Forearm Fasciocutaneous Flap Research Articles

Reconstructive surgery and adjuvant radiotherapy for the multimodal approach in oral cancer: a single cancer centre experience

Introduction and importance: Ablative surgery for oral cancer, irrespective of the histological subtype, causes large tissue defects, functional and aesthetic damage. Microsurgical free flaps have been widely used in reconstruction after resection, with satisfactory success rates in conjunction with adjuvant radiotherapy (RT). This study aims to describe our clinical institutional experience based on the multimodal treatment performed in four cases diagnosed with oral squamous cell carcinoma with the use of different microvascular free flaps and RT. Case series presentation: Four patients underwent reconstructive microsurgery after surgical resection of oral cancer, using three types of free flap: radial forearm fasciocutaneous, osteomyocutaneous fibular, and anterolateral thigh musculocutaneous flaps; RT was performed in Case 2 and Case 3. In the period of 3 years after microsurgical reconstruction and RT, flaps remain clinically stable without failure signs in full patients submitted to multimodal treatment. Clinical discussion: After resection of oral carcinomas, extensive tissue defects can be successfully treated with reconstructive microsurgery using different types of microvascular free flaps. RT for locoregional control is a feasible option and did not seem to interfere with the survival of flaps. Conclusion: An enhance long-term follow-up to assess overall and disease-free survival rates and quality of life must be carried out; however, cohort studies would be necessary for better understanding of the role of each treatment in the multimodal scheme.

Repair of Surgical Defect by Pectoralis Major Flap Versus Free Radial Forearm Flap in Buccal Carcinoma: Assessment of Quality of Life

Background: Soft tissue reconstruction of the oral cavity is the most critical factor in achieving a successful functional result. Malignant lesions occurring in the buccal area are usually treated with primary surgical and/or radiotherapy of the head and neck region. Depending on the location and size of the buccal tumor, radical surgical treatment often affects all oral function such as speech, swallowing, chewing, oral rehabilitation, nutrition and appearance. To maximize postoperative function, flap repair is currently the preferred method for reconstruction of buccal defects after major surgery. Among the flaps most commonly used are pedicle pectoralis major myocutaneous flap and the free radial forearm fasciocutaneous flap. The choice of the best reconstructive option is still controversial. Objective: To find out the quality of life after repair of surgical defect by pectoralis major flap versus free radial forearm flap in buccal carcinoma. Methods: This prospective study was conducted in the department Otolaryngology- Head & Neck Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka from September 2017 to August 2019. A total number of 44 cases of buccal carcinoma patient who had the inclusion criteria were enrolled as a study sample. These subjects were selected from the Department of Otolaryngology-Head & Neck Surgery, Department of Oral & Maxillofacial Surgery, Bangabandhu Sheikh Mujib Medical University, Shahbag, National Institute of ENT, Tejgaon, Dhaka. Comparison of nominal or ordinal variables between patients who have undergone surgery with either the RFFF or PMMF were analyzed using a chi-square test. The UW-QOL scores were compared for each domain using the nonparametric Mann-Whitney test. P-value < .05 was accepted as the level of significance. Results: In this study 40 out of 44 patients were completed UW-QOL questionnaires. The median age was 52 (range 40-65years), the male-female ratio was 1.44:1. All were habituated in either smoking or betel leaf/ nut or alcohol. Most of them were illiterate to the primary level of education and suffering from stage- iii tumor. All these variables were statistically insignificant except gender. Patients reconstructed with RFFF felt better in shoulder domains than PMMF but felt worse appearance domains and these were statistically significant in both 3 months and 6 months postoperatively. Conclusion: The study result had shown that reconstruction of the defect after buccal cancer resection using either RFFF or PMMF significantly influences patient’s quality of life. This study will provide valuable information for surgeons who will decide reconstruction modalities for buccal cancer and also will help the patients getting a better outcome. Bangladesh J Otorhinolaryngol 2023; 29(1): 32-38

Usefulness of Reverse Radial Forearm Flaps in Covering Soft Tissue Defects of Hand and Wrist

