Local Pedicled Flaps Research Articles

Modified salpingopharyngeus myomucosal flap: a novel technique for skull base reconstruction.

Advancements in endoscopic skull base surgery have enabled complex tumor resections, necessitating a variety of reliable reconstructive techniques to repair resultant defects. Vascularized flaps represent optimal options, but frequently used local pedicled intranasal flaps may be unavailable due to tumor invasion or prior surgery. This study applies a modification to the previously described salpingopharyngeus myomucosal flap (Dicle flap) with potential for its use in extensive endoscopic skull base surgery defect's repair. Cadaveric dissections (n = 5) were performed utilizing endoscopic visualization to access the skull base via endonasal and transoral routes. A superiorly based posterior pharyngeal myomucosal flap along the salpingopharyngeus muscle was elevated off the superior pharyngeal constrictors, preserving their vascular pedicles. This combined flap could be 180 degrees transposed to reconstruct clival defects up to the sella turcica. The modified salpingopharyngeus myomucosal flap (Modified Dicle flap) provided approximately 40 cm2 of robust vascularized tissue based on the ascending pharyngeal artery and random posterior pharyngeal vessels. It was sufficiently mobilized to cover extensive skull base defects in the craniocervical junction, sella turcica, and protecting the exposed internal carotid artery segments. The modified Dicle flap offers a viable reconstructive option for extensive endoscopic endonasal skull base defects when commonly utilized vascularized flaps are unavailable. Further research on clinical cases is warranted to investigate postoperative function and refine techniques to minimize donor site morbidity. Not applicable.

Microsurgical Reconstruction with and without Microvascular Anastomosis of Oncological Defects of the Upper Limb.

The choice of the most adequate surgical technique for upper limb defects remains challenging. The aim of this article is to discuss the main microsurgical (pedicled or free) reconstructive options for the post-oncological reconstruction of different anatomical areas of the upper extremity. We reviewed different reconstructive methods reported in the literature needing microsurgical expertise and compared them to our clinical experience, in order to provide further guidance in the choice of different flaps for upper limb soft tissue reconstruction. Six clinical cases, one for each anatomical district, are presented as examples of possible solutions. We report the options available in the literature for post-oncologic upper limb reconstruction, dividing them by anatomical area and type of flap: local flaps, regional flaps, free flaps, and distant pedicled flaps. Our examples of the reconstruction of each anatomical area of the upper limb include one reverse ulnar pedicled perforator flap, one free Antero-Lateral Thigh (ALT) flow-through flap, one perforator-based lateral arm flap, two myocutaneous latissimus dorsi pedicled flaps, and one parascapular perforator-plus flap. In oncological cases, it is important to consider reconstructive options that provide stable tissue and allow for the early healing of the donor and recipient site if the patient needs to undergo adjuvant radiotherapy or chemotherapy. A wider range of flap options is essential when choosing the proper technique according to the patient's needs, surgeon's preference, and logistical possibilities. Perforator flaps combine the advantages of other flaps, but they require microsurgical expertise. Free flap reconstruction remains the gold standard to obtain a better overall and cosmetic outcome in complex and wide defects, where no suitable local pedicled flap option exists. The pedicled latissimus dorsi flap should still be included among the reconstructive options for its strong vascularization, size, and arc of transposition.

Fifty free flaps from the ear

Reconstruction of facial and intraoral defects is often challenging. Local pedicled flaps may not always be available and distant free flaps usually have suboptimal color match and texture for the facial area. The aim of this study was to assess whether auricular free flaps are a valid reconstructive option. Clinical data and outcomes of patients who underwent reconstruction with microsurgical flaps from the ear between 2011 and 2021 were analyzed. Patient demographic data, type of flaps, etiology, location and size of the defect, features of the pedicle and recipient vessels, complications, and additional surgeries were reviewed. Overall, 48 patients with 50 microsurgical flaps were identified. Thirty-one patients (65%) were men and 17 were (35%) women. The median age was 62 years. Among the 50 flaps, 26 (52%) were helix flaps, 20 (40%) were temporal artery posterior auricular skin flaps, and 4 (8%) were extended helix flaps. The nose was the most frequently reconstructed region (n=32, 64%), followed by the tongue (n=6, 12%), floor of the mouth (n=5%), lower eyelid (n=2%), and in one (2%) patient each, restoration of the upper eyelid, ear, larynx, esophagus, lower lip, and palate. The median follow-up was 74 months. Three flaps (6%) were lost, and the overall rate of complications was 46%. Surgical intervention was required in 7 (14%) cases. All cases healed with acceptable cosmesis. The ear is a valuable source of tissue for complex reconstructions of the face and intraoral regions. However, this technique is surgically demanding and should be reserved for selected cases.

