Soft Tissue Defects Research Articles

Two-stage microsurgical soft tissue reconstruction of a complex sacral wound using an arteriovenous loop

The surgical reconstruction of sacral soft tissue defects is challenging, and complications are frequent. We report a successful two-stage three-dimensional microsurgical soft tissue reconstruction of a wide and deep sacral defect anastomosing a free combined ALT/TFL/rectus femoris flap to an ipsilateral vena saphena magna arteriovenous loop which was applied primarily. This case shows that complex microsurgical procedures can be promising in this demanding patient population if the indication is correct and the operative/perioperative strategy is clear.

Research progress in cell therapy for oral diseases: focus on cell sources and strategies to optimize cell function.

In recent years, cell therapy has come to play an important therapeutic role in oral diseases. This paper reviews the active role of mesenchymal stem cells, immune cell sources, and other cells in oral disorders, and presents data supporting the role of cell therapy in oral disorders, including bone and tooth regeneration, oral mucosal disorders, oral soft tissue defects, salivary gland dysfunction, and orthodontic tooth movement. The paper will first review the progress of cell optimization strategies for oral diseases, including the use of hormones in combination with stem cells, gene-modified regulatory cells, epigenetic regulation of cells, drug regulation of cells, cell sheets/aggregates, cell-binding scaffold materials and hydrogels, nanotechnology, and 3D bioprinting of cells. In summary, we will focus on the therapeutic exploration of these different cell sources in oral diseases and the active application of the latest cell optimization strategies.

Pedicled flap transfer after chest wall malignant tumor resection and potential risk of postoperative respiratory problems for patients with low FEV1.0.

Musculoskeletal transfer for chest wall tissue defects is a crucial method, and pedicled flaps around the chest wall are preferred in terms of location and simplicity of transfer. These require special care because of complications such as partial necrosis, fistula, wound dehiscence, infection, hematoma and restricted function of the arm or shoulder. However, studies of respiratory function are rare. In the present study, we investigated the complications including respiratory problems after wide resection for malignant chest wall tumors with musculoskeletal pedicle transfer. A total of 13 patients (15 operations) who underwent wide resection of primary, recurrent, or metastatic malignant chest wall tumors and musculoskeletal pedicle transfer for coverage of tissue defects were enrolled in the present study. A retrospective review of all patients was performed using data collected from hospital records and follow-up information. The complications of musculoskeletal transfer after chest wall wide resection, including respiratory problems, are evaluated. Rib or sternal resection was performed in 12 operations, and only soft tissue resection was performed in 3 operations. Latissimus dorsi (LD) pedicle transfer was performed in 13 operations, and pectoralis major (PM) pedicle transfer was performed in 2 operations; basically, wounds were closed primarily. Surgical complications were observed following 5 of the 15 operations (33.3%). Respiratory complications were seen in 7 of the 15 operations (46.7%). Patients with respiratory complications showed significantly lower preoperative FEV1.0% values than those without respiratory complications (p = 0.0196). Skin resection area tended to be higher in the complication group than in the no complication group (p = 0.104). Pedicled myocutaneous flap transfers such as LD, PM, and rectus abdominus can be used following multiple resections. After harvesting LD or PM, the wound can be closed primarily for an 8-10-cm skin defect in patients with normal respiratory function. However, for patients with low FEV1.0%, after primary closure of LD or PM transfer for wide soft tissue defects, attention should be paid to postoperative respiratory complications.

Artificial dermis combined with negative pressure wound therapy and platelet-rich plasma to treat traumatic wounds: a retrospective study.

