effect of slow-released angiogenin by silicon micro-needle on angiogenesis in the Choke zone of dorsal multiple-territory perforator flap in rats, as well as its mechanism. Thirty-six adult Sprague-Dawley (SD) rats were randomly divided into control group, model group, and four experimental groups. In model group, slow-release saline through a silicon micro-needle was placed in choke II zone of the flap 7 days before the operation. For rats in four experimental groups, angiogenin was released via micro-needle in the choke I and choke II zones of the cross-zone flap 7 days before and 3 days before flap surgery, respectively. A 12 cm × 3 cm cross-zone perforator flap model was made on the back of all five groups. The flap survival rate in slow-release angiopoietin group was statistically higher than that in model group (P<0.05). Angiogenin in choke zone of the flap was increased in slow-release angiogenin group (P<0.05). In slow-release angiogenin group, the micro-vessel density was increased and the arteriovenous diameter was decreased, while the arteriovenous diameter was increased in model group (P<0.05). The levels of vascularendothelialgrowthfactorA (VEGF-A) and angiotensin 1 (ANG-1) in choke zone were both elevated in slow-release angiogenin group (P<0.05). The expression of CD31 was significantly elevated in flaps of experimental groups (P<0.05). Micro-needle to slow release Angiogenin can increase the drug concentration in the tissues of the choke zone, promote the vascularization of rat dorsal crossover area perforator flap, reduce the possibility of flap ischemic necrosis, and improve the flap survival rate.

Development of a porcine training model for microvascular fasciocutaneous free flap reconstruction

BackgroundIn reconstructive surgery, improvements are needed in the effective teaching of free flap surgery. There is a need for easily accessible and widely available training without high financial costs or ethical concerns while still providing a realistic experience. Our aim was to develop an appropriate training model for microvascular flaps.MethodsWe identified pig head halves as most appropriate regarding availability, cost, and realism. These accrue largely by the food industry, so no animals need to be sacrificed, making it more ethical from an animal welfare perspective. We evaluated the suitability as flap donor site and analyzed the vascular anatomy of 51 specimens.ResultsAnatomical evaluation revealed a reliable and constant vascular anatomy, allowing the design of a flap model that can effectively illustrate the entire process of microvascular flap surgery. The process was divided into 6 key steps. The flap can be harvested after marking the vascular pedicle 5.3 cm from the lateral corner of the mouth. Skin island design and subsequent tissue dissection follow until a fasciocutaneous flap is raised, similar to a radial flap. Upon completion of flap harvesting, it can be freely transferred for defect reconstruction. Microvascular anastomosis can be performed on recipient vessels in the cervical region, and the difficulty can be individually adjusted.ConclusionsThe developed training model is a reasonable compromise in terms of surgical realism, availability, didactic value, and cost/time effectiveness. We believe it is a powerful and effective tool with high potential for improving surgical education and training.