Tissue Flaps Research Articles

Empiric flap coverage for the pneumonectomy stump: How protective is it? A single-institution cohort study

ObjectiveTo evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy. MethodsPatients who underwent pneumonectomy between January 2001 and December 2019 were included. Primary end point was development of BPF. Secondary end points were impact of flap type on BPF rates, time to BPF development, and perioperative mortality. ResultsDuring the study period, 383 pneumonectomies were performed; 93 were extrapleural pneumonectomy. Most pneumonectomy cases had empiric flap coverage, with greater use in right-sided operations (right: 97%, 154/159; left: 80%, 179/224, P < .001). Empiric flaps harvested included intercostal, latissimus dorsi, serratus anterior, omentum, pectoralis major, pericardial fat/thymus, pericardium, and pleura. BPF occurred in 10.4% of the entire cohort but decreased to 6.6% when extrapleural pneumonectomy cases were excluded; 90% (36/40) of BPFs occurred on the right side (P < .001). Median time to develop BPF was 63 days, and 90-day mortality was greater in patients with BPF (12.5% BPF vs 7.4% non-BPF, P < .0001). Intercostal muscle had the lowest rate of BPF (4.5%), even in right-sided operations (8.7%). In contrast, larger muscle flaps such as latissimus dorsi (21%) and serratus anterior (33%) had greater rates of BPF, but the sample size was small in these cohorts. ConclusionsEmpiric bronchial stump coverage should be performed in all right pneumonectomy cases due to greater risk of BPF. In our series, intercostal muscle flaps had low BPF rates, even in right-sided operations. Coverage of the left pneumonectomy stump is unnecessary due to low incidence of BPF in these cases.

A retrospective unicentric cohort study, evaluating the impact of tranexamic acid on autologous free flap tissue reconstruction

The use of tranexamic acid (TXA) has been shown to be effective in reducing haemorrhage and mortality in numerous surgical settings. However, its use in plastic surgery has been limited due to misconceptions related to increased thrombotic events in microsurgery. We performed a retrospective single-centre cohort study including any patients who underwent autologous free flap tissue transfer at Lister Hospital, Stevenage, from 1 January 2016-20 April 2022. The Chi-squared test was used to determine if there were any significant differences between the proportion of patients who developed any evidence of microvascular thrombosis, flap failure, or return to theatre, and univariate logistic regression was used to calculate odds ratio. The treatment group (N = 160) received TXA (1 g intravenous) at the time of general anaesthetic induction as per the senior author's routine practice, while the control group (N = 80) did not receive TXA at any point of the hospital admission, according to the normal practice of other surgeons. No differences were found between the proportion of patients who developed microvascular thrombotic complications between the TXA and control group, contributing evidence that TXA is safe to use in microvascular surgery. TXA may have a role in improving outcomes in plastic surgery procedures by reducing the need for blood transfusions and through anti-inflammatory effects. Our study shows that TXA administration did not increase microvascular thrombosis in free flap reconstructive surgery, contributing evidence that TXA is safe to use in microvascular surgery, however further larger studies are required to improve the power of this study.

Evaluation of Intraoperative Anastomotic Patency with Angiography in Microsurgical Breast Reconstruction.

Microsurgical breast reconstruction is one of the most challenging, yet rewarding procedures performed by plastic surgeons. Several measures are taken to ensure safe elevation of the flap, preparation of recipient vessels, microvascular anastomosis, and flap inset. Reestablishing proper blood flow to the flap tissue after microvascular anastomosis is one of many critical steps for surgical success. Several measures to assess blood flow to the flap have been used; however, the use of indocyanine green angiography (ICGA) of the anastomosis in breast reconstruction has not been well documented. We present a series using ICGA for the evaluation of microvascular anastomosis success in breast reconstruction. Cases from patients who underwent microsurgical breast reconstruction between March 2022 and January 2023 and who had intraoperative ICGA were retrospectively reviewed. We compared the intraoperative findings on ICGA to flap success. Sixteen patients underwent bilateral deep inferior epigastric perforator flap reconstruction with intraoperative ICGA of the microvascular anastomosis, constituting 32 deep inferior epigastric perforator flaps. The ICGA demonstrated return of blood flow in all the flaps after microvascular anastomosis and no flap loss in our sample population. Nine flaps required additional drainage using the superficial inferior epigastric vein, and the superficial circumflex vein was used for additional drainage in one of the flaps. The use of intraoperative ICGA provides reliable visual feedback regarding the patency and direction of the blood flow through the microvascular anastomosed vessels. ICGA can be used as an additional tool in the plastic surgeon's armamentarium for successful breast reconstruction.

