Rectus Abdominis Flap Research Articles

A Misdiagnosed Metastatic Squamous Cell Carcinoma of the Vulva

BACKGROUND: Early diagnosis of vulvar squamous cell carcinoma (SCC) is directly related to better prognosis and higher survival rate. Missed gynecologist follow-up, some cultural traditions and refrain from facing with a problem that involves intimacy and sexual sphere can be the cause of delayed diagnosis and treatment. Radical surgery still represents the gold standard, but narrow excision margins can progressively lead to local recurrence, even after years. CASE REPORT: The case we present is a rare case of misdiagnosed metastatic SCC of the vulva after radical excision and groin dissection 2 years before. After a full-through discussion with patient on treatment options and prognosis, a multidisciplinary surgical approach was planned, consisting in wide surgical resection of groin, part of mons pubis and right pelvic iliac-obturator lymphadenectomy. Femoral artery excision was performed due to absence of a clear margin, and reconstruction was accomplished with interposed great saphenous vein graft. The plastic reconstruction consisted in harvest of transverse rectus abdominal flap (TRAM), that was transposed inferiorly to repair right groin. Pathologist confirmed free margins of excision and pelvic lymph nodes resulted negative (pT1b, N3, M0 – stage IV A). DISCUSSION: When deep structures of the groin - such as femoral vessels - are involved by relapse, the condition is potentially life-threatening. A multidisciplinary approach consents to perform a radical surgery with free margins and likewise to achieve a satisfying functional reconstruction. CONCLUSION: This case should emphasize that skin ulceration on a non-weight-bearing surface is always suspicious for skin malignancy, an incisional biopsy is easy to perform and consents a rapid diagnosis. A history of recurrent vulvar SCC should always warn about the risk of late lymph node metastasis even years after a radical excision of the primary tumor and concomitant lymphadenectomy.

3D-printed, patient-specific DIEP flap templates for preoperative planning in breast reconstruction: a prospective case series.

Modern imaging technologies, such as computed tomographic angiography (CTA), can be useful for preoperative assessment in deep inferior epigastric artery perforator (DIEP) flap surgery. Planning perforator flap design can lead to improved surgical efficiency. However, current imaging modalities are limited by being displayed on a two-dimensional (2D) surface. In contrast, a 3D-printed model provides tactile feedback that facilitates superior understanding. Hence, we have 3D-printed patient-specific deep inferior epigastric artery perforator (DIEP) templates, in an affordable and convenient manner, for preoperative planning. Twenty consecutive patients undergoing 25 immediate or delayed post-mastectomy autologous breast reconstruction with DIEP or muscle-sparing transverse rectus abdominis (MS-TRAM) flaps are recruited prospectively. Using free, open-source softwares (3D Slicer, Autodesk MeshMixer, and Cura) and desktop 3D printers (Ultimaker 3E and Moment), we created a template based on a patient's abdominal wall anatomy from CTA, with holes and lines indicating the position of perforators, their intramuscular course and the DIEA pedicle. The mean age of patients was 52 [38-67]. There were 15 immediate and 10 delayed reconstructions. 3D printing time took mean 18 hours and 123.7 g of plastic filament, which calculates to a mean material cost of AUD 8.25. DIEP templates accurately identified the perforators and reduced intraoperative perforator identification by 7.29 minutes (P=0.02). However, the intramuscular dissection time was not affected (P=0.34). Surgeons found the template useful for preoperative marking (8.6/10) and planning (7.9/10), but not for intramuscular dissection (5.9/10). There were no immediate flap-related complications. Our 3D-printed, patient-specific DIEP template is accurate, significantly reduces intraoperative perforator identification time and, hence, may be a useful tool for preoperative planning in autologous breast reconstruction.

Breast reconstruction after breast cancer surgery- persistent pain and quality of life 1-8 years after breast reconstruction.

