Musculocutaneous Flap Research Articles

Elbow flexion reconstruction after arm-sparing excision for high-grade triton sarcoma: a case report

BackgroundSoft tissue sarcomas affecting the root of an upper extremity raise the question of limb amputation depending on their location, size, and malignancy. Malignant triton tumors are a rare subtype of neurofibrosarcomas that have been poorly reported in the literature. We report the case of a challenging reconstruction of the upper extremity using a pedicled latissimus dorsal flap.Case presentationA 25-year-old Occidental man was referred to our sarcoma unit for the management of a large, high-grade malignant peripheral nerve sheath tumor with no regional or distant extension and very fast progression. He was treated first by concomitant neoadjuvant radiotherapy and chemotherapy. Carcinologic excision was performed “en bloc” including the skin, the tumor, and the flexor muscles of our patient’s elbow. Coverage of the skin defect and elbow flexion restoration were achieved by using a homolateral pedicled musculocutaneous latissimus dorsi flap. Histological analysis showed an R0 resection. The reconstruction process recovered a complete bending of his elbow. He is still in remission at 26 months follow-up.ConclusionsA malignant triton tumor is a rare, aggressive, and high-grade sarcoma. It was successfully treated and this case report describes an effective treatment modality. Reconstructive surgery, allowing large, complete tumor removal, is indispensable after neoadjuvant chemotherapy and radiotherapy.

Incidence and Reconstruction of Chronic Radiation-Induced Chest Wall Ulceration in Postoperative Breast Cancer Patients

Background: Breast cancer patients who receive radiotherapy for postoperative tumor control are exposed to the possibility of adverse effects including osteoradionecrosis and ulceration. The purpose of this study is to explore reconstruction of ulcers according to their characteristics, and also to investigate the incidence of skin ulcers in patients who had undergone radiotherapy after modified radical mastectomy (MRM).Methods: Data of patients who underwent radiation therapy after MRM from 1979 to 2003 were collected. Demographics and radiation details were analyzed along with their reconstruction outcomes and pathologic characteristics. Effects of surgical debridement and reconstruction strategies for success were also assessed.Results: A total of 113 patients had radiotherapy after MRM in our institution, out of which nine patients (7.96%) developed ulcerations in the chest wall. Eleven patients underwent reconstructive surgery, including the nine patients who developed chest wall ulcerations and an additional two patients from other hospitals. Seven patients had thoracoepigastric flaps while three had latissimus dorsi musculocutaneous flaps and one had a perforator flap. The average initial wound size was 5.77 cm<sup>2</sup>, and this average was enlarged by 23.6 times after debridement. There was no reconstructive failure in any of the patients. Fibrosis, necrosis with ulceration, and dystrophic calcification were common pathological findings. Dystrophic calcification was found in seven of 11 cases. Additionally, ossification with bone formation was noted in three of seven cases with dystrophic calcification.Conclusion: A thorough preparation of the wound bed and reconstruction with flaps appropriate for the defect can successfully treat chronic radiation-induced ulceration.

Comparison between head and neck melanomas with trunk and extremity melanomas

Background: Head and neck melanomas (HNMs) have been associated with prognostic factors different from those on other locations. Objective: The goal of the present study was to compare the demographic and clinical characteristics and the outcomes of surgical treatment between patients with HNM and those with trunk and extremity melanoma (TEM). Material and methods: The clinical records of patients undergoing surgery for melanoma between October 2014 and April 2018 were retrospectively reviewed. Fifteen patients (22.3%) had HNM and 52 (77.7) presented TEM. Results: There were no differences in age between both groups (63.8 ± 21.1 versus 58.5 ± 16), but there was a trend toward higher percentage of men in the HNM group (80% versus 61.3%). Patients with HNM had lower tumor thickness than those with TEM (2.07 versus 5.5 mm), higher incidence of melanoma in situ [5 (33.3%) versus 8 (15.3%)]; lymph node resection was more common (33% versus 25%) as well as reconstruction of the primary defect with local and musculocutaneous flaps. During follow-up, two patients in the HNM group developed local recurrences that were excised and three presented distant metastases in the lung, small bowel and abdomen and finally died due to the disease. In the TEM group, one patient had local recurrence and five died due to systemic metastases. The sample size was not sufficient to assess statistically significant differences. Conclusion: Head and neck melanomas occur in a wide age range and stages and has some clinical differences with TEM. The defects produced after the excision of the primary lesion often require more complex procedures and should be managed with a multidisciplinary approach.