The reconstruction of complex soft tissue defects with exposure of bones and tendons represents an increasing challenge in wound care, especially in large extremity wounds. The aim of this study was to detect the clinical efficacy of combined use of negative pressure wound therapy (NPWT), artificial dermis (ADM), platelet-rich plasma (PRP) and split-thickness skin grafting (STSG) in the reconstruction of large traumatic extremity skin defects. In this study, eight cases were treated with combined therapies for repairing complex extremity wounds and the results were reviewed retrospectively. After surgical debridement, all wounds received ADM, PRP and delayed STSG, which were all aided with NPWT. The patients consisted of five males and three females, with a mean age of 44 years. A total of six lower extremity wounds were located at the foot/ankle, with exposed tendon in five, bone exposure in three and both in two. Of the group, two patients had exposed tendon on arm/hand wounds. The size of wounds and ADM averaged 126cm2 and 42.3cm2, respectively. ADM was used to cover the exposed bone or tendon, the granulation and muscular tissue were covered with vacuum sealing drainage (VSD) directly, for NPWT. The survival rate of ADM averaged 98.9%. The average time for survival of ADM was 12.8 days and the mean uptake of autologous skin graft was 93.5%. Only one patient received repeated skin grafts. All patients achieved successful healing and reported no complications. The mean length of hospital stay was 36.1 days. Our study revealed that ADM in conjunction with NPWT, PRP and STSG could be used for repairing large traumatic extremity wounds. Wound closure was achieved without flaps, the aesthetic and functional outcomes were acceptable, and only one patient developed a 35% loss of skin graft. This work was supported by grants from the Natural Science Foundation of Hubei Province (grant no. 2020CFB464) and Youth Foundation of Wuhan Municipal Health Commission (grant no. WX20Q15). The authors have no conflicts of interest to declare.

Pedicled Peroneus Brevis Muscle Flaps as an Alternative to Fasciocutaneous Rotational Flaps for Lower-Extremity Soft Tissue Defects.

To report our experience using a peroneus brevis flap (PBF) for soft tissue defects of the distal third of the tibia, ankle, and hindfoot in resource-challenged environments. Retrospective review. Rural outpatient surgical facility in Honduras. Patients who sustained tibia, ankle, or hindfoot fractures or traumatic degloving, with critical-sized soft tissue defects treated with either a proximally based or distally based pedicled PBF to achieve coverage of the middle and distal third of the leg, ankle, and/or hindfoot. Flap healing, complications, and reoperations. Twenty-three patients, 4 with proximally based and 19 with distally based PBF flaps were included. The mean patient age was 37.3 (SD = 18.3; range 18-75 years). Duration of follow-up averaged 14.7 months (SD = 11.4; range 4-46). The PBF successfully covered the defect without the need for additional unplanned surgical flap coverage in all but 2 patients. Thirty percent of the PBFs received a split thickness skin graft, while the remainder granulated successfully without skin graft. Four flaps were partially debrided without additional flap mobilization, while 1 flap was lost completely. Ten patients had successful re-elevation of their flaps for secondary procedures such as implant removal, spacer exchange, deep debridements, and bone grafting. All donor site incisions healed without complication. The pedicled PBF allows coverage of distal leg, ankle, and hindfoot wounds using muscle in patients who may otherwise require free tissue flaps or transfer to another institution for coverage. PBFs can be learned and implemented without the use of microvascular techniques. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

DermaClose: A Case Series in the Management of Large Soft Tissue Defects in Diabetic Foot Infection

Abstract: Diabetic foot infection poses a complex problem due to several interrelated issues, including rapidly spreading infection, poor vascular supply, and reduced healing ability. Management may require multiple operative procedures and prolonged treatment with a high risk of morbidity, such as amputation, and mortality. Debridement of infection commonly creates large wounds and soft tissue defects, with limited soft tissue reconstructive options due to adverse local and systemic factors. In this setting, treatment often consists of protracted periods of secondary wound healing by granulation, de-tensioning the tissues by removing bone, and minor or major amputation. Flaps and grafts may be considered but often carry unacceptable rates of failure. We present 3 cases in which DermaClose, an automated wound management system, was employed by a joint Orthopedic and Plastic Surgery team with excellent results and rapid closure of large soft tissue defects. Level of Evidence: Level IV.

A Model to Study Wound Healing Over Exposed Avascular Structures in Rodents With a 3D-Printed Wound Frame.

