Myocutaneous Flap Reconstruction Research Articles

Determinants of 90-day readmission following ventral hernia repair with and without myocutaneous flap reconstruction: a National Readmissions Database analysis.

Readmission status is an important clinical component of healthcare outcomes. 90-day readmission following complex open ventral hernia repair has not been well studied with national level data. This study aims to compare readmission rates for patients undergoing standard vs. complex (myocutaneous flap-based) ventral hernia repair. We hypothesize that complexity of reconstruction will be an independent predictor of readmission after ventral hernia repair. A retrospective cohort study was performed with 1:1 matching of hernia repair type using the National Readmissions Database. Patients were selected using ICD-9 codes corresponding to ventral hernia repair with or without myocutaneous flap. 90-day readmissions were determined on patients within the first through third quarters of each year. After matching, a multivariable logistic regression analysis was performed using confounding variables including hospital setting, comorbidities, type of repair, urgency of repair, sociodemographic status, and payer. Likelihood of 90-day readmission was calculated from odds ratios. Readmission rates were 19.1% (38,313 out of 200,266) and 22.5% (692 out of 3075) at 90-day for standard ventral hernia repair and complex ventral hernia repair, respectively. 3116 standard ventral hernia repair patients were matched with 3074 complex ventral hernia repair patients. After matching there was a significantly increased readmission rate for repairs involving myocutaneous flaps, with odds ratio (OR) 1.30 (95% CI 1.22-1.60). Payer status (OR 1.82; 95% CI 1.21-2.74), teaching hospital status (OR 1.42; 95% CI 1.23-1.64) and income quartile (OR 1.35; CI 1.10-1.65) were independent predictors of readmission. Patients undergoing myocutaneous flap-based reconstruction have higher readmission rates than those undergoing less complex ventral hernia repair. Socioeconomic disparity as reflected in payer status is a particularly strong predictor of readmission. The data support the concept that focused efforts are needed to optimize patient outcomes for patients requiring more complex repair, including socioeconomically disadvantaged patient populations.

Pectoralis Major Myocutaneous Flap Reconstruction with Deltopectoral Flap Incision in the Surgical Treatment of Oral Cancer

Background: One of the main goals of patient management is the reconstruction of tissue defects following surgical resection for oral cancer. A variety of flaps used for this purpose, the most frequent being a Pectoralis Major Myocutaneus Flap (PMMF). This flap is currently widely used for the reconstruction of different defects of the head and neck. Methods: Surgical resection of the primary tumor, as well as neck dissection, performed on 29 patients with oral squamous cell carcinoma between 2011–2017 in City Hospital #1 and Surgical Training Clinic of Azerbaijan Medical University. PMMF used for the reconstruction of defects using a deltopectoral flap incision. Results: In 22 patients (75.8 %) primary healing occurred following a PMMF. Four patients (13.8 %) suffered PMMF necrosis and were took back to the operating room for secondary reconstruction with a deltopectoral flap. In three patients (10.3%) the skin of the flap underwent necrosis, resulting in the development of an orocutaneous fistula. Conclusion: Use of PMMF with deltopectoral flap incision enables deltopectoral flap availability. This flap can then used early on or if PMMF fails.

Revisiting the musculocutaneous external oblique flap as a versatile alternative in large thoracic wall defects

BackgroundThe external oblique myocutaneous flap has been previously described for reconstruction of chest-thoracic wall defects smaller than 400–500 cm2. However, it is utilized less often than workhorse flaps such as the omental, pectoralis, rectus abdominis, and latissimus dorsi myocutaneous flaps as many plastic surgeons are not aware that the flap can cover larger areas than previously documented.Case presentationWe report a 57-year-old female tobacco user who underwent a resection of a grade 3 breast angiosarcoma resulting in a high left chest wall soft tissue defect approximating 900 cm2. The patient underwent an external oblique myocutaneous pedicle flap reconstruction of the defect, most notably in anticipation of postoperative adjuvant radiation therapy. No gross flap complications and or patient impairment were noted. Thirteen months status post flap reconstruction, the patient underwent an aortic valve replacement requiring re-elevation of the same flap for exposure. The flap demonstrated excellent viability during the procedure and postoperatively.ConclusionThe pedicled external oblique myocutaneous flap should be considered when reconstructing larger high chest wall defects when other more common flaps used in chest reconstruction may not be indicated. The external oblique myocutaneous flap is an excellent tool in the armamentarium of any reconstructive surgeon; it is a straightforward and versatile flap that can be safely and reliably used in durable reconstruction of defects of the chest wall and covers defects larger than previously described in the literature.

