Pedicled Muscle Flap Research Articles

Immediate versus early soft tissue coverage for severe open grade III B tibia fractures: a comparative clinical study

Controversy remains regarding timing in the management of grade III-B open tibia fractures. Many authors recommend an immediate definitive soft tissue coverage within a critical period of 12 hours, yet in many patients, this may be impossible due to concomitant injuries or delayed referral. The present case series aims to compare the role of immediate versus early soft tissue coverage for severe open grade III-B tibial fractures. 20 cases of tibial fractures of were divided into two groups; 10 cases each. Immediate group (within 12 hours) and early group (3-7 days), according to the soft tissue coverage time. Strict criteria for inclusion in the first group included debridement within 12 hours of injury, no sewage or organic contamination, the presence of bleeding skin margins, and the absence of systemic illness. All 20 cases had been treated by a debridement and soft-tissue cover with a muscle pedicle or fasio-cutanous flap. Functional outcome measures included deep infection rate, stable soft tissue coverage, number of inpatient’s stays, number of surgical procedures, and union time. The mean follow-up period was 24 months. Mean inpatient time was 30 and 41 days respectively. Mean surgical procedures were 2.2 and 3.4 respectively and union time was 26 versus 34 weeks. Mean inpatient time, mean surgical procedures per time and union time were pointedly less in the immediate flap coverage group which significantly improves results concerning early union, healing time, and cost of hospitalization and rehabilitation.

Full-thickness chest wall reconstruction after resection of recurrent desmoid-type fibromatosis

Introduction. Desmoid-type fibromatosis (DF) is a benign but locally infiltrative soft tissue tumor that develops from fascia and musculoaponeurotic tissue with high local recurrence rate. The aim of this article was to present a case of recurrent DF of the chest wall and chest wall reconstruction after tumor resection. Case outline. A 62-year-old man came for an examination due to a tumor localized on the right anterior chest wall. The previous year, the patient had undergone surgical excision of DF of the abdominal wall. Physical examination found a firm and painless 6?7 cm mass on the right side of the chest wall with no swelling of superficial lymph nodes. A computed tomography scan revealed a homogenous mass of soft tissue density, measuring 7.12 ? 4.23 cm, arising from right anterolateral wall of thoracic cage with adjoining ribs destruction. The patient was taken to surgery, and right thoracotomy was done with excision of tumor along with resection of the eighth, nineth and tenth rib. The results of pathological examination were consistent with the frozen section, and the patient was diagnosed with DF. Despite the absence of postoperative radiotherapy, there was no evidence of local recurrence two years later. Conclusion. Surgical treatment of recurrent DF of the chest wall requires a wide resection with negative margins. Multidisciplinary approach in case of full-thickness defect of the chest wall and combination of pedicled muscle flap and polypropylene mesh are important to provide chest wall stability.

Perspective: Timely diagnosis and repair of intraoperative thoracic/lumbar cerebrospinal fluid (CSF) leaks.

Our review of 12 articles for this perspective showed the frequency of intraoperative thoracic and/or lumbar CSF fistulas/dural tears (DT) ranged from 2.6% - 8% for primary surgical procedures. Delayed postoperative CSF leak/DT were also diagnosed in 0.83% (17/2052 patients) to 14.3% (2/14 patients) of patients undergoing thoracic and/or lumbar procedures. Further, the rate of recurrent postoperative CSF leaks/DT varied from 13.3% (2/15 patients) to 33.3% (4/12 patients). Intraoperative, postoperative delayed, and recurrent postoperative traumatic postsurgical thorac CSF leaks/DT can be limited by performing initially sufficient operative decompressions and/or decompressions/fusions (i.e., utilizing adequate open exposures vs. inadequate minimally invasive (MI) approaches). The incidence of CSF leaks/DT can be further reduced by spine surgeons' utilization of operating microscopes, and their avoiding routine attempts at total synovial cyst excision and/or complete resection of hypertrophied/ossified yellow ligament in the presence of significant dural adhesions. Multiple CSF leak/CT repair techniques included; using interrupted, non-resorbable sutures for direct dural repairs (i.e. 7-0 Gore-Tex sutures where the suture is larger than the needle thus plugging needle holes), and adding where needed muscle patch grafts, microfibrillar collagen, the rotation of Multifidus muscle pedicle flaps, fibrin sealants (FS)/fibrin glues (FG), lumbar drains (LD), and/or lumbo-peritoneal (LP) shunts. Intraoperative, postopertive delayed, and/or recurrent postoperative thorac and/or lumbar traumatic surgical CSF leaks can be reduced by choosing to initially perform the appropriately extensive open operative decompressions and/or decompresssions/fusions. It is critical to use an operating microscope, non-resorbable interrupted sutures, and where necessary, muscle patch grafts, microfibrillar collagen, the rotation of Multifidus Muscle Pedicle Flaps, FS/FG, LD, and/or LP shunts.

