Medial Perforant Research Articles

Perforator Characteristics and Impact on Postoperative Outcomes in DIEP Flap Breast Reconstruction: A Systematic Review and Meta-Analysis.

High-quality evidence on perforator selection in deep inferior epigastric perforator (DIEP) flap harvesting is lacking, making preoperative planning and choice of perforators "surgeon-specific." This lack of consensus is a subject of continuous debate among microsurgeons. We aimed to systematically review perforator characteristics and their impact on DIEP flap breast reconstruction outcomes. We conducted a systematic review and meta-analysis across six databases: ClinicalTrials.gov, Cochrane Library, Medline, Ovid Embase, PubMed, and Web of Science for all studies on DIEP flap breast reconstruction focused on perforator characteristics-caliber, number, and location. The primary goal was to analyze the impact of perforator characteristics on partial and/or total flap failure and fat necrosis. Data was analyzed using RevMan V5.3. Initial search gave us 2,768 articles of which 17 were included in our review. Pooled analysis did not show any statistically significant correlations between partial and/or total flap failure and perforator number, or perforator location. Sensitivity analysis accounting for heterogeneity across studies showed that, the risk for fat necrosis was significantly higher if single perforators (relative risk [RR] = 2.0, 95% confidence interval [CI] = 1.5-2.6, I 2 = 39%) and medial row perforators (RR = 2.7, 95% CI = 1.8-3.9, I 2 = 0%) were used. Our findings suggest that a single dominant perforator and medial row perforators may be associated with higher risk of fat necrosis after DIEP flap breast reconstruction. Adopting a standardized perforator selection algorithm may facilitate operative decision making, shorten the learning curve for novice surgeons, and optimize postoperative outcomes by minimizing the burden of major complications. This in turn would help improve patient satisfaction and quality of life.

Combined great toe dorsal nail-skin flap and medial plantar flap for one-stage reconstruction of degloved finger

BackgroundHistorically, the degloved finger with the total loss of nail and skin had been resurfaced with an expanded great toe wrap-around flap transfer for better outcomes. The purpose of this study aims to present our experience with a related modified design, with total preservation of a weight-bearing plantar skin. MethodFrom April 2016 to September 2019, nine fingers (5 index and 4 middle fingers) in nine cases, with skin loss to the base of the proximal phalangeal or metacarpophalangeal (MCP) joint level, were reconstructed with combined great toe dorsal nail-skin flap and medial plantar artery perforator (MPAP) flap. The dorsal great toe donor was covered with a thin groin flap, and the medial plantar site was covered with a full-thickness skin graft. The cutaneous nerves were preserved within both flaps. Standardized assessment of outcome in terms of sensory, functional, and esthetic performance of the reconstructed fingers was completed. ResultsFlap survival was achieved in all cases. The contour of the reconstructed digits was comparable with the contralateral one. The fingers were available for a mean follow-up of 28 months (ranged, 22-39 months). The mean dimension of the great toe dorsal nail-skin flap was 8.5 × 4.0 cm (ranged, 6.5 × 3.5-11.0 × 4.5 cm). The average size of the MPAP flap was 6.5 × 4.5 cm (ranged, 5.0 × 3.5-8.0 × 5.5 cm). At the last follow-up, the functional and aesthetic consequences were satisfactory, as well as the restored sensory. ConclusionReconstruction of degloved fingers with the great toe dorsal nail-skin flap combined MPAP flap, preserving a plantar weight-bearing area, results in excellent contour and functional outcome. Donor-site morbidity in the foot was minimal.

Postnatal Choline Supplementation Rescues Deficits in Synaptic Plasticity Following Prenatal Ethanol Exposure.