Soft tissue defects with exposed avascular structures require reconstruction with well-vascularized tissues. Extensive research is ongoing to explore tissue engineered products that provide durable coverage. However, there is a lack of controlled and affordable testbeds in the preclinical setting to reflect this challenging clinical scenario. We aimed to address this gap in the literature and develop a feasible and easily reproducible model in rodents that reflects an avascular structure in the wound bed. We created 20 × 20 mm full thickness wounds on the dorsal skin of Lewis rats and secured 0.5-mm-thick silicone sheets of varying sizes to the wound bed. A 3D-printed wound frame was designed to isolate the wound environment. Skin graft and free flap survival along with exposure of the underlying silicone was assessed. Rats were followed for 4 weeks with weekly dressing changes and photography. Samples were retrieved at the endpoint for tissue viability and histologic analysis. The total wound surface area was constant throughout the duration of the experiment in all groups and the wound frames were well tolerated. The portion of the skin graft without underlying silicone demonstrated integration with the underlying fascia and a histologically intact epidermis. Gradual necrosis of the portion of the skin graft overlying the silicone sheet was observed with varying sizes of the silicone sheet. When the size of the silicone sheet was reduced from 50% of the wound surface area, the portion surviving over the silicone sheet increased at the 4-week timepoint. The free flap provided complete coverage over the silicone sheet. We developed a novel model of rodent wound healing to maintain the same wound size and isolate the wound environment for up to 4 weeks. This model is clinically relevant to a complex wound with an avascular structure in the wound bed. Skin grafts failed to completely cover increasing sizes of the avascular structure, whereas the free flap was able to provide viable coverage. This cost-effective model will establish an easily reproducible platform to evaluate more complex bioengineered wound coverage solutions.

S2k guideline: Diagnosis and therapy of localized scleroderma.

The updated S2k guideline deals with the diagnosis and therapy of localized scleroderma (LoS). LoSrepresents a spectrum of sclerotic skin diseases in which, depending on the subtype and localisation, structures such as adipose tissue, muscles, joints, and bones may also be affected. Involvement of internal organs or progression to systemic sclerosis does not occur. LoScan be classified into four main forms: limited, generalized, linear, and mixed forms, with some additional subtypes. For cases of limited skin involvement, the guideline primarily recommends therapy with topical corticosteroids. UV therapy can also be recommended. In subtypes with severe skin or musculoskeletal involvement, systemic therapy with methotrexate is recommended. During the active phase of the disease, systemic glucocorticosteroids can be used additionally. In cases of methotrexate and steroid refractory courses, contraindications, or intolerance, mycophenolate mofetil, mycophenolic acid, or abatacept can be considered as second-line systemic therapies. In the case of linear LoS, autologous adipose-derived stem cell transplantation can also be performed for correcting soft tissue defects.

Effect of Functionalization of Texturized Polypropylene Surface by Silanization and HBII-RGD Attachment on Response of Primary Abdominal and Vaginal Fibroblasts.

Soft tissue defects, such as incisional hernia or pelvic organ prolapse, are prevalent pathologies characterized by a tissue microenvironment rich in fragile and dysfunctional fibroblasts. Precision medicine could improve their surgical repair, currently based on polymeric materials. Nonetheless, biomaterial-triggered interventions need first a better understanding of the cell-material interfaces that truly consider the patients' biology. Few tools are available to study the interactions between polymers and dysfunctional soft tissue cells in vitro. Here, we propose polypropylene (PP) as a matrix to create microscale surfaces w/wo functionalization with an HBII-RGD molecule, a fibronectin fragment modified to include an RGD sequence for promoting cell attachment and differentiation. Metal mold surfaces were roughened by shot blasting with aluminum oxide, and polypropylene plates were obtained by injection molding. HBII-RGD was covalently attached by silanization. As a proof of concept, primary abdominal and vaginal wall fasciae fibroblasts from control patients were grown on the new surfaces. Tissue-specific significant differences in cell morphology, early adhesion and cytoskeletal structure were observed. Roughness and biofunctionalization parameters exerted unique and combinatorial effects that need further investigation. We conclude that the proposed model is effective and provides a new framework to inform the design of smart materials for the treatment of clinically compromised tissues.

Lower Extremity Trauma: A Multidimensional Reconstructive Approach with Hyperbaric Oxygen Therapy.