To assess the long-term outcome of breast reconstructions with special focus on chronic postsurgical pain (CPSP) in a larger cohort of breast cancer survivors. A cross-sectional study on 121 women with mastectomy and breast reconstruction after mean 2 years 4months follow up. The mean time from breast reconstruction to the follow-up visit was 4 years 2months. We studied surveys on pain (Brief Pain Inventory, BPI and Douleur Neuropathique 4, DN4), quality of life (RAND-36 health survey), sleep (insomnia severity questionnaire, ISI), mood (Beck's Depression Index, BDI; Hospital Anxiety and Depression Scale, HADS), and a detailed clinical sensory status. Patients were divided into three groups: abdominal flap (Deep inferior epigastric perforator flap, DIEP; Free transverse rectus abdominis flap, fTRAM, and Pedicled transverse rectus abdominis flap, pTRAM), dorsal flap (Latissimus dorsi flap, LD and Thoracodorsal artery perforator flap, TDAP), and other (Transverse myocutaneous gracilis flap, TMG; implant). Clinically meaningful pain was defined≥4/10 on a numeric rating scale (NRS). We used patients' pain drawings to localize the pain. We assessed preoperative pain NRS from previous data. 106 (87.6%) of the patients did not have clinically meaningful persistent pain. We found no statistically significant difference between different reconstruction types with regards to persistent pain (p=0.40), mood (BDI-II, p=0.41 and HADS A, p=0.54) or sleep (p=0.14), respectively. Preoperative pain prior to breast reconstruction surgery correlated strongly with moderate or severe CPSP. Moderate to severe CPSP intensity was present in 14% of patients. We found no significant difference in the prevalence of pain across different reconstruction types. Preoperative pain associated significantly with postoperative persistent pain.

How Big Is Too Big?: The Effect of Defect Size on Postoperative Complications of Vertical Rectus Abdominis Flap Reconstruction.

The vertical rectus abdominis myocutaneous (VRAM) flap has been frequently used for perineal reconstruction given the high potential for wound complications associated with direct closure of this area. However, the relationship between defect size and postoperative complications remains undefined. A retrospective chart review of the last 20 years for VRAM flaps was performed. Defect size, age, body mass index (BMI), cause of defect, sex, radiation, and flap donor laterality were recorded. Complications of infection, partial flap loss, total flap loss, minor wounds, treated nonoperatively, and major wound, which required reoperation, were analyzed with respect to defect size. Descriptive statistics were used to summarize the demographic and clinical characteristics of the included patients. Associations were assessed using binary logistic regression analysis, and difference in means for compared groups was assessed using the independent samples t test. P values were set at 5% for all comparisons. There were 65 patients with VRAM flaps identified during the review period. Mean defect size was 204.71 cm2. Mean age was 63.97, and mean BMI was 27.18. History of prior radiation was noted in 90.77% of patients (n = 59). When adjusted for age and BMI, mean defect area was significantly different for patients with minor or major wounds. Larger perineal defects were associated with increased risk of major wound complications (odds ratio, 1.012; 95% confidence interval, 1.003-1.022). The vertical rectus abdominis flap has been a workhorse flap for perineal reconstruction. Defect size does not affect risk of partial flap necrosis, complete flap loss, infection, abdominal fascial dehiscence, ventral hernia, or seroma, which supports the utility of VRAM flap for perineal reconstruction. Larger perineal defects are associated with increased risk for major wound complications, which required reoperation, regardless of age or BMI. Future studies should be performed to determine if there is a maximum defect size cutoff that limits the utility of VRAM flap reconstruction or to develop a predictive model to assess the risk of major wound complications based on defect size.

Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods.

The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques. A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach. The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently. Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.

Outcomes and Utility of Intracranial Free Tissue Transfer.

Complications associated with intracranial vault compromise can be neurologically and systemically devastating. Primary and secondary repair of these deficits require an air and watertight barrier between the intracranial and extracranial environments. This study evaluated the outcomes and utility of using intracranial free tissue transfer as both primary and salvage surgical repair of reconstruction. A retrospective review was performed of all subjects who underwent intracranial free tissue transfer as primary or salvage repair. A total of 13 intracranial free tissue transfers were performed on 11 subjects: osteocutaneous radial forearm free flaps (n = 6), partial myofascial rectus abdominis flaps (n = 5), temporoparietal fascia flap (n = 1), and serratus anterior myofascial flap (n = 1). Primary reconstruction was performed on 4 subjects with the remaining being salvage repair. Indications for surgery included neoplasm (n = 6 of 11), ballistic trauma (n = 3 of 11), motor vehicle accident (n = 1 of 11), and infection (n = 1 of 11). Three subjects required additional surgical repair for CSF leak and pneumocephalus, with 2 subjects requiring an additional free tissue transfer at a different site. In our experience, free tissue transfer is an effective primary and salvage surgical technique in the reconstruction of complex intracranial problems.