Current Status and Factors Influencing Surgical Options for Breast Cancer in China: A Nationwide Cross-Sectional Survey of 110 Hospitals.

There are limited nationwide data regarding breast cancer surgery in China. The Chinese Anti-Cancer Association's Committee of Breast Cancer Society and the Chinese Society of Breast Surgeons conducted a nationwide survey to examine the use of and barriers associated with surgical options among patients with breast cancer. Surveys were sent via e-mail to the directors of 110 centers that performed at least 200 breast cancer operations in 2017. The electronic questionnaire contained 183 questions and covered six aspects, including demographic information about the hospitals and surgeons, surgical practice, and application of breast reconstruction. The selected hospitals were from 31 provinces or municipalities. The overall proportion of breast-conserving surgery (BCS) was 22%. Local gross domestic product was significantly related to the rate of BCS (p = .046). Sentinel lymph node biopsy was performed routinely in 76% of hospitals. Only 14.5% (16/110) of hospitals used the dual-tracer method, including radioisotopes. For patients with cN0 disease receiving BCS with one or two positive sentinel lymph nodes, 20% (22/110) of hospitals accepted omitting axillary lymph node dissection (ALND). For patients who underwent mastectomy, only 4% (4/110) of hospitals accepted omitting ALND. There was an obvious polarization trend in the proportion of oncoplastic breast-conserving surgery (OPS); 35/110 (32%) performed OPS in fewer than 10% of cases, whereas 36/110 (33%) performed OPS in more than 50% of cases. OPS was more likely to be performed in academic hospitals. Volume displacement was more commonly used than volume replacement (p < .001). Breast reconstruction was routinely performed in 96/110 (87%) of hospitals, 62% of which involved cooperation with the plastic surgery department. Factors influencing breast reconstruction after mastectomy included the establishment of a plastic surgery department, regional economy, and cooperation between the plastic and general surgery departments. Overall, the proportion of breast reconstruction procedures after mastectomy was 10.7%, with 70% being implant-based reconstruction, 17% autologous tissue reconstruction, and 13% a combination. Overall, 22% of the hospitals predominantly performed immediate breast reconstruction. For delayed reconstruction, two-stage implant-based breast reconstruction was the first choice for 46% of centers, whereas 20% of centers chose autologous reconstruction. Among the 96 centers that performed autologous-based reconstruction, 96% performed latissimus dorsi flap reconstruction, 65% performed transverse rectus abdominis musculocutaneous flap reconstruction, and 45% used deep inferior epigastric artery perforator flaps. The results are of great value for promoting the implementation of a consensus on diagnostic and treatment standards, development of guidelines for breast cancer, and training of breast specialists. This study aimed to establish comprehensive baseline data on the status of current breast cancer treatment in China by presenting the statistics on clinical treatments and surgeries, the distribution of clinical stages, and the demographic characteristics of patients. This report is based on a survey conducted by the Chinese Anti-Cancer Association's Committee of Breast Cancer Society and the Chinese Society of Breast Surgeons, which examined the use of breast cancer surgical options in hospitals all over the country and the factors hindering the adoption of procedures and techniques. This study makes a significant contribution to the literature because there are limited nationwide data regarding breast cancer surgery in China.

Conventional and variant origin of the transverse cervical artery in a select kenyan population