Aim: To emphasize on the importance of reverse radial forearm flap (RRF flap) in the coverage of soft tissue defects of hand and wrist. Study design: This is a descriptive experimental study. Study place and duration: Study was comprised on the period of six months from January 2022 to June 2022. It was conducted in the plastic surgery department of Allama Iqbal Memorial Teaching Hospital Sialkot Methodology: Patients with the soft tissue defects of hand and wrist due to road traffic accidents, industrial or mechanical trauma and firearm injury were admitted to the plastic surgery ward. After achieving healthy wound with wound debridement, soft tissue coverage was done using reverse radial fasciocutaneous forearm flap. Patients with amputation of thumb and those with partial or complete bone loss were excluded from the study. Ages of the patients were 17-50 years with mean age of 31.42±5.3 years. Donor site of the flap was covered with split thickness skin graft and follow-up of the patients was done for at least three months. Results: 20 cases were included in this study including 16(80%) male and 04(20%) female cases. 15(75%) cases had soft tissue defect on the dorsum of hand, 04(20%) cases had palmar defect and in 01(5%) case there was amputation at transmetacarpal level and flap coverage of the stump was done. Partial loss of the flap happened in one 01(5%) case and it was treated with debridement and skin coverage. In one case superficial epidermolysis was found and managed conservatively. Practical implication Conclusion: Reverse radial forearm fasciocutaneous flap is an excellent option for the coverage of soft tissue defects of hand and wrist due to its greater arc of rotation which makes it easy to apply to the recipient site. Key words: Hand trauma, Soft tissue defects of hand, Reverse Radial Forearm Flap, Flap Coverage of Hand

The arterialised saphenous venous flow-through flap for managing the radial forearm free flap donor site.

BackgroundThe radial forearm fasciocutaneous flap (RFFF) is a workhorse flap, however concerns with donor site morbidity include tendon exposure, delayed wound healing, impaired sensitivity, and poor cosmesis, have seen it fall out of favor. We present a method of using an arterialised saphenous flow through flap to reconstruct the RFFF donor site.MethodA cohort study of six patients (five male, one female; mean age 59 [range 19–90]) who had their RFFF donor site reconstructed with an arterialised saphenous flow through flap is presented. The use of multiple peripheral efferent venous anastomoses, flap rotation 180 degrees prior to inset, and the ligation of intra‐flap connecting veins were three modifications employed. Primary outcomes include complication rates. Secondary outcomes were patient reported outcome measures via the Michigan Hand Outcomes Questionnaire, and patency and flow through the flap.ResultsIn all six cases, there was flap survival. RFFF dimensions ranging from lengths of 6–15 cm (mean 11.5 cm) and widths of 4–6 cm (mean 5.3 cm), with an average flap area of 58 cm2 (range 24–90). There were no total flap losses, one partial superficial flap loss and one minor donor site delayed healing, over a mean follow‐up of 6 months (4–24 months). The average overall patient satisfaction was 91 on Michigan Hand Outcomes Questionnaire. Pain was well tolerated with a low average pain score of 15.ConclusionThe modified arterialised saphenous flow through flap is a useful option for reconstructing the soft tissue defect and reconstituting the radial artery after RFFF harvest.

Complications of free-flap procedures for phalloplasty in female-to-male transgender surgery: 25-year experience a single medical center.

To present the complications of free-flap phalloplasty in three-staged female-to-male transgender surgery. This retrospective study included patients who underwent a three-staged free-flap phalloplasty for female-to-male transgender surgery between January 1988 and December 2013. Data regarding demographics, operative techniques, and complications were collected and analyzed. A total of 101 patients with a mean age of 30.2 years were included. Phalloplasty with traditional free forearm tube-in-tube fasciocutaneous flap was performed in 25 (24.8%) patients, free forearm fasciocutaneous flap with vaginal mucosa for a prefabricated urethra in 30 (29.7%) patients, free radial forearm osteocutaneous flap with vaginal mucosa for a prefabricated urethra in 22 (21.8%) patients, and free fibula osteocutaneous flap with vaginal mucosa for a prefabricated urethra in 24 (23.8%) patients. Complication rates of partial flap loss, urethrocutaneous fistula, urethral stricture, and hair or stone formation were 12.9%, 49.5%, 24.8%, and 5.0%, respectively. Patients receiving fibula osteocutaneous flap phalloplasty had the lowest overall complication rate (33.3%), followed by those with radial forearm osteocutaneous flap (40.9%), forearm fasciocutaneous flap (43.3%), and forearm tube-in-tube fasciocutaneous flap (80.0%). Forearm tube-in-tube fasciocutaneous flap procedure was associated with significantly higher rates of overall complications (p = 0.05), urethrocutaneous fistula (p = 0.005), and hair or stone formation (p = 0.002) compared with the other three types of procedures. Rates of all complications did not significantly differ among fibula osteocutaneous flap, radial forearm osteocutaneous flap, and forearm fasciocutaneous flap procedures. In free-flap phalloplasty for female-to-male transgender surgery, utilization of free fibula osteocutaneous flap with vaginal mucosa for a prefabricated urethra resulted in the lowest complication rate. Further comparisons among different procedures of phalloplasty are warranted.