Narrative Review: Submental Artery Island Pedicled Flap, Indications, Tips, and Pitfalls.

Narrative review. To describe the advantages, challenges, and potential indications of the submental artery island flap as a local pedicled flap for head and neck reconstruction. We conducted a comprehensive review of the literature to describe the submental artery island flap's surgical technique, indications, and outcomes. Data sources included peer-reviewed articles, case reports, and clinical studies on using the submental flap in head and neck surgery reconstruction. The submental artery island flap, while offering advantages such as minimal donor site morbidity, and good cosmetic outcomes, presents challenges related to the pedicle dissection and patient selection. This flap is particularly suitable for defects in the oral cavity, oropharynx, parotid bed, and midface or neck skin. Simultaneous neck dissection is feasible but should be approached with caution in patients with a history of prior neck surgery. The submental artery island flap is a valuable option for selected cases. When performed in the right patient with a correct technique, this flap can reconstruct defects in the oral cavity, oropharynx, parotid bed, and skin of the midface or neck with a minimally visible scar of the donor site.

Successful four flap reconstruction for extensive crush injuries of bilateral lower limbs using local pedicled flaps in a 73-year-old patient: a rare case report

Extensive soft tissue defects with periosteal stripping over critical areas of tibia pose a tough challenge to the reconstructive plastic surgeon. Treatment of choice for these defects is free tissue transfer. Local pedicled fasciocutaneous or muscle flaps are used only when the free tissue transfer is not possible. The gastrocnemius and soleus flaps either used as a combined flap or as individual separate flaps can be an alternate reconstructive option for these defects in selected cases. Here we report a 73-year-old male patient a case of extensive crush injury involving both lower limbs following a motor vehicle accident (MVA) in whom we have successfully reconstructed the extensive soft tissue defects with exposed tibia with four local pedicled flaps. The purpose of writing this case report is that when free tissue transfer is not possible in such extensive crush injuries, a durable functionally and cosmetically acceptable reconstruction with pedicled hemi gastrocnemius and medial hemisoleus flaps can be done after a meticulous planning and flap design without any significant functional donor site morbidity.

Complications and Functional Outcomes After Esophageal Reconstruction with an Intact Larynx.

Esophageal defects can result from primary pathologies such as malignancy or stricture, or secondary ones such as perforation due to trauma or iatrogenic injury. Techniques, management, and outcomes of reconstruction in this setting are poorly understood. Herein, we aim to highlight surgical outcomes in patients undergoing local and free flap reconstruction of esophageal defects in the setting of an intact larynx. Retrospective review of patients who underwent esophageal reconstruction with an intact larynx between 2009 and 2022 at our institution was performed. Ten patients met inclusion criteria. Esophageal reconstruction was performed for extruded spinal hardware (n = 8), and esophageal stricture (n = 2). Four patients underwent reconstruction with free tissue transfer, and six with local pedicled flaps. There were no cases of flap failure, esophageal fistula, hematoma, or wound dehiscence. One patient had post-operative bleeding requiring return to the operating room. Three patients had a postoperative wound infection, two of whom required washout. There were no unplanned 30-day readmissions. At three months after operation, all patients who were not tube feed-dependent prior to surgery returned to oral intake. Of the four patients who were tube feed-dependent preoperatively, three were tolerating oral intake at nine months postoperatively. Nine patients (90%) had stable flexible laryngoscopy exams pre- and postoperatively with no voice changes. Reconstruction of esophageal defects in the setting of an intact larynx can be challenging. In this series, surgical intervention with free tissue transfer and local pedicled flaps was effective in returning patients to oral intake with low long-term morbidity. 4 Laryngoscope, 134:1227-1233, 2024.