Data from previous studies have highlighted on the use of transverse cervical artery (TCA) flaps as posterior neck musculocutaneous flaps in reconstructive surgeries. General preference of flap selection relies heavily on the neurovascular supply of the flap in question and even though known, the transverse cervical artery has been shown to vary among populations, therefore affecting its use as a potential flap. Additionally, variant points of origin of the trans-cervical artery have been shown to predispose to brachial plexus compression. Our data on the same, however, remains partly elucidated and therefore a study aimed at describing the conventional and variant origin of the TCA in a Kenyan population would aid in deciding on its use as musculocutaneous flaps and determining the possible prevalence of brachial plexus compression because of its variant origin. The origin of the transverse cervical artery was studied bilaterally in 26 adult Kenyan cadavers in the Department of Human Anatomy, University of Nairobi. As regards their origin, the different types were photographed and grouped into five: Types I to V relative to its origin. The data collected was then analysed using SPSS version 21 and findings presented as percentages. The findings were presented in a bar graph and pie chart. The TCA was present in all the 26 cadavers studied. Type I origin of the TCA was the most common (71.15%) while type V was the least (1.92%). While type I origin occurred mostly on the left limbs, the other types were more prevalent on the right side. The significant variant origin of the TCA and its resultant aberrant course should be important considerations during the planning of posterior neck musculocutaneous flaps as well as in understanding brachial plexus compression associated with its variant origin.&#x0D; Key Words: Anatomy, Transverse cervical artery.

Use of a Pedicled Sternocleidomastoid Musculocutaneous Flap in a Large Tracheoesophageal Fistula

Repairing a large tracheoesophageal fistula with extensive involvement of the membranous wall of the trachea is sometimes troublesome because of the lack ofan ideal replacement for the large defect. We report the successful use of a pedicled sternocleidomastoid musculocutaneous flap to repair a large tracheoesophageal fistula in which the cutaneous component was applied to the defect of the membranous trachea after tracheal resection and the muscular component was interposed between the tracheal and esophageal walls.

Total and near‐total lower eyelid reconstruction with prefabricated orbicularis oculi musculocutaneous island flap

Full thickness lower lid defects are frequently encountered during daily practice. The unique anatomy of the eyelids hinders reconstructive efforts. The aim of the study is to develop an effective and easy procedure for the reconstruction of full thickness defects of the lower eyelid. Here we present six cases, which we treated with an orbicularis oculi musculocutaneous island flap prefabricated with a chondrocutaneous graft. Five of the six cases suffered from tumors, while one had congenital coloboma of the lower lid. A chondrocutaneous graft harvested from the ear was placed under the orbicularis oculi musculocutaneous flap. Three weeks later, the defect was created and the prefabricated flap was transposed to the defect. Two cases had superficial distal skin loss and one had prolonged oedema. No major complication or tumor recurrence was seen. Using this method, the principle "replace with like" is fulfilled. Orbicularis oculi musculocutaneous island flap prefabricated with postauricular chondrocutaneous composite graft seems to be a feasible method for the reconstruction of full thickness defects of the lower eyelid with its low donor morbidity and good outcomes.

RADICAL STERNO- COSTAL RESECTION OF SKIN TUMOR AND IMMEDIATE RECONSTRUCTION: A CASE REPORT

Purpose: We managed a 30 years old male Albino with Basal Cell Carcinoma of the Sternum with local deep invasion to the Pleura with the aim of offering a cure.Methodology: Information of the patient from the medical records showed a 30-year-old Albino (Fitzpatrick Skin type I) who was exposed to tropical sun rays for about three decades before presenting with 1-year history of locally advanced sternal skin basal cell carcinoma. This was resected five times in another teaching hospital, but the fungating lesion recurred locally after each attempted local wide excision.Result: He was found to have 18cm x 22cm malignant ulcer which penetrate over the manubrium and middle of the sternum. It also extended bilaterally to cover the anterior ribs and costochondral joints though his general condition was stable.Contribution to Theory, Policy and Practice: After detailed investigations and obtaining an informed consent, he had a radical en-bloc resection of the tumor: including the involved sternum and the affected anterior part of the affected pleura. Full thickness reconstruction of the anterior chest wall was done with marlex methacrylate mesh and steel wire support, obliteration of dead space, soft tissue cover with latissimus dorsi pedicle musculocutaneous flap with satisfactory outcome. The use of Stainless wires in our chest reconstruction provided a simpler and cheaper alternative to the use of advanced Tridimensional titanium printed custom made prosthesis, and less morbidity to alternative use of autologous ribs.