Background: Distal lower extremity reconstruction is challenging. This study aims to propose a protocol for the treatment of traumatic soft tissue defects. The key concept is to combine the surgical armamentarium of the reconstructive surgeon with the advantages provided by hyperbaric oxygen therapy. Methods: This retrospective study analyzed data of 57 patients affected with unilateral or bilateral lower extremity trauma distal to the knee and involving soft tissues with no indication of immediate reconstruction between 2010 and 2021. Before the reconstructive procedure, all the patients underwent a stick swab procedure for the collection of microbiological samples and debridement. Patients were divided into two treatment groups and only one group underwent a combined therapeutic procedure with hyperbaric oxygen therapy. Negative pressure wound therapy (NPWT) was employed only if deemed necessary according to the defect's depth and wound exudate. Surgical techniques, outcomes, and complications were discussed. Results: All patients achieved a complete recovery with no major complications and only minor complications observed. The study group treated with HBOT had a lower complication rate and lower percentages of minimal and partial graft loss compared with the same complications observed in the control group. No patients experienced HBOT-related complications. Significant reductions in the time to complete healing and the time from reconstruction to healing were found (p = 0.002 and p < 0.00001, respectively). Conclusions: A lower complication rate was observed in the group treated with HBOT. The administration of HBOT prior to soft tissue reconstruction significantly reduced the time to complete healing and the time interval from skin grafting to healing. However, prospective studies and randomized trials with larger cohorts should be designed to investigate the efficacy of HBOT for the treatment of lower extremity injuries with extensive soft tissue defects.

NovoSorb® Biodegradable Temporising Matrix (BTM): What we learned from the first 300 consecutive cases

IntroductionExtensive full-thickness soft-tissue defects remain a challenge in reconstructive surgery. NovoSorb® Biodegradable Temporising Matrix (BTM) represents a novel dermal substitute and was evaluated in wounds deriving from different aetiologies and to highlight risk factors for poor take rates. MethodsAll patients treated with BTM at our department between March 2020 and October 2022 were included. Differences in univariate and linear regression models identified predictors and risk factors for take rates of BTM and split-thickness skin grafts (STSG). ResultsThree hundred patients (mean age 54.2±20.1 years, 66.3% male, 59.7% burns, 19.7% trauma, 20.6% others) were evaluated. Mean take rates of BTM and STSG after BTM delamination were 82.7±25.2% and 86.0±22.6%. Multiple regression analyses showed that higher body mass index (BMI,OR-0.43,95%CI-0.86,-0.01,p=0.44), prior allograft transplantation (OR-15.12,95%CI-26.98,-3.31,p=0.041), longer trauma-to-BTM-application intervals (OR-0.01,95%CI-0.001,-0.001,p=0.038), positive wound swabs before BTM (OR-7.15,95%CI-13.50,-0.80,p=0.028), and peripheral artery disease (OR-10.80,95%CI-18.63,-2.96,p=0.007) were associated with poorer BTM take. Higher BMI (OR-0.40,95%CI-0.76,-0.08,p=0.026), increasing BTM graft surface areas (OR-0.58,95%CI -1.00,-0.17,p=0.005), prior allograft (OR-12.20,95%CI -21.99, -2.41, p=0.015) or autograft transplantations (OR-22.42,95%CI-38.69,-6.14,p=0.001), tumour as the aetiology of the wound (OR-37.42,95%CI-57.41,-17.83,p=0.001) diabetes (OR-6.64,95%CI-12.80,-0.48,p=0.035), and impaired kidney function (OR-5.90,95%CI-10.94,-0.86,p=0.021) were associated with poorer STSG take after delamination of BTM, whereas higher BTM take rates were associated with better STSG take (OR0.40,95%CI0.31,0.50,p<0.001). ConclusionExtensive complex wounds of different aetiologies unsuitable for immediate STSG can be successfully reconstructed by means of two-staged BTM-application und subsequent skin grafting. Importantly, presence of wound contamination or infection and prior allograft coverage appear to jeopardize good BTM and STSG take.