Reconstruction of Composite Soft Tissue Defect in the Distal Finger Using Partial Toenail Flap Transfer.

Composite tissue loss involving the distal finger pulp and the nail is a common but challenging finger injury to restore. This study introduces a reconstruction procedure for a distal finger pulp and nail defect using a partial toenail flap transfer. Twenty digits, including 16 thumbs, two index fingers, and two middle fingers, with composite soft tissue defects were treated with a partial toenail flap transfer from October 2015 to January 2020. Shortening revision of the great toe phalanx, a V-Y advancement flap of the toe pulp, and a local pedicle flap from a second toe transfer were used to cover the donor sites, and no skin grafts were required. Functionality was evaluated using the validated Spanish version of the Quick-DASH scale. The aesthetics of both the reconstructed and donor sites were evaluated using the Vancouver Scar Scale (VSS). The static two-point discrimination (2-PD) of the finger pulp was used as a measure of tactile agnosia. All donor site wounds healed well. The average follow-up time was 23.6 months (6-39 months). The mean Quick-DASH functional score was 7.1. The VSS scores were 4.02 ± 0.29 and 4.00 ± 0.38 for the reconstructed and donor sites, respectively. The static 2-PD of finger pulp was 4.5 ± 0.76 mm. The patients were satisfied with finger motion, sensory function, and aesthetic contour. Partial toenail flap transfer is the recommended treatment to regain motion, sensation, function, and a satisfactory aesthetic appearance when considering repairing a composite soft tissue distal finger defect with accompanying loss of the perionychium, particularly in the thumb, index finger, or middle finger.

Complications and Peri-operative Characteristics of Flaps for Reconstruction of Defects after Ablation of Squamous Cell Carcinoma of the Floor of the Mouth.

To determine the appropriate method to use to repair defects after ablation of squamous cell carcinoma (SCC) of the floor of the mouth (FOM). A retrospective review of 119 patients who underwent surgical resections of SCC of the FOM and flap reconstructions was conducted. A Student t test was used to examine the statistical differences in operative time, length of hospital stay and complications among groups with different reconstructions. Advanced-stage patients were repaired with more free flaps than local pedicled flaps that provided more reconstructions for small-to-medium defects. The most common recipient complication was wound dehiscence, and patients in the anterolateral thigh flap group developed a greater number of overall recipient site complications compared with those in other groups. Patients undergoing local flap reconstructions had shorter operative times compared with those with free flap reconstructions. In contrast to a radial forearm free flap as a more appropriate reconstruction for defects involving the tongue, an anterolateral thigh flap was better suited for defects with dead spaces. A fibular flap was appropriate for massive complex defects involving the mandible, FOM and tongue. A pectoralis major musculocutaneous flap provided the last line of reconstruction for patients with relapsed SCC or high-risk factors for microsurgical reconstructions.

Assessment of treatment result of soft tissue defects of fingers by local pedicle flap

Background: The hands, especially fingers, are one of the nicest organs in the bodies movement system and participate in most daily activities. It performs the function of sophisticated movement and good touch. Thus, the risk of hand injury, especially digital defects is very high. Besides, the defects after removing the contracture scar, if treatment is not done well, will leave sequelae affecting the function and aesthetics of the hand. Subject and method: The uncontrolled clinical interventional study on 39 patients with 41 soft tissue defects of fingers reconstructed by the local pedicle flap in Plastic - Comestic - Hand Departement, Hue Central Hospital. Result: In 41 flaps used, there were 100% cases of flap survived, ensuring the coverage function, including 8/41 flap congested in the postoperative period, 1/41 flap infected with flap’s margin, There were no failed cases requiring additional recovery surgery. In all cases, the donor area of the flap healed well in the first stage (31/41 in cases of skin grafting in the flap, 10/41 in the cases that can be sutured to close the donor area directly). The 1-month follow-up results showed that 82.9% of flaps achieved good results, 17.1% of flaps achieved average results, there were no cases of bad results and failures. The results of the 3-month follow-up were 87.8% with good results and 12.2% with moderate results. All of the patients were satisfied with the surgical results. Conclusion: There are many options of flaps available for use in finger soft-tissue defect contouring, flexibility is needed in using flaps for each type of defect to provide the best results in terms of coverage and aesthetics. Key words: finger soft-tissue defect, local pedicle flap.

