Reconstruction Of Large Defects Research Articles

Reconstruction of Large Perineal and Pelvic Wounds Using Gracilis Muscle Flaps.

The reconstruction of large defects after abdominoperineal resections and pelvic exenterations has traditionally been accomplished with vertical rectus myocutaneous flaps (VRAMs). For patients requiring two ostomies, robot-assisted abdominoperineal resections (APRs), and to avoid the morbidity of a VRAM harvest, the authors have used the gracilis muscle flap to reconstruct the large dead space in these patients. A retrospective analysis of 16 consecutive APRs (10 with concomitant pelvic exenterations) reconstructed with gracilis flaps during a 2-year period was performed. Gracilis muscle flaps were used to obliterate the dead space after primary skin closure was ensured with adduction of the legs. All 16 patients had locally advanced cancers and had received neoadjuvant chemotherapy and radiation. Of these 16 patients, 10 had pelvic exenterations. All the patients had reconstruction with gracilis flaps (6 bilateral flaps). One major wound complication in the perineum occurred as a result of an anastomotic leak in the pelvis, but this was managed with conservative dressing changes. Three patients had skin separation in the perineum greater than 5 mm with intact subcutaneous closure. No patients required operative debridement or revision of their perineal reconstruction. No perineal hernias or gross dehiscence of the skin closure occurred. Large pelvic and perineal reconstructions can be safely accomplished with gracilis muscle flaps and should be considered as an alternative to abdominal-based flaps.

Surgical Reconstruction for Large Defects of the Heel and Plantar Area

Surgical Reconstruction for Large Defects of the Heel and Plantar Area

Anterolateral thigh adipofascial flap in mucosal reconstruction.

This study describes a reliable technique for mucosal reconstruction of large defects using components of a common free flap technique. To review the harvest technique and the varied scenarios in which the anterolateral thigh adipofascial flap (ALTAF) can be used for mucosal restoration in oral cavity and nasal reconstruction. A retrospective review of the medical records of 51 consecutive patients was conducted. The patients had undergone ALTAF head and neck reconstruction between January 2009 and June 2013. Each case was reviewed, and flap survival and goal-oriented results were evaluated. Thirty patients met the inclusion criteria and were included in the analysis. The mean patient age was 60.6 years. Reconstruction sites included the tongue, palate, gingiva, floor of the mouth, and nasal mucosa. All mucosal reconstructions maintained function and form of replaced and preserved tissues. One patient (3%) experienced flap failure that was reconstructed with a contralateral adipofascial flap with excellent outcome. Three patients (10%) required minor flap revisions. There were no other complications. The ALTAF is a versatile flap easily harvested for use in several types of mucosal reconstructions.

Flow-through deep inferior epigastric perforator flaps transplantation for reconstruction of large defects at the extremities

To investigate the clinical application of flow-through deep inferior epigastric perforator flaps for reconstruction of large defects at the extremities. The deep inferior and superior epigastric arteries were designed as the axial vessel and the arterial supply to the flap was the paraumbilical perforator artery. Free deep inferior epigastric perforator flaps were harvested in flow- through manners to reconstruct associated arterial defect in the wound. The sensation assessment,Enneking score,and questionnaire of the flap aesthetic were all performed during follow-up period. From December 2011 to September 2012, 5 patients with large defects at extremities were treated. The deep inferior and superior epigastric arteries were designed as the axial vessel and the arterial supply to the flap was the paraumbilical perforator artery. The wound defects ranged form 11 cm x 5 cm to 30 cm x 11 cm. And the flap size ranged from 13 cm x7 cm to 33 cm x 13 cm. All flaps survived completely. The recipient arteries were all bypassed well documented by color Doppler examinations. All cases had 12-24 months' follow-up period. The flaps had good appearance and high aesthetic satisfactory(100%). 12 months after operations, sensation assessment were all S3+, and the Enneking score ratios were 82%-95% ,with 87.2% in average. Flow-through deep inferior epigastric perforator flaps are reliable and effective for reconstruction of large defects at the extremities with maintenance of the vascular status of the extremities. The flaps can also be designed in transverse or oblique mode for clinical application.