Prenatal ethanol exposure (PNEE) is a leading cause of neurodevelopmental impairments, yet treatments for individuals with PNEE are limited. Importantly, postnatal supplementation with the essential nutrient choline can attenuate some adverse effects of PNEE on cognitive development; however, the mechanisms of action for choline supplementation remain unclear. This study used an animal model to determine if choline supplementation could restore hippocampal synaptic plasticity that is normally impaired by prenatal alcohol. Throughout gestation, pregnant Sprague Dawley rats were fed an ethanol liquid diet (35.5% ethanol-derived calories). Offspring were injected with choline chloride (100 mg/kg/day) from postnatal days (PD) 10–30, and then used for in vitro electrophysiology experiments as juveniles (PD 31–35). High-frequency conditioning stimuli were used to induce long-term potentiation (LTP) in the medial perforant path input to the dentate gyrus of the hippocampus. PNEE altered synaptic transmission in female offspring by increasing excitability, an effect that was mitigated with choline supplementation. In contrast, PNEE juvenile males had decreased LTP compared to controls, and this was rescued by choline supplementation. These data demonstrate sex-specific changes in plasticity following PNEE, and provide evidence that choline-related improvements in cognitive functioning may be due to its positive impact on hippocampal synaptic physiology.

Long-term outcomes of oncoplastic breast resection with local perforator flaps

Background. Oncoplastic breast resections with perforator flaps are relatively common now; however, many studies demonstrate contradictory results, especially in terms of long-term outcomes.Objective: to assess short-term and long-term outcomes of oncoplastic breast resection with defect repair using perforator flaps.Materials and methods. This study included 62 breast cancer patients who underwent oncoplastic breast resection with defect repair using local perforator flaps, including lateral intercostal artery perforator (LICAP) flaps (40.3 %), lateral thoracic artery perforator (LTAP) (19.4 %), anterior intercostal artery perforator (AICAP) (27.4 %), and medial intercostal artery perforator (MICAP) (12.9 %) flaps. The assessment of oncological, functional, and aesthetic outcomes was performed in patients who were followed-up for at least a year (n = 57). Mean follow-up time was 26.5 months (range: 14–38 months).Results. The following complications were registered among the patients studied: seroma in the area of excised primary tumor (8.1 %), insufficient blood supply of the flap that caused focal lipofibrosis/liponecrosis (3.2 %), positive resection margin (3.2 %), low position of the submammary fold (11.3 %), locoregional recurrence (0 %), generalized process (3.5 %). All women evaluated their functional and aesthetic result as good or excellent. According to BCCT.core 3.0, 91.3 % of patients achieved good and excellent results.

Vaginal reconstruction: Progress by perforator flaps

ABSTRACT Introduction Gracilis and rectus abdominis myocutaneous flaps have been used for reconstruction of a wide range of vaginal defects, but recently, minimally invasive reconstruction with various perforator flaps has become popular. Vaginal reconstruction for the past 41 years is reported. Patients Summary 15 cases of vaginal defects were surgically treated. The case was that the age at surgery was 23 to 87 years, with an average of 55 years. The original disease is vesico-vaginal fistula 6 cases, Paget cancer 4 cases, labial1 cancer 1 case, pudendal radiation ulcer associated with lymphedema 1 case, Rokitansky syndrome 1 case, GID (Male to female)1 case, vaginal stenosis 1 case. Flaps for reconstruction are: gracilis musculocutaneous flap 5, superficial circumflex artery perforators (SCIP) flap 4, pudendal artery perforator flap 3, medial femoral perforator Flap 2, scrotal flap 1, gracilis perforator flap 1, free latissimus dorsi musculocutaneous flap 1. Reconstruction using multiple flaps was performed for extremely widespread defects. Results and Conclusion Postoperative follow-up was 2weeks to 20 years with an average of 2.5 years. As complications, recurrence of bladder-vaginal fistula occurred in 2 of 6 cases (33%), and partial necrosis of the flap was observed in 1 of 16 cases (6%). For vaginal reconstruction, the surrounding myocutaneous flap or perforator flap can be selected depending on the depth and extent of the defect. Donors can be closed by using combined flaps, especially for a wide range of defects. Irradiated bladder-vaginal fistulas may require a bilateral approach from the bladder and vagina. In the future, reconstructive surgery that considers sexual function will be required for GID as well. Disclosure Work supported by industry: no. A consultant, employee (part time or full time) or shareholder is among the authors (Luxanos).