Complex Soft Tissue Defects in Operative Urology: Pedicled Perforator Flaps of the Anterior Lateral Thigh for Tissue Reconstruction of the Lower Trunk

Background: Complex soft tissue defects involving the lower abdomen, perineum, and groin (LAPG) represent reconstructive challenges following urologic surgery. Consequently, these often require an interdisciplinary approach involving plastic surgery. While pedicled flaps from the lower abdomen are a reliable option, previous placement of colostomies and urinary urostomies renders these flap types unavailable. Here, the pedicled anterolateral thigh perforator (ALT) flap represents a reliable pedicled alternative which can harvest from the thigh. Materials and Methods: A retrospective data analysis of pedicled perforator flaps harvested from the thigh to reconstruct soft tissue defects was conducted. Seven patients treated in the urology department with soft tissue defects following tumor resection, infection, and dehiscence were included. Results: In all patients, the ALT flap was utilized successfully to reconstruct soft tissue defects up to 450 cm² in size. All flaps survived. In 1 case, prolonged wound healing was observed. All defects were adequately addressed with no recurrence of dehiscence or fistula formation. Conclusions: Pedicled perforator flaps represent a valid option for the soft tissue reconstruction of the lower abdomen and perineum when a pedicled rectus abdominis flap is no longer available. This flap is, therefore, a good option in an interdisciplinary approach to soft tissue reconstruction, especially following urologic surgery, which is predominantly performed in the LAPG region.

The role of the rectus abdominis flap in head and neck reconstruction

The rectus abdominis free flap, based on the deep inferior epigastric artery and vein has been used extensively in breast reconstruction. It is a reliable soft tissue donor, has a long pedicle, favourable diameter vessels and is ideally suited for large defects. The distribution of perforators allow for versatility in designing the flap and a variety of patterns of the skin paddle may be used. It can be harvested as a muscle-only or myocutaneous flap. However, despite these advantages, its application in head and neck reconstruction is not widely appreciated.

Case Study: Infected Disrupted Perineal Wound Treatment with Negative Pressure Wound Therapy (NPWT) and Wound Reconstruction Using Gracilis Muscle Flap Following the Abdominoperineal Excision (APE) in Patient with Rectum Injury Due to Motorcycle Accident

Blunt trauma sustained in traffic accidents can cause significant rectum injury, either intra or extraperitoneal. Severe injuries have high mortality rates and many complications, including pelvic absesses, sepsis, rectal fistulas, stenosis, and rectal incontinence. Following the initial surgical procedure, many reconstructive methods can be used to treat perineal wounds, including gracilis myocutaneus flap, rectus abdominis flap, gluteal flap, perforator flap, posterior thigh flap, groin flap, and pudendal fasciocutaneous flap. NPWT is used to promote formation of granulation tissue, reduce and prepare tissue gap to be covered, improve perfusion through removal of excessive fluid, and reduce bacterial wound colonization. Some of the complications of this method are pain, skin irritation and maceration, tissue necrosis, bleeding, and infection. The success rate of NPWT depends on multiple factors, including patient characteristics, effectiveness of primary surgical procedure and need for further surgical interventions, size and depth of the wound, and proper NPWT application technique. NPWT has shown to reduce total treatment cost due to shorter patient hospital stay, reduction of complication rates, reduction of further surgical interventions, and lower frequency of dressing change compared with standard dressings. In this case study, I present a 53-year-old motorcyclist who was injured in a traffic accident and sustained fracture of the sacrum, rupture of the pubic symphysis, fracture of L5 vertebrae, and penetrant injury to the rectum. Multiple explorative laparotomies, colostomy, and supportive and drug treatment methods were carried out to obtain a successful outcome.