Upper Limb Vascular Traumas with Vascular Exposure: Difficulties of Reconstruction in an Isolated Cardiovascular Surgical Environment

Abstract Introduction and Objective: Advocate for the knowledge and development of intrahospital therapeutic management of vascular trauma with vascular exposure, in our working conditions. Materials and Methods: This was a descriptive retrospective study which covered the period from January 2015 to June 2022. It was carried out from the medical records of patients operated on for vascular trauma with exposure of the vessels, in the Cardiovascular Surgery Department at the Abidjan Heart Institute. The following data were studied: epidemiological data, anatomo-clinical characteristics, and therapeutic data. Results: Nine medical records of eight male and one female patient were collected. The average age of the patients was 36 years. Elementary vascular lesions were as follows: complete section of the brachial artery and vein (n = 3), loss of substance of the brachial artery (n = 2), contusion of the brachial artery (n = 1), lateral wound of the ulnar artery (n = 2), and complete section of the radial artery (n = 1). Revascularization consisted in a brachio-brachial arterial bypass using a great saphenous vein graft (n = 3), end-to-end, respectively, arterial and venous anastomosis (n = 3), direct suture of the ulnar artery (n = 2), and in a radio-radial end-to-end arterial anastomosis (n = 1). The covering flaps used were the biceps brachii brachial muscle pedicled flap (n = 6) and the pedicled fasciocutaneous inguinal flap of McGregor (n = 3). The immediate and short-term postoperative follow-up was simple in all patients with scars of good trophicity. Conclusion: The surgical treatment requires skills in plastic surgery for the cardiovascular surgeon or the joint participation, in an emergency, of the cardiovascular surgeon and the plastic surgeon or, if necessary, the management of the patient in two stages. This last therapeutic modality generates additional morbidities and financial cost for the patient.

Biological reconstruction of bone defect after resection of malignant bone tumor by allograft: a single-center retrospective cohort study

BackgroundAllograft reconstruction following the resection of malignant bone tumors is associated with high rates of complications and failures. This study aimed to evaluate the efficacy and current problems of allograft reconstruction techniques to optimize treatment strategies at our center.Materials and methodsThirty-eight cases (16 men and 22 women), who were diagnosed with malignant bone tumors and had undergone allograft reconstruction, were recruited. Allograft was fixed by intramedullary nail, single steel plate, double plate, and intramedullary nail combined plate in 2, 4, 17, and 15 cases, respectively. Allograft union, local recurrence, and complications were assessed with clinical and radiological tests. Tumor grade was assessed using the Enneking staging of malignant bone tumors. Functional prognosis was evaluated by the Musculoskeletal Tumor Society (MSTS) scoring system.ResultsIntercalary and osteoarticular reconstructions were performed in 32 and 6 cases, respectively. Six patients underwent reoperation related to allograft complications, four patients had local recurrence, and three patients with allograft fracture underwent allograft removal. A total of eight host–donor junctions showed nonunion, including seven cases (18.4%) in diaphysis and one case (3.1%) in metaphysis (p < 0.01). Host rejection and secondary osteoarthritis occurred in nine and two cases, respectively. No deep infection and internal fixation device fracture occurred. The overall allograft survival rate was 81.6%. Postoperative MSTS score of patients with allograft survival was 26.8 ± 2.9, indicating a significant improvement as compared to their preoperative function.ConclusionsAllograft represents an excellent choice for intercalary bone defects after malignant bone tumor resection. Robust internal fixation protection across the whole length of the allograft is an important prerequisite for the survival of the allograft, while multidimensional osteotomy, intramedullary cement reinforcement, and pedicled muscle flap transfer can effectively improve the survival rate and healing rate of the allograft.

Reconstructing complex peripatellar defects using the descending genicular artery perforator flap.