Surgical Outcomes after Abdominoperineal Resection with Sacrectomy and Soft Tissue Reconstruction: Lessons Learned.

Abdominoperineal resection (APR), which involves resection of the rectum, anal canal, and perianal skin, results in a large dead space in the pelvis, devascularized tissues, and high bacterial loads. This predisposes to wound complications, especially in the setting of neoadjuvant chemoradiotherapy. Additional sacral resection further compounds these effects. We aimed to assess perineal wound outcomes and complications in patients who underwent flap reconstruction for APR with sacrectomy (APRS) at our institution. We reviewed the charts of all patients who underwent flap reconstruction for APRS over a 20-year period (1999-2018). Medical comorbidities, details of the surgical procedure, and major and minor wound complications were recorded and analyzed. Forty-six patients underwent flap reconstruction following APRS-28 (60%) for colorectal cancer, 8 (17%) for sacral chordoma, and 10 diagnosed with other malignant histologies. Rectus abdominis myocutaneous (RAM) flap reconstruction was used in 42 patients (91%). The median time to the first major perineal complication was 111 days (interquartile range: 22-660 days). Half of our cohort (n = 23) experienced a major perineal complication. No significant differences were found in major or minor perineal or abdominal wall complications between RAM flap and other flaps. APR with high sacrectomy was performed in 27 patients (59%) and was associated with significantly increased full-thickness dehiscence in the perineal region when compared with APR with low sacrectomy, 33 versus 0%, respectively (p = 0.0076). Complete flap loss occurred in one patient. The RAM flap was the workhorse flap for pelvic reconstruction following APRS in our cohort. Wound complications are common following APRS. High sacrectomy is associated with higher incidence of complications compared with low sacrectomy. Optimal surgical planning and patient counseling is fundamental to improve current surgical outcomes.

Primary Ewings Sarcoma/Primitive Neuroectodermal Tumor (PNET) of the Breast: a Rare Tumor

Extra osseous Ewing’s sarcoma (EES) is regarded as a member of Ewing’s sarcoma family of tumors (ESFT). A 16-year-old lady presented to the outpatient department of our institute with awareness of progressively increasing lump in the right breast of 5 months duration. Biopsy from the lump done elsewhere was suggestive of poorly differentiated malignancy. On examination, there was a large mass occupying almost the entire right breast. Computed tomography scan (chest) showed a large well-defined minimally enhancing heterogeneous soft tissue lesion of size 17.3 × 14.6 × 14.4 cm in the right breast. Both lungs were normal. Metastatic work up was within normal limits. Review of the biopsy at our center showed fragmented tissue exhibiting sheets of monotonous population of round cells with dark staining nuclei with mitotic figures and minimal cytoplasm. On immunohistochemical (IHC) analysis, the neoplastic cells exhibited CD99 and Friend leukemia integration 1 (FLI1) positivity whereas they were negative for leucocyte common antigen (LCA), desmin, and myogenin, which was consistent with Ewing’s sarcoma/PNET family of tumor. She received 2 cycles of neoadjuvant chemotherapy with VAC (vincristine, doxorubicin, cyclophosphamide) + IE (ifosfamide, etoposide) alternately following which simple mastectomy with latissimus dorsi myocutaneous flap reconstruction was done. Less than 4 cases of EES of the breast have been documented in Indian literature so far. In this report, we discuss the clinicopathological features of this rare and fascinating tumor with a brief review of literature.