Surgical reconstruction of the sternum following cardiac surgery complicated by mediastinitis—implantation of a custom-made sternal implant: a case report

: Mediastinitis represents an uncommon but potentially life-threatening complications following median sternotomy. There remains a lack of consensus regarding the optimal treatment option(s). Custom tridimensional titanium printing provides an effective method for construction of complex prothesis. We report the case of a 49-year-old female with previous sternal dehiscence and deep wound infection following coronary artery bypass grafts, necessitating sternectomy. A year later, she presented with chronic severe pain and audible crepitations of her ribs/clavicles. Lack of identification of a mechanical cause, poor localisation and suboptimal medical pain management culminated in the consideration for a novel approach for sternal reconstruction. By way of bridging the final placement of the titanium prothesis, the patient underwent placement of a methyl methacrylate spacer. The surgical approach involved the removal of the temporary spacer, with tissue samples taken to guide post-operative antimicrobial therapy. Concurrently, the reaming, irrigation and aspiration technique of bone marrow harvesting, for seeding of the central web structure of the implant, was employed under fluoroscopic guidance. Following adequate dissection under the pectoral muscle, and debridement of the anterior chest wall, final placement of the prothesis was made via bicortical fixation to the ribs. Finally, the mobilised pectoral muscles were sutured medially and fixed to the previously placed rectus abdominis flap. Three-dimensional printing of a custom prosthesis offers a novel and effective approach to full reconstruction; maintaining pulmonary mechanics and stability of the anterior chest wall

A Case Series of Robot-assisted Rectus Abdominis Flap Harvest for Pelvic Reconstruction: A Single Institution Experience

To analyze outcomes and postoperative complications in patients undergoing robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction. Case series. Academic setting. Pelvic reconstruction surgery patients. The rectus abdominis muscle flap can be used as a flap for pelvic reconstruction, providing a large volume of soft tissue that can be used in the treatment of many comorbid conditions, including genital fistulas, postradiation pelvic exenteration, and abdominoperineal resection defects. Intraperitoneal harvest of the rectus muscle using a robotic approach allows avoidance of laparotomy and subsequent disruption of the anterior rectus sheath, thus preserving the integrity of the abdominal wall. A retrospective analysis of patient demographic and clinical characteristics was performed for all patients who underwent robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction at our institution from October 1, 2016, to October 31, 2018. The postoperative complications analyzed included bowel obstructions, surgical site infections, emergency room visits, and need for readmission. Six patients (4 women and 2 men), with a mean age of 69.2 years (range = 57-79 years) and median follow-up time of 9.2 months (range = 5-12 months), were included. Muscle flap harvest was performed on the right side in 4 patients and on the left in 2 patients. The indications for reconstructive surgery included vesicovaginal fistula, complex pelvic organ prolapse, anterior and posterior exenteration, partial and total vaginectomy, partial vulvectomy, and abdominoperineal resection. Two patients received neoadjuvant chemoradiation. One of the 6 cases was converted to laparotomy; however, this was not owing to the rectus harvest. Three patients experienced no complications after reconstruction; 1 patient reported occasional abdominal pain; 1 patient had intermittent bowel obstruction; and 1 patient developed a pelvic abscess, requiring readmission. All 6 patients achieved satisfactory healing of the pelvic wound after robot-assisted rectus abdominis flap inset. Robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction is a reliable means of defect closure, despite the presence of substantial comorbidities and risk factors in this patient cohort. Patient selection and counseling are crucial to optimize surgical outcomes in this complex population.

Post-operative monitoring of free flaps using a low-cost thermal camera: a pilot study

BackgroundCareful post-operative monitoring of free flaps is important in flap survival; immediate action increases flap salvage rate. Although various methods are available, room for improvement remains. Thermal cameras have proven their value in medicine and are nowadays readily available at low costs. The objective of this study was to evaluate the potential of an affordable infrared thermal camera and software in the detection of failing free flaps during post-operative monitoring.MethodsFree myocutaneous rectus abdominis flaps were harvested in 16 female landrace pigs and replanted after several hours of storage. All flaps were assessed with indocyanine green fluorescence angiography as well as hourly clinical assessment of skin colour, turgor and capillary refill. Furthermore, thermal photographs were taken simultaneously with the FLIR One thermal camera smartphone module. These photographs were processed in MATLAB and evaluated on their additional value as an indicator for flap failure.ResultsOut of 16 flaps, three flaps failed due to arterial failure and one flap developed venous congestion. The mean flap temperature compared to adjacent control skin proved to be most indicative for flap failure. All unsuccessful flaps showed lower temperatures after failure compared to the uncompromised free flaps.ConclusionsAn affordable thermal camera module can potentially contribute to post-operative free flap monitoring. Vascular compromise in free flaps can be distinguished by investigating relative temperature differences between the flap and reference skin. Until the FLIR One camera has been extensively investigated in a human population, it should be used in conjunction with conventional monitoring techniques.Level of evidence: Level IV, diagnostic study

The Superiorly Based Partial Rectus Abdominis and External Oblique Flap for Lower Pole Coverage in Prosthetic Breast Reconstruction: A Prospective Cohort Study of 47 Consecutive Flaps.