Aesthetic reconstruction of the scar contracture deformity in chin and neck with expanded flaps based on the "MRIS" principle

Objective: The surgical reconstruction strategy for scar contracture deformity in chin and neck was explored, aiming to obtain better aesthetic outcome. Methods: A retrospective observational study was conducted. From December 2017 to April 2021, 34 patients with scar contracture deformity in chin and neck after burns were hospitalized in the Department of Plastic Surgery of the First Affiliated Hospital of Army Medical University (the Third Military Medical University), aged 12-54 years, including 13 males and 21 females, 4 cases with chin affected only, 7 cases with neck affected only, and 23 cases with both chin and neck affected. The scar areas were 48-252 cm2. All the patients were treated by operation with expanded flaps, following the "MRIS" principle of matching of the color and thickness of the repair flaps (match), reconstructing of the aesthetic features of subunits (reconstruction), design of incision according to the plastic principle (incision), and prevention of the surgical incision scar (scar). The rectangular or kidney shaped skin and soft tissue expander (hereinafter referred to as the expander) with rated capacity of 80-400 mL was embedded in the first stage, which was routinely expanded to 3-5 times of the rated capacity of the expander. In the second stage, scar resection and expanded flap excision were performed to repair the secondary wound, and the flap donor site was sutured directly. The expansion ratio of the expander (with average value being calculated), the type of flaps used, the reconstruction of local aesthetic morphology, the appearance of postoperative incision, the survival of flap, and the situation of donor and recipient sites observed during follow-up were recorded. Results: Among the 34 patients, the average expansion ratio of the implanted expander was 3.82 times of the rated capacity of the expander. Three cases were repaired by the expanded local pedicled flap only, 19 cases by the expanded shoulder and/or chest perforator pedicled flap only, 10 cases by the expanded local pedicled flap combined with the expanded shoulder and/or chest perforator pedicled flap, and 2 cases by the expanded local pedicled flap combined with the expanded free flap of the second intercostal perforator of internal thoracic artery. After scar resection, the shapes of lower lip and chin-lip groove were reconstructed in 10 cases, chin process reconstruction and chin lengthening were performed in 16 cases, and the cervico-mental angle and mandibular margin contour were reconstructed in 28 cases. The surgical incision was concealed, most of which were located at the natural junction or turning point of the chin and neck subunits. The vertical incision of neck was Z-shaped or fishtail-shaped. All the expanded flaps in 34 patients survived after operation, of which 8 patients had minor necrosis at the edge or tip of the expanded flaps 1-3 days after operation and healed after dressing change. During the follow-up of 3-18 months, little difference in color and thickness between the expanded flap and the skin of chin and neck was observed, and the aesthetic shape of chin and neck was significantly improved, with mild scar hyperplasia of surgical incision. Conclusions: Reconstruction of scar contracture deformity in chin and neck by using expanded flaps based on the "MRIS" principle is beneficial to improve the quality of surgery and achieve better aesthetic outcome.

Musculocutaneous flap of the medial head of the triceps brachii: pedicled flap to cover the posterior cubital region.