Complex peripatellar defects are commonly reconstructed with free flaps or pedicled muscle flaps, whereas pedicled fasciocutaneous perforator flaps are commonly overlooked. The descending genicular artery perforator (DGAP) flap is a versatile flap that offers thin and pliable tissue that provides ideal 'like with like' peripatellar soft tissue defect reconstruction. This paper aims to demonstrate the safe use of a pedicled fasciocutaneous DGAP flap for extensive traumatic peripatellar defect reconstructions and to exhibit the surgical pearls via a case series. A retrospective cohort study of consecutive complex peripatellar reconstructions with DGAP flaps was conducted from January 2011 to December 2018. Patient demographics, medical comorbidities, aetiology/size/and location of the defects were reviewed. Flap, donor site, and overall surgical outcomes were clinically assessed and documented. Descriptive statistics were conducted and analysed by IBM SPSS Statistics 23. Five consecutive cases with complex peripatellar defects (5 × 8 to 8 × 10 cm) were recruited. Two were males, and three were females, with a mean age of 38.4 years. Four were trauma, and one was an oncological case. Descending genicular artery (DGA) perforators and DGA terminal branches were consistent. One patient needed a split-thickness skin graft to reconstruct the secondary defects. All the flaps survived with an average follow-up of 24 months. The DGAP flap provides a reliable alternative to free flap for the large, complex peripatellar defect. With the inclusion of the proximal long saphenous vein and judicious selection of DGA perforators and its terminal branches, the DGAP flap can be harvested and used safely in the high-velocity impacted knee.

Use of the Intercostal Artery-based Latissimus Dorsi Muscle for Intrathoracic Reconstruction after Division of the Thoracodorsal Vessels and Latissimus Dorsi Muscle.

The latissimus dorsi muscle is the workhorse flap for intrathoracic reconstruction. Prior thoracotomy, which divides the latissimus dorsi muscle, limits the muscle's intrathoracic reach. We present our experience using the distal portion of the muscle for intrathoracic reconstruction based off an intercostal vessel. We also demonstrate the ability of this intercostal perforator to allow for chimeric flap elevation with a separate skin paddle, depending on the branching pattern of the intercostal vessels. This study provides a case series of three consecutive patients, treated between September 2021 and June 2022. The intrathoracic pathology addressed in these patients are bronchopleural fistula, aortoesophageal fistula, and bronchoesophageal fistula. All patients had the resolution of symptoms related to intrathoracic fistulae and did not experience recurrence. This novel pedicled muscle flap can be an additional option for patients with prior thoracotomy and avoids the morbidity which can be seen with the serratus or rectus abdominis muscle flaps.

FRACTURE-RELATED INFECTION: DIAGNOSIS AND MANAGEMENT AT A MAJOR TRAUMA CENTRE

IntroductionFracture related infection (FRI) is a challenging complication to manage in an orthoplastic setting. Consensus guidelines have been created to standardise the diagnosis of FRI and comprise confirmatory and suggestive criteria. In this study, the aim is to assess the diagnostic criteria and management of FRI with a particular focus on soft tissue reconstruction.Materials &amp; MethodsA retrospective study to identify the outcomes of FRI in the lower limb over a five year period at a Major Trauma Centre. Fracture specific information that was analysed includes: open versus closed, fractured bone(s) and site, initial fracture management, method of diagnosis and soft tissue management.ResultsA total of 40 patients were identified, 80% of whom were male (n= 32). The mean age for FRI diagnosis was 54 years (range 18–83 years). In our patient cohort, 10% were immunosuppressed and another 12.5% had a formal diagnosis of Diabetes Mellitus. A diagnosis of acute FRI (i.e. &lt; six weeks from time of injury) was made in 9 patients (22.5%). Chronic FRI was noted in 25 patients (62.5%). There was equal incidence of FRI in patients with closed fractures and open fractures (42.5%). Tibia and fibula fractures were most common (87.5%, n=35). Regardless of fractured bone(s), the more distal the fracture the higher the incidence of FRI (60% distal versus 12.5% proximal). Gram-positive cocci were the most commonly identified pathogens, identified in 25% of patients. Five patients underwent free flap reconstruction, two patients received pedicled muscle flaps and another two patients received split thickness skin grafts.ConclusionsThe diagnosis of FRI can be confirmed through the presence of a combination of confirmatory and suggestive criteria. We advocate a staged approach in the management of FRI with radical wound excision and temporary coverage followed by definitive soft tissue reconstruction.

