Soft Tissue Deficits Research Articles

An immunologically active, adipose-derived extracellular matrix biomaterial for soft tissue reconstruction: concept to clinical trial

Soft tissue reconstruction remains an intractable clinical challenge as current surgical options and synthetic implants may produce inadequate outcomes. Soft tissue deficits may be surgically reconstructed using autologous adipose tissue, but these procedures can lead to donor site morbidity, require multiple procedures, and have highly variable outcomes. To address this clinical need, we developed an “off-the-shelf” adipose extracellular matrix (ECM) biomaterial from allograft human tissue (Acellular Adipose Tissue, AAT). We applied physical and chemical processing methods to remove lipids and create an injectable matrix that mimicked the properties of lipoaspirate. Biological activity was assessed using cell migration and adipogenesis assays. Characterization of regenerative immune properties in a murine muscle injury model revealed that allograft and xenograft AAT induced pro-regenerative CD4+ T cells and macrophages with xenograft AAT additionally attracting eosinophils secreting interleukin 4 (Il4). In immunocompromised mice, AAT injections retained similar volumes as human fat grafts but lacked cysts and calcifications seen in the fat grafts. The combination of AAT with human adipose-derived stem cells (ASCs) resulted in lower implant volumes. However, tissue remodeling and adipogenesis increased significantly in combination with ASCs. Larger injected volumes of porcine-derived AAT demonstrated biocompatibility and greater retention when applied allogeneicly in Yorkshire cross pigs. AAT was implanted in healthy volunteers in abdominal tissue that was later removed by elective procedures. AAT implants were well tolerated in all human subjects. Implants removed between 1 and 18 weeks demonstrated increasing cellular infiltration and immune populations, suggesting continued tissue remodeling and the potential for long-term tissue replacement.

Staged revision still works for chronic and deep infection of total elbow arthroplasty?

Purpose: Infected total elbow arthroplasty (TEA) is challenging. We evaluate the clinical and radiologic outcomes for chronic and deep infection of TEA with two-stage revision surgery. Methods: A total of 10 elbows were included in the study. The mean age was 69.1 ± 15 years (range, 34–83 years). The mean follow-up was 62 (range, 24–108) months. The clinical outcomes were assessed using a visual analog scale (VAS), range of motion (ROM) arc, and Mayo elbow performance score (MEPS). Moreover, radiographic outcomes, time to revision, pathogenic bacteria, preoperative complications, and disease period were evaluated. Results: Mean preoperative VAS score of 6.1 had improved to 3.3. Mean preoperative ROM was 68° (flexion-extension), which improved to 86.7°. Mean preoperative MEPS was 46 (range, 0–70), which improved to 75.5 (range, 35–85). The mean disease duration was 8.4 months (range, 5–20 months). The most common causative organism was methicillin-resistant Staphylococcus aureus. The second revision rate was 80% at the final follow-up. Radiographic outcome at final follow-up showed that 3 (30%) of 10 patients exhibited radiolucency evidence around the components. Three patients showed nonprogressive radiolucency around the implant interfaces without other indications of infection at the most recent follow-up. Conclusion: In patients with chronic and deep infection of TEA, two-stage revision can be an affordable option for eradication of the infection, relieving pain, and restoring joint function. However, the high second revision rate owing to bone and soft-tissue deficits remains a critical issue.Level of evidence: Level IV, Case series, Treatment study

Extended Scalp Expansion for Larger Defects During Staged Cranioplasty.