The medial head of the triceps brachii flap is already described as a local muscular or as a free flap. It allows coverage of defects of the posterior cubital region. The aim of this study was to describe the vascular anatomy of the musculocutaneous medial triceps brachii pedicled flap. Eleven fresh-frozen upper limbs (6 come from women and 5 from men) were proximally injected with Indian ink agar solution. The medial head of the triceps brachii muscle was dissected and the superior ulnar collateral artery (SUCA) was isolated with its collaterals. The collateral arteries were dissected to determine whether there were septocutaneous or musculocutaneous arteries for vascularization of the skin in front of the medial head. Lengths of those collaterals arteries were measured. The average number of collaterals arteries from the SUCA supplying the medial head of the triceps brachii is 4.5 (from 3 to 6 arteries). Among these collaterals' arteries, there are one average 1.5 (0.6-4.5) septocutaneous arteries and 3 (1-4.8) musculocutaneous arteries. A musculocutaneous flap with the medial head of the triceps brachii muscle can be described with the muscle. The SUCA gives perforator arteries musculocutaneous and septocutaneous for the vascularization of the triceps brachii medial head. The use of local pedicled flap with similar tissue maximizes healing with a minimal morbidity of the donor site. This study demonstrated the feasibility of the medial head triceps brachii musculocutaneous flap to cover defect of the posterior aspect of the elbow.

A0784 - Clinical study of urethroplasty combined free grafting of internal preputial lamina with onlay local pedicled flap

A0784 - Clinical study of urethroplasty combined free grafting of internal preputial lamina with onlay local pedicled flap

A new classification of maxillary defect and simultaneous accurate reconstruction

Objective: To select the preferred flaps for the reconstruction of different maxillary defects and to propose a new classification of maxillary defects. Methods: A total of 219 patients (136 males and 83 females) underwent the simultaneous reconstruction of maxillary defects in the Beijing Tongren Hospital, Capital Medical University, between January 2005 and December 2018 were reviewed. Age ranged from 16 to 78 years. Based on the proposed new classification of the maxillary defects, 22 patients with class Ⅰ defects (inferior maxillectomy), 44 patients with class Ⅱ defects (supperior maxillectomy), 132 patients with class Ⅲ defects (total maxillectomy) and 21 patients with class Ⅳ defects (extensive maxillectomy) were enrolled. Survival rate, functional and aesthetic outcomes of flaps were evaluated. Survival analysis was performed in 169 patients with malignant tumor, Kaplan-Meier method was used to calculate the survival rate, and Log-rank method was used to compare the difference of survival rate in each group. Results: A total of 234 repairs for maxillary defects were performed in 219 patients. Fibula flaps were used in 4/13 of class Ⅰ defects; temporal muscle flaps (11/24, 45.8%) and anterolateral thigh flaps (6/24, 25.0%) used in class Ⅱ defects; temporal muscle flaps (71/128, 55.5%), anterolateral thigh flaps (6/24, 25.0%) and fibula flaps (12/128, 9.4%) used in class Ⅲ defects; and anterolateral thigh flaps (8/20, 40.0%) and rectus abdominis flaps (8/20, 40.0%) used in class Ⅳ defects. The success rate of local pedicled flaps was 95.6% (109/114) and that of free flaps was 95.8% (115/120). Thrombosis(10/234,4.3%) was a main reason for repair failure. Among the followed-up 88 patients, swallowing and speech functions recovered, 82 (93.2%) of them were satisfied with appearance, and 75 (85.2%) were satisfied with visual field. The 3-year and 5-year overall survival rates were 66.5% and 63.6%, and the 3-year and 5-year disease-free survival rates were 57.1% and 46.2%, respectively, in the 169 patients with malignant tumors. Conclusion: A new classification of maxillary defects is proposed, on which suitable flaps are selected to offer patients good functional and aesthetic outcomes and high quality of life.

A New Extraperitoneal Method for Entero-atmospheric Fistula Closure Using a Free Muscle Flap.

Summary:Treatment of an entero-atmospheric fistula (EAF) is challenging and associated with significant morbidity and mortality. For an EAF with protrusion of mucosa, chances for spontaneous closure are minimal. Standard surgical procedures may be associated with a high risk for complications in patients with a hostile abdomen. This article describes a new method for extraperitoneal closure of an EAF in a patient with a hostile abdomen. A free segmental latissimus dorsi musculocutaneous flap was harvested on its thoracodorsal pedicle, leaving the remaining muscle innervated. The flap was anastomosed to the internal mammary vessels. The muscle was sutured into the fistula opening using a parachute technique and temporarily immobilized with a negative wound pressure device. The skin of the flap was used for monitoring and later replaced by a skin graft. The postoperative course was uneventful. At 24 months follow-up, there were no signs of recurrences. The patient had no pain and had no defecation problems. Extraperitoneal closure of an EAF with a segmental free latissimus dorsi muscle flap sutured into the fistula opening with a parachute technique may be a new promising technique in patients where standard surgical procedures are associated with too high a risk for complications and where a local pedicled muscle flap is not available. The advantages of this method are that no laparotomy is required, the intestinal lumen is not reduced in diameter, and that no bowel resection is performed, which is a particular advantage in cases with a short bowel syndrome.