This study evaluated health related quality of life and morbidity in patients who had a superiorly based partial rectus abdominis and external oblique (SPREO) flap for lower pole coverage as a component of 2-stage prosthetic breast reconstruction. A prospective cohort study of patients undergoing immediate and delayed 2-stage breast reconstruction including a SPREO flap for lower pole coverage was conducted. The BREAST-Q and a study-specific questionnaire were used to determine outcomes after this procedure. BREAST-Q questionnaires were completed preoperatively and postoperatively and compared with normative values. BREAST-Q questionnaires were completed by 27 women. The mean patient age was 54.3 ± 9.6 years. Mean BREAST-Q scores improved significantly between preoperative and postoperative time points in Satisfaction with Breasts (preoperative 43.2 ± 26.9, postoperative 66.2 ± 19.5, P = 0.001) and Psychosocial Wellbeing (preoperative 59.4 ± 16.4 postoperative 75.5 ± 19.4, P = 0.002). Mean scores were not significantly different in the domains Physical Wellbeing Chest, Physical Wellbeing Abdomen and Sexual Wellbeing. Postoperative BREAST-Q scores were significantly higher (P < 0.05) than previously published normative scores in Satisfaction with Breasts. This study reports the use of the SPREO flap for lower pole coverage in 2-stage prosthetic breast reconstruction and demonstrates that it may be a useful addition to the existing repertoire of flaps used in breast reconstruction.

USE OF THE “VERTICAL RECTUS ABDOMINIS MYOCUTANEOUS FLAP” MODIFIED FOR PELVIC RECONSTRUCTION AFTER TRAUMATIC REMOVAL OF THE HEMIPELVIS

Reconstructive surgery in case pelvis defect is a technical challenge. It takes into account the etiology, the general condition of the patient; the location and size of the defect. Pedicled musculocutaneous flaps is necessary in case of deep and large defect. The rectus abdominis flap is frequently used. Our observation demonstrates the difficulties and technical particularities of reconstructing a large traumatic defect. It is a rupture of the hemipelvis following a traffic accident, exposing the peritoneum, part of the bladder and the anal canal. The use of fasciocutaneous flap was doomed to necrosis. Our recourse was the use of the "vertical rectus abdominis myocutaneous flap" (VRAM) by making a technical modification. The muscle was dissected separately from the fascia. This allowed us to spread it out and cover a wider area. Complete cutaneous coverage was provided by using two fasciocutaneous flaps: hypogastric and perineal. Good healing was obtained, and the patient received a prosthesis.

Role of fat grafting in late breast reconstruction after failure of immediate breast reconstruction with implants – experience of hospital de clínicas in porto alegre

Introduction: The breast reconstruction techniques with tissue expanders and silicone implants were the most used ones in the past decade. Immediate post-mastectomy reconstruction can evolve to loss of implants, causing significant morbidity to the patients. The knowledge of techniques that use fat grafting has allowed the use of more late reconstruction techniques. Objectives: To assess the application of fat grafting in late breast reconstruction in patients submitted to mastectomy with immediate reconstruction, who presented loss of implant (expanders and prostheses). Method: Cross-sectional study carried out through data collection in electronic medical records. We selected patients from the Mastology Service in HCPA, submitted to immediate breast reconstruction with expanders/prostheses in the period from May/2000 to May/2019. Results: We analyzed 241 cases of mastectomy with immediate breast reconstruction based on implants – 127 (52.7%) expanders and 114 (42.3%) direct prosthesis. In 24 cases (10.0%), there was loss of implants. Among these 24 patients, 20 (83.3%) had not undergone radiotherapy before mastectomy, and 4 (16.7%) had been submitted to previous radiotherapy. Of these, in 18 cases (75.0%), late reconstruction was performed: 3 cases (20.8%) of reconstruction with rectus abdominis flap (TRAM), 4 cases (23.4%) of reconstruction with latissimus dorsi muscle flap (LD), 1 case (5.5%) of fat grafting with flap planning, 6 cases (33.6%) of exclusive flap grafting, and 4 cases (23.4%) of expander/prosthesis after the plastron fat grafting. Conclusions: Breast reconstruction after the loss of expanders/prosthesis can be carried out through several surgical techniques. The knowledge of the mastologist about the different techniques aims at providing the best choice to be used, according to the individual risk profile of each patient. Plastron fat grafting after loss of implant is an important ally in late reconstruction, improving the local conditions and allowing, in our sample, the prevention of the indication of flaps 57% of the time.