The impact of repeated bladder surgery on successful bladder neck closure in classic bladder exstrophy: The role of mucosal violations

Restoration of genitourinary anatomy with functional urinary continence is the reconstruction aim is the exstrophy-epispadias complex (EEC). In patients who do not achieve urinary continence or those who are not a candidate for bladder neck reconstruction (BNR), bladder neck closure (BNC) is considered. Interposing layers including human acellular dermis (HAD) and pedicled adipose tissue are routinely placed between the transected bladder neck and distal urethral stump to reinforce the BNC and minimize failure due to fistula development from the bladder. The aim of this study was to review classic bladder exstrophy (CBE) patients who underwent BNC to identify predictors of BNC failure. Specifically, we hypothesize that increased operations on the bladder urothelium leads to a higher rate of urinary fistula. CBE patients who underwent BNC were reviewed for predictors of failed BNC which was defined as bladder fistula development. Predictors included prior osteotomy, interposing tissue layer use and number of previous bladder mucosal violations (MV). A MV was defined as a procedure when the bladder mucosa was opened or closed for: exstrophy closure(s), BNR, augmentation cystoplasty or ureteral re-implantation. Predictors were evaluated using multivariate logistic regression. A total of 192 patients underwent BNC of which 23 failed. Patients were more likely to develop a fistula with a wider pubic diastasis at time of primary exstrophy closure (4.4 vs 4.0 cm, p=0.0016), have failed exstrophy closure (p=0.0084), or have 3 or more MVs before BNC (p=0.0002). Kaplan-Meier analysis of fistula-free survival after BNC, demonstrated an increased fistula rate with additional MVs (p=0.0004, Figure1). MVs remained significant on multivariate logistic regression analysis with a per-violation odds ratio of 5.1 (p<0.0001). Of the 23 failed BNC's, 16 were surgically closed including 9 using a pedicled rectus abdominis muscle flap which was secured to the bladder and pelvic floor. This study conceptualized MVs and their role in bladder viability. Increased MVs confer an increased risk of failed BNC. When considering BNC, CBE patients with 3 or more prior MVs may benefit from a pedicled muscle flap, in addition to HAD and pedicled adipose tissue, to prevent fistula development by providing wellvascularized coverage to further reinforce the BNC.

Description of the Pedicled Osteo-Muscular Flap of Split Temporal Muscle.

Reconstruction of the head and neck is dominated by free flaps, and for bone reconstruction by fibula and scapula flaps. However, this choice is sometimes difficult to make in patients who cannot tolerate an extensive and lengthy surgical procedure. In addition, vascular micro-anastomoses are sometimes complicated in patients who have been previously irradiated. Pedicle flaps remain an option and can sometimes be considered as first choice for head and neck reconstruction. In this study, we describe the feasibility of a split temporal muscle pedicled flap with coronal harvesting for a reconstruction that can reach the midline. Ten fresh-frozen human cadaver heads were dissected, and the length of the split flap was noted, followed by the length of the non-split flap. The mean length was 155.7mm (± 20.0) for the split flap, from the point of rotation to the tip of the coronoid process. These results coincide with the tragus-midline distance, which makes it possible to consider reconstruction of the midline, especially the maxilla and the mandible, which has not yet been described in the literature. This technique would then allow a supply of pedicled vascularized bone for loco-regional reconstruction.

Prevention of bronchial fistulas after pneumonectomies for selected cavitary drug resistant lung tuberculosis.

The World Health Organization guidelines for management drug resistant tuberculosis include surgery as an additional method in selected cases. Pneumonectomies have higher risk of morbidity such as bronchial fistulas which may be prevented by bronchial stump covering. We compare two methods of bronchial stump reinforcement. A retrospective single center follow-up study was done in 52 patients who underwent pneumonectomy for drug resistant pulmonary tuberculosis. Between 2000 and 2017 we performed pneumonectomies with pericardial fat reinforcement of bronchial stump in group 1 (n = 42), and between 2017 and 2021 in group 2 with pedicled muscle flap reinforcement group 2 (n = 10). Bronchial fistulas occurred in 17/42 (41%) of patients group 1 and there was no fistula in group 2, and this was statistically different (Fisher's test p = 0.02). Post-operative complications were seen in 24/42 (57%) of the patients in Group 1, and 4/10 (40%) patients in Group 2 (Fischer's test p = 0.53). In group 1 positive bacteriology decreased from 74% to 24% just after surgery, and in group 2 it decreased from 90% to 10%, but this was not statistically different (Fisher's test p = 0.63). In group 1 no-one died the first month, but 8/42 (19%) died within a year; in group 2 one died within a month, and only this death (10%) within a year. This difference in case fatality was not statistically significant. The use of pedicle muscle flap for bronchial stump coverage during the pneumonectomies for destructive drug resistant tuberculosis can prevent severe postoperative fistulas and improve postoperative life.

