Reconstruction Of Large Defects Research Articles

Five-year experience with titanium mesh for rigid chest wall reconstruction

ObjectiveTo characterize the performance of titanium mesh (TM) (off-label) for rigid chest wall reconstruction at a single institution over a 5-year period. MethodsBetween January 1, 2019, and May 15, 2023, 22 patients (median age, 61 years) underwent chest wall resection with TM reconstruction at Cleveland Clinic. Indications for resection included sarcoma (n = 15), breast cancer (n = 2), lung cancer (n = 2), chondroblastoma (n = 1), and benign neoplasm (n = 2). Patients were followed every 6 months with computed tomography scans for cancer recurrence. Continuous variables are summarized as median (interquartile range [IQR]); categorical variables, as frequency and percentage. Time to mesh fracture was assessed nonparametrically using Kaplan-Meier analysis. ResultsAmong the 22 patients over 21,870 patient-days of TM implantation, 21 (95%) had an R0 resection. The mean area of mesh coverage was 108 cm2 (IQR, 97-180 cm2). No patient experienced respiratory complications or mesh failure postoperatively. Of the 3 reoperations (13.6%), 2 were for delayed regional infection (at 7 and 12 months postoperatively), necessitating localized mesh removal, and the third was for local cancer recurrence. Fifteen implants developed visible fractures on imaging at a median time of 9 months after implantation. There were no adverse sequelae, including migration/erosion or clinical decline in respiratory function. ConclusionsChest wall resections, particularly those for sarcomas, require large margins for optimal oncologic outcomes. Rigid reconstruction of large defects is desirable, yet options are limited. TM reconstruction provides a promising alternative because of its biocompatibility, rigidity, robust incorporation into surrounding structures, and resistance to infection.

Understanding the Mechanical Forces on the Sacrum Can Help Optimize Flap-based Pilonidal Sinus Reconstruction.

Pilonidal sinus can be treated with excision and flap reconstruction, but treatment is often complicated by wound dehiscence, infection, and recurrence. Understanding the mechanical forces on the sacrococcygeal area during posture change could help guide optimal flap choice. Sixteen volunteers underwent measurements of skin-stretching, pressure, and shear stress on the sacrum when sitting relative to standing. Skin-stretching was measured by drawing a 4 × 4 cm square on the sacrum and measuring the vertical, horizontal, and diagonal axes. Pressure and shear stress was measured at six sacral points with a device. The data analysis highlighted the potential of the superior gluteal artery perforator (SGAP) flap for dissipating mechanical forces. Ten pilonidal sinus cases treated with SGAP flaps were retrospectively reviewed for 6-month outcomes. Sitting is associated with high stretching tension in the horizontal direction [estimated marginal mean (95% confidence intervals) = 17.3% (15.4%-22.6%)]. The lower sacrum experienced the highest pressure [106.6 (96.6-116.5) mm Hg] and shear stress [11.6 (9.7-13.5) N] during sitting. The transposed SGAP flap was deemed to be optimal for releasing the horizontal tension and providing sufficient subcutaneous tissue for ameliorating pressure/shear stress during sitting. It also has high blood flow and can therefore be used with large lesions. Moreover, its donor site is above the high-pressure/stress lower sacrum. Retrospective analysis showed that no patients experienced complications. Sitting is associated with high mechanical forces on the sacrococcygeal skin. The transposed SGAP flap may ameliorate these forces and thereby reduce the risk of complications of pilonidal sinus reconstruction for large defects.

Integra® Dermal Regeneration Template in Complex Scalp Reconstruction.

Background/Objectives: The need for surgical reconstruction of scalp defects following the excision of cutaneous skin cancers is an increasingly common procedure. Particular challenges arise when considering options for reconstruction of large defects not amenable to local skin flap coverage. The use of skin grafts poses the risk of donor site morbidity. This paper investigates the emerging use of Integra®, a synthetic acellular dermal regeneration template, as an alternative or adjunct to skin grafting in scalp reconstruction. Methods: The study presents a retrospective analysis of 101 patients who underwent Integra®-based reconstruction of scalp defects. Demographics, procedure details, complications, need for further surgery, and time to healing were evaluated. Results: The overall success rate of the one-stage Integra®-only procedure was 95%, with a minor complication rate of 30.7%. Anticoagulation medication was identified as an independent risk factor for post-operative infection, while previous head and neck radiotherapy and increased defect depth were associated with the requirement for a second-stage skin graft. Conclusions: These findings support the consideration of Integra® as a safe and viable alternative for both partial and full thickness scalp defects in a select cohort of complex highly co-morbid patients, reducing complications and the need for additional procedures.

