Obliteration Of Dead Space Research Articles

Evaluation of surgical dead space obliteration in modified radical mastectomy for incidence of seroma formation, drain volume and duration of drain

Evaluation of surgical dead space obliteration in modified radical mastectomy for incidence of seroma formation, drain volume and duration of drain

Bilateral Superior Gluteal Artery Perforator (SGAP) Flap: Modified Concept in Perineal Reconstruction.

Background/Objectives: Perineal reconstruction after abdominoperineal excision often requires complex closures and is fraught with wound healing complications. Flap-based approaches introduce non-irradiated vascularized tissue to the area of resection to fill a large soft-tissue defect and dead space, reduce the risk of infection, and facilitate wound healing. Employing perforator flaps with their beneficial donor site properties, the authors have developed a concept of bilateral superior gluteal artery perforator (SGAP) flaps to restore extensive perineal defects. Methods: This retrospective case series was conducted between September 2015 and December 2019. We included three patients who received bilateral SGAP flap reconstruction after oncological resection. One deepithelialized SGAP flap was used for obliteration of dead space, combined with the contralateral SGAP flap for superficial defect reconstruction and wound closure. Results: Within this patient population, two male and one female patient, with a median age of 62 years (range, 52-76 years), were included. Six pedicled SGAP flaps were performed with average flap dimensions of 9 × 20 cm (range 7-9 × 19 × 21). No flap loss or no local recurrence were documented. In one case, partial tip necrosis with prolonged serous drainage was observed, which was managed by surgical debridement. No further complications were detected. Conclusions: The combination of two SGAP flaps provides maximal soft tissue for defect reconstruction and obliteration of dead space, while maintaining a very inconspicuous donor site, even with bilateral harvesting. Given these advantages, the authors recommend this promising approach for successful reconstruction of perineal defects.

Review On Biological Properties of Suture Materials

Suture is a general term for all materials used to stitch torn tissues. Surgical sutures are imperative in management of surgical and traumatic wounds. Sutures are primarily used to oppose tissues together to assist and accelerate the recovery process after an incident or surgical operation. In addition, sutures also aid in obliteration of dead space, even distribution of stress on the incision line, and maintenance of adequate tensile strength throughout the critical wound healing process until appropriate tissue strength is achieved. Considering availability of a wide variety of suture materials, it’s important to know the differences between various sutures before making an informed decision. Suture material's overall performance is influenced by its physical qualities, handling features, and biological factors. The aim of this seminar paper is to give highlights on the biological properties of suture materials. Suturing is not simply about closing a wound; it is a skill that requires finesse and can significantly impact the healing process, reduce complications, and even affect long-term results. Suture selection involves the choice of both the appropriate type and size of suture material. Sutures may cause different host reactions in living tissues. While the suture remains in the tissue, it can trigger the inflammation cascade through different pathways such as degradation, a foreign body reaction, an allergic reaction, or abrasion. Natural suture materials such as catgut and silk are more immunogenic than synthetic materials because they are degraded by proteolysis in contrast to synthetic suture materials, which are degraded by hydrolysis. Therefore, surgery professionals should choose a suture material with good tissue acceptance.

Robotically-harvested, thoracoscopically-tunneled transdiaphragmatic omental pedicle flap for obliteration of radiated empyema cavity

Intra-thoracic defects continue to pose a challenge for the reconstructive surgeon. Stable soft tissue coverage and obliteration of dead space can be particularly challenging when complicated by infection or previous radiation. These cases may require a less conventional method of reconstruction. We describe a case in which vacuum-assisted closure followed by pedicled omental flap transposition was successfully used to reconstruct a complicated intra-thoracic wound following pneumonectomy, radiation therapy, and recurrent wound dehiscences secondary to chronic infection.