544 Effect of Tranexamic Acid on Microvascular Thrombosis in Autologous Free Tissue Transfer

Abstract Aim The use of Tranexamic Acid (TXA) has been shown to be effective in reducing haemorrhage and mortality in numerous surgical settings and has a wide range of proposed benefits linked to anti-inflammatory effects which promotes healing and reduces pain and discomfort. However, the surgical community has been reluctant to incorporate TXA use into mainstream practices in microvascular surgery due to possible risk of thromboembolic events. Hence, we aim to report our experience with the use of TXA in microsurgical reconstruction. Method We performed a retrospective single-centre cohort study including any patients who underwent autologous free flap tissue transfer at a district general hospital, from 1 January 2016 to 20 April 2022. The Chi-squared test was used to determine if there were any significant differences between the proportion of patients who developed any evidence of microvascular thrombosis, flap failure, or return to theatre. Univariate logistic regression was used to calculate odds ratio. Results The treatment group (N = 160) received TXA (1g intravenous) at the time of general anaesthetic induction as per the senior author’s routine practice, while the control group (N = 80) did not receive TXA at any point of the hospital admission, according to the normal practice of other surgeons. No differences were found between the proportion of patients who developed flap failure, venous congestion or were returned to theatre between the TXA and control group. Conclusions Our study shows that TXA administration did not increase microvascular thrombosis in free flap reconstructive surgery, contributing evidence that TXA is safe to use in microvascular surgery.

Do the Histological Differences of Soft Tissue Sarcomas Affect the Rate of Skin Defect Reconstruction?

In soft tissue sarcoma (STS) resection, flap reconstruction and/or skin grafting is frequently required. However, it is not clear whether the histological difference affects the rate of reconstruction. The present study aimed to investigate it. This study compared in 5 classifications (105 adipocytic tumors, 102 fibroblastic tumors, 39 muscle tumors, 31 peripheral nerve sheath tumors, and 178 tumors of uncertain differentiation). In addition, the reconstruction rates of detailed tumor sites were compared. The median and case number (percentage) were calculated. Tumor size (adipocytic 112 mm vs fibroblastic 79 mm, muscle 72 mm, nerve 90 mm, uncertain 74 mm, P < 0.0001 in all comparisons), histological low-grade rates (adipocytic 43.8% vs uncertain 3.9%, P < 0.0001; fibroblastic 46.1% vs muscle 15.4%, P = 0.003; fibroblastic vs uncertain, P < 0.0001; nerve 19.4% vs uncertain, P = 0.003) and reconstruction rates (adipocytic 5.7% vs fibroblastic 42.2%, muscle 33.3%, nerve 32.3%, uncertain 25.8%, P < 0.0001 in all comparisons) were significantly different. In the region of lower extremity, the regions of thigh [adipocytic 1/62 (1.6%) vs fibroblastic 7/32 (21.9%), P = 0.002], and lower leg [adipocytic 1/16 (6.3%) vs fibroblastic 11/19 (57.9%), P = 0.002] were significantly different. In adipocytic tumors, the tumor size was significantly large; however, the skin defect reconstruction rate was significantly lower than that of the other STS. Histologically, the reconstruction rate of STS derived from superficial tissue increases, whereas the reconstruction rate derived from deep tissue such as adipocytic tumor decreases.