Anatomy of septocutaneous blood vessels of the anterior forearm.

Aim To measure a calibre of radial and ulnar septocutaneous perforators at the anterior forearm, and to count its number in proximal, middle and distal thirds. Methods The study was conducted on 50 fresh amputated forearms (trauma, tumours) in the period between January 2012 and December 2021. Forearms were collected from several hospitals in Belgrade, and analysed at the Institute of Anatomy, Medical School, University of Belgrade, Serbia. Injection of ink-gelatin and fine dissection of autopsy material was performed on 30 forearms, and corrosion method with injecting methyl methacrylate for 3D analysis on the other 20 forearms. Results A mean calibre of septocutaneous perforators on the radial artery was 0.53±0.46 mm (0.2-0.85). Averagely, there were 8.1 radial artery septocutaneous perforators - two perforators on the proximal third, 3.7 on the middle third, and 2.7 on the distal third. The mean calibre of ulnar artery perforators was 0.65±0.35 mm (0.18-1.8). The average number of septocutaneous perforators of the ulnar artery was 5.6; 1.2 on the proximal third, two on the middle third, and 2.2 on distal third. Conclusion Determination of the origin, calibre and spreading directions of the arterial septocutaneous perforators on the anterior forearm provide quantification of data about arborisation of radial and ulnar septocutaneous perforators at the anterior forearm. Clinical relevance of those anatomical data is in defining of safe locations and dimensions of forearm fasciocutaneous flaps in plastic surgery.

A Cadaveric Study of Superficial Palmar Arch with Surgical Importance

Introduction: Arterial supply of hand is by two arterial anastomotic arches formed by radial and ulnar arteries and their branches. The anastomoses between the branches of radial and ulnar arteries such as palmar carpal and dorsal carpal arches at the wrist and superficial and deep palmar arches in the palm, maintain a rich arterial supply to the wrist and palm. Effective collateral circulation in palm is essential in peripheral arterial diseases such as Raynaud’s disease and in harvesting radial artery or the ulnar artery for Coronary Artery Bypass Graft (CABG) surgery. Aim: To observe the variations in the formation of superficial palmar arch. Materials and Methods: A descriptive study was performed on 45 formalin fixed upper limbs of both sex in the Department of Anatomy, JSS Medical College, Mysuru, Karnataka, India. The study was conducted during routine dissection of upper limbs for undergraduates as per the Cunningham’s manual for practical anatomy. Few rare variations in the formation of superficial palmar arch and the arterial pattern of hand were noticed. The variations found were classified according to Coleman and Anson classification. Results: Out of 45 limbs, complete arch was found in 36 limbs and incomplete arch in nine limbs. In complete arch type, we found an arterial arcade, bifurcation of ulnar artery and in incomplete arch type, radial-radial anastomosis. Another rare findings of highly tortuous ulnar artery in forearm and in the palm. Conclusion: The findings in the variations of superficial palmar arch are essential in microvascular surgery, forearm fasciocutaneous flap, radial artery and ulnar artery harvesting in coronary artery bypass graft procedure.

Fasciocutaneous Flaps for Refractory Intermediate Stage Osteoradionecrosis of the Mandible—Is It Time for a Shift in Management?