English

Malignant fibrous histiocytoma is the commonest form of adult soft tissue sarcomas, albeit very few cases have been reported arising in the pubic region. Large defect resulting after extirpation of such tumors pose a problem in their reconstruction. Wound closure with well vascularized tissue (flaps) is most suitable, which leads to early recuperation and avoids delay in instituting postoperative radiotherapy. We report a case in which a 42 years old lady presented with a large pubic region growth. We present this case firstly because sarcoma in pubic region is rare and secondly we use VRAM flap (Reversed TRAM flap) for reconstruction of large defect after wide local excision of the tumor, which is simple to execute with good functional outcome.

Clinical application of the adjacent horn shaped perforator fasciocutaneous flap in the trunk area

To study the anatomy basis for the clinical application of the adjacent horn shaped perforator fasciocutaneous flap for the reconstruction of small and medium-sized defects in the trunk area. (1) Ten adult antiseptic cadavers (20 sides) were perfused with red latex. The skin blood supply, line of the blood vessels, branches in accordance with the distribution and crossing were observed. (2) Fifteen cases with defects in the trunk were treated with the adjacent horn shaped perforator fasciocutaneous flaps. The defects size ranged from 5 cm x 5 cm to 13 cm x 13 cm with the size of the flaps ranging from 10 cm x 6 cm to 35 cm x 15 cm. The trunk skin is supplied by mainly 17 groups arteries such as thyrocervical trunk, internal thoracic artery, posterior intercostal arteries, superior epigastric artery, arteria epigastrica inferior, lumbar arteries, and so on. The perforators (diameter > 0.5 mm) numbers are about 20, 40, 24, 6, on the chest, abdomen and perineum, upper back, waist, respectively. All the flaps survived completely with primary healing both on donor and recipient sites. The flaps color, texture, function and appearance were satisfactory during the follow-up period of 1-24 months. The adjacent horn shaped perforator fasciocutaneous flap should be designed flexibly. The defects in the donor sites could be closed directly without skin graft. It is an effective, easy and ideal method for the reconstruction of large defects in the trunk.

The contralateral subgaleal sliding flap for the single-stage reconstruction of large defects of the temple and lateral forehead

Due to the relative lack of a mobile tissue reservoir, the flap repair of large defects of the temple and lateral forehead is challenging. To present our experience of the contralateral subgaleal sliding (CLASS) flap for the single-stage aesthetic repair of such defects. Data were collated on all patients at one regional Mohs centre in whom the CLASS flap had been performed since 2011. The CLASS flap was performed on 16 patients (11 male, five female) with an average age of 63years (range 42-90). The average defect size was 2·8×3·1cm. A single case of postoperative infection occurred, which settled with appropriate therapy with no adverse sequelae. All patients rated their outcome as good or excellent. The CLASS flap is a reliable, aesthetic, single-stage reconstructive technique for large defects of the lateral forehead and temple.

Outcome of microvascular free flaps in a high-volume training centre

PurposeMicrovascular free tissue transfer allows major ablative defects following oncologic surgical and traumatic reasons to be reliably reconstructed in the head and neck region. A retrospective analysis of the microvascular flap procedures which were performed within one year in a high volume training centre was performed. Patients and methodsThe microvascular free flap procedures of the year 2011 were reviewed and followed up until the 31st December 2012. The type and indication of the reconstructive procedure, operation time, operating team, experience and level of training of the surgeons involved, postoperative IMC (intermediate care unit) and/or ICU (intensive care unit) time, inpatient time, flap revisions, further postoperative complications, preoperative and postoperative radiation of the patients, the placement of dental implants were studied. ResultsFrom 1st of January 2011 to 31st of December, 2011, the data of 101 patients with 103 microvascular free flap procedures were analysed of which 72% (84 flaps) were harvested by residents. The patients ranged in age from 14 to 89 years (mean age 59 years, 71 males and 40 females). The mean operation time was 591 min with the longest operation times for scapular flaps (744 min) and the shortest operation times for ALT flaps (455 min). Mean inpatient time was 34.2 days with a minimal time for the fibular flaps of 27.2 days and a maximum of 45.7 days for the latissimus dorsi flaps. 24 flaps (23.3%) in total had to be revised with bleeding being the main cause of immediate revisions (41.7% of all revisions). 5 flaps (4.85% of all flaps) were lost despite a revision procedure meaning a successful revision rate in 79.2% of all revisions. ConclusionMicrovascular reconstruction procedures are safe and should be considered as standard procedures for reconstruction of large defects especially in high volume training centres. Intensive flap monitoring and early revisions maximize the flap outcome.