Use of pedicled flaps after oncologic resections in pediatric patients.

The aim of this study is to review the indications of pedicled flaps and analyze the results.A observational retrospective study of under 18-year-old oncology patients who required reconstructive surgery with pedicled flaps between 2011 and 2022 was performed. Demographic and clinical variables, indications, complications, and outcomes were collected.236 patients were reviewed and 13 met inclusion criteria, eight girls and five boys (mean age: 10.6years). Indications were Ewing's sarcoma (5), osteosarcoma (5), neuroblastoma, desmoid tumor, and neurofibroma. Preoperative PET-CT, MRI and bone scintigraphy were performed. The flaps were used on costal and extremity reconstruction: latissimus dorsi (5), pectoralis (2), medial gastrocnemius (2), combined latissimus dorsi, trapezius and serratus muscle, biceps femoris, fascio-neuro-cutaneous saphenous and cutaneous advancement-rotation. Two were performed on allograft and eight on prosthesis. All allowed immediate and complete closure. Six patients received intraoperative radiotherapy. One flap infection and two vascular complications were reported, a total necrosis, which required a new flap, and a partial necrosis, treated with a local plasty. Chemotherapy was resumed after 21days (15-31). Mean follow-up time was 5.34years.Flaps are an effective therapeutic option allowing reconstruction of large defects after pediatric oncologic surgeries. The most frequent complication was vascular.

Nasal Dorsum Rotation-Transposition Flap Associated with Guitar-String Sutures: One-Stage Reconstruction of Large Defects on the Nose.

(1) Background: The preferred reconstructive option for closing small- or medium-sized defects of the distal half of the nose is the use of local flaps. The dorsal nasal (Rieger) flap is suitable for closing medium-sized defects at this location, especially when they are medially located, and are wider rather than tall. We describe a rotation-transposition dorsal nasal flap reconstruction for large nasal defects. The novelty of this design includes the addition of a small transposition lobe to the rotation flap, enabling the acquisition of tissue from either the lateral sidewall or the nasolabial sulcus, facilitating closure with guitar-string sutures. (2) Methods: We conducted a retrospective chart review of all the patients with large defects (>20 mm) of the nose who underwent nasal dorsum rotation-transposition flap repair between January 2019 and November 2022 at a single academic center. (3) Results: Fourteen patients (eight males, six females; ages 47-83, mean age 60 years) with defects (range: 20.00-35.00 mm) on the dorsum and nasal tip were recruited. Follow-up duration ranged from 12 months to 3 years, with all cases showing good or excellent oncologic and cosmetic results. (4) Conclusions: The rotation-transposition dorsal nasal flap was demonstrated to be a reproducible one-stage technique for large defects of the dorsum and nasal tip, with minimal risk of aesthetic or functional complications. Guitar-string sutures allowed the reduction of the defect size, facilitating a smaller flap design.

Trends in free flap reconstruction of the head and neck: a single surgeon series of 1027 free tissue transfers.

Free tissue transfer has fundamentally changed head and neck surgery, enabling reliable reconstruction of large defects with better function and aesthetics. This study assesses two decades of trends in free flap reconstruction, and how disease incidence, survival, surgeon caseload, team approach, and technology have impacted practice. Retrospective analysis of 1027 head and neck free flaps from 2006 to 2022. Outcomes examined include chronological changes in flap selection, indication, length of stay, incorporation of virtual surgical planning (VSP), annual caseload, survival, and their associations with the single versus multi-team approach. There were 764 soft-tissue and 263 osseous reconstructions utilizing 21 different flaps. Anterolateral thigh and radial forearm accounted for 76.7% of soft tissue flaps, with recent increase in superficial circumflex iliac perforator flaps in young patients. Osseous flap proportion remained stable, but fibula flaps increased five-fold with more VSP, dental implants, oral cancer, and multi-team surgery. Outcomes such as complication rates, length of stay and disease specific/overall survival have improved over time despite increasing complexity (P = 0.001, P = 0.001, P < 0.001, and P < 0.001, respectively). However, there was no significant difference in operative time, complication rate, or disease specific/overall survival between single team or multi-team approaches (P = 0.45, P = 0.054, P = 0.57, and P = 0.60, respectively). Single and multi-team approaches may have similar fundamental outcomes, but as caseload, complexity, and life-expectancy increases, both patients and surgeons benefit from a collaborative multi-team approach that focuses on improving long-term functional outcomes.