Role of the Gastrocnemius Musculocutaneous with a Propeller Style Skin Flap in Knee Region Reconstruction: Indications and Pitfalls.

Background Soft tissue reconstruction around the knee area is still an open question, particularly in persistent infections and multiple reoperations scenario. Flap coverage should guarantee joint mobility and protection, even when foreign materials are implanted. The chimeric harvesting of the musculocutaneous gastrocnemius flap, based on the sural artery perforators, can extend its applicability in soft tissue reconstruction of the upper leg, overcoming the drawbacks of the alternative pedicled flaps. Methods A multicenter retrospective study was conducted enrolling patients who underwent to a pedicled, chimeric gastrocnemius musculocutaneous-medial sural artery perforator (GM-MSAP) or lateral sural artery perforator (GM-LSAP) flap for knee coverage in total knee arthroplasty (TKA) recurrent infections and oncological or traumatic defects of the upper leg from 2018 to 2021. Outcomes evaluated were the successful soft tissue reconstruction and flap complications. Surgical timing, reconstruction planning, technique, and rehabilitation protocols were discussed. Results Twenty-one patients were included in the study. Nineteen GM-MSAPs and 2 GM-LSAPs were performed (soft tissue reconstruction in infected TKA [12], in infected hardware [4], and in oncological patients [5]). Donor site was closed primarily in 9 cases, whereas a skin graft was required in 12. Flap wound dehiscence (1), distal flap necrosis (1), distal necrosis of the skin paddle (1), and donor site infection (1) were the encountered complications. Flap reraise associated to implant exchange or extensive debridement was successful without requiring any further flap surgery. Conclusion The propeller-perforator GM-MSAP offers qualitative defect coverage and easiness of multiple flap reraise due to skin availability and its laxity.

Personalized 3D printed implants in the treatment of extensive chest wall tumors: clinical cases

3D printing has opened new opportunities for the development of personalized systems for prosthetics of extensive chest wall defects after radical surgical interventions for malignant tumors. However, risk factors for an adverse outcome of such operations have not yet been identified.Clinical cases. A 65-year-old man with primary chondrosarcoma of the V rib, underwent surgical resection of three ribs, plasty with local tissues, and an individual 3D printed titanium implant was installed on the sternum and IV-VI ribs. Follow up for 26 months showed no complaints or signs of recurrence. A 52-year-old woman with radiation-induced soft tissue sarcoma of the chest wall, that developed 9 years after radiation for breast cancer, underwent resection of four ribs and pectoral muscles and a 3D printed titanium implant was installed on the sternum and II-V ribs. The operation was complicated by the marginal necrosis of the soft tissue flap and infection of the endoprosthesis, which required removal of the metal structure and reconstruction using TRAM flap. After 9 months, a local recurrence of the tumor was diagnosed. Discussion. As a factor of a positive outcome in a man should be noted a thick layer of subcutaneous fat with muscle tissue, due to which plastic surgery was performed, covering the defect without tension. An extensive resection of the pectoral muscles in a woman created a tissue deficit. Another factor of an unfavorable outcome can be considered the radio-induced nature of the sarcoma. Further research is needed to improve the strategy for selecting patients with malignant tumors of the chest wall for prosthetics.

Repair of ischial tuberosity pressure ulcer with a perigluteal muscle flap

Background: Pressure ulcers are caused by long-term pressure on tissues. Hip pressure ulcers are the most common type. Pressure ulcers in the buttocks are classified into three types: sacrococcygeal, ischial tuberosity, and femoral tuberosity. Methods: We used perigluteal muscle tissue flaps to treat nine cases of grade IV pressure ulcers from January 2016 to August 2018. A retrospective study was conducted on all patients who had an ischial tuberosity pressure ulcer repaired with a perigluteal muscle flap. The gluteus maximus myocutaneous flap was combined with the gluteal fasciocutaneous flap, the biceps femoris myocutaneous flap was combined with the gluteal fasciocutaneous flap, the gracilis myocutaneous flap, the biceps femoris myocutaneous flap, and the semitendinosus and semimembranosus myocutaneous flap. Wounds of different sizes and depths were encountered, the details of which are discussed in treatment methods. Data from patients, including age, gender, cause of injury, wound dimensions, the timing of flap coverage, and complications, were analyzed. Results: The appearance of the skin flap was complete after muscular tissue flap repair, with no visible scar hyperplasia. However, after six to 12 months of follow-up, the flap was soft and left a small linear scar. Conclusions: In the repair of an ischial tuberosity pressure ulcer, a peri gluteal muscle flap provides both aesthetic and functional results. Before using muscle tissue flap transplantation, it is recommended to perform multiple debridement + VSD to improve the wound foundation.