Improving the Safety of DIEP Flap Transplantation: Detailed Perforator Anatomy Study Using Preoperative CTA.

Background: Deep inferior epigastric perforator and muscle sparing transverse rectus abdominis muscle flaps are commonly used flaps for autologous breast reconstruction. CT-angiography allows to analyse the perforator course preoperatively. Our aim was to compare the different aspects of perforator anatomy in the most detailed study. Methods: CT-angiographies of 300 female patients with autologous breast reconstruction of 10 years were analysed regarding the anatomy of the deep inferior epigastric artery and every perforator. Results: Overall, 2260 perforators were included. We identified correlations regarding the DIEA branching point and number of perforators and their intramuscular course. The largest perforator emerged more often from the medial branch of the DIEA than the smaller perforators (70% (416/595) vs. 54% (878/1634), p < 0.001) and more often had a direct connection to the SIEV (large 67% (401/595) vs. small 39% (634/1634), p < 0.01). Medial row perforators were larger than the laterals (lateral 1.44 mm ± 0.43 (n = 941) vs. medial 1.58 mm ± 0.52 (n = 1304) (p < 0.001)). The larger and more medial the perforator, the more likely it was connected to the SIEV: perforators with direct connection to the SIEV had a diameter of 1.65 mm ± 0.53 (n = 1050), perforators with indirect connection had a diameter of 1.43 ± 0.43 (n = 1028), perforators without connection had a diameter of 1.31 mm ± 0.37 (n = 169) (p < 0.001). Medial perforators were more often directly connected to the SIEV than lateral perforators (medial 56% (723/1302) vs. lateral 35% (327/941), p < 0.001). A lateral perforator more often had a short intramuscular course than medial perforators (69% (554/800) vs. 45% (474/1055), p < 0.001), which was also more often observed in the case of a small perforator and a caudal exit of the rectus sheath. Conclusion: The largest perforator emerges more often from the medial branch of the DIEA and frequently has a direct connection to the SIEV, making medial row perforators ideal for DIEP flap transplantation.

Characterizing Outcomes of Medial and Lateral Perforators in Deep Inferior Epigastric Perforator Flaps.

Perforators are typically found in rows in the deep inferior epigastric perforator (DIEP) flap. As methods to assess flap perfusion continue to improve, surgeons may be more likely to select perforators traditionally avoided. The purpose of this article is to describe clinical outcomes based on row and number of perforators to reevaluate flap and abdominal donor site morbidity. A retrospective analysis was performed on patients who underwent breast reconstruction with DIEP flaps by four microsurgeons from 2013 to 2020. The row and number of perforators were determined from operative reports. Chi-square and t-test or nonparametric Fisher's exact test and Wilcoxon two-sample test were used for discrete and continuous variable, respectively, as applicable. Logistic regression was used for multivariable analyses. Of 628 flaps, 305 were medial row (58.7%), 159 were lateral row (30.6%), and 55 had both rows (10.6%). Partial flap loss was higher in both rows (p = 0.003). Fat necrosis was higher with medial (p = 0.03) and both rows (p = 0.01) when compared with lateral using multivariable analysis. Hernia or bulge was higher in lateral row flaps (lateral: 8/157, 5.1%; medial, 5/299, 1.7%; both, 0/55; p = 0.05); however, mesh was more commonly used in both row flaps (p = 0.05). There was no difference in fat necrosis or abdominal morbidity between single and multiple perforators. There was no difference in fat necrosis based on the number or row of perforators. The lateral row provides adequate perfusion but may be associated with an elevated risk of hernia or bulge. Patients may benefit from mesh, especially when both rows are dissected.