Reconstructive surgery of the scrotum: a systematic review.

The term scrotoplasty embraces several techniques which aim to restore a normal scrotal appearance and function. We provide here a quick reference tool to allow the urologist to select the appropriate surgical strategy among the several available options. A comprehensive research was carried out on MEDLINE/PubMed to identify relevant studies concerning this topic, including a range of key words, e.g., scrotoplasty, ventral phalloplasty, scrotal reconstruction, scrotomegaly, penoscrotal web, scrotal lifting, scrotal reduction, scrotectomy, scrotal lymphoedema. Scrotal skin defects may be related with Fournier's gangrene, traumatic events, and surgery for genital cancers or peno-scrotal lymphoedema. The reconstructive management of these conditions is relatively reproducible in the hands of experienced urologists, if aware of the basics of scrotal surgery. Primary tension-free wound closure and local pedicled flaps typically allow optimal surgical outcomes for repairing most of these scrotal defects, with split-thickness skin grafts (STSGs) and/or distant flaps being required only when dealing with extensive skin losses. The demand for genitals' aesthetic surgery among adults is on the increase recently. Although the scientific evidence regarding this topic is scarce, reduction scrotoplasty and peno-scrotal webbing correction techniques are easy, safe and effective solutions to improve genital cosmesis, being carried out in isolation or in combination with penile prosthesis implantation. More robust scientific evidence is needed to achieve a uniformed consensus regarding the optimal surgical management in this broad field, and surgical innovation should continue to refine current reconstructive techniques.

A systematic approach to plastic surgical foot reconstruction

Soft tissue defects of the foot are very common sequelae after trauma and require an individual reconstructive approach. Recommendations for the treatment of soft tissue injuries to the foot are given. The criteria of soft tissue reconstruction, postoperative follow-up and complications are first discussed before the therapeutic approach is explained depending on the reconstruction site. Case examples are given for illustration. Decision making for soft tissue reconstruction of the foot is based on the location, the 3‑dimensional extent of the defect, the patient requirements and concomitant diseases. Standardized treatment algorithms are usually applied that need to be adapted according to individual patient factors. Randomized and local pedicled flaps can be applied for foot reconstruction; however, these options involve asignificant risk of complications. Consequently, free flaps are frequently indicated after appropriate preoperative diagnostics of the perfusion of the foot. Due to the vast variety of donor sites, free flaps allow an individualized reconstruction, which is adapted to local and patient requirements. Precise preoperative reconstructive planning and analysis of the vascularization form the foundation for asuccessful soft tissue reconstruction of the foot. The aims of the individualized approach to soft tissue reconstruction of the foot are stable soft tissue coverage, resistance to weight bearing of the sole of the foot, the ability to wear normal shoes and maintenance of sensibility.

Evaluation of pedicled flaps for type IIIB open fractures of the tibia at a tertiary care center

BackgroundSoft tissue coverage plays a vital role in replacing the vascularity of the underlying bone in Gustilo type IIIB fractures. The aim of this article was to evaluate the feasibility of local pedicled flaps in type IIIB fractures at a tertiary care center.MethodsWe included all cases of open Gustilo-Anderson type IIIB fractures of the tibia treated with local flap coverage from January 2017 to February 2019. We carried out a retrospective analysis to investigate the relationships of complications, hospital stay, and cost-effectiveness with the choice of flap, infective foci, site and size of the defect, and type of fixation.ResultsOut of 138 Gustilo type IIIB fractures analyzed in our study, 27 cases had complications, of which 19 (13.76%) involved flap necrosis, four (2.89%) were infections, three (2.17%) involved partial necrosis, and one (0.72%) was related to bone spur development. Flap complications showed a statistically significant association with the perforator flap category (propeller flaps in particular) (P=0.001). Flap necrosis showed a significant positive correlation with cases treated within 3 weeks after trauma (P=0.046). A significant positive correlation was also found between defect size and the duration of hospital stay (P=0.03).ConclusionsAlthough local flaps are harvested from the same leg that underwent trauma, their success rate is at least as high as microvascular flaps as reported from other centers. Amidst the local flaps, complications were predominantly associated with perforator flaps.