Secondary cranioplasty is often required following trauma, infection, radiation, or oncologic care, but is complicated by soft-tissue deficits with limited regional options. Scalp tissue expanders can provide hair-bearing, vascularized tissue for tension- free closure yielding optimal aesthetic results. However, the upper limit of safe scalp expansion has not been explored. This study sought to evaluate the efficacy of extended scalp tissue expansion for challenging cranioplasties in a consecutive series. Patients who underwent scalp tissue expansion before cranioplasty were retrospectively identified from a single institution between the years 2017 and 2020. Patient demographics, tissue expansion characteristics, and complications during expansion and after cranioplasty were collected. Six patients were identified who underwent staged scalp expansion for cranioplasty; 5 were male (83.3%) with a mean age of 43.8 ± 12.5 years. Indications for cranioplasty included 2 epilepsy- related procedures, 1 oligodendroglioma, 2 infectious processes, and 1 traumatic incident. A single expander was used in 5 cases, whereas 2 were used in the remaining case. The average expander fill volume was 434.3 ± 115 ccs with a mean expansion time of 3.3 ± 1.4 months. Expander infection occurred in 1 case and expander exposure in another, but adequate scalp expansion was still achieved in both. Successful closure over cranioplasty was obtained in 5 cases (83.3%); 1 patient ultimately required free flap reconstruction for soft-tissue coverage. In cases of extended scalp defects, scalp tissue expansion remains the preferred method for recruiting large quantities of like tissue before implant cranioplasty.

Canine-Origin Platelet-Rich Fibrin as an Effective Biomaterial for Wound Healing in Domestic Cats: A Preliminary Study.

Platelet-rich fibrin (PRF) is a recent platelet-based biomaterial, poised as an innovative regenerative strategy for the treatment of wounds from different etiologies. PRF is defined as a biodegradable scaffold containing elevated amounts of platelets and leukocytes having the capability to release high concentrations of bioactive structural proteins and acting as a temporal release healing hemoderivative. This study aimed to evaluate the performance of canine-origin PRF, obtained from blood of screened donors, as a regenerative biomaterial suitable for the treatment of critical wounds in felines. Four short-hair felines with naturally occurring wounds were enrolled in this study. Three of the wounds were considered infected. Each PRF treatment was the result of the grafting of newly produced PRFs at the recipient area. The PRF treatment was initially performed two to three times per week, followed by single weekly treatments. The study was finalized when complete wound closure was achieved. No topical antimicrobial/antiseptic treatment was applied. The present research demonstrated that xenogenic PRFs significantly induced healthy vascularized granulation tissue in lesions with soft tissue deficit, also prompting the epithelization at the injured site. No rejection, necrosis, or infection signs were recorded. Additionally, PRF-therapy was revealed to be a biological cost-effective treatment, accelerating the wound healing process.

QS5: Cryopreserved Adipose for Hypodermal Augmentation After Full-thickness Burns

Purpose:Burn and blast injuries to the face and extremities are highly morbid injuries affecting quality of life, ability to work, and psychosocial well-being. Without exception, extensive burn injuries require surgical debridement, with standard of care reconstruction involving autologous skin grafting to restore cutaneous integrity. This treatment modality is limited in extensive burns or in highly visible areas by lack of donor site and/or soft tissue deficits resulting in significant disfigurement. Hypodermal restoration via autologous adipose transplantation provides padding for the overlying skin, helps restore native features, and enhances contour and texture. However, this technique is limited by graft retention and often requires multiple rounds of grafting and consequently, multiple rounds of surgery, each with separate anesthesia, to achieve adequate results. The goal of this study was to demonstrate the therapeutic validity and efficacy of utilizing cryopreserved adipose to avoid multiple liposuction events when serial skin and fat grafting procedures are performed to restore epidermal, dermal, and hypodermal integrity after full-thickness burn.Methods:Adipose was collected from female Yorkshire swine and processed day-of-collection for immediate cryopreservation. This adipose was preserved for 3 months prior to initiation of the next stage of the experiment. After three-month elapse, female Yorkshire swine received 16, 4x4 cm full-thickness burns using an electric brand. After 48 hours, eschar was removed down to fascia. Skin grafts were collected as split-thickness skin grafts. The pigs were maintained for 8 weeks from time of engraftment and interval serum, photography, ultrasound, and biopsies were collected. At 8 weeks post-engraftment animals were sacrificed and all wounds were collected for histology and proteomic evaluation.Results:Split thickness skin graft take was greater than 95% in all injuries. Adipose grafts from Group B, were noted to remain present and incorporated into the granulation tissue in absence of skin graft with viability confirmed on biopsy. Initial increase in granulation layer thickness was noted in presence of fat graft with Group B vs. Group A. On serial ultrasound assessment, penetrating adipose grafts from Group D were noted to be present without gross resorption at all time points. Cryopreserved adipose remained viable throughout the duration of the experiment with histologic evidence of incorporation at 8 weeks post-operative.Conclusion:Burn and blast injuries predominantly affect military personnel and first responders for whom improvement in protective equipment has decreased mortality without resolving the risk of morbidity to the face or extremities. Hypodermal augmentation with lipografting as part of a strategy of autologous skin grafting addresses contour deficits and skin quality, however is limited by the need for multiple liposuction and grafting procedures, requiring multiple trips to the operating room with increased surgical and anesthetic risk and high economic burden. Here we demonstrate cryopreservation of adipose as an avenue to alleviate that burn.