Application of wrap-around great toe flap combined with medial plantar artery perforator flap for completely degloved fingers

To investigate the effectiveness of the wrap-around great toe flap combined with medial plantar artery perforator flap (MPAP) for repairing the completely degloved fingers. Between February 2018 and December 2019, 12 patients with the completely degloved fingers caused by machine strangulation were admitted. There were 9 males and 3 females with a median age of 32 years (range, 18-42 years). The injured finger was index finger in 7 cases, middle finger in 3 cases, and ring finger in 2 cases. The skin was avulsed from the metacarpophalangeal joint level, with the intact tendon and joint. The interval between injury and admission was 1-8 hours (mean, 5 hours). All fingers were taken debridement during the emergency operation. The size of the skin defect ranged from 8.0 cm×5.0 cm to 12.0 cm×7.5 cm. After flap thinning, the wrap-around great toe flap (8.0 m×2.0 cm-12.0 cm×3.5 cm) and MPAP (8.0 cm×4.0 cm-12.0 cm×5.5 cm) were used to repair the degloved finger. The donor sites were repaired with the full-thickness skin graft or the flap. All flaps and skin grafts survived completely without significant complications and the wounds at recipient and donor sites healed by first intention. All patients were followed up 12-16 months (mean, 14 months). The texture, appearance, and color of the affected fingers were close to those of normal fingers, and the nails grew normally. At last follow-up, the mean two-point discrimination of the flap was 9 mm (range, 8-10 mm), and the sensation of the injured finger recovered to S3-S4. And 10 cases were rated as excellent and 2 cases as good according to the Michigan Hand Outcomes Questionnaire (MHQ). There was no complication such as pain from walking or skin ulceration at the donor site. The American Orthopaedic Foot and Ankle Society (AOFAS) score was excellent in 9 cases and good in 3 cases. Treating for the completely degloved fingers, the wrap-around great toe flap combined with MPAP can obtain good effectiveness in the respect of the sensation, function, and appearance.

Versatility of Medial Sural Artery Islanded Pedicled Perforator Flap for Resurfacing Areas Around the Knee.

Soft tissue defects with exposed tendon, bones, and joints around the knee are difficult and challenging to treat because of its location over a joint, requires a stable cover that is supple and stretchable. For any knee defects, the gastrocnemius muscle flap is the first choice for the reconstruction, although it causes less functional deficit; however, because of its less reach, it is difficult to cover the defect in the superolateral aspect of knee joint and anterior to the tibial tuberosity with the other disadvantage being the bulkiness. The medial sural artery perforator flap (MSAPF) provides thin fasciocutaneous tissue similar to the adjacent normal soft tissue in the knee and so, its use leads to an improved reconstruction of contour and eliminating the need of a skin graft over the primary defect. Here, we will be discussing a case series using MSAPF to cover the defects around the knee.

The Medial Sural Artery Perforator Flap: A Historical Trek from Ignominious to “Workhorse”

Rather than just another “review,” this is intended to be an “overview” of the entire subject of the medial sural artery perforator (MSAP) flap as has been presented in the reconstructive literature from its inception in 2001 until the present, with any exceptions not purposefully overlooked. Unfortunately, the pertinent anatomy of the MSAP flap is always anomalous like most other perforator flaps, and perhaps even more variable. No schematic exists to facilitate the identification of a dominant musculocutaneous perforator about which to design the flap, so some adjunctive technology may be highly valuable for this task. However, if a relatively thin free flap is desirable for a small or moderate sized defect that requires a long pedicle with larger caliber vessels, the MSAP flap deserves consideration. Indeed, for many, this has replaced the radial forearm flap such as for partial tongue reconstruction. Most consider the donor site deformity, even if only a conspicuous scar on the calf, to be a contraindication. Yet certainly if used as a local flap for the knee, popliteal fossa, or proximal leg, or as a free flap for the ipsilateral lower extremity where a significant recipient site deformity already exists, can anyone really object that this is not a legitimate indication? As with any perforator flap, advantages and disadvantages exist, which must be carefully perused before a decision to use the MSAP flap is made. Perhaps not a “workhorse” flap for general use throughout the body, the MSAP flap in general may often be a valuable alternative.