Use of External Tissue Expanders to Assist in Reverse Sural Flap Donor Site Closure

Background: Complex lower extremity injuries can cause large soft tissue defects that require reconstruction. In the distal third of the lower leg, the reverse sural artery fasciocutaneous flap is a viable coverage option due to its versatility, vascular supply, and ability to cover larger defects than other local pedicled flaps. Although advances in techniques have improved reliability of reverse sural flaps, complications such as donor site morbidity remain a challenge for surgeons. Donor wounds may be difficult to close, and delayed closure can increase the risk for infection and other postoperative complications. In these cases, donor site skin grafting can cause additional morbidity and/or mobility restrictions. Methods: In this case series, 16 patients underwent reconstruction with large reverse sural artery fasciocutaneous flaps and a continuous external tissue expander to assist in donor site closure. Results: One patient was lost to follow-up. All donor sites healed without complication with an average time to healing of 9.2 weeks (n = 15, range: 3–18). At the most recent follow-up, all flaps survived without complication. Conclusions: Given our success in 100% of patients, we purport that this system of enhanced closure may be a valuable adjunctive therapy in closing reverse sural artery fasciocutaneous flaps. We believe that this method may be useful in closing other difficult donor wounds.

Covid-19 crisis promotes innovation: The extended indications for pedicled perforator flaps in breast cancer surgery.

Background: During the height of the Covid-19 pandemic in the United Kingdom (March-May 2020) the use of implants and DIEP flaps was prohibited to avoid extended patient in-hospital stay and exposure to risk. Due to a requirement to innovate, we increased our use of local pedicled perforator flaps (PPF) to optimise wide excision allowing for clear margins and replacing tissue to maintain cosmesis and also to provide whole breast reconstruction whilst minimising length of hospital stay (LOS) and risk of complications requiring readmission.

Reconstruction of motorcycle spokes wheel injury fingertip amputations with reposition flap technique: a report of 40 cases

Replantation of the distal fingertip amputation poses a technical challenge to the treating hand surgeon especially dealing with motorcycle spokes wheel injury causing Allen's type III and IV amputation. The reason being the pulp charred and severely crushed. Various reconstructive options have been described in the literature. We analyze the surgical option of repositioning the amputated stump with local pedicle flaps in such injuries and interpreting the results and functional outcome. Forty patients with motorcycle spokes wheel fingertip amputations involving thumb (60%) and index, middle, and ring fingers were operated by reposition flap between 2017 and 2019. Group I was Allen's type III amputations (n = 20). Group II was type IV amputations (n = 20). Range of movements, 2-point discrimination, sensation, intolerance to cold, nail aesthetics outcome, VAS, quick DASH score and return to work were analyzed in these two groups and evaluated. The average follow-up of our study in group I and group II was 24.6 and 24.4months, respectively. All patients returned to work in an average of 13.4weeks with a good radiological bone union and an excellent range of movements. All had an average 2-point discrimination of 8.5mm and 8.3mm; VAS as 0.2, mean quick DASH score 5.4 and 5.0, respectively in both groups. 15% dysplastic nail and 30% had cold intolerance; all had satisfactory sensation in the final follow-up with an average finger shortening of 4.7 and 5mm. No finger stiffness and donor site morbidity seen. Reposition of the amputated distal phalanx, free nailbed graft with cross finger flap in motorcycle spokes wheel injury is safe, and effective. It preserves the pulp contour and gives a good functional outcome. It is a viable alternative option to replantation in Allen's type III and IV fingertip amputations especially in motorcycle spokes wheel injury with pulp loss. IV.