Revisiting the Pericranial Flap for Scalp Reconstruction.

Soft tissue deficits of the scalp due to trauma, infection, or tumor resection present a unique challenge to the reconstructive surgeon whose goal is to achieve excellent cosmesis in a hair bearing area without compromising coverage. While extensive undermining for large rotation flaps or free tissue transfer can provide necessary coverage, the pericranial flap is an excellent alternative for less ideal surgical candidates who cannot tolerate more extensive interventions or for patients who require long-term cancer surveillance. Elevation of the pericranial flap limits the need for back cuts through the skin and uses blunt dissection to preserve overlying hair follicles. Here we present a review of the anatomy and historical use of the pericranial flap for scalp coverage and we present 4 cases to demonstrate its current utility.

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

Application of Spare Parts in Combination with Targeted Muscle Reinnervation Surgery.

Targeted muscle reinnervation is a contemporary technique designed to enhance an amputee's ability to operate a myoelectric prosthesis. This technique has been shown to decrease neuropathic pain, including neuroma and phantom limb pain. In certain amputations, especially forequarter and hindlimb levels, there may be no nearby recipient muscle sites, or the residual nerve may be too short to perform targeted muscle reinnervation. Applying the spare parts concept can help solve this problem by providing nerve autograft or additional muscle recipient sites within the spare parts flap for successful targeted muscle reinnervation surgery procedures. A retrospective review of all patients that underwent spare parts targeted muscle reinnervation reconstructions between 2016 and 2019 at two institutions was performed. Patients were assessed for healing, neuroma and phantom limb pain, and function. Twelve patients underwent targeted muscle reinnervation during spare parts reconstruction; eight were male and four were female. The mean patient age was 55.3 years (range, 16 to 72 years). For those with known soft-tissue deficit size, the surface area of the donor site spared by using spare parts reconstruction ranged from 216 to 856 cm2. None of the 12 patients subsequently experienced neuroma, and 75 percent had no phantom limb pain after 3 months. Three patients have obtained insurance-approved myoelectric prosthetics, and all three demonstrated intuitive control of targeted muscles. Using a spare parts reconstruction in conjunction with targeted muscle reinnervation may optimize reconstructive efforts in the setting of major limb amputations and aid in decreasing phantom limb and neuroma pain, and facilitate the possibility of functional prosthetic and/or myoelectric prosthesis use. Therapeutic, IV.

Possibilities of using microsurgical autotransplantation of tissue complexes in children