Historically, free tissue transfer has been reserved for advanced stage osteoradionecrosis (ORN) of the jaw with pathologic fracture or cutaneous fistula. The purpose of this study was to evaluate if in patients with recalcitrant intermediate stage ORN, would mandibular debridement in combination with vascularized soft tissue coverage result in durable symptom and disease resolution. A retrospective cohort study of patients with mandibular ORN was performed comparing a mandibular preserving approach with a fasciocutaneous forearm flap for progressive treatment-resistant intermediate stage ORN to mandibulectomy and vascularized bone flap (VBF) reconstruction for advanced stage ORN. The primary outcome was ORN resolution. The sample was composed of 35 patients. One-hundred percent of patients undergoing a mandibular preserving approach experienced ORN resolution compared with 83.3% in the segmental mandibulectomy and VBF reconstruction group (P=.28). Patients in the mandibular preservation group experienced a shorter hospitalization (6 vs 9days; P=.07), decreased length of surgery (384.9 vs 406.3minutes; P=.01), and less delayed healing requiring local wound care (9.1 vs 45.8% of patients; P=.06). A mandibular preserving approach is successful at arresting intermediate stage ORN and is associated with a decreased operative time, a shorter hospitalization, and less need for prolonged wound care when compared with VBF reconstruction for advanced stage ORN.

Local Immunosuppression for Vascularized Composite Allografts: Application of Topical FK506-TyroSpheres in a Nonhuman Primate Model.

Transplantation of vascularized composite allografts (VCAs) provides a means of restoring complex anatomical and functional units following burns and other disfigurement otherwise not amenable to conventional autologous reconstructive surgery. While short- to intermediate-term VCA survival is largely dependent on patient compliance with medication, the myriad of side effects resulting from lifelong systemic immunosuppression continue to pose a significant challenge. Topical immunosuppression is therefore a logical and attractive alternative for VCA. Current formulations are limited though, by poor skin penetration but this may be mitigated by conjugation of immunosuppressive drugs to TyroSpheres for enhanced delivery. Therefore, we investigated the topical application of FK506-TyroSpheres (in the form of a gel dressing) in a clinically relevant nonhuman primate VCA model to determine if allograft survival could be prolonged at reduced levels of maintenance systemic immunosuppression. Six Major Histocompatibility Complex (MHC)-mismatched cynomolgus macaques (Macaca fascicularis) served as reciprocal donors and recipients of radial forearm fasciocutaneous flaps. Standard Bacitracin ointment and FK506-TyroSpheres were applied every other day to the VCAs of animals in groups 1 (controls, n = 2) and 2 (experimental, n = 4), respectively, before gradual taper of systemic FK506. Clinical features of VCA rejection still developed when systemic FK506 fell below 10 ng/ml despite application of FK506-TyroSpheres and prolonged VCA survival was not achieved. However, unwanted systemic FK506 absorption was avoided with TyroSphere technology. Further refinement to optimize local drug delivery profiles to achieve and maintain therapeutic delivery of FK506 with TyroSpheres is underway, leveraging significant experience in controlled drug delivery to mitigate acute rejection of VCAs.

Transmandibular Approach in Head and Neck Oncological Surgery.

Objective: To evaluate the advantages and disadvantages of the transmandibular approach to the posterior area of the maxilla, oropharyngeal region and the hypopharynx in head and neck surgery. Methods: A series of 42 patients who underwent a lip-split mandibulotomy procedure to access malignant tumours affecting deep areas of the head and neck region between 2008 and 2018 in the Department of Oral and Maxillofacial Surgery at the Ramón y Cajal University Hospital (Madrid, Spain) were retrospectively reviewed. The diagnosis and operations data of the patients were collected and analysed. Results: Using the transmandibular approach, 42 patients were operated on to access malignant tumours located in the oropharynx (n = 23, 54.76%) including the posterior third of the tongue, tonsil and soft palate, retromolar trygone (n = 9, 21.43%), floor of the mouth (n = 3, 7.14%), skull base (n = 2, 4.76%), superior maxilla (n = 3, 7.14%) and deep lobe of the parotid gland (n = 2, 4.76%). Primary reconstruction was carried out in all cases. The most used flap reconstruction method was the forearm fasciocutaneous flap in 48.71% of cases, followed by the anterolateral thigh flap in 20.51% of cases. The remaining cases were treated with other methods. The most frequent complication was surgical wound infection. Conclusion: The transmandibular approach is a good alternative to provide access for the removal of complex tumours affecting the oropharyngeal region. This approach facilitates direct visualisation of the lesion and bleeding control, allowing tumour resection with wide margins and making primary reconstruction easier. Although further progress in the transoral robotic approach could be a good option in selected cases, given the current state of knowledge, the transmandibular approach is a good option to access tumours affecting deep areas of the oral cavity and oropharynx.