Bilateral Perineal Reconstruction Using an Oblique V-shaped DIEP Flap

The reconstruction of soft tissue defects in the peritoneal region after malignant tumor resection is challenging. To reconstruct large defects, primary closure or local flaps are inadequate, and they do not provide cosmetically and functionally good results. The gracilis, gluteal, and rectus abdominis flaps are workhorse flaps for reconstructing large peritoneal defects. Surgical procedures should be carefully chosen on the basis of the size and location of the defect. In this report, we describe two cases of bilateral large defect reconstruction after malignant tumor resection using a V-shaped deep inferior epigastric artery perforator flap. Our procedure is useful as it shows that single flaps can be used to reconstruct large and bilateral peritoneal defects.

Anterolateral Thigh Chimeric Flap: An Alternative Reconstructive Option to Free Flaps for Large Soft Tissue Defects.

The anterolateral thigh (ALT) skin flap provides abundant, thin, pliable skin coverage with adequate pedicle length and calibre, and tolerable donor site morbidity. However, coverage of relatively large defects using the ALT flap alone is limited. We present our experience of using the ALT flap coupled with the vastus lateralis (VL) flap supplied by the same pedicle for large defect reconstruction. Between 2016 and 2020, ten patients with extensive lower-extremity or trunk defects were treated using the ALT/VL chimeric flap. The ALT portion was used to cover the cutaneous and joint defect while the VL part was used to resurface remnant defects, and a skin graft was performed. All flaps were based on the common descending pedicle, and branches to separate the components were individually dissected. All defects were successfully reconstructed using the ALT/VL chimeric flap. No surgery-related acute complications were observed, and the patients had no clinical issues with ambulation or running activities during the long-term follow-up period. With the separate components supplied by a common vascular pedicle, the ALT/VL chimeric flap allows us to reconstruct extensive defects with joint involvement or posterior trunk lesions. Thus, the ALT/VL chimeric flap may be a suitable alternative for extensive tissue defect reconstruction.

Long-term outcome of local muscles transposition for the functional restoration of large upper or lower lip defects

Background Although more than 200 techniques have been reported for the reconstruction of their and lower lip defects since 1000 BC, none of them is ideal. Local flaps come at the expense of extra skin scarring and, in some cases, the surgeon may be confronted with the lack of sufficient tissues for the reconstruction of large defects. It has been reported that several methods exist for performing near-total lip reconstruction. Currently, free micro-vascular tissue transfer and local flap repair (the Bernard von Burrow-Webster method) are the two most prominent methods. Aim To evaluate the functional results of using local muscles transposition-assisted dermal fat flap and muco-buccal flap to treat upper or lower lip defects. Patients and methods This study was carried out on 128 patients, who presented to us with malignant tumors affecting the lips. Results Lip defect sizes ranged from four to 6 cm in length. There was no evidence of flap failure, and the aesthetic and functional outcomes are very well. All patients healed successfully, and 100% of the flaps survived. No cases of microstomia were reported. Conclusion The use of local muscle transposition, assisted with dermal fat flap and muco-buccal flap technique, showed excellent results in regaining, oral competence, and lip mobility, and as much as possible, increasing the aesthetic outcome.

Bilateral anterolateral thigh free flap in a flow-through chimeric pattern for a extensively large defect reconstruction: a case of an elderly patient under spinal-epidural anesthesia

An 83-year-old male patient presented with a Marjolin’s ulcer on his lower leg, which developed 60 years after a bomb blast injury. The lesion was a 24×12-cm2 chronic ulcer located circumferentially around the mid-third lower leg. Considering the patient’s age, vessel status, and the extent of the defect after wide excision, which included a section of the tibia, reconstruction utilizing bilateral anterolateral thigh free flaps in a flow-through pattern under spinal-epidural anesthesia was planned. The operative time was 9 hours, and the patient fully recovered without any complications. The patient was able to walk without any orthosis, and no evidence of recurrence was found during a 3-year postoperative follow-up period.

Reconstruction of large defects of anterior floor of mouth with free flaps using a novel individualized flap design method

The purpose of this study was to introduce a novel individualized flap design method for large anterior floor of the mouth (AFOM) defect reconstruction, review experience with the use of this flap design method for large AFOM defect reconstruction, and assess its functional results.A retrospective study of patients who received large AFOM defect reconstruction with free flaps was conducted. There was a cohort of patients who were treated using the novel individualized flap design method and a cohort without flap design. Functional outcomes were evaluated with appropriate scales. Outcomes were analyzed, and a p-value <0.05 was considered significant.22 patients received the individualized flap design, while 21 patients were treated without a special flap design. All flaps survived. All free flaps harvested with the novel individualized flap design method better matched AFOM defects. Relative to patients without flap design, patients in the novel individualized flap design group showed significant improvement in speech intelligibility (p = 0.036) and swallowing function (p = 0.019).Within the limitation of the study it seems that large AFOM defect reconstruction with the novel individualized flap design method can not only cover and close the wound to avoid oral-neck fistulae, but also maintains tongue mobility to achieve better functional outcomes than in patients without flap design.