Background. Applications of traditional treatment methods in children with congenital and acquired pathology of the musculoskeletal system are often limited, as wound defects of significant area and depth with a soft tissue and bone deficit may occur during the reconstruction of the segment. Microsurgical techniques, including autotransplantation of blood-supplied tissue complexes, make it possible to realize the aims of musculoskeletal segment reconstruction and reduce surgical treatment time.
 Aim. This study aimed to perform a retrospective (statistical) analysis of using microsurgical autotransplantation of tissue complexes in children.
 Materials and methods. Treatment outcomes of 871 patients with congenital and development deformities of the musculoskeletal system who underwent 1048 microsurgical autotransplantations of various tissue complexes in 19842018 were analyzed. Complications associated with impaired blood supply to transplanted autografts, requiring revision microsurgical interventions, were also statistically processed.
 Results. The mean patient age was 5.8 years (range, 10 months to 17 years). In children with congenital pathology (n = 597), transplantation of blood-supplied tissue complexes in 85.9% of the cases was performed in cases with hand deformities. In 285 cases of acquired deformities, post-traumatic finger stumps accounted for 45.5%, scar changes of soft tissues for 39.6%, and other pathological conditions for 14.9%. Most of the microsurgical operations were toe-to-hand transfers, which accounted for 81.8% of the total number of surgeries. In 79.4% of the cases, the second toe was used for the toe-to-hand transfer. Accordingly, the remaining toes were transferred in 20.6% of the cases. When replacing soft tissue defects, a thoracodorsal flap was used in 84 cases, which was 5.6% (of the total number of autotransplantations), and a groin flap was used in 22 patients. To replace bone defects, a blood-supplied fibula graft was used in 47 patients and a metatarsal bone graft in 41 children. Circulatory disorders in the postoperative period were noted in 5.9% of the total operations, which in 3.1% of cases resulted in the necrosis of the transplanted autograft.
 Conclusion. The treatment outcomes of using microsurgical autotransplantation of blood-supplied tissue complexes in the reconstruction of tissues and segments of the musculoskeletal system confirm their high efficacy.

Nasal dorsum reconstruction after pediatric nasal dermoid excision

BackgroundTo review our experience with pediatric nasal dermoids, and discuss reconstructive options for the nasal dorsum after pediatric nasal dermoid removal. MethodsRetrospective review of pediatric nasal dermoid cases from January 1 2005 through October 1 2016. ResultsTwenty-five cases (12 males, 13 females) were identified. Median age at time of surgery was 24 months (7–144). Ten nasal dermoids were superficial; eleven, intraosseous; one, intracranial extradural; three, intracranial intradural. Seven were located on the glabella; fifteen, dorsum; three, nasal tip. Twelve underwent vertical midline incision; ten underwent external rhinoplasty; and three combined approach with craniotomy. There was one recurrence four years postoperatively; which was secondarily resected completely via external rhinoplasty approach. Seven cases utilized endoscopic assistance. Conchal cartilage grafting was utilized in nine cases for dorsal reconstruction. A temporoparietal fascial graft was utilized to reconstruct the soft tissue defect in three patients. Median follow-up was 1.17 years (1 month-10 years). ConclusionsNasal dermoid is a rare congenital pathology. Recurrence rate is generally low provided that complete surgical excision is achieved. Achieving complete surgical excision means sometimes compromising the upper lateral cartilages and nasal bones. Conchal cartilage grafting is useful in reconstruction for lesions that significantly disrupt the nasal cartilages and/or nasal bones, wherein the defect is significant and osteotomies may not be sufficient. Temporoparietal fascia is a favorable adjunct for reconstructing soft tissue deficits when the skin is thin. Further studies and longer follow up are needed to adequately assess functional and cosmetic outcomes.

"Purse-String" Capsular Closure for Decreasing Dislocation Rates in Proximal Femur Replacements.

Hip joint dislocation is the most common complication after a proximal femur replacement. As the utilization of proximal femur replacements continues to increase, it becomes imperative for surgeons to find the optimal method to decrease postoperative dislocation and its sequelae. These cases often involve extensive soft-tissue deficits that require reconstruction to provide postoperative strength and stability. Patients report good functional outcomes; however, dislocation remains a concern. Although “described” previously in the literature, the authors illustrate the “purse-string” hip joint capsular closure technique to help other surgeons understand it and apply to their practice as deemed necessary. We also present the senior author's results with using a modified version of the “purse-string” hip joint capsular closure technique.

Stem Cells Regenerating the Craniofacial Skeleton: Current State-Of-The-Art and Future Directions.