Custom mega prosthetic reconstruction of juxta articular giant cell tumors

Introduction: Giant cell tumor (GCT) also called osteoclastoma of bone is the most common osteolytic bone tumor encountered by an orthopedic surgeon. En bloc resection of major joints creates a problem for the reconstruction of large defects. Recent advances in tumor resection defects involve the use of custom-built joints for the reconstruction of defects near joints. This article analyzes the functional outcomes after resection of juxta articular GCTs and reconstruction by custom mega prosthetic arthroplasty. Aims and Objectives: To study the functional results of custom mega prosthetic reconstruction in juxta articular GCTs with intra articular extension. Materials and Methods: Four patients with juxta articular GCTs around the hip and knee with mean age of 40 yrs (range 30 to 50 yrs) underwent resection and reconstruction by custom mega prosthetic arthroplasty during the period 2011 to 2013. Two patients were males and two were females. All of them were in Enneking stage 3. Proximal femur was involved in one patient, distal femur in one and proximal tibia in two patients. Results: Functional results were analyzed using Ennekings criteria. Excellent results were obtained in all the patients without recurrence, periprosthetic fractures, infections or aseptic loosening. Conclusion: By using the technique of custom mega prosthetic reconstruction in juxta articular GCTs with pathological fractures or intra articular extension, the desired goals of reconstruction with good functional results and least complications can be achieved.

Inclusion of the Perforating Branch of the Tenth Intercostal Artery in the Distal Skin Paddle of the Divided Latissimus Dorsi Flap

Sir: We read with great interest the article on the divided latissimus dorsi flap by Zhang et al.,1 who reported the use of the latissimus dorsi flap with multiple separate skin paddles for the reconstruction of large defects and achievement of primary closure of the donor site. The largest surface area elevated was 280 and 340.5 cm2 for the bilobed and trilobed flaps, respectively. They described two cases of trilobed flaps, one of which was complicated by partial necrosis of a skin paddle. Sawaizumi and Maruyama2 described a sliding shape–designed latissimus dorsi flap in 1996. They divided an oval defect into two parts in the oblique long axis direction, and these two semicircular parts were traced onto the latissimus dorsi flap to lengthen it vertically. After the extended latissimus dorsi flap was elevated, it was divided into two semicircular flaps and united again to create an oval flap. This method enabled them to elevate an area up to 360 cm2 (20 × 18 cm) while avoiding partial necrosis and achieving primary closure of the donor site. However, they did not describe the detailed vascular anatomy of the flap. In an anatomical study by Watanabe et al.,3 a descending branch of the thoracodorsal artery running parallel to the lateral border of the latissimus dorsi muscle was connected directly to the perforating branches of the ninth and tenth intercostal arteries in the lateral part of the muscle by means of a true anastomosis. Furthermore, a horizontal branch running parallel to the superior border of the latissimus dorsi muscle was connected directly to the perforating branches of the ninth intercostal artery in the medial part of the muscle by means of a true anastomosis. These three perforators from the intercostal artery were included in the first vascular territory of the latissimus dorsi muscle. Furthermore, an anatomical study conducted by Minabe et al.4 demonstrated that the tenth perforator is dominant among the intercostal artery perforators. We consider the inclusion of the tenth perforator in the distal skin paddle of the divided latissimus dorsi flap to be important because it allows for extension of the skin paddle in the anterior, posterior, and distal directions, thereby overcoming the choke vessel in the subcutaneous tissue. Distally, the skin paddle can be safely extended up to the iliac crest. The partially necrosed trilobed flap presented by Zhang et al.1 may not have included an adequate perforator. Besides, the design of the flap and the shape of the donor-site scar were complicated. We included the tenth perforator in the distal skin paddle and used the sliding shape–designed flap to reconstruct a large defect, thus facilitating safe elevation and a sigmoid curvilinear donor-site scar (Fig. 1). Although elevation of multilobed skin paddles nourished by a pedicle of the thoracodorsal artery may be beneficial, the divided sliding shape–designed flap including the tenth perforator of the tenth intercostal artery in the distal skin paddle is preferable for elevating a large flap and achieving primary closure of the donor site. Fig. 1: A 60-year-old woman who underwent resection of a liposarcoma on the right shoulder. (Left) The location of the perforating branches of the tenth intercostal artery in the lateral part of the latissimus dorsi muscle was detected by color Doppler sonography. The divided latissimus dorsi flap was designed to include the perforator in the distal flap. (Right) Three months after primary closure of the donor site.DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Shinsuke Akita, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Chiba Cancer Center Nobuyuki Mitsukawa, M.D., Ph.D. Department of Plastic, Reconstructive, and Aesthetic Surgery Chiba University Faculty of Medicine Tatsuya Ishigaki, M.D. Department of Plastic and Reconstructive Surgery Chiba Cancer Center Shintaro Iwata, M.D., Ph.D. Tsukasa Yonemoto, M.D., Ph.D. Department of Orthopaedic Surgery Chiba Cancer Center Kaneshige Satoh, M.D., Ph.D. Department of Plastic, Reconstructive, and Aesthetic Surgery Chiba University Faculty of Medicine Chiba City, Japan