Mid-Cheek Reconstruction after a Dog Bite: Case Report and Literature Review

The incidence of animal bite injuries affecting the anatomical regions of the head and neck is notably prevalent, particularly among individuals within the younger demographic. Canine species have been identified as the primary source of the majority of bite injuries in the human population, the spectrum of injuries encompasses a range of traumatic manifestations, which may encompass uncomplicated lacerations or punctures, as well as more complex avulsions characterized by the presence or absence of accompanying tissue. The anatomical regions most frequently affected by the condition under investigation include the buccal region, nasal area, and labial region. The acquisition of comprehensive data regarding the vaccination status of both the animal and the patient is of paramount significance in the realm of medical research. Furthermore, it is imperative to duly administer prophylactic measures such as tetanus or rabies prophylaxis, contingent up on the presence of any indications warranting such interventions. The aforementioned wounds necessitate comprehensive assessment, meticulous cleansing, and, on occasion, surgical debridement or reconstruction within the confines of the operating theater. The selection of the appropriate reparative intervention is contingent upon a comprehensive assessment of the precise anatomical site and magnitude of the inflicted trauma, thereby encompassing a spectrum of potential modalities including primary closure, microsurgical replantation, dermal grafting, tissue flaps, and in rare instances, facial allograft transplantation.

Temporalis Flap in Lateral Skull Base Reconstruction: A Case Report and Literature Review

The resolution of small to intermediate-sized anomalies affecting the craniofacial region can pose a formidable problem for surgical practitioners in instances where indigenous soft tissue flaps fail to provide sufficient tissue volume or suitable tissue characteristics to fulfill the desired reconstructive requisites. In the present scenarios, the preferred reconstructive modalities involve the utilization of regional pedicled flaps or free tissue transfers. The utilization of flaps originating from the temporalis muscle, fascia, or a combination of them, was initially documented by Yolovine in the year 1898. Subsequently, Murphy employed these flaps in 1914 for surgical interventions targeting the temporomandibular joints (TMJ). Subsequent to their initial utilization, axial flaps predicated upon the middle and deep temporal vessels have been subject to extensive and comprehensive deployment. This study seeks to provide a comprehensive understanding of the temporalis flap procedure, its indications, outcomes, and potential complications by analyzing a single case and conducting an exhaustive literature review.

Surgical Management of Infection Secondary to Cemento-osseous Dysplasia.

Cemento-osseous dysplasia (COD) of the jaws generally has no clinical manifestations when asymptomatic, thus requiring no treatment. However, secondary infection in COD requires surgical intervention. This study was focused on the evaluation of the surgical treatment of COD patients with secondary infections. The clinical data of COD patients with secondary infections, treated at the Peking University, Hospital of Stomatology between March 2021 and June 2022, were retrospectively reviewed. The data included age, sex, lesion characteristics, number of surgeries, and surgical outcomes. Seven COD patients with secondary infections underwent curettage, and the wounds were repaired using local soft tissue flaps, such as the buccal fat pad. Four of the patients had primary wound healing, while 3 presented with wound dehiscence. Healing occurred in 2 of these 3 patients after ~1 month of dressings. The remaining patient showed no improvement after 9 weeks, and underwent a second surgery, which led to primary wound healing. In conclusion, secondary infection in COD is an indication for surgical intervention, which may arrest the disease progression.