The Vertical Rectus Abdominis Myocutaneous Flap for Complex Abdominal Wall Reconstruction on a Relapse Case of Monophasic Synovial Sarcoma

Introduction: Vertical Rectus Abdominis Myocutaneous (VRAM) flap is a chosen method for a large wound closure instead of Anterolateral Thigh (ALT) flap. Both versatile and highly vascularized flaps share almost similar advantages for large wound closure. In our case, the site and size of the wound are the points of consideration. Case Presentation: A 16-year-old girl with a chief complaint of a large progressive lower abdominal mass enlarged since January 2021 that has grown back from the same site. Abdominal CT-Scan shows a tumor in the right lower abdomen infiltrated to the pelvic cavity and spanning from the lower abdominal area all the way to the groin area. Histopathology interpretation suggests a Monophasic Synovial Sarcoma. The patient underwent a second tumor resection with VRAM flap as the wound closure. The benefits of this versatile flap are excellent dead space obliteration and low Surgical Site Occurrence (SSO’s). Conclusion: As postulated in many studies VRAM flap is an excellent flap for a CAWR procedure. The expected SSO’s is non-existence during the postoperative follow-up

Second surgery for complications of major pulmonary resection—the technique of thoracoplasty with muscle flap

: Second surgery for postoperative complications after lung resection is one of the important issues that thoracic surgeons must overcome. Chronic empyema after lung resection, which is caused by bronchopleural or pleural fistula remains a challenge in modern medicine. Especially in cases in which decortication is not indicated, treatment is difficult, hospitalization is prolonged, and the condition is sometimes life-threatening. Surgical treatment of chronic empyema requires not only decortication and debridement, but also closure of the bronchopleural fistula and obliteration of dead space. From this viewpoint, thoracoplasty and muscle flap transposition are important techniques that lead to complete and reliable closure of the empyema cavity. Although they are performed less frequently today, they are procedures with which every thoracic surgeon should be familiar. This clinical practice review focuses on the use of muscle flaps in thoracoplasty and describes the historical background, types of muscle flaps, tips on surgical techniques, and treatment results. There is a wide variety of types and utilization of muscle flaps. Since the selection of an appropriate muscle flap is directly related to the success of the treatment, careful preoperative planning is necessary. It is important to understand the characteristics of each type of muscle flap and to select the appropriate technique for the patient’s pathological and general condition.

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.

Effect of Mastectomy Flap Fixation on Post-operative Fluid Drainage and Seroma Formation in Breast Cancer Patients A Double-blinded Randomised Control Trial.

<b> Introduction:</b> Post-operative seroma formation is one of the most common complications following modified radical mastectomy (MRM). Quilting is a technique where the mastectomy flaps are sutured to the underlying chest wall muscles with sutures, obliterating the dead space. The authors hypothesised that post-mastectomy dead space obliteration by intermittent mastectomy flap fixation leads to decreased drain output and seroma formation. </br></br> <b> Material and methods: </b> A double-blinded randomised control trial with two arms was conducted from November 2019 to March 2021 in our institute located in India. Patients with non metastatic breast carcinoma planned for MRM were randomly categorised into two groups of 35 patients each. In the test group, each flap was fixed to the underlying muscle using four intermittent 3-0 polyglactin sutures, which was followed by skin closure, and only skin closure was done in the control group. </br></br> <b>Results:</b> The test and control groups did not differ significantly with respect to demographic and tumour characteristics. The average drain output of the test group (155.43 ml) was significantly less than of the control group (206.29 ml). The overall incidence of seroma formation is lower in the test group (5.7%) when compared to the control group (28.6%). The duration of hospital stay in the test group (4.63 days) was significantly shorter when compared to the control group (6.66 days). There was no significant increase in the overall operating time or complications like surgical site infection or skin dimpling due to flap fixation. </br></br> <b>Conclusions:</b> Fixation of MRM flaps is associated with better post-operative outcomes related to drain output and seroma formation without a significant increase in other morbidities or usage of resources.