Pedicled chimeric muscle and anterolateral thigh fasciocutaneous flap reconstruction of trochanteric pressure wounds: Presentation of two cases

Abstract Trochanteric pressure wounds are a significant cause of morbidity among paraplegic and comorbid patients. Their surgical management requires femoral head ostectomy followed by robust soft tissue coverage both for dead space obliteration and for skin and subcutaneous tissue replacement. Many flap options and their variations have been presented for this purpose. We present a unique methodology utilizing a chimeric pedicled muscle and anterolateral thigh (ALT) flap for reconstruction. First, we present a paraplegic 39-year-old male who underwent a right Girdlestone procedure followed by a pedicled chimeric vastus lateralis and ALT flap for trochanteric pressure wound reconstruction. Secondly, we present a 55-year-old paraplegic male with a similar pathology on the left, who underwent a pedicled chimeric rectus femoris and ALT flap reconstruction. Both surgical courses were uncomplicated and with no wound recurrence. Our cases demonstrate that this modification of previously described reconstructions is a viable option for the reconstruction of trochanteric pressure wounds. The literature abounds with reconstructive options for trochanteric wound reconstruction, but none without limitations. We add another durable and robust coverage modality to the reconstructive surgeon’s armamentarium. The chimeric pedicle muscle and ALT flap surgical reconstruction is a viable technique in management of trochanteric pressure wound reconstruction. • Chimeric flap design provides benefits of both muscle and fasciocutaneous flaps. • Chimeric flap design is a viable technique for trochanteric pressure wounds. • There are many options for paddle selections. • Donor site morbidity is minimal and it creates nominally, if any, more scar burden.

Microvascular Lower Extremity Reconstruction after Oncologic Resection and Revascularization: A Single-Center 21-Year Experience

INTRODUCTION: Tumors of the lower extremity necessitating vascular resection and reconstruction increase the complexity of flap reconstruction. We present the reconstructive outcomes of these composite defects at a large center. METHODS: A prospectively maintained database was used to identify patients who underwent lower extremity tumor resection requiring both bony or soft tissue reconstruction and vascular reconstruction. The study included all patients from 2000 to 2021. RESULTS: A total of 18 patients met inclusion criteria. Mean age was 50.1 years (range 15–83) and mean BMI was 26.5 kg/m2 (range 18.5–45.5). Pathology was sarcoma in 14 patients and squamous cell carcinoma in 4 patients. Radiation was given to 11 patients. Vascular reconstruction consisted of prosthetic and autologous grafts. Tissue reconstruction consisted of pedicled muscle flaps in 11 patients and free tissue transfer in 7 patients. Bone resection was performed in 4 patients, of which 3 were reconstructed with metallic implants and 1 with fibula osteocutaneous free flap. Overall complication rate was 61% (11 of 18 patients) and consisted of hematomas in 3 patients, infections in 7 patients, delayed wound healing in 5 patients, and partial flap loss in 1 patient. All patients underwent limb salvage. Mean follow-up duration was 23.89 months (range 1.48 months to 45.8). Functional outcomes were independent ambulation 13 (72.2%) patients, ambulation with assistive devices in 3 (16.6 %) patients and no ambulation in 2 (11.11 %) patients. CONCLUSION: Free flap reconstruction of lower extremity wounds after tumor resection results in excellent rates of limb salvage with good functional outcomes.

FUNCTIONAL OUTCOME OF MEDIAL GASTROCNEMIUS MUSCLE PEDICLE FLAP FOR SOFT TISSUE RECONSTRUCTION AROUND THE KNEE AND PROXIMAL LEG