Versatility of the Pedicled Latissimus Dorsi Myocutaneous Flap in Reconstruction of Upper Limb and Trunk Soft Tissue Defects

Purpose The purpose of the study was to share our indications, technique, outcome, and complications associated with the pedicled latissimus dorsi myocutaneous flap (LDMF) for reconstructing various upper limb and trunk soft tissue defects.Patients and Methods We reviewed the prospectively collected data of the patients who underwent reconstruction of upper limb/trunk soft tissue defects with pedicled LDMF between January 2016 and March 2019. By analyzing the clinical scenarios, the location of flap inset, the arc of rotation, reach of the flap, and associated complications, we put forward few significant findings from our experience.Results Thirty-four patients were included in the study: 13 of them underwent LDMF for coverage of upper limb defects, 12 of them for postradical mastectomy soft tissue defects, 8 for posterior trunk reconstruction, and 1 for sternal wound infection. LDMF was successfully used to cover the scapula, anterior and posterior arms, axilla, cubital fossa, mid-forearm, breast, sternum, and midline dorsal wounds. When used reversely, the flap could cover the exposed spine in the midline dorsum. Three patients (9%) had major complications (two patients had partial flap necrosis which required additional debridement and skin grafting, and one patient required an additional transpositional flap). Three patients had minor complications (managed nonoperatively).Conclusion Pedicled LDMF is a straightforward and versatile option for reconstruction of the varied upper limb and trunk soft tissue defects with minimal complications.Level of Evidence This is a level IV, therapeutic, retrospective study.

Assessment of Masticatory Function in Oral Cancer Patients with Mandibulectomy Followed by Pectoralis Major Myocutaneous Flap Reconstruction.

Mandibular resections have a dramatic effect on oral cavity functions. Ablative surgical defects are complex which are better reconstructed with free flaps. In developing countries like India, where majority of patients come from low socioeconomic status, pectoralis major myocutaneous flap is the most preferred reconstructive option. A retrospective questionnaire study was carried out to assess the mastication in patients with mandibulectomy followed by pectoralis major myocutaneous flap reconstruction. At the end of the study, it was observed that 86.6% of the patients had a good performance despite the lack of bony reconstruction. Thus, pectoralis major myocutaneous flap still stands strong in reconstructing large oral cavity defects.

The Use of Vertical Rectus Abdominis Myocutaneous Flap for Pelvic Reconstruction: What Are the Risk Factors for Complications?

PURPOSE: Perineal and pelvic defects resulting from radical surgical resection, pelvic exenteration, sacrectomy, and recurrent cancer resections are frequently large and frequently present a reconstructive challenge. These defects often require flap reconstruction to close a large skin defect, obliterate the pelvic or sacrectomy cavities, or reconstruct the vaginal canal.1,2 One of the most common used flaps for pelvic reconstruction is the inferiorly based vertical abdominis myocutaneous (VRAM) flap.3 This flap has reliable vascularity and can be easily prepared, providing a potentially large amount of tissue.2 The aim of this study is to present a 25-year single institution experience with VRAM flaps for perineal and pelvic reconstruction and study risk factors associated with surgical complications. METHODS: A retrospective chart review of patients who underwent pelvic resection followed by VRAM flap reconstruction from 1994 to 2019 was done. Patient demographics, clinical and surgical characteristics, postoperative outcomes, and complications were reviewed. Univariate and multivariable conditional logistic regression models were used to assess predictors of risk factors for surgical complications (wound dehiscence, wound infection, hematoma, seroma, or flap necrosis). All the tests were 2-sided, and a value of P < 0.05 was considered significant. Receiving operating characteristics curves and area under the curves were calculated to study the effect of body mass index (BMI) in surgical site complications and postoperative hernia. Analyses were performed in JMP, Pro 14 (SAS Institute Inc., Cary, N.C.). RESULTS: A total of 235 patients were evaluated, with mean follow-up of 41.2 months (interquartile range, 7.8–62). On multivariate analysis, patients who had pre-existing abdominal hernia at the time of surgery (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.3–8.6; P = 0.016), received immunosuppressive drugs (OR, 6.1; 95% CI, 1.4–25.9; P = 0.015), or used mesh in the donor site of the VRAM (OR, 2.6; 95% CI, 1.1–5.9; P = 0.031) were significantly associated with developing surgical complications. Additionally, patients with higher BMI were associated with an increased risk of developing a postoperative abdominal hernia (P = 0.047). For each point increase in BMI, the odds of hernia increased by 4.9% and the optimal cutoff to predict higher hernia rates in these patients was a BMI of 32 kg/m2 (area under the curve, 0.586). CONCLUSION: Patients undergoing VRAM flaps for pelvic or perineal reconstruction who were immunosuppressed, had a pre-existing abdominal hernia at the time of surgery, or underwent placement of mesh in the donor site are at increased risk of surgical complications. In addition, patients with high BMI have an increased risk of developing postoperative ventral hernias. Better preoperative patient selection and counseling based on the identified risk factors may help improve outcomes for patients undergoing VRAM for pelvic reconstruction. REFERENCES: 1. Butler CE, Gundeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg. 2008;206:694–703. 2. Creagh TA, Dixon L, Frizelle FA. Reconstruction with vertical rectus abdominus myocutaneous flap in advanced pelvic malignancy. J Plast Reconstr Aesthet Surg. 2012;65:791–797. 3. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg. 2009;123:175–183.