Inclusion of a latissimus dorsi segment in an extended lower trapezius musculocutaneous flap facilitates complex defect reconstruction

The pedicled lower trapezius musculocutaneous flap (LTMF) can extend far beyond the lateral border of the trapezius muscle, with a reliable blood supply. However, the distal part of the extended LTMF lacks a muscular component, limiting its usage in complex defect reconstruction, which often requires obliteration of dead space and coverage of vital structures. To overcome this limitation, we modified the LTMF by adding a segment of latissimus dorsi muscle (LDM). Between 2014 and 2021, the modified extended LTMF was used to reconstruct complex defects in the head, neck, shoulder, and contralateral chest wall and back in 19 patients. By preserving the interconnections between the branches of the posterior intercostal arteries, we were able to include various amounts of LDM within the extended LTMF. The LDM component was used to obliterate dead space and repair wounds involving cerebrospinal fluid leakage, infection, radioactive osteomyelitis, exposed carotid artery, lung, and implant materials. The average flap size was 30.7cm × 10.9cm (range: 25 × 8 cm-40 × 14cm). The average size of the LDM was 113.9 cm2 (range: 27.7-216.6 cm2). Partial flap necrosis occurred in two patients and the secondary defects were reconstructed using a local flap. The remaining 17 flaps survived completely. The LTMF carrying a segment of the LDM could be considered for patients undergoing reconstruction of complex defects in the head, neck, shoulder, and contralateral chest wall and back and for patients who are ineligible for free flap reconstruction.

Soft Tissue Defect Reconstruction and Lymphatic Complications Prevention: The Lymphatic Flow-Through (LyFT) Concept.

Background and Objectives: When a lymphatic-rich area is severely damaged, either after trauma or a surgical procedure, both soft tissue defect reconstruction and lymphatic drainage restoration are necessary. In this setting, we aim to show the potential of the lymphatic flow-through flap (LyFT) concept, which might be an attractive new solution to reduce postoperative lymphatic complications. Materials and Methods: Between 2018 and 2021, 12 patients presenting a soft tissue defect involving damage to the lymphatic drainage pathway received a lymphatic flow-through flap for volume and lymphatic drainage restoration. Different flaps were employed: 3 pedicled superficial circumflex iliac artery perforator (SCIP) flaps, 2 free SCIP flaps, 3 pedicled deep inferior epigastric perforator (DIEP) flaps, 2 pedicled vertical posteromedial thigh (vPMT) flaps, and 2 pedicled anterolateral thigh (ALT) flaps. A range of 1 to 3 lymphovenous anastomosis (LVA) with flap’s veins was performed (mean 1.9). For a better dead space obliteration, an additional vastus lateralis muscle flap was performed in one case. Indocyanine green (ICG) lymphography was used in all cases to identify the lymphatic pathway, make the preoperative markings, and check the patency of the anastomoses. Results: In all cases, the reconstructive results were satisfactory from both the functional and aesthetic points of view. No secondary surgeries were required, and only one minor complication was encountered: an infected seroma that was managed conservatively. The mean follow-up was 9.9 months (range 6–14 months). Conclusions: Lymphatic flow-through flaps seem to effectively reduce the risk of lymphatic complications after the reconstruction of soft tissue defects with a compromised lymph pathway. This is a versatile solution that might be used in different body regions resorting to different flap types.

Postpartum spontaneous vulvar hematoma as a cause of maternal near miss: a\xa0case report and review of the\xa0literature

BackgroundPostpartum spontaneous vulvar hematoma is a rare complication of childbirth that can potentially cause maternal death if not managed properly and in a timely manner.Case summaryWe present the case of maternal near miss secondary to postpartum hemorrhage secondary to vulvar hematoma after home delivery in a 28-year-old para IV mother from rural Ethiopia. The case was surgically managed under spinal analgesia. The mother and her newborn were discharged on the fourth postprocedure day.ConclusionNeglected and inappropriately managed postpartum vulvar hematoma can cause significant maternal morbidity; therefore, timely surgical exploration, ligation of bleeding vessels, and obliteration of dead space can avert severe maternal complications

The Five-Step Rhinoplasty Dead Space Closure Technique.