Background: Soft tissue coverage around the knee and a proximal third leg can be done using a medial Gastrocnemius Muscle Pedicle Flap (GMPF). There are variable results in the literature about its outcome and such study is lacking in our country. The present study was undertaken to evaluate the outcome of the medial GMPF to reconstruct the defect around the knee and proximal 3rd leg. Methods: It was a retrospective study of 21 cases of medial GMPF reconstruction to cover the defect around the knee and proximal third leg over 2 years in tertiary care hospital. The outcome variables measured were flap and graft take up, fracture union, knee range of motion, and complications. Data was analyzed using SPSS software version 20.0 with descriptive statistics for categorical and discrete variables. Results: The mean age of the patient was 37.19 years (range 21-65). Out of a total of 21 cases, 20 (95.2%) were traumatic wound defects, whereas 1 case was complications of necrotizing fasciitis. Flap and graft take-up was good in all the cases. The mean time for union of tibia fracture was 24.57 weeks (range 16-36). The mean knee range of motion was 125 degrees (range 90-145). Two cases had a superficial infection and one had a deep infection. Conclusions: Medial GMPF gives satisfactory results in soft tissue reconstruction about knee and proximal 3rd leg and it can be performed well by trained orthopedic surgeons also with consistently good results.

Comparison of clinical outcomes of autologous bone graft versus pronator quadratus pedicled vascularized bone graft in the treatment of scaphoid nonunion.

We aimed to compare the union rate and clinical outcome of autologous bone graft versus pronator quadratus vascularized pedicled muscle flap in treatment of scaphoid nonunion. Forty patients with a diagnosis of scaphoid nonunion who underwent unilateral pseudarthrosis surgery were included in this study. Notably, the scaphoid nonunion was unilateral, and the contralateral wrist was asymptomatic with normal function, per the physical and radiological examinations. Pronator quadratus vascularized pedicled muscle flap was used in 16 patients (group 1), and autologous bone graft was used in 24 patients (group 2). Patients were compared used Scapholunate angles, Natrass carpal height ratio and Mayo wrist score pre and postoperatively. Fifteen of the 16 (93.3%) patients in group 1 and 19 of the 24 (79.2%) patients in group 2 achieved bone union. Four of twelve patients in group 2 with avascular necrosis (AVN) and one of eight in group 1 with AVN were not able to achieve union. The group 2 (34%) had higher nonunion rate than group 1 (12%) in AVN patients. The scapholunat angle was significantly decreased and the Natress ratio was significantly increased postoperatively compared to the preoperative measurement in both group. There was no statistically significant difference in the postoperative measurement. The postoperative Mayo wrist score showed no statistically significant differences between both groups. The pronator quadratus vascularized pedicled muscle flap was superior to non-vascularized bone grafting in the treatment of scaphoid nonunion with AVN. However, management of the patients without avascular necrosis is not requiring the vascularized pedicled muscle flap technique.

EP-583 Review of lower limb orthoplastic flap monitoring protocol

Abstract Aim To improve upon the existing muscle and fascio-cutaneous flap monitoring protocol. The objective is to follow the patient's journey from the time of admission up to discharge and then follow up, in a tertiary care hospital in the Northern region of England, United Kingdom. Method The patients were selected from the online plastic surgery audit tool regularly used for documentation, handover and maintaining continuity of care. We looked at the patients requiring free muscle flaps, pedicled muscle flaps and fascio-cutaneous flaps, following fractures sustained to the lower limb, from April 2016 to April 2021. The exclusion criteria were elective free flaps or pedicled flaps and open fracture with no wound management concerns. The parameters being evaluated were patient observations, flap observations, urine output, bloods, intravenous fluids, patient-controlled analgesia, oxygen, dressing, nutrition, mobility and follow up. Following analysis of the results, a more standardised protocol was distributed across the wards. The response to the new monitoring protocol was measured based on continuity of care, staff satisfaction and outcomes. Results There was an initial need for standardisation of monitoring protocols and elimination of multiple charts. This included the nutrition status, use of blood products, dressings and physiotherapy, in addition to the previously mentioned parameters. Conclusion The staff feedback was positive and felt better equipped. It removed the ambiguity and patients were aware of their follow up dates prior discharge. The collaboration with the physiotherapy team was well coordinated. This led to an organised recovery period.

A treatment protocol for chronic post-pneumonectomy empyema associated with bronchopleural fistula: A single-centre retrospective study.