The bioengineering of perfusable endocrine tissue with anastomosable blood vessels

Organ transplantation is a definitive treatment for endocrine disorders, but donor shortages limit the use of this technique. The development of regenerative therapies would revolutionize the treatment of endocrine disorders. As is the case for harvested organs, the ideal bioengineered graft would comprise vascularized endocrine tissue, contain blood vessels that could be anastomosed to host vessels, have stable blood flow, and be suitable for transplantation into various sites. Here, we describe a transplantable endocrine tissue graft that was fabricated by ex vivo perfusion of tricultured cell sheets (islet β-cells, vascular endothelial cells (vECs), and mesenchymal stem cells (MSCs)) on a vascularized tissue flap of in vivo origin. The present study has three key findings. First, mild hypothermic conditions enhanced the success of ex vivo perfusion culture. Specifically, graft construction failed at 37 °C but succeeded at 32 °C (mild hypothermia), and endocrine tissue fabricated under mild hypothermia contained aggregations of islet β-cells surrounded by dense vascular networks. Second, the construction of transplantable endocrine tissue by ex vivo perfusion culture was better achieved using a vascular flap (VF) than a muscle flap. Third, the endocrine tissue construct generated using a VF could be transplanted into the rat by anastomosis of the graft artery and vein to host blood vessels, and the graft secreted insulin into the host’s circulatory system for at least two weeks after transplantation. Endocrine tissues bioengineered using these techniques potentially could be used as novel endocrine therapies.

Fuyuan Huoxue Decoction Promotes Skin Flap Survival Via the P38MAPK/IKK/NF-κB Pathway in Rats

Objective Fuyuan Huoxue decoction (FHD) is a traditional Chinese medicine that can promote blood circulation, inhibit inflammatory reactions and effectively relieve pain. This study investigated the effect of FHD on rat skin flap survival and the p38 MAPK/IKK/NF-κB pathway. Methods The pathological condition of the flap tissue was examined by H&amp;E staining. The expression levels of CD34 and VEGF in skin flap tissues were examined by immunohistochemistry. The levels of TNF-α, IL-6, CRP, and HO-1, superoxide dismutase (SOD) activity, and MDA content were detected by ELISA. The protein expression levels of Bax, Bcl-2, cleaved-caspase 3, p-IKKαβ, p-p38, p-p65, α-SMA, CK14, CK15, and SOX2 were detected by western blotting. Results Fuyuan Huoxue decoction upregulated the levels of CD34, VEGF, and Bcl-2, downregulated the expression of TNF-α, IL-6, p-IKKαβ, P-P38, P-P65, Bax, and cleaved-caspase 3, increased the activity of SOD, and inhibited the level of MDA. In addition, FHD promoted the proliferation and differentiation of skin flap. Conclusions Fuyuan Huoxue decoction improved the survival of the rat skin flap model by regulating the p38MAPK/IKK/NF-κB signaling pathway, and the mechanism may be related to the promotion of skin flap proliferation, differentiation, and revascularization and the inhibition of inflammation and oxidative stress.

The effect of smoking on clinical and biochemical early healing outcomes of coronally advanced flap with connective tissue graft: Prospective cohort study.