Medial Sural Artery Perforator Flap in Resurfacing Superficial Dorsal Defect of the Foot

Medial Sural Artery Perforator Flap in Resurfacing Superficial Dorsal Defect of the Foot

Medial Plantar Fasciocutaneous Flap Reconstruction for Load-Bearing Foot Defects in Patients With Acral Melanoma

Acral lentiginous melanoma (ALM) is a rare subtype of malignant melanoma that usually involves the weight-bearing plantar area. Plantar defect reconstruction has traditionally been performed with skin grafts or free flaps. This study examined the efficacy and safety of a medial plantar artery perforator flap (MPAPF) for plantar defect reconstruction after wide excision of an ALM. Twenty-five patients who underwent reconstruction with a MPAPF between 2011 and 2021 were enrolled in this study. The defects were classified into 6 plantar zones. Demographic and clinical data were retrospectively analyzed. Reconstruction with medial plantar fasciocutaneous island flaps was performed in all cases, except for 4 patients who had lesions in forefoot, which required free medial plantar flaps. Defects in lateral and posterior heel were more likely to present with venous congestion and require longer healing times and revision surgery (P < 0.05). The average follow-up period was 49 months. Four and 5 patients developed local recurrence and distant metastasis, respectively. Four cases of hyperkeratosis and paresthesia were documented, but there were no cases of ulceration or wound dehiscence. None of the cases required secondary debulking procedures. The MPAPF is safe and effective for plantar defect reconstruction among patients with ALM. Meticulous dissection and adequate tunneling are needed, particularly for defects in the lateral and posterior heel, to minimize flap congestion and revision operations.

Medial plantar artery-based perforator and island flaps: a case series of applications in sole defects.

Soft tissue defects of the plantar foot pose a challenge to the reconstructive surgeon. The plantar region of the foot has a unique skin structure, which helps in its paramount functions of weight-bearing and providing protective sensation. It is best replaced with tissue of its own kind. The medial plantar artery (MPA) flap fulfils all the requirements of an ideal replacement for small-to-medium-sized defects in the mid plantar and heel region. This study describes our experience with MPA-based flaps for small-to-medium-sized defects of the plantar foot. The study was conducted in a tertiary referral hospital between April 2017 and March 2020 on patients who presented with defects on the mid plantar region and heel. MPA perforator (MPAP) flap or island flap were applied. The donor site was covered with split-thickness skin grafts. The study included 21 patients. MPAP flap was applied in nine patients and the island flap was applied in 12 patients. The mean age of the patients was 37.95 years and the mean flap size was 36.6cm2. All flaps survived well. In two patients, venous congestion developed which resolved spontaneously, while three patients had small graft loss which also healed with conservative treatment. All patients regained protective sensation within five months of flap coverage. Based on the MPA, both perforator and island flaps can be raised due to the fairly constant position of the perforators. These flaps have the advantage of robust vascularity with the replacement of identical tissue for weight-bearing functions along with acceptable aesthetic outcomes. Since they also have the added advantage of conferring sensation, they can be used as a primary option in cases of small-to-medium-sized plantar foot defects.