Chronic post-pneumonectomy empyema (CPPE) associated with bronchopleural fistula (BPF) is a potentially fatal complication and remains a surgical challenge. This study aims to propose a treatment protocol for managing this severe disease. From July 2009 to June 2021, 47 CPPE with BPF patients were treated in our department. CT scan with 3D reconstruction was used to detect BPF and to evaluate the location and volume of empyema cavity. Different surgical techniques were used to close BPFs according to they sizes. Multiple pedicled muscle flaps were chosen to fill the empyema cavity, and among them, latissimus dorsi (LD) was the mostly used flap. For cases that regional flaps were not suitable, free flaps were used. Patients were followed-up from 7.9 to 102.8months. Forty-four patients (93.6%) healed after the operation. Closure of BPFs failed in three patients (6.4%), leading to regional infection. These patients were treated by bronchoscopic application of sealants, continuous drainage and antibiotics, and they eventually healed. Total or partial flap loss was not seen in any of the cases. Treatment protocol was proposed based on these results. CT scan with 3D reconstruction is an effective examination to evaluate pleural cavity defect and BPF. Proper technique to close the BPF and right choice of flap to fulfil the empyema cavity are the two most important key points to treat CPPE associated with BPF patients.

Partial Lateral Eyebrow Defect Reconstruction Using the Contralateral Orbicularis Oculi Muscle Pedicled Skin Island Flap: A Case Report

The reconstruction of scarring eyebrow defects is a challenging task for plastic surgeons as the eyebrow is an important cosmetic landmark of the face. Various methods are used for eyebrow reconstruction; free hair follicle transplantation, scalp composite graft, local flap transposition, and hair-bearing island scalp flap have been widely reported in the past and are applied according to the size and position of the eyebrow defect. For partial eyebrow defects, the best option is the use of local flaps from the remaining ipsilateral eyebrow, which have characteristics highly similar to those of the recipient site. Herein, we present a case in which an orbicularis oculi muscle pedicled flap from the contralateral eyebrow was used as a donor site with good results.

Three-Dimensional Immersive Photorealistic Layered Dissection of Superficial and Deep Back Muscles: Anatomical Study

IntroductionThe distinct anatomy of the superficial and deep back muscles is characterized by complex layered courses, fascial planes, specific vascularization, and innervation. Knowledge of these anatomical parameters is important for some surgical approaches, including lumbar disc herniation, cerebrospinal fluid fistula repair, vascularized muscle pedicle flaps, and posterior fossa extra-intracranial bypass. In the present study, we use modern techniques of three-dimensional (3D) surface scanning to help better illustrate the layered anatomy of the back muscles.Material and methodsWe dissected in layers the back muscles of one cadaver. Every step of the dissection was 3D scanned using a technique called photogrammetry, which allows the extraction of 3D data from 2D photographs. The 3D data were processed using Blender software, and the 3D photorealistic models were uploaded to a dedicated website for 3D visualization. This allows users to see the 3D models from every desktop or mobile device, as well as augmented (AR) and virtual reality (VR) formats.ResultsThe photorealistic 3D models present the back muscles' anatomy in a volumetric manner, which can be visualized on any computer device. The web 3D features, including AR and VR, allow users to zoom, pan, and rotate the models, which may facilitate learning.ConclusionThe technology of photorealistic surface scanning, modern 3D visualization possibilities of web-dedicated formats, as well as advances in AR and VR, have the potential to help with a better understanding of complex anatomy. We believe that this opens the field for further research in the field of medical education.

Vastus lateralis versus rectus femoris muscle flaps for recalcitrant hip joint infection: An anatomical study comparing the effectiveness of acetabular dead space control.

Eliminating recalcitrant prosthetic hip joint infections remains one of the greatest challenges in orthopedic surgery. In such cases, the salvage procedure of femoral head excision (the Girdlestone procedure) is often performed. There has been emerging surgical interest in filling the resulting acetabular dead space with a pedicled muscle flap, to enable antibiotic delivery. Both vastus lateralis (VL) and rectus femoris (RF) muscle flaps have been described for this purpose with good success. This study is the first anatomical investigation comparing VL and RF as candidates for interposition myoplasty following hip joint excision. Following standard surgical technique, the Girdlestone procedure and interposition myoplasty of both RF and VL were performed on 10 cadavers. The primary aim was to determine which muscle flap eliminated a greater volume of acetabular dead space. Secondary aims were to characterize the blood supply to RF and assess additional metrics indicative of the likelihood of flap success. The VL flap eliminated more dead space than RF. However, the use of the RF flap was feasible in all cases and has several benefits, including ease of harvest, mobility, and aesthetics. The location of the inferior vascular pedicle into RF was relatively consistent and the most effective predictor of flap success. Both VL and RF are effective in reducing acetabular dead space. While VL can fill a greater volume, the RF flap has technical advantages, related to the predictability of the blood supply.