REVERSE RADIAL FOREARM FLAP

Objectives: To highlight the usefulness of reverse radial forearm fasciocutaneous flap in covering various soft tissue defects of hand and wrist. Study Design: Descriptive, experimental study. Setting: Department of Plastic & Reconstructive Surgery, Dow University of Health Sciences & Dr Ruth KM Pfau Civil Hospital Karachi. Period: December 2016 to January 2018. Material & Methods: A total of 16 reverse radial forearm flaps were utilizedto cover various soft tissue defects of hand and wrist from various etiologies including road traffic accidents, mechanical trauma, and industrial trauma and fireworks injuries were included. Patients with segmental bone loss and those patients having partial of complete amputation of thumb were excluded. The age ranged from 18 – 45 (mean 29.25) years. Soft tissue defects of dorsum were covered with this flap in 8 cases, 4 cases on palmer aspect and 2 cases for transmetacarpal level and 1st web space defects each. Donor site was covered with split skin graft in all cases. Patients were followed for at least three months postoperatively. Results: We had partial loss of flap in two cases which was managed with debridement and skin grafting. Superficial epidermolysis was found in one case and managed conservatively. Donor site was skin grafted in all cases which was healed uneventfully and quite acceptable to the patients in due course of time. Conclusion: Reverse radial artery flap has a quite long arc of rotation, which brings it great ease to cover the soft tissue defects of various areas of hand like palm, dorsum and first web space.

The Reverse-flow Radial Forearm Flap for Soft Tissue Reconstruction of the Wrist and Hand

Soft-tissue injuries of the hand and wrist regions are quiet common casualty. Flap coverage is often required to achieve primary wound closure and to achievea good functional result. The use of the reversed flow radial forearm fasciocutaneous flap in the reconstruction of the hand and wrist soft tissue defectshas been described by many authors to be an easy-to-learn and very versatile technique in hand injuries and reconstruction.In this report, the anatomy and vascular basis of the reversed flow radial forearm flap are presented along with the evaluation of its application in twenty patients with different hand and wrist soft tissue defects.

Combined Direct and Indirect Cerebral Revascularization Using Local and Flow-Through Flaps.

Extracranial-intracranial bypass is indicated in ischemic disease such as moyamoya, certain intracranial aneurysms, and other complex neurovascular diseases. In this article, we present our series of local and flow-through flaps for cerebral revascularization as an additional tool to provide direct and indirect revascularization and/or soft tissue coverage. A retrospective review of a prospectively maintained database was performed identifying nine patients. Ten direct arterial bypass procedures with nine indirect revascularization and/or soft tissue reconstruction were performed. Indications for arterial bypass included intracranial aneurysm (n = 2) and moyamoya disease (n = 8). Indications for soft tissue transfer included infected cranioplasty (one) and indirect cerebral revascularization (eight). Four flow-through flaps and five pedicled flaps were used including a flow-through radial forearm fasciocutaneous flap (one), flow-through radial forearm fascial flaps (three), and pedicled temporoparietal fascial (TPF) flaps with distal end anastomosis (five). The superficial temporal vessels (seven) and facial vessels (two) were used as the vascular inflow. Arterial bypass was established into the middle cerebral artery (six) and anterior communicating artery (three). There were no intraoperative complications. All flaps survived with no donor-site complications. In one case of flow-through TPF flap, the direct graft failed, but the indirect flap remained vascularized. Local and flow-through flaps can improve combined direct and indirect revascularization and provide soft tissue reconstruction. Minimal morbidity has been encountered in early outcomes though long-term results remain under investigation for these combined neurosurgery and plastic surgery procedures. The level of evidence is IV.

Functional Outcomes and Complications of Robot-Assisted Free Flap Oropharyngeal Reconstruction.