Comparison of the reconstruction of through-and-through cheek defects involving the labial commissure following tumor resection using four types of local and pedicle flaps

BackgroundThe reconstruction of through-and-through cheek defects involving the labial commissure following cancer ablation is a surgical challenge.MethodsThis study evaluated 35 patients with buccal squamous cell carcinoma (SCC) involving the labial commissure who underwent Abbe–Estlander (A-EF), folded extended supraclavicular fasciocutaneous island (SFIF), folded pectoralis major muscle (PMMF), or folded extended vertical lower trapezius island myocutaneous (TIMF) flap reconstruction of through-and-through cheek defects involving the labial commissure following radical resection.ResultsThe A-EF and SFIF groups differed significantly (P < 0.05) from the PMMF and TIMF groups in terms of tumor clinical stage and type of treatment. The inner PMMF (median 6.3 × 4.5) and TIMF (median 9.8 × 6.7) skin paddle dimensions were larger than those of the A-EF (median 1.8 × 2.2) and SFIF (median 5.5 × 4.3) groups (P < 0.05). The outer PMMF (median 6.3 × 6.6) and TIMF (median 9.8 × 13.2) dimensions were larger than those of the A-EF (median 1.8 × 3.8) and SFIF (median 5.5 × 4.6) groups (P < 0.05). The esthetic results, orbicularis oris function, and speech function were significantly (P < 0.05) better in the A-EF group than in the SFIF, PMMF, and TIMF groups. The patients were followed for 6–38 months (median 26.8, 25.0, 22.1, and 20.8 months in the A-EF, SFIF, PMMF, and TIMF groups, respectively). At the final follow-up, 4 (80.0%) patients in the A-EF, 7 (87.5%) in the SFIF, 5 (55.6%) in the PMMF, and 5 (38.4%) in the TIMF groups were alive with no disease; 1 (20.0%), 1 (22.2%), 2 (22.2%), and 4 (30.8%) patients, respectively, were alive with disease; and 2 (22.2%) patients in the PMMF and 4 (30.8%) in the TIMF group had died of local recurrence or distant metastases at between 9 and 38 months. There was a significant survival difference in the A-EF and SFIF groups compared with the PMMF and TIMF groups (P < 0.05).ConclusionsThe A-EF is suitable for reconstructing defects of clinical stage II disease; the SFIF for clinical stage II or III disease; the PMMF for clinical stage III or IV; and the TIMF for clinical stage rCS III or rCS IV disease.

The latissimus dorsi myocutaneous flap for reconstruction of head and neck defects - a comparative analysis of pedicled vs free vascularized flap

The latissimus dorsi myocutaneous flap for reconstruction of head and neck defects - a comparative analysis of pedicled vs free vascularized flap

Transverse myocutaneous gracilis flap reconstruction is feasible after pelvic exenteration: 12-year surgical and oncological results

IntroductionPelvic exenteration (PE) is the only curative treatment for certain locally advanced intrapelvic malignancies. PE has high morbidity, and optimal reconstruction of the pelvic floor remains undetermined. Materials and methodsA retrospective chart review was performed at a tertiary university center to assess the surgical and oncological outcomes of 39 PE procedures over a 12-year period. The majority of patients (n = 25) underwent transverse musculocutaneous gracilis (TMG) flap reconstruction for pelvic floor reconstruction. ResultsThe 1- and 5-year overall survival (OS) was 72% (95%CI 58%–86%) and 48% (95%CI 31%–65%), respectively. In multivariate analysis, lymph node metastasis (HR 3.070, p = 0.024) and positive surgical margins (HR 3.928, p = 0.009) were risk factors for OS. In this population, 71.8% of the patients had at least one complication. The complication rate was 65.4% and 84.6% for patients with versus without flap reconstruction, respectively (p = 0.191). The length of stay was longer for patients with a major complication 16,0 ± 5,9 days vs. 29,4 ± 14,8 days, p = 0,001, but complications did not affect OS. ConclusionFor selected patients, PE is a curative option for locally advanced, residual, or recurrent intrapelvic tumors. Pelvic floor and vulvovaginal defects can reliably be reconstructed using TMG flaps. TMG flaps are favored in our institution over abdominal-based flaps because the donor site morbidity is reasonable and TMG does not interfere with enterostomy.