This study aimed to determine the effects of smoking on early (≤3 months) clinical outcomes and relevant molecular biomarkers following root coverage surgery. Eighteen smokers and 18 nonsmokers, status biochemically verified, with RT1 gingival recession defects were recruited and completed study procedures. All patients received coronally advanced flap plus connective tissue graft. Baseline and 3 month recession depth (RD), recession width (RW), keratinized tissue width (KTW), clinical attachment level (CAL), and gingival phenotype (GP) were recorded. Root coverage (RC) percentage and complete root coverage (CRC) were calculated. Recipient (gingival crevicular fluid) and donor (wound fluid) site VEGF-A, HIF-1α, 8-OHdG, and ANG levels were determined. There were no significant intergroup differences for any baseline or postoperative clinical parameters (P>0.05), except for whole mouth gingival index (increased in nonsmokers at 3 months; P<0.05). Compared to baseline, RD, RW, CAL, KTW, and GP significantly improved postoperatively, without significant intergroup differences. There were no significant intergroup differences for RC (smokers=83%, nonsmokers=91%, P=0.069), CRC (smokers=50%, nonsmokers=72%, P=0.177), and CAL gain (P=0.193). The four biomarker levels significantly increased postoperatively (day 7; P≤0.042) in both groups and returned to baseline (day 28) without significant intergroup differences (P>0.05). Similarly, donor site parameters were not different between groups. Strong correlations, consistent over time, were found between biomarkers implicated in angiogenesis (VEGF-A, HIF-1α, and ANG). The early (3 month) clinical and molecular changes after root coverage surgery utilizing a coronally advanced flap plus connective tissue graft are similar between smokers and nonsmokers.

Subcutaneous pedicled propeller flap technique for microscopic reconstruction of eyelid defects.

To describe the subcutaneous pedicled propeller flap technique for the microscopic reconstruction of eyelid defects and evaluate its outcomes. The clinical data of 23 patients (23 eyes) who underwent microscopic reconstruction of eyelid defects with the subcutaneous pedicled propeller flap technique were retrospectively analyzed. All patients underwent eyelid tumor resection and one-stage microscopic reconstruction with the subcutaneous pedicled propeller flap for anterior- or posterior-layer eyelid defects. The survival rate of the propeller flap, eyelid function and appearance, tumor recurrence rate, and patient satisfaction were evaluated after the surgery. The patients consisted of 12 men and 11 women, aged 31-82y (mean, 58.9y). The longest follow-up time was 5y, and the shortest was 3mo. All the propeller flaps survived well. There was no significant difference in color and luster between the flap and adjacent tissues, and there was no dog ear phenomenon. No obvious scarring was observed. There were no obvious abnormalities of eyelid morphology or function, and no adverse complications such as exposure keratitis, entropion, ectropion, ptosis, and eyelid retraction. No tumor recurrence was found at the time of the last follow-up. All patients were satisfied with the surgical results. The subcutaneous pedicled propeller flap technique for the microscopic reconstruction of eyelid defects has satisfactory outcomes in terms of eyelid function and esthetics, and merits clinical application.

Titanium plates salvage in irradiated facial areas with the lipomodeling technique

Major defects of the facial structures cause severe functional and aesthetic impairment. For composite defects with bone loss, the use of a titanium plate bridging the bony defect, associated or not to a soft tissue pedicled flap is to be considered in complex cases, or for patients with high comorbidities. The principal limit of this technique is the risk of plate exposure, especially for patients who had adjuvant radiation therapy. We present two clinical cases of patients who had a facial reconstruction using a titanium plate associated with a locoregional soft tissue flap, and who presented a near-exposed plate a few years after the first surgery and adjuvant radiation therapy. In order to prevent plate exposure, we performed several lipomodeling sessions between skin and plate. Our results are very encouraging, with no plate exposure and thickening of the soft tissues which cover the plate at 10-years follow-up. The knowledge of the possibility to use fat grafting transfer could therefore lead to a strong return to the use of titanium plates in facial reconstruction.

Treatment of Rat Lymphedema by Propeller Lymphatic Tissue Flap Combined with Nanofibrillar Collagen Scaffolds.