Robotic surgical systems provide a clear, magnified 3-dimensional visualization as well as precise, stable instrumental movement, thereby minimizing technical difficulties that may be encountered in the surgical treatment of oropharyngeal tumors. This study assessed the outcomes of robotic-assisted free flap oropharyngeal reconstruction compared with those of conventional free flap reconstruction. A retrospective review of 47 patients who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects was conducted over a 20-month period (May 2013-December 2014). Complications were evaluated for a robot-assisted reconstruction group and a conventional reconstruction group; postoperative complication rates and revision rates were further evaluated. The Functional Intraoral Glasgow Scale (FIGS) was adopted for functional outcome assessment. This study recruited 47 people who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects (14 robot-assisted and 33 conventional reconstructions). The mean postoperative FIGS score was 10.29 ± 2.02 in the robot-assisted group (P = 0.010) and 8.42 ± 2.29 in the conventional group at 1 month postoperatively. The mean postoperative FIGS score was 12.57 ± 1.91 in the robot-assisted group (P = 0.005) and 9.91 ± 3.09 in the conventional group at 3 months postoperatively. Complication rates between the robot-assisted and conventional groups were similar for flap failure (P = 0.531), partial necrosis, wound infection, hematoma or seroma formation (P = 0.893), wound dehiscence, and fistula formation (P = 0.515). The number of flap revision operations requiring additional surgery (P = 0.627) was comparable between the cohorts. There is no significant difference in complications or revision rates between the robot-assisted and conventional oropharyngeal reconstructions. The functional postoperative outcomes of robot-assisted reconstructions are superior to those of conventional reconstructions. Robotic surgical systems provide a safe option with optimal postoperative oral function for the free flap reconstruction of oropharyngeal defects without lip or mandible splitting.

Comparison of morbidity after reconstruction of tongue defects with an anterolateral thigh cutaneous flap compared with a radial forearm free-flap: a meta-analysis

Currently the radial forearm fasciocutaneous flap and the anterolateral thigh flap are among the most popular free flaps used for reconstruction of oral soft tissue. However, there is controversy about their efficacy after reconstruction of tongue defects because of their respective intrinsic properties, so we have compared them in reconstruction of tongue defects using meta-analysis. We conducted a search in Pubmed, EMBASE, OVID, Science Direct, the Cochrane Library, and Chinese National Knowledge Infrastructure, which covered all papers published before January 2015. Twelve clinical papers, that included 366 patients with 198 radial forearm flaps and 168 anterolateral flaps, met the criteria. Relevant data were extracted and analysed using systematic meta-analyses. The results showed that the incidence of localised numbness at the donor site of the radial forearm flap postoperatively was significantly higher and satisfaction with the appearance of the donor site significantly lower than in the anterolateral thigh group. There were no differences in flap survival, incidence of vascular crises in the flap, complications, satisfaction with the appearance of the tongue, or the postoperative clarity of speech and swallowing ability. Results suggested that the anterolateral thigh flap is the ideal soft tissue flap for reconstructing defects in the tongue, as there was minimal numbness at the donor site and patients were much more satisfied. Further research is needed to address details of the site and the extent of surgical defects as well as the relations between dissection of the radial flap and repair of the skin graft.

Management of recurrent carpal tunnel disease with reverse radial forearm fasciocutaneous flap and external neurolysis

Management of recurrent carpal tunnel disease with reverse radial forearm fasciocutaneous flap and external neurolysis

Infection in total elbow arthroplasty with stable components: outcomes of a staged surgical protocol with retention of the components.

We describe the use of a protocol of irrigation and debridement (I&D) with retention of the implant for the treatment of periprosthetic infection of a total elbow arthroplasty (TEA). This may be an attractive alternative to staged re-implantation. Between 1990 and 2010, 23 consecutive patients were treated in this way. Three were lost to follow-up leaving 20 patients (21 TEAs) in the study. There were six men and 14 women. Their mean age was 58 years (23 to 76). The protocol involved: component unlinking, irrigation and debridement (I&D), and the introduction of antibiotic laden cement beads; organism-specific intravenous antibiotics; repeat I&D and re-linkage of the implant if appropriate; long-term oral antibiotic therapy. The mean follow-up was 7.1 years (2 to 16). The infecting micro-organisms were Staphylococcus aureus in nine, coagulase-negative Staphylococcus in 13, Corynebacterium in three and other in six cases. Re-operations included three repeat staged I&Ds, two repeat superficial I&Ds and one fasciocutaneous forearm flap. One patient required removal of the implant due to persistent infection. All except three patients rated their pain as absent or mild. Outcome was rated as good or excellent in 15 patients (mean Mayo Elbow Performance Score 78 points, (5 to 100) with a mean flexion-extension arc of 103° (40° to 150°)). A staged protocol can be successful in retaining stable components of an infected TEA. Function of the elbow may compare unfavourably to that after an uncomplicated TEA. Cite this article: Bone Joint J 2016;98-B:976-83.