Feasibility and Reliability of Microvascular Reconstruction in the Vessel-depleted Previously Operated Neck.

Background:Microvascular reconstruction of defects in the head and neck has always been a challenge in patients who have undergone previous neck dissection, owing to the prior resection of potential recipient blood vessels used for free flap perfusion.Objective:The objective of the study is to evaluate the reliability and safety of free flap reconstruction in patients who have had previous neck dissection.Materials and Methods:Twenty-four free flaps were performed in 22 patients with a previous history of neck dissection for head-and-neck squamous cell carcinoma. These included patients who underwent salvage surgery for recurrent cancer as well as patients undergoing secondary reconstruction following previous oncological resections. Flap includes 12 radial forearm free flaps, 5 fibula flaps, 1 rectus abdominis flap, and 6 anterolateral thigh flaps.Results:In cases with the previous history of selective neck dissection, recipient vessels on the ipsilateral/same side of the previously operated neck were used, while contralateral vessels were used in patients with a history of modified radical or radical neck dissection. Vein grafts were not necessary, except for one case. In our series, we did not have any flap loss or considerable increase in operative time.Conclusions:Free flap reconstruction of head-and-neck defects is highly successful in patients with a history of previous neck dissection, despite a relative scarcity of recipient blood vessels. Careful planning and relying on flaps with a long vascular pedicle obviates the need to perform a suitable vein graft. In our present series, careful planning and the right choice of a free flap with a long vascular pedicle contributes to the absence of free flap failure. In our experience, previous neck dissection should not be considered as a contraindication to microvascular reconstruction of previously operated oncologic defects.

Selecting a free flap for soft tissue coverage in lower extremity reconstruction

BackgroundGoals of lower extremity microvascular reconstruction (LEMR) include the restoration of function, prevention of infection, and optimal cosmesis. Indications for LEMR include large defects that are not amenable to pedicled options, a large zone of injury, and large complex defects. The novice microsurgeon should first master a handful of free flaps to develop an armamentarium of options for addressing such defects. The scope of this review is to provide free flap options for LEMR in any of the thirds of the lower leg. After reading this article, the reader will understand variations, advantages, disadvantages, indications, and tips for raising each of these flaps. MethodsSix most commonly used free flaps for LEMR are described in this paper, including the anterolateral thigh flap (ALT) and its variations, the radial forearm flap (RFFF), the lateral arm flap (LAF), the gracilis muscle flap, the rectus abdominis flap (RAF) and the latissimus dorsi flap and its variations. Indications, advantages, disadvantages and technique tips are discussed for each flap. Moreover, selection of the recipient vessels, preoperative management along with an algorithm are also provided. ConclusionsThe ALT flap is a workhorse in covering defects of the leg, foot, and ankle. It's the flap of choice at our institution, especially given the number of traumatic wounds seen as a result of motor vehicles, all-terrain vehicles (ATV), lawnmowers, and gunshot wounds (GSW). At times, the lower extremity zone of injury requires a distant donor site. The RAF can also provide coverage for large soft tissue defects but donor-site morbidity remains its main drawback. The LAF and RFFF provide two pliable options, one that provides pliable soft tissue with minimal donor site morbidity and another that provides a long pedicle. The free gracilis flap is an excellent choice for crossing the ankle joint. Lastly, the free latissimus dorsi is indicated for large defects of the lower extremity independently of the location.