Valsalva Maneuver to Identify Dermal Bleeders after Paramedian Flap Elevation Under Local Anesthesia.

The paramedian forehead flap (PFF) provides a reliable reconstruction option for complex nasal tip defects. The robust blood supply from a well perfused pedicle allows for reconstruction of large defects of the nasal tip for which simpler methods/techniques would provide inadequate coverage or result in inferior cosmesis. A well-designed PFF containing the supratrochlear artery inherently predisposes to small vessel bleeding from the pedicles cut edge. Due to the well perfused nature of the pedicle, there is an increased risk of post-operative bleeding. We describe a technique for better identifying bleeding points from the pedicle to optimise intra-operative haemostasis by performing the Valsalva maneuver using a syringe intraoperatively.

A novel technique of reconstruction of the distal tibia using allograft after resection of giant cell tumor: A case report with literature review

Giant cell tumor (GCT) of the distal tibia can result in significant bone loss and soft tissue compromise, which can present a challenge for reconstruction. Various techniques have been described for the reconstruction of large defects, including the use of allografts. In this article, we describe a novel technique of reconstruction of a large defect in the distal tibia using two femoral head allografts after resection of GCT. The technique involves using two femoral head allografts, which are shaped to fit the defect and secured with a locking plate and screws. Using this technique, we present a case report of a patient with GCT of the distal tibia who underwent resection and reconstruction. At the 18-month follow-up, the patient had good functional outcomes and no evidence of tumor recurrence. This technique offers a viable option for reconstructing large defects in the distal tibia after GCT resection, particularly in cases where autograft is not available or not feasible. Further studies are needed to evaluate the long-term outcomes and complications associated with this technique.

Autologous Fat Grafting as Adjuvant Treatment in Facial Reconstructive Surgery: Case Report

Introduction: Autologous fat grafting (lip transfer) allows the repair and augmentation of soft tissues and is increasingly used in both cosmetic and reconstructive surgery. Autologous fat has several advantages, including biocompatibility, versatility, natural appearance, and low donor site morbidity. The main limitation is unpredictable graft resorption, which ranges from 25% to 80%, probably as a result of ischemia and lack of neo angiogenesis. To avoid these drawbacks, several studies have sought new ways to increase the viability of transplanted tissue. Aim: To present a clinical case that highlights current practices and short-term future applications of fat transfer for maxillofacial reconstruction of large defects. Clinical case: This is a 33-year-old male patient who presented scarring atrophy due to multiple surgical interventions previously performed for mandibular resection and reconstruction due to a plexiform ameloblastoma in the right hemimandible. The fat transplant preparation technology was applied, using the manual liposuction and centrifugation method. Lip transfer was performed in one phase. Conclusion: Fat transfer has the potential to be an intervention in which resorption rate, tissue quality and safety can be predicted, as it appears to be an effective treatment for contour deformities in facial reconstruction.

A Case of Reconstruction of Large Defect in Posterior Wall of Bony External Auditory Canal Using Cavum Conchal Cartilage

External auditory canal (EAC) wall defect may occur due to cholesteatoma, and surgeries for chronic ear diseases, trauma, neoplasm or idiopathic. Conservative treatment is available if the severity of the symptom is mild or asymptomatic. However, these defects require repairment not only to attain relief from intermittent otologic symptoms but also to prevent retraction pockets and sequential cholesteatoma. There have been no reported cases of reconstruction of EAC wall defect by cartilage with perichondrium and groove of wall defect by drilling. We manipulated the conchal cartilage so that it could effectively provide robust reconstruction of the canal wall defect. Herein we report a case of EAC reconstruction with mastoidectomy with no further complications.

Minimally invasive excision and reconstruction of Achilles tendon xanthoma using free autologous semitendinosus tendon transfer: a surgical technique

BackgroundTendon xanthomatosis is often associated with familial hypercholesterolemia, but it can also occur in other medical conditions. The Achilles tendon is the most common site of tendon xanthomas. Reconstruction of large defects after the xanthoma excision, can be challenging.MethodsWe propose a novel technique for Achilles tendon reconstruction with the use of an ipsilateral autologous semitendinosus tendon graft. The technique consists of six steps.ResultsThis procedure has a low rate of complications and provides results that are at least comparable with those reported with other surgical approaches.