USING MEDIAL SURAL ARTERY PERFORATOR FLAP IN RECONSTRUCTION OF LIMB SOFT TISSUE DEFECTS

Aims: To evaluate the results of covering limb soft tissue defects with medial sural artery perforator free flap. Materials and Method: Non-randomised interventional study was performed on 10 cases of limb soft tissue defects exposing tendons, bones, blood vessels or nerves covered by medial sural artery perforator free flap. The lesion characteristics and flap features have been described. The effectiveness of defect coverage and the impact of the donor site were evaluated at the time of hospital discharge and 3 months after surgery. Results: 7 soft tissue defects of the lower limbs and 3 defects of the fingers, exposing tendons and bones were included in research. The average size of flaps was 5.9x11.2 cm2, the average thickness of flaps was 10.2±2.1mm, the average length of vessel pedicles was 10.3±2.6 cm and there were average of 1.9 perforators per flap. No postoperative complications were recorded. 100% of the flaps survived and covered the defects complettly. 100% of the donor sites were closed directly. After 3 months, 8/10 patients showed good limb function, 2/10 patients suffered from limited function at recontructed limb due to severe primary injury despite of good results in covering and healing. 7/10 flaps were flat, 3/10 flaps were thicker than expectation. 100% of the donor sites showed normal function. Although 6/10 cas appeared hypertrophic scars and 7/10 cas showed hyperpigmentation but all of the patients were sactisfied. Conclusions: The medial sural artery perforator flap has the advantages of being thin, less morbidity at the donor site and being suitable for medium soft tissue limb defects. Key words: Soft tissue limb defects, medial sural artery perforator flap, free flap.

Transcranial focused ultrasound induces sustained synaptic plasticity in rat hippocampus

Transcranial focused ultrasound (tFUS) neuromodulation provides a promising emerging non-invasive therapy for the treatment of neurological disorders. Many studies have demonstrated the ability of tFUS to elicit transient changes in neural responses. However, the ability of tFUS to induce sustained changes need to be carefully examined. In this study, we use the long-term potentiation/long term depression (LTP/LTD) model in the rat hippocampus, the medial perforant path (mPP) to dentate gyrus (DG) pathway, to explore whether tFUS is capable of encoding frequency specific information to induce plasticity. Single-element focused transducers were used for tFUS stimulation with ultrasound fundamental frequency of 0.5 MHz and nominal focal distance of 38 mm tFUS stimulation is directed to mPP. Measurement of synaptic connectivity is achieved through the slope of field excitatory post synaptic potentials (fEPSPs), which are elicited using bipolar electrical stimulation electrodes and recorded at DG using extracellular electrodes to quantify degree of plasticity. We applied pulsed tFUS stimulation with total duration of 5 min, with 5 levels of pulse repetition frequencies each administered at 50 Hz sonication frequency at the mPP. Baseline fEPSP is recorded 10 min prior, and 30+ minutes after tFUS administration. In N = 16 adult wildtype rats, we observed sustained depression of fEPSP slope after 5 min of tFUS focused at the presynaptic field mPP. Across all PRFs, no significant difference in maximum fEPSP slope change was observed, average tFUS induced depression level was observed at 19.6%. When compared to low frequency electrical stimulation (LFS) of 1 Hz delivered to the mPP, the sustained changes induced by tFUS stimulation show no statistical difference to LFS for up to 24 min after tFUS stimulation. When both the maximum depression effects and the duration of sustained effects are both taken into account, PRF 3 kHz can induce significantly larger effects than other PRFs tested. tFUS stimulation is measured with a spatial-peak pressure amplitude of 99 kPa, translating to an estimation of 0.43 °C temperature increase when assuming no loss of heat. The results suggest the ability of tFUS to encode sustained changes in synaptic connectivity through mechanism which are unlikely to involve thermal changes.

Age-Dependent and Pathway-Specific Bimodal Action of Nicotine on Synaptic Plasticity in the Hippocampus of Mice Lacking the miR-132/212 Genes.