The L-shaped modification of the transverse upper gracilis (TUG) flap

A variety of free tissue flaps have been described for autologous breast reconstruction. Although the deep inferior epigastric perforator (DIEP) flap is most microsurgeons’ first choice, there is no consensus regarding which is the second-best alternative. The transverse upper gracilis (TUG) flap has gained popularity for cases where the abdomen is not a suitable donor site. This musculocutaneous flap has the advantage of an easy dissection, allowing the harvest of tissue from the medial thigh area with the patient supine. However, drawbacks include a tedious donor site closure and a limited amount of soft tissue that can be transferred. The authors hereby present a modification of the TUG flap, introducing an L-shaped skin paddle: the L-shaped upper gracilis (LUG) flap. This alternative allows harvesting extra tissue from the medial thigh, while providing an easier donor site closure with the patient supine. A prospective case series of 14 LUG flaps is presented. No flap failures or episodes of fat necrosis were encountered; only one developed a donor site seroma that settled after drainage. The LUG flap is a useful development of the TUG flap concept providing up to 50% more tissue than a standard TUG flap with an aesthetically pleasing donor site closure which is useful for cases in which abdominal flaps are not possible.Level of evidence: Level IV, therapeutic study.

Total glossectomy in multimodal treatment of oropharyngeal cancer: immediate results

The study objective is to analyze the results of combined antitumor therapy, which included glossectomy, to treat locally advanced and recurrent oropharyngeal squamous cell cancer.Materials and methods. We performed a retrospective analysis of multimodal antitumor therapy of 19 patients, who were treated in the Nizhny Novgorod Regional Clinical Oncologic Dispensary within 2009–2019. All patients underwent segmental resection of the mandible due to massive tumor invasion into the periosteum. After total glossectomy the defect was filled using pectoralis musculocutaneous flap. Due to the wide local tumor spread, a neck dissection (n = 7) or radical cervical lymphadenectomy (n = 12) were performed. During preventive surgery, metastases that were not detected before surgery were revealed in 2 patients in 1 neck lymph node. Results. Eleven patients had local purulent-necrotic postoperative complications. It was noted that after surgery but without radiation therapy complications developed in fewer patients (n = 4) and were less severe: of I degree – in 3 patients, of III degree – in 1 patient. Radiation therapy before surgery resulted in more severe purulent-necrotic complications in 7 patients: of I degree – in 2 patients, of II degree – in 1, of III degree – in 4. Mortality rates: 30-day, 60-day and 90-day – 10.5 %, 21 % and 37 %, respectively. The causes of death were complications of gastrostomy: profuse bleeding from the stomach wall (n = 1), acute psychosis complicated by cerebral edema (n = 1), increased heart failure (n = 1), necrosis of the anterior abdominal wall and cachexia, developed after gastrostomy (n = 1), continued tumor growth between chemotherapy courses (n = 3). Twelve patients survived more than 90 days after surgery, 3 patients – more than 2 years. As most of the patients could not swallow, they were administered a nasogastric tube, since a simultaneous gastrostomy increases the duration of a traumatic operation and aggravates the postoperative period.Conclusion. Multicomponent surgery after radiation therapy results in more often local purulent-necrotic postoperative complications than if the surgery is performed before radiation therapy. High mortality in the first 90 days after surgery (n = 7) due to local cancer spread is generally determined by the severe condition of patients with advanced cancer and the concomitant diseases. However, rejection of gastrostomy in favor of nasogastric tube seems reasonable, since several deaths in the early postoperative period may be occurred due to complications associated with gastrostomy.

Three-Dimensional–Printed Model as a Template for Chest Wall Reconstruction

To our knowledge, this is the first time that a three-dimensional (3D)-printed model was used as an intraoperative template to recreate the resected portion of the lateral chest wall after resection of a large chest-wall tumour. Fabrication of 3D-printed models requires collaboration among a surgeon, radiologist, segmenter, and 3D printing centre. Three-dimensional models are created with computed tomographic and magnetic resonance data. These models can provide an accurate guide for surgical resection and can be used intraoperatively as a template to construct tailored prostheses. We achieved complete resection of the chest wall defect, restored skeletal function and physiologic chest excursion, and achieved the best cosmetic appearance in all cases. Small- to medium-sized chest wall defects can be repaired with musculocutaneous flaps with or without prosthetic materials, but more complicated defects require increasingly sophisticated reconstructive techniques and technologies. An advanced technique is the use of a 3D-printed model of the chest wall as an intraoperative template.

Less Invasive Management of Tissue Deficits for Deep Sternal Wound Infections.