The craniofacial region comprises the most complex and intricate anatomical structures in the human body. As a result of developmental defects, traumatic injury, or neoplastic tissue formation, the functional and aesthetic intricacies of the face and cranium are often disrupted. While reconstructive techniques have long been innovated in this field, there are crucial limitations to the surgical restoration of craniomaxillofacial form and function. Fortunately, the rise of regenerative medicine and surgery has expanded the possibilities for patients affected with hard and soft tissue deficits, allowing for the controlled engineering and regeneration of patient-specific defects. In particular, stem cell therapy has emerged in recent years as an adjuvant treatment for the targeted regeneration of craniomaxillofacial structures. This review outlines the current state of the art in stem cell therapies utilized for the engineered restoration and regeneration of skeletal defects in the craniofacial region.

Bone health in young adult survivors born extremely preterm or extremely low birthweight in the post surfactant era.

Most infants born extremely preterm (EP; <28weeks' gestation) or extremely low birthweight (ELBW; <1000g birthweight) in the post surfactant era (early 1990s) are now surviving into adulthood. Preterm birth/low birthweight are risk factors for reduced bone growth and mineralisation in infants and children. However, little is known about their bone health around peak bone mass and through adult life. To compare bone health (bone mineral measures, bone structure and strength) in young adults born EP/ELBW with controls (>2499g birthweight), and within the EP/ELBW group examine perinatal and later variables associated with long term bone health. A geographic cohort comprising all 297 survivors born EP/ELBW in 1991-92 in the state of Victoria, Australia, and 260 contemporaneous controls (>2499g birthweight) were recruited into a longitudinal study from birth. At age 25years, investigations included dual energy X ray absorptiometry and peripheral quantitative computed tomography to measure bone, muscle and soft tissue variables, and fasting blood samples to measure serum 25 hydroxyvitamin D (25(OH)D) and bone turnover markers (BTM). Linear regression analysis, with models fitted using generalised estimating equations, was used to compare outcomes between groups, adjusting for height and weight. Compared with controls (n=129), young adults born EP/ELBW (n=162) had lower areal bone mineral density (g/cm2) (mean difference [MD] -0.044; 95% confidence interval [CI] -0.076,-0.013) and Z-scores (MD -0.53; 95% CI -0.75, -0.30) in the femoral neck, and lower total hip Z-score (MD -0.35; 95% CI -0.54, -0.15) after adjusting for height and weight. EP/ELBW males generally displayed more bone and soft tissue deficits than females, compared with their respective controls. Within the EP/ELBW group, early growth, male sex, height and lean mass, muscle measures, 25(OH)D levels, and BTM were independently associated with bone mineral measures, structure or strength. Young adults born EP/ELBW had evidence of impaired bone health around the age of peak bone mass compared with controls. Further follow-up of the EP/ELBW groups will determine if they have a heightened low-trauma fracture risk in later life.

Selective Neck Dissection in Oral Cavity Cancer Is Not Without Morbidity

The objective of this study is to analyze the morbidity of selective neck dissection (SND) in oral cavity squamous cell carcinoma (OCSCC). This is a cross-sectional study of 106 consecutive patients with T1 and T2 (AJCC seventh edition) stage cancers. Morbidity in terms of scar characteristics, cervical lymphedema, sensation, shoulder dysfunction, and smile asymmetry were analyzed. Scar outcomes were inferior in terms of poor complexion in 15 patients (14.2%), poor texture in 25 patients (23.6%), limited skin movement in 9 patients (8.5%), soft tissue deficit in 13 patients (12.3%), and lymphedema in 14 patients (13.2%). Smile asymmetry was seen in 29.2%. Shoulder dysfunction was seen in 7.5%. Patients who received adjuvant treatment had significant scar issues (p = 0.001), lymphedema (p < 0.001), and sensory issues (p = 0.003). SND in OCSCC is not without morbidity. Smile asymmetry was the commonest problem. Patients who got adjuvant treatment had significantly more morbidity.