Nicotine addiction develops predominantly during human adolescence through smoking. Self-administration experiments in rodents verify this biological preponderance to adolescence, suggesting evolutionary-conserved and age-defined mechanisms which influence the susceptibility to nicotine addiction. The hippocampus, a brain region linked to drug-related memory storage, undergoes major morpho-functional restructuring during adolescence and is strongly affected by nicotine stimulation. However, the signaling mechanisms shaping the effects of nicotine in young vs. adult brains remain unclear. MicroRNAs (miRNAs) emerged recently as modulators of brain neuroplasticity, learning and memory, and addiction. Nevertheless, the age-dependent interplay between miRNAs regulation and hippocampal nicotinergic signaling remains poorly explored. We here combined biophysical and pharmacological methods to examine the impact of miRNA-132/212 gene-deletion (miRNA-132/212−/−) and nicotine stimulation on synaptic functions in adolescent and mature adult mice at two hippocampal synaptic circuits: the medial perforant pathway (MPP) to dentate yrus (DG) synapses (MPP-DG) and CA3 Schaffer collaterals to CA1 synapses (CA3–CA1). Basal synaptic transmission and short-term (paired-pulse-induced) synaptic plasticity was unaltered in adolescent and adult miRNA-132/212−/− mice hippocampi, compared with wild-type controls. However, nicotine stimulation promoted CA3–CA1 synaptic potentiation in mature adult (not adolescent) wild-type and suppressed MPP-DG synaptic potentiation in miRNA-132/212−/− mice. Altered levels of CREB, Phospho-CREB, and acetylcholinesterase (AChE) expression were further detected in adult miRNA-132/212−/− mice hippocampi. These observations propose miRNAs as age-sensitive bimodal regulators of hippocampal nicotinergic signaling and, given the relevance of the hippocampus for drug-related memory storage, encourage further research on the influence of miRNAs 132 and 212 in nicotine addiction in the young and the adult brain.

Novel use of Pedicled Medial Sural Artery Perforator flap for Post Burn Knee Contractures

<br><b>Background:</b> Postburn flexion contractures of the knee may arise even with adequate treatment of the burn injury. Pedicled medial sural artery perforator (MSAP) flap has been described for the reconstruction of defects of the knee and proximal third of the leg. Its use in the management of postburn contracture release is sparse. We are presenting the use of a medial sural artery pedicled flap for the reconstruction following postburn knee contracture release. <b>Materials and Methods:</b> This study included six patients with postburn unstable scars and a mild degree of knee contractures who underwent release of the contracture and coverage using MSAP pedicled flap. The results in terms of flap size, recurrence, complications, functional outcome, and cosmesis were assessed. <b>Results:</b> The flap size ranged from 7 cm × 6 cm to 13 cm × 7 cm with a mean pedicle length of 9.41 cm. All six flaps survived without any complications with a satisfactory outcome. The patients were followed up for 6–18 months. There was no recurrence of contracture without any restriction of knee joint mobility. <b>Conclusion:</b> MSAP flap is a reliable flap and should be considered for the management of postburn knee contracture of grade 2 and grade 3 contractures, as it provides optimum and ideal coverage with fewer chances of recurrence.<br>