Background:The frequency of sternomyelitis after cardiovascular surgery has been reported to be 0.4% -5%.Methods:The treatment method used for 47 patients (29 male and 18 female) who developed sternomyelitis after sternotomy with tissue defects in the chest was examined retrospectively.Results:Of the original conditions, the most frequent was coronary artery disease undergoing bypass grafting (22 cases, 46.8%), followed by acute aortic dissection (10 cases, 21.3%). The number of times debridement was performed was: once, 35 cases; twice, 11 cases; 7 times, 1 case; and unknown, 2 cases. The most frequent time of occurrence of sternomyelitis was within 2 weeks after surgery (12 patients, 25.5%). A residual internal thoracic artery remained on both sides in 28 cases (59.6%), and only on the right side in 17 cases (36.2%); there was no remaining one in 2 cases (4.2%). The reconstruction method was a pectoralis major musculocutaneous flap in 31 cases (66.0%), internal mammary artery perforator flap in 7 cases (14.9%), rectus abdominis musculocutaneous flap in 4 cases (8.5%), omentum transplant in 3 cases (6.4%), superior epigastric artery perforator flap in 2 cases (4.3%), external abdominal oblique muscle flap in 1 case (2.1%), and latissimus dorsi musculocutaneous flap in 1 case (2.1%). The internal mammary artery perforator flap and the superior epigastric artery perforator flap have been effective treatment.Conclusions:In 47 patients, our method of treatment for tissue defects of the chest wall after sternal osteomyelitis was examined, and an algorithm using less invasive management was proposed.

Incidence of Complications in Delayed Abdominal-Based Flap Breast Reconstruction Using a Drainless Recipient Site: A Case Series.

Seroma is a common complication after breast surgery such as mastectomy and immediate reconstruction. However, there is a lack of evidence for the utility of drains in the recipient site in delayed autologous breast reconstruction. We reviewed our experience with delayed abdominal-based flap breast reconstruction with a drainless recipient site. A single-surgeon retrospective case review was performed for delayed abdominal-based flap breast reconstruction using drainless recipient sites from May 2018 to June 2019. Primary outcomes were recipient-site complications. Thirty-one delayed abdominal-based flap breast reconstructions that did not use drains in the recipient site were identified in 22 patients. Mean age was 52.8 years (SD, 9.7 years). Mean body mass index was 30.1 kg/m (interquartile range [IQR], 28.2-35.0 kg/m). Common comorbidities were obesity (45.4%), prior tobacco use (31.8%), and diabetes (10.0%). Median time to abdominal-based flap reconstruction was 27.5 months (IQR, 9.9-105.2 months). There were 22 muscle-sparing transverse rectus abdominis musculocutaneous flaps and 9 deep inferior epigastric artery perforator flaps performed. Ten patients (45.4%) underwent bilateral reconstruction. Mean operative time was 302 minutes (SD, 85 minutes). Flap take back occurred in 1 case (3.2%). Mean length of stay was 4 days (SD, 0.8 days). Recipient-site complications were healing complications (32.3%), seroma (3.2%), hematoma (3.2%), and fat necrosis (19.4%). Median follow-up was 4.2 months (IQR, 2.5-11.5). In this case series, our data indicate that delayed autologous reconstruction without drain placement at the recipient site has been proven to be safe and successful and did not increase the rate of seroma or other complications. Adopting a drainless approach may also improve patient comfort and satisfaction.

Volumetric change of the latissimus dorsi muscle after postoperative radiotherapy in immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap.

BackgroundThis study aimed to determine the magnitude of volume reduction of the latissimus dorsi (LD) muscle after treatment using only postoperative radiotherapy (PORTx) in patients who underwent immediate breast reconstruction using an extended LD musculocutaneous (eLDMC) flap after partial mastectomy.MethodsWe retrospectively reviewed 28 patients who underwent partial mastectomy and an eLDMC flap, received only PORTx, and underwent chest computed tomography (CT) 7 to 10 days after surgery and 18±4 months after the end of radiotherapy, from March 2011 to June 2016. The motor nerve to the LD was resected in all patients. One plastic surgeon performed the procedures, and the follow-up period was at least 36 months (mean, 46.6 months). The author obtained LD measurements from axial CT views, and the measurements were verified by an experienced radiologist. The threshold for statistical significance was set at P<0.05.ResultsA statistically significant decrease in the LD volume was found after the end of PORTx (range, 61.19%–80.82%; mean, 69.04%) in comparison to the measurements obtained 7 to 10 days postoperatively (P<0.05). All cases were observed clinically for over 3 years.ConclusionsThe size of an eLDMC flap should be determined considering an average LD reduction of 69% after PORTx. Particular care should be taken in determining the size of an eLDMC flap if the LD is thick or if it occupies a large portion of the flap.