111 Predicting Restoration of Joint Function in the Contracted Burned Hand: The Benefit of the Soft Tissue to Skeletal Ratio

Abstract Introduction Long-standing burn contractures of the hand produce marked soft tissue deficits across mobile joint surfaces. Optimum functional reconstruction requires attention to the ratio of soft tissue contracture to skeletal length. Maturation of burn scar and anticipated growth in children play a role in selecting procedures that maximize function and range. Methods Burn contractures of the hand show functional loss of motion by flexion/extension deformities of the fingers and wrist. Analysis of soft tissue shortening (contraction), measured against existing skeletal length was used to customize procedures to restore maximum function. Twenty six patients, aged 3 to 57 years underwent post burn reconstruction to maximize hand function. Each procedure selected was based on the ratio of existing soft tissue to skeletal length. Results Flexion/extension at all joints requires a balanced glide of soft tissue over existing bone length defining a 1:1 ratio between soft tissue and skeletal length. Burn contracture shortens soft tissue and restricts motion over joints. An objective ratio was applied to each joint contracture. A comparison of soft tissue quality to skeletal length (including growth in children) was used to determine the procedure for reconstruction associated with the best prognosis for maximum outcome with the least recurrence. Abnormalities included post burn boutonniere deformities, webspace contractures, flexion and extension contracture deformities of the hand, and digits. Burn scar hypertrophy and induration worsened the ratio. Eight patients with a soft tissue to skeletal ratio of 0.4:1 or less required bone shortening in the form of either joint arthrodesis, trapeziectomy, or wrist fusion. Twelve patients with a ratio of 0.7:1 or better were managed with skin grafts and/or adjacent tissue rearrangement. In the remaining group, four patients required a combination of procedures including composite soft tissue and tendon expansion restoring length of all soft tissue relative to bony length precluding the need for flap reconstruction and tendon lengthening. Two patients underwent bone shortening with prosthetic joint replacement. All patients restored to a 0.8:1 ratio or better regained optimum position of joint position and function. No secondary procedures were required for deterioration of function at two years. Conclusions A balanced dynamic soft tissue to skeletal ratio is essential in restoring maximum function to the burned hand. Understanding soft tissue contraction compared to existing bone length will permit the objective design of a reconstructive hand/finger procedure that will predict outcome and maximize hand function. Applicability of Research to Practice Predicable outcomes of functional hand reconstruction are possible based on the relationship of burn scar contracture to measurable skeletal length.

Attributes of Perforator Flaps for Prophylatic Soft Tissue Augmentation Prior to Definitive Total Knee Arthroplasty.

As our population ages, the demand for total knee arthroplasty (TKA) will dramatically increase to ensure an independent lifestyle with unimpeded and pain-free ambulation. Complications will be inevitable, especially in that patient with preexisting soft tissue deficits or extensive scarring in the knee region. Under these circumstances, prophylactic soft tissue augmentation should be strongly considered and be extremely beneficial. A retrospective review of all TKA procedures at our institutions over the past two decades revealed seven patients who specifically had soft tissue augmentation prior to their definitive TKA. Each had a single perforator flap used to achieve this. In no cases was a muscle flap used for this purpose. Excluded were all patients who had a flap of any kind for coverage of an exposed prosthesis or to accomplish wound healing after the TKA. Seven perforator flaps were utilized in seven patients for soft tissue replacement prior to the ultimate TKA. For smaller defects in three patients, a local island medial sural artery perforator flap was used. For larger defects in four patients, an anterolateral thigh perforator free flap was necessary. All flaps were successful. The only complication was an implant infection after one anterolateral thigh free flap that required a revision arthroplasty that eventually allowed salvage. Unrestricted ambulation was possible in all patients except for one who had a preexisting contralateral below-knee amputation. As the number of TKA procedures in the near future increases, prevention of the absolute number of complications becomes even more important. An awareness that any knee region suboptimal soft tissue base can lead to wound breakdown and then periprosthetic infection should alert all involved that prevention of this sequela can be best achieved by prior soft tissue augmentation. Preferably, this may be possible by capturing the assets of local and free perforator flaps.

Fat Grafting into Younger Recipients Improves Volume Retention in an Animal Model.