Clinical Manifestation, Diagnosis, and Surgical Treatment of Chronic Radiation Ulcer Related to Percutaneous Coronary Intervention

INTRODUCTION: Chronic radiation ulcers that develop after cardiac catheterization had become more common nowadays because of the rapid increase in the use of diagnostic and interventional cardiac catheterization procedures1-3. However, diagnosis and treatment remain difficult. MATERIALS AND METHODS: We present 10 patients with National Cancer Institute (NCI) grade 4 radiation ulcers related to prolonged percutaneous coronary interventions. Collected data, including clinical presentations and treatments, were analyzed. A quality-of-life questionnaire was scored by patients preoperatively and postoperatively. RESULTS: Most of the lesions (8/10 patients) were located at the back. All of the patients received prolonged cardiac catheterization of more than 3 hours, at least once. The coronary artery lesions all included chronic total or near-total occlusion. The surgical procedures were complete resection of the lesion followed by fasciocutaneous flap coverage (9/10) and skin grafting (1/10). The mean follow-up time was 23.3 months. All of the wounds healed well without complications. After the operation, the symptoms were relieved and quality of life improved significantly according to the scoring of the quality-of-life questionnaire (Figures 1 and 2).Figure 1: Left elbow lesion in case 5.Figure 2: En bloc excision of the lesion and pedicled forearm fasciocutaneous flap reconstruction.CONCLUSION: Early diagnosis of chronic ulcers related to prolonged percutaneous coronary interventions relies on careful history taking and highly suspicious clinical presentation. Complete resection and immediate reconstruction with flaps or grafts for NCI grade 4 radiation ulcers achieved improved symptomatology and reliable wound coverage without complications.

Anatomical rationale for elevating revascularized ulnar forearm fasciocutaneous flap for head and neck reconstruction

In this paper we studied in detail features of the blood supply to the tissues of the forearm of the pools ulnar and radial arteries, the technique of line access and the formation of skin-fascial ulnar flap by using a layered dissection with contrast vessels on non fixed human cadavers. Blood supply of the forearm carried out by branches radial and ulnar arteries, which allows to create in this area radial flap and ulnar flap loo. The size of the skin-fascial ulnar flap can reach 3-10 cm in length, 2-6 cm in width, the length of vessel pedicle of the transplant can reach 12 cm. The research studied the characteristics of blood supply of the forearm and the comparative evaluation of tissue perfusion of the radial and ulnar arteries; proved localization forming ulnar flap. Studies have shown that revascularised skin-fascial ulnar flap may be can be an alternative donor material for elimination of soft tissue defects with less traumatization donor area and reduce upper limb function compared with radial flap.

Perforator anatomy of the ulnar forearm fasciocutaneous flap

The ulnar forearm fasciocutaneous flap (UFFF) is a favourable alternative to the radial forearm flap when thin and pliable tissue is required. The precise anatomy of the cutaneous perforators of UFFF has not been previously reported. The position of cutaneous perforators>0.5 mm was recorded while raising 52 consecutive free UFFFs in 51 patients at our Centre. Three (6%) UFFFs in two patients demonstrated direct cutaneous supply through a superficial ulnar artery, a known anatomic variance. There was no cutaneous perforator>0.5 mm in one flap. Among the remaining 48 dissections, an average of 3 (range, 1-6) cutaneous perforators were identified. Ninety-four percent of these forearms demonstrated at least one perforator>0.5 mm within 3 cm, and all had at least one perforator within 6 cm of the midpoint of the forearm. Proximal perforators were more likely to be musculo-cutaneous through the edge of flexor carpi ulnaris or flexor digitorum superficialis, while mid- to distal perforators were septo-cutaneous. UFFF skin paddle designed to overlie an area within 3 cm of the midpoint between the medial epicondyle and the pisiform is most likely to include at least one cutaneous perforator from the ulnar artery, without a need for intra-operative skin island adjustment. This novel anatomic finding and other practical generalisations are discussed to facilitate successful elevation of UFFF.