Geometric Measurements of Nipple Position in Breasts Reconstructed with Transverse Rectus Abdominis Musculocutaneous Flap: A 5-Year Prospective Study.

After breast reconstruction, nipple position and other long-term changes in the reconstructed breast relative to the contralateral breast remain poorly understood. In this prospective cohort study, the authors performed serial nipple position measurements over 5 years in patients who had undergone breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap. The effects of adjuvant radiotherapy on nipple position over time were also investigated. The authors studied 150 patients who had undergone nipple-sparing mastectomy, using radial incision followed by immediate unilateral pedicled TRAM flap breast reconstruction. Measurements of sternal notch-to-nipple, midline-to-nipple, and inframammary fold-to-nipple distances were performed 1 day before reconstruction and 6, 12, 36, and 60 months after surgery, on patients' reconstructed and nonoperated breasts. The average sternal notch-to-nipple distance increased in both reconstructed and nonoperated breasts at every follow-up visit, with an average difference of 0.393 cm at the 60-month visit (p < 0.0001). Comparing the pattern of distance change, reconstructed breasts tend to change more slowly than nonoperated breasts until 36 months postoperatively. In irradiated breasts, the sternal notch-to-nipple distance was significantly smaller than in nonirradiated breasts, and nipple position changed minimally between 1 and 3 years after surgery. Nipple position in TRAM flap-reconstructed breasts changed over time compared with that in nonoperated breasts, especially along the vertical axis. The pattern of nipple position change in reconstructed breasts became similar to nonoperated breasts 3 years after surgery. In patients who had undergone adjuvant radiation therapy, nipple position remained consistent for 1 to 3 years. Therapeutic, IV.

Implications of abnormal abdominal wall computed tomographic angiography findings on postmastectomy free flap breast reconstruction.

BackgroundPreoperative computed tomography angiography (CTA) of the abdominal wall vessels is used when planning free flap breast reconstruction (FFBR) because it provides a surgical road map which facilitates flap harvest. However, there are few reports on the effect of abnormal findings on the operative plan.MethodsWe conducted a retrospective study of all FFBRs performed at a tertiary referral center over a 6-year period (November 2011 to June 2017). One consultant radiologist reported on the findings. Details on patient demographics, CTA reports, and intraoperative details were collected.ResultsTwo hundred patients received preoperative CTAs. Fourteen percent of patients (n=28) had abnormal findings. Of these findings, 18% were vascular anomalies; 36% tumorrelated and 46% were “miscellaneous.” In four patients, findings subsequently prevented surgery; they comprised a mesenteric artery aneurysm, absent deep inferior epigastric (DIE) vessels, bilateral occluded DIE arteries, and significant bone metastases. Another patient had no suitable vessels for a free flap and the surgical plan converted to a pedicled transverse rectus abdominis musculocutaneous flap. The remaining incidental findings had no impact on the surgical plan or appropriateness of FFBR. More than one in 10 of those with abnormal findings went on to have further imaging before their operation.ConclusionsCTA in FFBR can have a wider impact than facilitating surgical planning and reducing operative times. Incidental findings can influence the surgical plan, and in some instances, avoid doomed-to-fail and unsafe surgery. It is therefore important that these scans are reported by an experienced radiologist.

Latissimus Dorsi-Myocutaneous Flap in the Repair of Titanium Mesh Exposure and Scalp Defect After Cranioplasty.