Soft-tissue deficits associated with various craniofacial anomalies can be addressed by fat grafting, although outcomes remain unpredictable. Furthermore, consensus does not exist for timing of these procedures. Whereas some advocate approaching soft-tissue reconstruction after the underlying skeletal foundation has been corrected, other studies have suggested that earlier grafting may exploit a younger recipient niche that is more conducive to fat graft survival. As there is a dearth of research investigating effects of recipient age on fat graft volume retention, this study compared the effectiveness of fat grafting in younger versus older animals through a longitudinal, in vivo analysis. Human lipoaspirate from three healthy female donors was grafted subcutaneously over the calvaria of immunocompromised mice. Volume retention over 8 weeks was evaluated using micro-computed tomography at three experimental ages: 3 weeks, 6 months, and 1 year. Histologic examination was performed on explanted grafts to evaluate graft health and vascularity. Recipient-site vascularity was also evaluated by confocal microscopy. The greatest retention of fat graft volume was noted in the youngest group compared with both older groups (p < 0.05) at 6 and 8 weeks after grafting. Histologic and immunohistochemical analyses revealed that improved retention in younger groups was associated with greater fat graft integrity and more robust vascularization. The authors' study provides evidence that grafting fat into a younger recipient site correlates with improved volume retention over time, suggesting that beginning soft-tissue reconstruction with fat grafting in patients at an earlier age may be preferable to late correction.

Principles of Wound Management and Soft Tissue Repair II

Wound management and soft-tissue repair can vary depending on the location. The head and neck, chest and back, arm and forearm, hand, abdomen, gluteal area and perineum, thigh, knee, lower leg, and foot all have different local options and preferred free flaps to use for reconstruction. Secondary reconstruction requires a detailed analysis of all aspects of the wound including any scars, soft tissue and/or skin deficits, functional defects, contour defects, complex or composite defects, and/or unstable previous wound coverage. Careful monitoring of both the patient and reconstruction is necessary in the postoperative period to ensure long-term success. This review contains 2 figures and 17 references. Key Words: free tissue transfer, pedicle flaps, soft-tissue coverage, wound closure, wound healing, wound management, wound reconstruction, tissue flaps

Principles of Wound Management and Soft Tissue Repair II

Wound management and soft-tissue repair can vary depending on the location. The head and neck, chest and back, arm and forearm, hand, abdomen, gluteal area and perineum, thigh, knee, lower leg, and foot all have different local options and preferred free flaps to use for reconstruction. Secondary reconstruction requires a detailed analysis of all aspects of the wound including any scars, soft tissue and/or skin deficits, functional defects, contour defects, complex or composite defects, and/or unstable previous wound coverage. Careful monitoring of both the patient and reconstruction is necessary in the postoperative period to ensure long-term success. This review contains 2 figures and 17 references. Key Words: free tissue transfer, pedicle flaps, soft-tissue coverage, wound closure, wound healing, wound management, wound reconstruction, tissue flaps

Autologous Fat Augmentation in Post Type III Cordectomy Patients.

Neocord formation after Type III cordectomy is insufficient for complete glottic closure due to scarring and soft tissue deficit. This study evaluates the role of autologous fat injection (AFI) in phonosurgical management of patients who have previously undergone Type III cordectomy for early glottic cancer. Data was collected from hospital records of patients who underwent AFI after previously undergoing Type III cordectomy. A minimum duration of 6months post-cordectomy was maintained before fat injection. Trans-oral injection was performed at a single site. Pre-operative voice evaluation was done using VHI, GRBAS scale and MDVP software. Post-operative evaluation was done at 6weeks. 21 out of 62 post-Type III cordectomy patients chose to undergo fat augmentation and were included in the study. A comparison of pre-operative and 6months post-operative AFI voice analysis showed a significant improvement in VHI, all parameters of GRBAS scale, and improvement in Jitter, Shimmer, SPI and NHR. There was a decrease in fundamental frequency but this was not statistically significant. AFI is an effective procedure for surgical voice rehabilitation of patients who have undergone Type III cordectomy for early laryngeal cancer.