Midface soft tissue defect closure with medial sural artery perforator flap

<h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Повышение эффективности хирургического лечения и реабилитации больных с мягкотканными дефектами средней зоны лица. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> В клиническом исследовании приняли участие 11 пациентов с мягкотканными дефектами и деформациями средней зоны лица; 10 пациентам дефекты устранили с использованием свободного лоскута на перфоранте медиальной икроножной артерии (ПЛМИА — перфорантный лоскут медиальной икроножной артерии). Выяснили этиологию возникновения дефектов, в последующем они были разделены согласно классификации J.S. Brown и R.J. Shaw (2010). Степень хирургического и анестезиологического рисков была оценена согласно шкале ACS NSQIP. Определили основные клинические характеристики лоскута и возможности его применения: размеры и толщину лоскута, количество перфорантных сосудов, участвующих в его кровоснабжении, длину сосудистой ножки. Динамическое наблюдение за пациентами позволило определить донорский ущерб. <h3>РЕЗУЛЬТАТЫ</h3> В 10 из 11 случаев нами был использован ПЛМИА для устранения дефектов средней зоны лица. В одном случае интраоперационно было принято решение отказаться от использования ПЛМИА. Площадь дефекта в среднем составляла 22,9 см². Размеры выделенных лоскутов варьировали от 3×4 см до 9×8 см, длина сосудистой ножки составляла от 11 до 16 см, толщина — от 0,4 до 0,9 см. В 3 случаях были сохранены по 2 перфоранта на лоскуте. Реципиентными сосудами выступали: верхнещитовидная, лицевая, подподбородочная, поверхностная височная артерии и вены и язычная вена. Средний показатель хирургического риска развития «серьезного осложнения» составил 25,16%, «любого другого осложнения» — 30,53% согласно результатам проведенного анализа по ACS NSQIP. <h3>ЗАКЛЮЧЕНИЕ</h3> Благодаря постоянству анатомии заднемедиальной поверхности голени, небольшой толщине подкожно-жировой клетчатки, возможности выделения различных размеров лоскута, длине сосудистой ножки, минимальному донорскому ущербу ПЛМИА является хорошим пластическим материалом для устранения дефектов мягких тканей средней зоны лица.

Comparison between Free Anterolateral Thigh Flap and Free Medial sural Artery Perforator Flap in Reconstruction of Posttraumatic Soft Tissue Defects of Dorsum of the Foot

Comparison between Free Anterolateral Thigh Flap and Free Medial sural Artery Perforator Flap in Reconstruction of Posttraumatic Soft Tissue Defects of Dorsum of the Foot

Accuracy of Stereovision-Updated Versus Preoperative CT-Based Image Guidance in Multilevel Lumbar Pedicle Screw Placement: A Cadaveric Swine Study.

Background:Change in vertebral position between preoperative imaging and the surgical procedure reduces the accuracy of image-guided spinal surgery, requiring repeated imaging and surgical field registration, a process that takes time and exposes patients to additional radiation. We developed a handheld, camera-based, deformable registration system (intraoperative stereovision, iSV) to register the surgical field automatically and compensate for spinal motion during surgery without further radiation exposure.Methods:We measured motion-induced errors in image-guided lumbar pedicle screw placement in 6 whole-pig cadavers using state-of-the-art commercial spine navigation (StealthStation; Medtronic) and iSV registration that compensates for intraoperative vertebral motion. We induced spinal motion by using preoperative computed tomography (pCT) of the lumbar spine performed in the supine position with accentuated lordosis and performing surgery with the animal in the prone position. StealthStation registration of pCT occurred using metallic fiducial markers implanted in each vertebra, and iSV data were acquired to perform a deformable registration between pCT and the surgical field. Sixty-eight pedicle screws were placed in 6 whole-pig cadavers using iSV and StealthStation registrations in random order of vertebral level, relying only on image guidance without invoking the surgeon’s judgment. The position of each pedicle screw was assessed with post-procedure CT and confirmed via anatomical dissection. Registration errors were assessed on the basis of implanted fiducials.Results:The frequency and severity of pedicle screw perforation were lower for iSV registration compared with StealthStation (97% versus 68% with Grade 0 medial perforation for iSV and StealthStation, respectively). Severe perforation occurred only with StealthStation (18% versus 0% for iSV). The overall time required for iSV registration (computational efficiency) was ∼10 to 15 minutes and was comparable with StealthStation registration (∼10 min). The mean target registration error was smaller for iSV relative to StealthStation (2.81 ± 0.91 versus 8.37 ± 1.76 mm).Conclusions:Pedicle screw placement was more accurate with iSV registration compared with state-of-the-art commercial navigation based on preoperative CT when alignment of the spine changed during surgery.Clinical Relevance:The iSV system compensated for intervertebral motion, which obviated the need for repeated vertebral registration while providing efficient, accurate, radiation-free navigation during open spinal surgery.