The creation of dead space in rhinoplasty creates a welcoming environment for erratic soft -tissue contraction. If rhinoplasty surgeons can control and reliably predict skin contraction and wound healing, rhinoplasty results will undoubtedly improve. Obliteration of dead space is a key component in rhinoplasty as it minimizes soft-tissue contraction, resulting in a more predictable outcome. In this article, the authors present a systematic five-step dead space closure surgical plan.

Lymphatic Complications Prevention and Soft Tissue Reconstruction after Soft Tissue Sarcoma Resection in the Limbs.

Background and Objectives: The definitive treatment of soft tissue sarcomas (STS) requires a radical surgical removal of the tumor, which often leads to large soft tissue defects. When they are located in the limbs, significant damage to the lymphatic pathways is not uncommon. In the present article, we present different techniques aimed at both reconstructing the defect and restoring sufficient lymph drainage, thus preventing short- and long-term lymphatic complications. Materials and Methods: Between 2018 and 2020, 10 patients presenting a soft tissue defect with lymphatic impairment received a locoregional reconstruction by means of either pedicled or free SCIP flap. Seven patients required a second flap to reach a good dead space obliteration. In six cases, we performed an interpositional flap, namely a soft tissue transfer with lymphatic tissue preservation, and in four cases a lymphatic flow-through flap. In all cases, the cause of the defect was STS surgical excision. The average age was 60.5 years old (ranging 39–84), seven patients were females and six were males. Results: All the patients were successfully treated. In two cases, minor post-operative complications were encountered (infected seroma), which were conservatively managed. No secondary procedures were required. The average follow-up was 8.9 months (ranging 7–12 months). No signs of lymphedema were reported during this time. In all cases, complete range of motion (ROM) and a good cosmetic result were achieved. Conclusions: A reconstructive procedure that aims not only to restore the missing volume, but also the lymphatic drainage might successfully reduce the rate of postoperative complications. Both lymphatic interpositional flaps and lymphatic flow-through flaps could be effective, and the right choice must be done according to each patient’s needs.

Analysis of epidemiological characteristics and surgical treatment of patients with pressure ulcer

Introduction/Objective A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence. It appears as a result of pressure or the combination of pressure and shear. Pressure ulcers can be identified within a wide variety of patient subpopulations and epidemiological and etiological aspects play a major role in their treatment. Methods A retrospective study of data analysis included 72 patients with pressure ulcers that were hospitalized and surgically treated in our institution over a five-year period. Main data features used in the analysis were sex, age, principal diseases, comorbidities, and biochemical indicators of malnutrition. The patients? data was obtained from the existing patients? records. Additionally, the study analyzed the method of treating pressure ulcers, types of reconstructive methods in surgical treatment, as well as the incidence rate of partial osteotomy. Results A total of 72 patients with pressure ulcers were included in this study, with a mean age of 54.7 ? 16.1 years. Three times more patients injured in traffic accidents were male (75% vs. 25%), while most of the patients with multiple sclerosis were female (85.7%). More than 95% of patients who had pressure ulcers of stage III or IV were treated surgically with a reconstructive method of transposition or rotation myocutaneous flap. Patients with stage IV pressure ulcer were usually treated with partial osteotomy. Conclusion Surgical reconstructive treatment with fasciocutaneous and myocutaneous flaps represents the gold standard for treating patients with pressure ulcers. These procedures provide reconstruction with adequate flap coverage and obliteration of dead space with well-vascularized tissue but with necessity of further implementation of antidecubitus measures.

Volumetric Evaluation of Dead Space in Ischial Pressure Injuries Using Magnetic Resonance Imaging: A Case Series.