Staged Treatment of Chest Wall Radiation-Induced Ulcer With Negative Pressure Wound Therapy and Latissimus Dorsi Myocutaneous Flap Transplantation.

Chest wall ulcer induced by postmastectomy radiation therapy (PRMT) remains challenging for plastic surgeons because of the reduced blood supply, fibrosis, and impaired cellular potential in the irradiated area. In this study, chest wall ulcer was treated with negative pressure wound therapy (NPWT) and the latissimus dorsi myocutaneous (LDM) flap reconstruction in 2 stages. A retrospective study was performed on consecutive patients with chronic radiation-induced ulcers in chest wall from June 2012 to June 2017. Surgical debridement and NPWT were performed in the first stage and the chest wall reconstructed by the LDM flap transplantation after extensive debridement in the second stage. There were 10 female patients with chest wall ulcers with a mean age of 60.3 years. The average duration of the ulcers was 21.2 months and the ulcers varied from 1 × 2 to 5 × 7 cm. Histological examination denied any recurrent breast cancer or radiation-related malignancy. Negative pressure wound therapy was applied with 100 to 125 mm Hg negative pressure during a period of 5 to 7 days in the first stage. The LDM flap varied from 11 × 15 to 15 × 20 cm. The mean follow-up was 25.9 months. All the flaps survived well with satisfactory appearance and there was no donor-site morbidity or ulcer recurrence during the follow-up period. The staged treatment of the chest wall radiation ulcer incorporated the benefits of NPWT and LDM flap. It is beneficial in increasing the blood and nutrient supply to the irradiated tissue, enhancing the debridement and promoting tissue healing, thus improving the flap survival and decreasing the ulcer recurrence.

Long-term outcomes for penile cancer patients presenting with advanced N3 disease requiring a myocutaneous flap reconstruction or primary closure-a retrospective single centre study.

Penile cancer patients with advanced metastatic disease in the inguinal region present a therapeutic challenge. We compared the outcomes for patients with advanced inguinal node disease requiring myocutaneous flap reconstruction (MFR) against primary closure for N3 disease. A retrospective comparative study of a consecutive cohort of advanced penile cancer patients with N3 disease was performed. Patient demographics, presenting symptoms, primary tumour site, stage and grade were recorded. The type of MFR used, patient outcomes and post-operative complications were recorded from an institutional database. Kaplan-Meier (KM) curves were calculated to analyse the cancer-specific survival (CSS) rates for the MFR group and compared with the no-MFR group. P values were calculated by log-rank and Chi square tests for CSS rates and complications respectively. Eighteen patients requiring MFR were identified; mean age 62 years. Ten (55.6%) patients had a first presentation with penile cancer and advanced nodal disease with the remaining 8 (44.4%) presenting with an inguinal recurrence having already undergone surgery. The majority (n=15) underwent a vertical rectus abdominis myocutaneous (VRAM) flap. The average length of stay was 23 days for the MFR group versus 8.5 days for the no-MFR group. The 5-year CSS was 20.9% for the MFR group and 39.8% for the no-MFR group (P<0.01). Aggressive surgical management for patients with extensive nodal disease and flap reconstruction is feasible and aids wound management although the long-term prognosis is still poor.