Rectus Abdominis Pedicled Flap: An Innovative Robotic Approach

Video Objective To provide education on the utility of rectus muscle flap during pelvic floor reconstruction and describe in detail a minimally invasive technique to avoid laparotomy. Setting Patients requiring pelvic floor reconstruction at an academic medical center. Interventions The rectus abdominis muscle flap can be used as a workhorse flap for pelvic reconstruction, providing a large volume of well vascularized soft tissue that can be used in treatment of complex pelvic floor reconstruction, including genital fistulas, post-radiation pelvic exenteration and abdominoperineal resection defects. Intraperitoneal harvest of the rectus muscle using a robotic approach allows avoidance of laparotomy and subsequent disruption of the anterior rectus sheath, thus preserving the integrity of the abdominal wall. This educational video demonstrates robotic docking as well as surgical techniques in detail to show the feasibility for robotic-assisted rectus flap harvest and pelvic floor reconstruction. Conclusion Robotic-assisted rectus abdominis flap harvest for pelvic floor reconstruction is a reliable means of defect closure. This novel approach is surgically feasible for the reconstructive surgeon and maintenance of minimally invasive technique allows for significant advantages over the traditional laparotomy approach.

Geriatric Patients with Free Flap Reconstruction: A Comparative Clinical Analysis of 256 Cases.

In elderly patients, complex soft tissue defects are increasingly observed due to the prolonged life expectancy and accompanying comorbidities. The aim of this study is to evaluate whether free tissue transfer is safe in very old patients without additional risk and complications. All patients older than 65 years undergoing free tissue transfer between November 2007 and September 2016 were reviewed in a retrospective study. Two cohorts were compared regarding perioperative morbidity and postoperative outcome (cohort 1 [old patients, ages 65-79]; cohort 2 [very old patients, ages ≥ 80]). In total, 256 patients were included in the study (cohort 1 [n = 217]; cohort 2 [n = 39]). Overall, 262 free flaps were performed due to a second microsurgical reconstruction in six cases. No statistically significant differences between cohorts were observed regarding surgical complications, total flap losses, and mortality. Detailed evaluation of cohort 2 revealed a significant learning curve during the observation period regarding the perioperative management and procedure of soft tissue reconstruction: operation length as well as postoperative intensive care unit stay decreased significantly over time (p < 0.05) and also surgical complications showed a positive trend (p = 0.07). We ascertained a shift toward a "more reliable" flap selection from predominantly anterolateral thigh flap) to axial flaps such as rectus abdominis and latissimus dorsi flaps. Our study showed that age is not associated with an increased risk of postoperative complications. Reliable muscle free flaps, two-stage procedures, and safe vascular supply are important strategic aspects to achieve microvascular tissue transfer with high success rates in geriatric patients.

Long-term Results of Mandibular Reconstruction Using Mandibular Reconstruction Plate After Resection of Mandibular Region Against Malignant Tumor

PURPOSE: In the mandibular reconstruction after resection of the mandibular region against malignant tumor, there are cases where a method using a mandibular reconstruction plate is selected depending on the patient’s general condition or stage. Problems of infection, manifestation, breakage of plate in the lower jaw. This time, we investigated long-term outcome of surgery on mandibular reconstruction using reconstruction of lower jaw performed at our hospital, surgery >10 years ago. However, there are few reports of long-term results. METHODS: From January 1993 to December 2008, for patients who underwent reconstruction of the mandible using the mandibular reconstruction plate at the National Cancer Center Hospital East after mandibular region resection, using a medical record and retrospectively. RESULTS: There were 52 patients who underwent mandibular reconstruction using the mandibular reconstruction plate during the same period, among which 38 patients were able to use medical record. In 38 cases, 26 men, 12 females, average age 78 ± 15 years old, all cases were cases of mandibular cancer. All of the cases were done with the mandibular reconstruction plate and the flap used was 28 free rectus abdominis flaps, 7 anterolateral thigh flaps, and 3 forearm flaps. The follow-up period was 38.6 ± 7 months (1–169 months), 5 cases of wound departure, 5 infections, 2 cases of infection, and 3 cases of plate exposure as postoperative complications. Thirty-three of 38 deaths occurred within 10 years, and 5 cases were observed after ≥10 years, among which 4 cases did not cause problems on the mandibular reconstruction plate. DISCUSSION: Mandibular cancer requiring reconstructive surgery often has advanced disease stage and has poor prognosis. In addition, patients are often older, and long-term follow-up was accompanied with difficulties. Long-term results were examined in the range that could be observed.