EVALUATION OF TREATMENT RESULTS IN 10 PATIENTS WITH SOFT TISSUE DEFECTS IN THE WRIST-HAND REGION USING RADIAL ARTERY PERFORATOR FLAPS

Purpose: Evaluate the treatment results of soft-tissue defects in the wrist-hand region by radial artery perforator flaps. Subjects and methods: A prospective, non-controlled study and cross-sectional description of 10 patients with soft-tissue defects in the wrist-hand region due to burns, indicated for reconstructive treatment using radial artery perforator flaps at the Center for Plastic and Aesthetic Surgery, Le Huu Trac National Burn Hospital, from January to September, 2021. Results: Patients aged between 17 and 69, mean age of 37.3 ± 14.5 years; ratio of male patients to female patients was 4/1. Regarding the location of injuries: 9 patients had soft-tissue defects in the dorsum of the wrist-hand; 1 patient had a soft-tissue defect in the volar aspect of the wrist-hand. Regarding treatment results: 8 patients showed excellent treatment results, 2 patients had satisfactory results, and there were no cases of treatment failure.

Powdered Cross-Linked Gelatin Methacryloyl as an Injectable Hydrogel for Adipose Tissue Engineering.

The tissue engineering field is currently advancing towards minimally invasive procedures to reconstruct soft tissue defects. In this regard, injectable hydrogels are viewed as excellent scaffold candidates to support and promote the growth of encapsulated cells. Cross-linked gelatin methacryloyl (GelMA) gels have received substantial attention due to their extracellular matrix-mimicking properties. In particular, GelMA microgels were recently identified as interesting scaffold materials since the pores in between the microgel particles allow good cell movement and nutrient diffusion. The current work reports on a novel microgel preparation procedure in which a bulk GelMA hydrogel is ground into powder particles. These particles can be easily transformed into a microgel by swelling them in a suitable solvent. The rheological properties of the microgel are independent of the particle size and remain stable at body temperature, with only a minor reversible reduction in elastic modulus correlated to the unfolding of physical cross-links at elevated temperatures. Salts reduce the elastic modulus of the microgel network due to a deswelling of the particles, in addition to triple helix denaturation. The microgels are suited for clinical use, as proven by their excellent cytocompatibility. The latter is confirmed by the superior proliferation of encapsulated adipose tissue-derived stem cells in the microgel compared to the bulk hydrogel. Moreover, microgels made from the smallest particles are easily injected through a 20G needle, allowing a minimally invasive delivery. Hence, the current work reveals that powdered cross-linked GelMA is an excellent candidate to serve as an injectable hydrogel for adipose tissue engineering.

Free neurovascular toe-(joint)-transfers compared to alternative reconstructive procedures for amputation injuries of two and tripartite fingers with substance loss.

Complex injuries of the hand frequently result in loss of essential functional features. Common reconstructive procedures for soft tissue defects of the thumb or phalanges are locoregional flaps like Moberg-, Foucher-, Cross-Finger- or Littler flaps. Microneurovascular toe (joint-) transfers complete the arsenal of operative reconstructive procedures and allow for most detailed reconstructions. Our experiences with free toe transplants are reported and diversely discussed regarding contending procedures. From 2010 until 2019 14 patients who received emergency or elective partial or complete toe transfers were compared with a control group (n = 12) treated with contending reconstructive procedures. Aim of the reconstructions was to cover the defect with well-vascularized, sensate tissue, while preserving length and range of motion in a reliable manner. The Kapandji score showed a significant difference (p- value = 0.04) with a score of 9.8 in comparison to control group (Kapandji index = 8.0). In our heterogenic patient collective free toe transplants have proven to achieve comparable functional results for reconstruction of two and tripartite phalanxes as opposed to common local reconstructive procedures.