Risk Factors for Surgical Site Infection in Patients Undergoing Free and Pedicled Myocutaneous Flap Reconstruction After Oral Cancer Resection

The aim of the study was to investigate risk factors for surgical site infection (SSI) at the recipient site in oral cancer resection surgery with neck dissection and reconstruction using a free or pedicled myocutaneous flap. Eighty-eight patients who underwent this procedure composed a nonrandomized retrospective cohort. Recipient site SSIs occurred in 27 patients (30.7%). In multivariate analysis, flap necrosis (partial or total; P=.003; odds ratio [OR]=12.8) and preoperative hypoalbuminemia (P=.025; OR=3.9) were independent risk factors for recipient site SSI. In an analysis restricted to flap survival cases, free flap (vs pedicled flap; P=.026; OR=25.0) and preoperative hypoalbuminemia (P=.014; OR=11.0) were significant risk factors for recipient site SSI. These results suggest that different preoperative nutritional interventions, such as a diet enriched with energy and protein, oral nutritional supplements, and, in patients with compromised swallow, enteral tube feeding or parenteral nutrition, could be important to decrease the frequency of recipient site SSIs. Pedicled and free flaps might result in SSIs for different reasons. Partial necrosis occurred more often with pedicled flaps than with free flaps and it might be important to use different techniques to decrease skin flap necrosis to lower the rate of SSIs.

Outcomes Analysis of Gynecologic Oncologic Reconstruction.

Background:Defects resulting from gynecologic oncology resections can range from small external defects to total exenterations, requiring complex pelvic reconstruction. We aim to investigate the patient and surgical factors that influence complication rates, reoperation rates, and length of stay. We hypothesize that this patient cohort will have high complication and reoperation rates that are likely most affected by their medical and extirpative surgery factors, with less direct impact from their reconstructive surgery procedures.Methods:All cases of reconstruction following resection of a gynecological oncology tumor at the University of Wisconsin Hospital over the last 14 years were reviewed. Forty-three patients were identified who required 66 flaps for reconstruction.Results:Mean follow-up period was 19 months. Overall complication rate was 65% and reoperation rate was 33%. Plastic surgery flap-specific complication and reoperation rates were 47% and 19%, respectively, and were not significantly associated with any patient risk factors. Flap reconstruction subtype was not associated with time to complete healing, complication rate, or reoperation. Prior chemotherapy was significantly correlated with increased rate of overall complication (P = 0.0253) and reoperation (P = 0.0448), but prior radiation was not. Mean hospital stay was 11 days (SD ± 9 d). Factors found to be significantly associated with an increase in hospitalization length were increasing number of comorbidities (P = 0.021), exenteration defects (P = 0.0122), myocutaneous flap reconstruction (P = 0.0003), radiation (P = 0.0004), and chemotherapy P = 0.0035).Conclusion:This patient cohort has an overall high complication and reoperation rate; however, increasingly complex reconstruction is not associated with significant differences in complication rates or reoperation.

The infrahyoid myocutaneous flap for reconstruction after oral cancer resection: A retrospective single-surgeon study.

ObjectiveTo review our experience with infrahyoid myocutaneous flap in reconstruction after oral cancer resection.MethodsChart reviews were completed for all patients who underwent oral reconstruction with an infrahyoid myocutaneous flap by a single surgeon in the Department of Otolaryngology at Chonburi Cancer Hospital from 2011 to 2017. Characteristics of the patients and postoperative complications were analyzed.ResultsOf the 34 patients in the study, 10 (29.4%) developed partial flap loss and 1 (2.9%) developed total flap loss. All cases of partial flap loss resolved with conservative treatment. Apparent cancer involvement of a cervical lymph node was significantly associated with flap failure (odds ratio: 5.0, 95% CI: 1.03–24.28).ConclusionsThe infrahyoid myocutaneous flap is a fairly reliable reconstruction method. The flap should be performed with caution in cases with gross lymph node involvement.

R0 resection and reconstruction for a large, rapidly progressive chest wall sarcoma