Temporoparietal Fasciocutaneous Island Flap for Forehead and Anterior Scalp Reconstruction.

Background: Forehead and anterior scalp large defect reconstruction is challenging and often requires skin grafting. Objective: To measure the advancing distance and the survival of the temporoparietal fascia (TPF) island flap in forehead and anterior scalp reconstruction. Methods: The study design was a retrospective case series. Participants included all patients who had undergone TPF island flap for forehead and anterior scalp defects of 3 cm and greater from 2009 to 2021. Flap advancing distance and vascular compromise were analyzed. Results: Patient's average age at time of surgery was 73 (standard deviation [SD] 14) years with more males (n = 24, 67%) than females (n = 12, 33%). Of 36 patients, 24 had forehead and 12 had anterior scalp defects, 26 cases had a full TPF island flap, and 10 cases underwent the partial island modification. Flap edge ischemia occurred in two cases (6%) and complete ischemia occurred in one case (3%). The median flap advancing distance was 3.7 cm (SD 1.2). Conclusions: In this 12-year review, we found that the TPF island flap is able to advance up to 7.5 cm and thus is an effective reconstruction for medium to large forehead and anterior scalp defects.

Multistage Reconstruction of a Large Upper Arm Defect Using a Keystone Type 1 Flap and a Synthetic Skin Substitute

Introduction: Reconstruction of large defects in the upper arm remains challenging due to insufficient tissue available, the tensions involved and anatomical limitations. Despite considerable donor site morbidity and technical difficulty, there are numerous techniques, including free and regional flaps, based on reliable and predictable anatomy. The introduction of perforator-based flaps has significantly led to reducing donor site morbidity. We aim to describe an approach combining a keystone type 1 flap and a synthetic skin substitute as a valid alternative for treating large upper arm defects. Materials and Methods: We report a case of a 67-year-old male who was adreessed to our department for melanoma wide excision on the posterior side of the upper left arm. Considering the significant size of the 14 x 8 cm defect and the good compliance of the patient, we decide to perform a multistage reconstruction. The first stage included a 1cm width safety margin surgical excision associated with axillary sentinel lymph node biopsy and a reconstruction based on the keystone type 1 flap with the temporary closure of the remaining tissue defect using a synthetic skin substitute. The second and third stages were performed one and two weeks later, respectively, and included removal of the temporary skin substitute and tension-free closure of the residual defect under local anaesthesia. Results: The recovery was uneventful with no surgical complications, and follow-up at 3-months postoperatively showed excellent aesthetic and functional outcomes. Conclusion: A combined approach based on keystone type 1 flap with a synthetic skin substitute can be used as a multistage procedure that allows reconstruction of large size defects of the upper arm. This is a viable option, especially for patients with good compliance. It provides optimal results while avoiding the donor site morbidity of other more challenging techniques.

Combined Tripier and V-Y Advancement Flaps for Reconstruction of Large Lid-cheek Junction Defects

Reconstruction of lid-cheek junction defects has a known risk of ectropion. Cervicofacial flaps require significant dissection and can still be prone to ectropion. V-Y advancement flaps have been described as less morbid, but their use is limited to moderate-size defects that do not involve the lid margin. The authors present a technique of combined Tripier and V-Y advancement flaps for reconstruction of large defects of the lid-cheek junction involving the lower eyelid. A retrospective review of patients undergoing the authors' technique was performed. A facial artery perforator flap was designed in a V-Y fashion and advanced into the cheek. An orbicularis oculi myocutaneous flap (Tripier flap) was elevated from the upper eyelid and rotated into the lower eyelid/upper cheek to meet the superior edge of the V-Y flap. A separate review of patients undergoing cervicofacial flap reconstruction was also performed. Demographics, operative details, and complications were recorded and compared. This technique was applied to five patients with large-size (19.9 ± 5.6 cm2) defects of the lid-cheek. In all cases, healing was achieved without ectropion, hematoma, infection, dehiscence, flap necrosis, or facial nerve injury. Twenty-four patients separately underwent cervicofacial flap reconstruction for defects of comparable size (15.8 ± 10.7 cm2). Two patients developed ectropion, one patient developed a hematoma, and two patients developed an infection. Combined Tripier and V-Y advancement flaps is a useful technique to reconstruct lid-cheek junction defects. This method allows for the reconstruction of large lid-cheek junction defects that involve the lid margin.

Cross‐finger flap as ultima ratio for the reconstruction of defects of the finger flexor sides

Cross‐finger flap as ultima ratio for the reconstruction of defects of the finger flexor sides