Bilateral reconstruction of palmar soft tissues defects of the hands after thermal injury

Introduction Thermal injury to the palmar surface of the hand is usually complicated by flexion desmogenic contracture of the finger joints. This condition is more complicated with significant wound areas and depths of soft tissue destruction. Conventional surgical methods and soft tissue reconstructions may fail to provide full restoration of the hand function.The objective was to present the optimal treatment strategy for patients with scar flexion contractures of the fingers after thermal injury to the palmar surface of both hands using a pediatric case report.Material and methods A child aged 2 years and 4 months underwent surgical treatment to include excision of scars, skin grafting of both hands with a vascularized fasciocutaneous flap raised with the radial artery.Result The patient could regain all types of hand grip on both sides 12 years after surgical treatment. Both hands were aesthetically acceptable.Discussion Treatment of patients with thermal injury and substantial soft tissue damage is a complex disease process. Conservative treatment and surgical procedures using non-vascularized skin flaps are normally used for the condition. These approaches are associated with cicatricial and arthrogenic flexion contracture of the finger joints. The radical treatment includes thorough wound debridement and early flap coverage and wound closure using a flap with an axial-pattern blood supply, free flaps and reverse-flow flaps. The surgical approach helps to avoid flexion contracture of the fingers initiating early restoration of professional, social stereotypes and stereotypes in everyday life.Conclusion The clinical observation has shown the possibility of one-stage organ-preserving surgical treatment using flaps with an axial blood supply.

Delayed reconstruction of the combat-related mandibular defects with non-vascularized iliac crest grafts: Defining the optimal conditions for a positive outcome in the retrospective study

BackgroundReconstruction of mandibular defects caused by combat injuries is challenging for clinicians due to soft tissue defects and high complication risk. This study evaluated the outcomes of mandibular continuous defects reconstruction with non-vascularized iliac crest graft (NVICG) in patients with combat injuries. Material and methodsPatients with continuous mandibular defects acquired by high-velocity agents, who received NVICG reconstruction with or without microvascular-free soft tissue or regional flaps, were included in the study. The outcome variable was graft loss due to postoperative complications or full (more than 90 %) resorption. The primary predictor variable was soft tissue defect in the recipient area. The secondary predictor variable was the length of the defect. Variables related to patients, defect site, surgery, and other complications were also evaluated. Statistical analysis was performed with the usage of independent sample t-test, Pearson's chi-squared and Fisher's exact tests with a significance level of P < 0.05 ResultsThe study included 24 patients with 27 mandibular defects. Overall, the general success rate of reconstructions was 59.3 %. Soft tissue defects were significantly associated with graft failure and other complications (p < 0.05), which were mostly related to soft tissue defects. The graft success rate was only 14.3 % even in minor soft tissue defects. In turn, in reconstructions with sufficient soft tissue coverage, the graft survived in 75.0 % of the cases. In addition, patients with more delayed reconstruction had significantly fewer graft failures than those with earlier surgery (p < 0.05). No associations were found between defect size and complications. ConclusionThe sufficient soft tissue coverage is essential in the reconstruction of mandibular defects caused by combat injuries. Also, minor soft tissue defects should be covered with soft tissue flaps to avoid complications and graft loss in these specific injuries. Even large defects can be reconstructed with NIVICG if the soft tissue coverage is sufficient.

Identification of optimal flap types for color matching in free flap-based facial reconstruction in Asian population

Large soft tissue defects of the face often require free flap-based reconstruction. To avoid a conspicuous patch-like appearance, choosing flaps with a color similar to that of the adjacent facial skin is crucial. This study aimed to identify the flap types that show the best color match via objective color evaluation.Patients who underwent free flap-based facial reconstruction between 2013 and 2023 were retrospectively reviewed. Based on standardized photographs, average color samples of the flap skin paddle and adjacent skin were obtained. The color differences were compared by flap type at two different time points, early (within 1–3 months, post-operative) and late (after 1 year, post-operative), using the delta E value.Fifty-eight free flaps were analyzed, including 22 thoracodorsal artery perforator (TDAP) flaps, 17 anterolateral thigh (ALT) flaps, nine superficial circumflex iliac artery perforator (SCIP) flaps, and eight radial forearm (RF) flaps. In the analysis of early outcomes, the RF flaps showed the least color difference, followed by the SCIP and TDAP flaps, and the ALT flaps showed the greatest difference, with the differences being significant. Most cases showed generally improved color matching over time. Time-dependent changes were significant in the ALT and TDAP flap groups. In the analysis of late outcomes, all flap types showed delta E values less than 10, with the RF flaps showing the least color difference, followed by the SCIP flap. The four workhorse flaps provided acceptable outcomes with long-term improvements. The RF flaps provided the best color matching in the long run.