Reconstruction of a complex midface defect from excision of a squamous cell carcinoma, according to regional aesthetic units

Extensive squamous cell carcinoma involving the skin of the upper lip, nasal ala, and cheek is relatively rare. Although numerous reconstruction techniques for the midface including lip, nose, and cheek have been described in the literature, reconstruction of large defects in this area continues to be challenging, as it is difficult to obtain satisfactory results with single-stage surgery. This case report concerns a 53-year-old woman with squamous cell carcinoma extending from the upper lip to the alar base and the cheek. It describes a step-by-step surgery undertaken according to defined regional aesthetic units of the face using several reconstruction methods, including a microvascular free flap, forehead flap, and conchal cartilage graft, rather than multistage reconstruction surgeries after first immediate reconstruction. Satisfactory functional and aesthetic results were achieved despite the extensive facial defects.

Virtual planning and navigation for mandibular reconstruction with fibula free flap

Background and objectives: According to the literature the gold standard for mandibular reconstruction of large defects is the fibula free flap. The use of virtual planning and 3D model has allowed more accurate preoperative planning, but there are many difficulties to reproduce it during the surgery. In this work we propose a proper method for verifying and transferring the data of the preoperative planning by surgical navigation.

Driedimensionale technologie en reconstructies van grote kaakdefecten

3D technology is increasingly being applied in dentistry and in oral and maxillofacial surgery. An important field of application is reconstructive surgery, especially in the reconstruction of large defects ofthe jaw. In such cases of reconstruction, the goal is the restoration of both the continuity of the defective area and its function. For the functional restoration implant supported dental structures are often employed. In such cases, CAD/CAM superstructures, 3D printed drill and saw templates, anatomical models, wafers and surgical outcome models are used. The combination of the digital planning and the digital fabrication ofsuperstructures and surgical aids offers many preoperative advantages. The use of saw, drill and positioning templates provides for accurate segmentation and implant positioning, by means of which the reconstruction can be carried out in a predictable way.

Integration of image guidance and rapid prototyping technology in craniofacial surgery

This technical note demonstrates the benefits of preoperative planning, involving the use of rapid prototype models and rehearsal of the surgical procedure, using image-guided navigational surgery. Optimum reconstruction of large defects can be achieved with this technique.

A Novel Design of the Multilobed Latissimus Dorsi Myocutaneous Flap to Achieve Primary Donor-Site Closure in the Reconstruction of Large Defects

The main drawback of the latissimus dorsi myocutaneous flap for large defect repairs is the relatively small skin paddle size that can be raised to allow primary closure of the donor site. In this article, the authors describe a novel design of the flap using multiple separate skin paddles, with each paddle nourished by independent perforators, to repair very large defects while maintaining primary donor-site closure. After the size of the defect was calculated, its total area was split into two or three skin paddles and marked on the back skin so that the largest width of each paddle did not exceed 8 cm. A multilobed skin paddle was designed with a total area that was much larger than traditional latissimus dorsi flaps. After harvesting the flap, several smaller skin paddles were transferred and rejoined at the recipient site. From June of 2009 to March of 2012, this method was used to restore posttraumatic and postoncologic defects of the head in seven cases and lower limb defects in two cases. Seven flaps were raised as bilobed flaps, and two flaps were raised as trilobed flaps. The donor site was closed primarily in all cases. One case was complicated by partial necrosis of one paddle and required further local flap coverage. Donor-site breakdown was not observed in any of the cases. The multilobed myocutaneous latissimus dorsi flap enables a customized reconstruction of large defects for all types of patients and direct closure of the donor site. Therapeutic, IV.