Titanium mesh was widely used for cranium defect repair but associated with high complication rates. In this study, the authors describe a method using latissimus dorsi-myocutaneous flap in the repair of titanium mesh exposure and scalp defect after cranioplasty, and the plate retaining is also achieved. Fifteen patients from April 2012 to May 2016 underwent this procedure, the age ranged from 32 to 62 years and 47 years old on average, and all the patient had plate exposure combined with surgical site infection and variation of scalp defect. All the patients had fully flap survive, and follow up ranged from 6 months to 24 months, 1 patient had titanium mesh re-expose and received additional operation to remove the plate. The free latissimus dorsi musculocutaneous flap could supply large size of bulky tissue coverage with good blood supply and strong anti-infection ability. This method was an option for retaining the titanium mesh and repairing the exposure for the mild infection with small size scalp defect patient.

The Utility of Disposable Negative Pressure Wound Therapy (PICO) in Wound Healing of Latissimus Dorsi Musculocutaneous Flap Donor Sites

Background: Among treatments aiming to solve surgical wound complications, negative pressure wound therapy (NPWT) is considered an innovative method. NPWT can promote wound healing, protect the wound from infection and reduce the tension on suture sites. At the same time, the large machine required in the therapy led to some inconvenience. The PICO system has recently been developed as a simple pocket-sized NPWT device. By comparing the time required for healing of the wound, incidence of wound complications, duration of hospital stays, and dressing costs, we attempted to confirm the utility of PICO for managing latissimus dorsi musculocutaneous flap donor sites.Methods: PICO was used on nine donor sites of patients who had undergone breast reconstruction using latissimus dorsi musculocutaneous flaps. PICO was applied immediately after operation and removed on the 9th day. In the control group, daily conventional dressings were administered commensurate with the condition of the wounds. We defined the wound healing time to the point when no more dressing was needed. For the costs of dressing, only costs incurred on the donor sites were included.Results: Wound healing was proven to be faster in the PICO group (P=0.035) versus the control group, and no complications were observed in the PICO group. Also, the cost of PICO was lower compared to the costs incurred by the conventional dressing method (P&lt;0.001).Conclusion: We suggest that PICO can reduce wound complications on areas where anatomical movement could lead to tension, while also reducing dressing costs.

Axillary Reconstruction Using a Pedicled Thoracodorsal Artery Perforator Flap Including Latissimus Dorsi Muscle Strip

For axillary reconstruction, most reconstructive surgeons use the latissimus dorsi flap because of its usefulness and reliability. However, the latissimus dorsi musculocutaneous flap poses complications such as donor site morbidity and poor aesthetic results. Moreover, the thoracodorsal artery perforator (TDAP) flap, without muscle, presents difficulties for the delicate procedure of dissecting the perforators separately. Therefore, we propose the use of a pedicled TDAP flap including a latissimus dorsi muscle strip for axillary reconstruction, as it is believed to be easier and safer to perform.

Thoracic Wall Reconstruction: Surgical Planning in Extended Malignant Resections.

The reconstruction of defects in thoracic wall remains a challenge for plastic surgeons. Advances in surgical treatment of illnesses of thoracic wall have been fostering the treatment of lesions within more advanced levels. Consequently, larger and more complex defects are generated, demanding soft tissue covering and framework repair. The aim of this study was to report the experience in chest wall reconstruction and demographics of a tertiary cancer center. All patients submitted to thoracic wall reconstruction by the plastic surgery department from January 2012 to May 2018 in a tertiary cancer center were evaluated. Thirty-two patients have undergone thoracic wall reconstruction. The majority of patients in our series were submitted to surgical treatment of locally advanced breast cancer (84.3%). The most common defect location was the right anterolateral region (65.6%). The latissimus dorsi musculocutaneous flap was the most used in thoracic wall reconstructions. Three cases of thoracectomy with rib resection were reconstructed with methylmethacrylate and polypropylene surgical mesh associated with musculocutaneous flap. Four patients presented major complications, and 12 patients (37.5%) presented minor complications. There were no deaths related to procedures or instability of thoracic wall. Twenty-two patients presented progression of the disease, and 16 died due to the primary pathology. Extended resection of the chest wall is associated in most cases with advanced disease, especially advanced breast cancer. Despite poor prognosis associated to locally advanced disease, it is imperative to perform chest wall reconstruction and allow the patient to continue adjuvant therapy (radiotherapy or chemotherapy) and improve quality of life.