Simple reconstruction of the skin and soft-tissue defect following Fournier’s gangrene

Fournier’s gangrene (FG) is a form of severe necrotizing fasciitis over the external genitalia, perineal, and perianal region with vessel thrombosis, sepsis, and multiorgan failure. Mortality and morbidity are high, treatment includes intensive resuscitation, emergency debridement, and parenteral antibiotics. The defects are closed later using negative pressure, skin grafting, muscle flaps, primary closure, thigh pockets, or a combination. The below case series included four patients who presented with FG involving the perineum and external genitalia, underwent serial debridement of the necrotic scrotal tissue exposing the testes, and once the wound was clean, a local cover for the testes either primary closure by mobilization of healthy skin around the scrotum, or by medial thigh pockets was done. The advantages of utilizing the local skin are reduced friction, good cosmesis, decreased infection, ensured functionality, easier to perform surgically, have reduced hospital stay; as compared to grafting, which leads to contractures with healing, decreased lubrication, and higher patient dissatisfaction. Utilizing the local skin around the scrotum and perineum can act as an efficient means of satisfactory restorative cosmesis and function in FG.

¨[Original in spanish] Update of techniques for the treatment of periodontal recessions.

Background: Along the years, a remarkable variety of periodontal surgical protocols has been proposed, the focus of which has shifted from the mere resolution of a soft tissue defect to the performance of predictable and minimally invasive procedures. Initially, the free gingival graft was used. Subsequently, many different techniques were experimented, including those using soft tissue substitutes, such as the Alloderm membrane. Nowadays, the association of the connective tissue graft with the coronally advanced flap is considered the gold standard. Finally, the Pinhole technique, being a more conservative method in terms of tissue preservation and aesthetic outcome, was proposed. Objectives: The aim of this review was the comparison of the updated techniques for the treatment of multiple periodontal recessions, affecting both maxilla and mandible. The procedure outcome was assessed in terms of complete root coverage, recession reduction, gain in height and volume, aesthetic outcome, patient’s post-operative pain and morbidity of donor and recipient sites. Material and methods: Electronic and hand searches were performed to collect split- mouth studies, randomized controlled clinical trials, case series, pilot studies, periodontal books, case studies, systematic reviews and meta-analysis, including maxillary and mandibular multiple gingival recession defects of all four Miller’s classes, for its extensive evidence. Results: Thirty-four publications were included and data regarding the surgical techniques outcome were extracted from eighteen articles. The clinical evaluation analyzed the amount of complete root coverage, recession reduction and gain in height and volume, while the patient’s perspective was expressed in terms of aesthetic satisfaction and possible postoperative complications. Procedures in the last ten years showed better results in all the above-mentioned factors. Conclusion: Procedural predictability and long-lasting treatment stability embody the factors driving the technique election process and adding value to more updated procedures. Progress was observed both at an aesthetic level, by reducing the discrepancies between the surgical region and the surrounding tissue, and at a postoperative level, by reducing patient discomfort. The challenges inherent to this branch could soon find answers thanks to its prompt evolution, which allows for further advances to be conceived.

Acute Free Fibula Reconstruction of a Ballistic Ulna Fracture

Long bone reconstruction is a complicated topic, especially in cases with a large bone deficit where traditional fixation methods would lead to a high rate of non-union requiring further surgical intervention. Our case is of a male with a gunshot wound to his ulna resulting in a 10cm bone defect and a 15x8cm soft tissue defect. Our goal was to maintain a both bone forearm by reconstructing his ulna to maintain forearm pronation and supination. A chimeric free fibula flap was transferred in the acute setting. Vascularized bone transfer in upper extremity reconstruction is typically considered as an operation after fracture non-union. We propose the use of a vascularized bone flap as a first line therapy in certain instances such as the case above. The use of the free fibula flap can provide vascularized bone and softs tissues and allow for optimal recovery while decreasing the need for further operations.