To establish a preoperative evaluation procedure by measuring the volume of dead space using MRI in patients with ischial pressure injuries. Patients with spinal cord injury and ischial pressure injuries who underwent treatment between August 2016 and November 2019 were included in the study. Preoperative MRI scan was conducted on all patients. The volume estimation and three-dimensional (3D) reconstruction were performed based on MRI data using a 3D Slicer. Based on the resulting volume, a muscle flap that could fit the dead space was selected. Surgery was performed with the selected muscle flap, and a fasciocutaneous flap was added, if necessary. A total of eight patients with ischial pressure injuries were included in the study. The mean patient age was 59.0 ± 11.0 years. The mean body mass index was 26.62 ± 3.89 kg/m2. The mean volume of dead space was 104.75 ± 81.05 cm3. The gracilis muscle was the most selected muscle flap and was used in four patients. In five of eight cases, a fasciocutaneous flap was used as well. The mean follow-up period was 16 months, and by that point, none of the patients evinced complications that required surgery. To the authors' knowledge, this is the first report on volumetric evaluation of dead space in ischial pressure injuries. The authors believe that the 3D reconstruction process would enable adequate dead space obliteration in ischial pressure injuries. The authors propose that preoperative MRI scans in patients with ischial pressure injury should become an essential part of the process.

Simple, but effective: Nasal splinting for airway securement in free flap reconstruction following orbital exenteration.

Orbital exenteration is a disfiguring procedure that often results in free tissue transfer for reconstructive purposes. The reconstructive focus is the obliteration of dead space while sparing the nasal airway, particularly if the medial orbital wall was resected. Prolapse of transferred tissue into the nasal airway may cause breathing difficulties drastically compromising quality of life. The objective of this study was to demonstrate the effectiveness and feasibility of temporary nasal septum splints as mechanical support for transferred tissue, to prevent airway obstruction. This novel application technique was employed in three patients between 2017 and 2018. No flap loss or sino‐orbital fistulas were observed. On postoperative MRI and endoscopy, a patent nasal airway was observed at all times. Temporary nasal splinting in combination with free tissue transfer proved to be a simple, but effective reconstructive option for securing the nasal airway following orbital exenteration with resection of the medial orbital wall.

Scarpa fascia versus rectus sheath plane in Lipoabdominoplasty flap dissection: Comparative study.

Background: Abdominoplasty and lipoabdominoplasty are frequently performed aesthetic procedures to improve the contour of abdomen and flanks. The improvement obtained would positively impact patient’s self-image and life quality. A lot of potential complications would compromise surgeon/patient satisfaction, the most frequent being seroma formation. A lot of measures/techniques were advocated to reduce seroma incidence including the use of suction drain, dead space obliteration by quilting sutures, and preservation of infraumbilical Scarpa fascia/deep fat layer. The latter is the focus of the current comparative study. Patients and Methods: 40 full lipoabdominoplasty cases were randomized into 2 equal groups based on infraumbilical dissection plane. Group A with traditional rectus sheath dissection plane and group B with supra Scarpa dissection plane. Post-operative drainage volume, time of drain removal and incidence of symptomatic seromas were documented. Results: Drainage volume and duration of drainage were significantly lower in supra Scarpa dissection group (B) than those of rectus plane group (A) (p < 0.001). Clinically evident seroma was detected in 3 cases of group (A) and in one case of group (B). All resolved after 2-3 aspirations in outpatient settings. Both groups were homogenous regarding BMI, age, volume of lipoaspirate, weight of excised dermofat and mean operative time. Conclusion: Scarpa fascia/deep fat preservation significantly reduced the drainage volume and duration. A lower seroma incidence was also observed.Key Words: Scarpa fascia, Lipoabdominoplasty, Seroma.