BackgroundChest wall sarcomas are a rare group of soft tissue malignancies with variable presentations. Here we describe the definitive management of a large, rapidly progressing chest wall sarcoma arising from the pectoralis major muscle.Case reportAn obese 42-year-old African American male with multiple medical comorbidities presented with new onset right-sided chest pain and a palpable right chest mass. Initial CT chest demonstrated a 9x9x9cm necrotic mass arising from the pectoralis major. CT-guided core biopsy was positive for high-grade spindle cell neoplasm (positive for smooth muscle actin, desmin, S100, and CD31; negative for CD34, PAX8, and beta-catenin). Staging imaging 2 months later demonstrated growth of the mass to 21.4 × 17.8 × 13.7 cm. The patient underwent neoadjuvant chemoradiation with surveillance CT imaging demonstrating a stable tumor. Then he underwent wide local excision of the mass followed by delayed local myocutaneous flap reconstruction and skin grafting. Final pathology was R0 resection, 38x20x18 cm tumor with 70% gross necrosis. Microscopic examination confirmed high-grade sarcoma with smooth muscle differentiation. Final pathologic staging was Stage III G3 pT2bNxMx.ConclusionsThis patient presented with a rare, rapidly enlarging high-grade leiomyosarcoma of the chest wall without metastases or violation of the thorax. We describe the definitive management including a multidisciplinary team to manage a complex and rapidly progressive sarcoma of the chest wall.

Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement.

Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE). A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations. Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications. This position statement updates clinicians on current evidence around perineal closure after APE surgery.

Pectoralis Major Myocutaneous Flap Reconstruction for the Mandibular Defects in Advanced Oral Cavity Malignancies: A Retrospective Study of 30 Cases.

To evaluate the utility of the pectoralis major myocutaneous (PMMC) flap for the reconstruction of the mandible in advanced oral cavity malignancies in the Indian population. It was a retrospective study contained 30 patients with advanced oral cancer from July 2012 to August 2016. The PMMC reconstruction was done in all the patients to repair the bony defects in segmental/hemi mandibulectomy. The patients were followed up for a mean period of 6months in the postoperative period and the utility of the PMMC flaps were evaluated. The mean age of the patients was 45years (range 30-63years). The average Karnofsky performance status score was 70 and majority of the patients had history of chronic medical illness. Of the 30 PMMC flaps, partial necrosis of the skin was noticed 2 (06.66%) patients. Orocutaneous fistula was detected in 2 (06.66%) patient and 3 (10%) patients presented with wound dehiscent in the immediate postoperative period. 3 (10%) patients had recurrence of the disease. PMMC flap can be a reliable option for advanced oral malignancies, especially in patients with poor status with the coexisting chronic illness. Due to the presence of a definite vascular pedicle, ease of harvesting the flap, quick surgical procedure, and the minimal postoperative morbidities, it can be considered as a valid alternative to the free flap to repair the bony defect, especially in patients with low socioeconomic corridor like India.

A Descriptive, Retrospective Study of Using an Oblique Downward-design Gluteus Maximus Myocutaneous Flap for Reconstruction of Ischial Pressure Ulcers

Despite advances in reconstruction techniques, ischial pressure ulcers continue to present a challenge for the plastic surgeon. The purpose of this retrospective study was to evaluate outcomes of using an oblique downward gluteus maximus myocutaneous (GMM) flap for coverage of grade IV ischial ulcers. Data regarding defect size, flap size, operation time, duration of wound healing, and surgical outcome were abstracted from the medical records of patients whose ischial pressure ulcers had been reconstructed using GMM island flaps between January 2010 and December 2015. The 22 patients comprised 15 men and 7 women with a mean age of 52 (range 16-81) years. Twenty (20) had paraplegia, 6 had a recurrent ischial ulcer, 2 were bedridden following a cerebrovascular accident, 1 had a myelomeningocele status post operation, and 19 were spinal cord injury patients. Follow-up time ranged from 6 to 40 months. Pressure ulcer size ranged from 3 cm x 2 cm to 10 cm x 5 cm (average 22.3 cm2). The average flap size was 158 cm2 (15.9 cm x 9.7 cm); the largest was 286 cm2 (22 cm x 13 cm). The operating time ranged from 52 minutes to 110 minutes (average, 80 minutes). In 2 cases, wound dehiscence occurred but completely healed after resuturing. One (1) ischial pressure ulcer recurred 6 months following surgery and was successfully covered with a pedicled anterolateral thigh flap. No recurrences or problems were observed in the remaining 20 patients. Time to complete wound healing ranged from 14 to 24 days (average 17.8 days). Treatment of ischial pressure ulcers with GMM flaps allowed for an easy, simple procedure that provided the adequate thickness of soft tissue needed to cover the bony prominence, fill dead space, and cover the lesion. This technique was a reliable and safe reconstructive modality for the management of ischial pressure ulcers, even in recurrent cases.