The aim of our study was to evaluate a new propeller vascularized lymphatic tissue flap (pVLNT) combined with aligned nanofibrillar collagen scaffolds (CS) (BioBridge) in reducing lymphedema in the rat lymphedema model. Unilateral left hindlimb lymphedema was created in 15 female Sprague-Dawley rats following inguinal and popliteal lymph nodes (LN) resection and radiation. An inguinal pVLNT was elevated from the contralateral groin and transferred through a skin tunnel to the affected groin. Four collagen threads were attached to the flap and inserted in the hindlimb at the subcutaneous level in a fan shape. The three study groups consisted of group A (control), group B (pVLNT), and group C (pVLNT + CS). Volumetric analysis of both hindlimbs was performed using micro-computed tomography imaging before the surgery (at initial time point) and then at 1 and 4 months, postoperatively, and the relative volume difference (excess volume) was measured for each animal. Lymphatic drainage was assessed by indocyanine green (ICG) fluoroscopy for number and morphology of new collectors and the time required for ICG to move from injection point to the midline. Four months after the induction of lymphedema, an increased relative volume difference remained in group A (5.32 ± 4.74%), while there was a significant relative volume reduction in group B (-13.39 ± 8.55%) and an even greater reduction in group C (-14.56 ± 5.04%). ICG fluoroscopy proved the functional restoration of lymphatic vessels and viability of pVLNT in both B and C groups. Notably, only group C demonstrated statistically significant improvements in lymphatic pattern/morphology and in the number of lymphatic collectors as compared with the control group A. The pedicle lymphatic tissue flap combined with SC is an effective procedure for the treatment of lymphedema in rats. It can be easily translated into treatment of humans' lower and upper limb lymphedema and further clinical studies are warranted.

Simplified soft tissue coverage of the distal lower extremity: The reverse sural flap.

Soft tissue defects involving the distal lower extremity present challenging problems for orthopaedic surgeons to manage. Historically, wounds not amenable to primary closure have necessitated assistance from multidisciplinary teams using plastic surgeons to obtain adequate soft tissue coverage through rotational flap or free tissue transfer procedures. Techniques related to soft tissue rearrangement and local rotational flap coverage have advanced over the years with a growing knowledge of local anatomy and vasculature. The reverse sural flap may be performed to cover soft tissue defects within 10 cm of the foot or ankle region, negating the need for microvascular intervention. The simplistic nature of the reverse sural flap is appealing to orthopaedic surgeons as a means to provide timely patient care without additional support because it does not require microvasculature work or the need for intraoperative microscopes and has been popularized among orthopaedic trauma surgeons as a necessary tool to possess. Here, we discuss the reverse sural flap to include history, relevant anatomy, clinical indications, and a description of the technique for application.

Prevalence and Factors Associated with Post-operative Strictures in Anorectal Malformations

Objective: Rectal strictures are a serious complication following operation for anorectal malformations (ARM). The purpose of this study was to determine the factors affecting rectal strictures following surgical treatments for ARM. Materials and Methods: Retrospective chart reviews of 204 patients with ARM who underwent surgical treatment at Siriraj Hospital between January 2003 and December 2019 were carried out. Results: Overall, the prevalence of post-operative rectal stricture was 19.6% (40/204). The higher types of ARM had higher rectal stricture rates. In low type ARM, the stricture rate following surgery for perineal fistula, vestibular fistula was 4.1% and 14.7%, respectively. Recto-bulbar urethral fistula and recto-prostatic urethral fistula had stricture rates of 19.2% and 26.7%, respectively, but in higher types, the stricture rates were above 70%. Complications such as wound infection, dehiscence, retraction, colonic necrosis and recurrent fistula all affected the post-operative stricture rate (p = 0.029, p = 0.01, p = 0.01, p = 0.042 and p = 0.002, respectively). The operation for low type ARM using local tissue flap, such as YV and cutback anoplasty, had low complications. More complicated operations were performed for higher type ARM. The higher the complication rate, the higher the post-operative rectal stricture. Routine rectal dilatation by parents seemed to prevent rectal strictures (p = 0.056). The surgical treatments for rectal strictures composed of 57.5% anoplasty, 17.5% PSARP, 15% abdo-assisted pull-through and 10% abdo-assisted PSARP. Conclusion: Post-operative rectal stricture occurred because of complications following complicated operations for high type ARM. A meticulous operative technique is crucial.

Discussion: Successful Use of WALANT in Local and Regional Soft Tissue Flaps: A Case Series.

Discussion: Successful Use of WALANT in Local and Regional Soft Tissue Flaps: A Case Series.