Free tissue transfer for skull base reconstruction - a review

Evolutions in skull base surgery and reconstructive technique have given surgeons the confidence to resect and repair increasingly advanced skull base pathologies. Free tissue transfer (FTT) provides a versatile option capable of addressing numerous simultaneous reconstructive goals. This review highlights some of the nuances, challenges, and considerations of performing FTT for skull base reconstruction in the anterior, central and lateral skull base. This review combines the expert opinion of the senior authors with those of the field at large as queried through PubMed searches regarding skull base reconstruction and FTT. Reconstructive goals include separation of intracranial from extracranial cavities, obliteration of dead space, and protection of vascular and neural structures. Atypical vascular pedicle management is commonly needed, especially for endonasal and central skull base resection. Virtual surgical planning may be beneficial for complex bony reconstruction. Familiarity with common complications such as cerebrospinal fluid leak, nasocutaneous fistula, and inferior flap displacement, as well as associations for their development, can help plan the reconstruction to minimize morbidity.

Lumbar Perforator Flaps for Coverage of Extensive Defects With Osteomyelitis.

Lumbar osteomyelitis is a rare, although serious condition if not appropriately treated, potentially leading to neurologic complications, such as radiculopathy. Traditionally, studies have suggested the preferred use of muscle or myocutaneous flaps to prevent recurrent infections. However, late evidence suggests that radical debridement and dead space obliteration are more important than the type of flap. The lumbar perforator flap is a reliable local option with low donor site morbidity. It is a powerful tool for local trunk reconstruction, but its use in case of osteomyelitis is scarcely described. We aimed to report long-term outcomes of lumbar perforator flaps to cover lumbar soft tissue defects with chronic osteomyelitis. This retrospective investigation was performed on a prospectively maintained database including 7 consecutive patients (10 flaps), all presenting extensive defects of the posterior midline at L2-S1 level (defect size 287 ± 136 cm [average ± SD]). Four patients presented defects after recurrent tumor resection, whereas in 2 patients, the defect was due to vascular jeopardy of internal iliac arteries with consequent necrosis. Last defect derived from debridement of a neglected wound in a paraplegic patient. All patients had concomitant bone infection. Infectious details and postoperative complications were recorded. Patients were in general poor medical condition (including peripheral arterial disease, hypertension, diabetes, or a combination of these). Eight flaps were raised as propeller perforator, whereas 2 as V-Y perforator. One propelled flap had venous congestion on postoperative day 1 and required a revision surgery to be converted to V-Y. Subsequent partial flap necrosis was treated conservatively. One patient presented a wound dehiscence that required surgical revision. All flaps were closed primarily except for 1 patient whose flap presented a mild intraoperative congestion, which was treated by delayed closure on postoperative day 6, with uneventful outcome. Time to complete healing was 29 ± 17 days (mean ± SD). No flap loss occurred, and all patients benefited from effective coverage at a mean follow-up of 20 months. Lumbar perforator flap is a reliable option to cover large soft tissue defects in the lumbar area despite chronic osteomyelitis, with low morbidity and acceptable cosmetic outcome.

Perineal Turn over Perforator Flap: A Novel Surgical Technique for Combined Perineal and Posterior Vaginal Wall Reconstruction

Extralevator Abdominoperineal Excision (ELAPE) and Abdominoperineal Resection create complex perineal defects made more challenging when combined with additional resection of the posterior vaginal wall. This composite defect requires the restoration of a functional vagina, in addition to the obliteration of the large perineal dead space, a need to reduce donor site, and perineal wound morbidity. Previously described fasciocutaneous and myocutaneous flaps for such defects are associated with long operations requiring intra-operative mobilization and are linked to post-operative complications including herniation, evisceration, flap loss, donor site morbidity and poor cosmetic outcome, amongst other issues. Herein we describe the case of a 60-year-old female patient that underwent combined ELAPE and posterior vaginectomy for anal squamous cell carcinoma. This complex defect was reconstructed using an extended version of the Perineal Turn-Over (PTO) flap based on the Internal Pudendal artery perforator.