Algorithm for the management of large abdominal wall defects due to laparostomy wounds following intra-abdominal catastrophe

Background Abdominal reconstruction of large defects is a challenge, and there is an additional morbidity and mortality when it is associated with emergency laparotomy or laparostomy. This study describes the surgical management of abdominal defects and describes an algorithm for complex abdominal reconstruction. We assessed complications such as fistula formation and the development of incisional hernias following formalised introduction of laparostomy for the management of these emergency patients.

La reconstruction du voile du palais

Soft palate reconstruction is complex. It has to restore swallowing and speech replacing the defect by dynamic and sensitive tissues. The means are multiple from direct suture to free flaps. Local flaps have the advantage to bring a mucosa animated by thin muscles, like in sphincteroplasty. Free flaps allow reconstruction of large defects, but they need some local adaptation (association with a local flap, adherence, suspension with tendon…) to improve the functional result. Indications depend on defect's size and local condition especially radiotherapy history.

Lower Lip Reconstruction Using Unilateral Nasolabial Gate Flap (Fujimori Technique)

Abstract Background: In the medical literature there are multiple reconstructive procedures for small and medium size defects of the lower lip, but only a few methods for larger defects involving the whole lower lip. Choosing the repairing procedure for larger lower lip defects must take into account two aspects: flap or flaps used should be local flaps, and suture lines should correspond to the natural facial creases or follow the functional lines of different facial aesthetic units. Finally, the flap or flaps should be large enough to restore the entire postexcisional defect. However, the more tissue is lost from the lower lip, the more challenging the reconstruction is from a functional and cosmetic point of view. Material and methods: During the last 2 years in the Oral and Maxillofacial Surgery Department of the County Emergency Clinical Hospital in Tîrgu Mureș, the unilateral Fujimori technique has been successfully used for the reconstruction of large lower lip defects in 4 patients with extended, neglected squamous cell carcinomas involving almost the whole lower lip tissue. These patients underwent complex surgical and oncological treatment. Surgery was performed in two stages: first, excision of the tumor and immediate lip reconstruction, and then removal of submandibular lymph nodes (level I), in the second stage. Results: The aesthetic and functional recovery of these patients was very good, with no need of other subsequent surgical corrections. Conclusions: The postoperative reconstruction of large defects of the lower lip is far from optimal, but it is very important to restore an adequate muscle function, the lip continence and a satisfactory facial appearance.

Propeller DICAP flap for a large defect on the back—Case report and review of the literature

Reconstruction of large soft tissue defects of the back is a challenging problem. Large defects of the back were reconstructed with multiple random pattern or local pedicled muscle (and skin graft) or musculocutaneous flaps. The clinical use of perforator flaps has demonstrated that harvesting of flaps on a single perforator is possible for reconstruction of large defects. We present a 71-year-old male with a lesion on his left mid back that measured 10 × 10 × 4 cm(3) . Biopsy of the lesion was consistent with dermatofibrosarcoma protruberans. Wide local excision of the lesion with 4 cm margin was performed. The soft tissue defect, ~20 cm in diameter, was reconstructed with a large propeller dorsal intercostal artery perforator (DICAP) flap. The DICAP flap measured 40 × 15 cm(2) based on a single perforator-lateral branch of dorsal rami of the seventh posterior intercostal artery on the right side. The perforator flap was elevated at the subfascial level and transposed 180° into the defect. The donor site on the right side of the back was closed directly. This case illustrates the size of the propeller DICAP flap that could be safely harvested on a single perforator from the dorsal rami of the posterior intercostal artery. To our knowledge this is the largest reported pedicled perforator flap harvested on a single perforator on the posterior trunk.

Retroauricular Revolving Door Island Flap

The retroauricular revolving door island flap, first described by Masson in 1972, is very useful for the reconstruction of large defects of the concha of the auricle of the ear. It is harvested from the retroauricular area and is raised as an island (Fig. 1) so that it can rotate like a hinge on its pedicle and pass through the defect in the auricle (Fig. 2). The flap is then sutured to cover the defect of the concha (Fig. 3), and the retroauricular area is closed by simple suture (Fig. 4).