Total Flap Necrosis Research Articles

Superficial circumflex iliac artery (SCIA) perforator flap for shaft-only phalloplasty: Surgical technique and outcomes

Background Phalloplasty is the surgical (re)construction of a phallus using pedicled and/or free tissue flaps. The pedicled superficial circumflex iliac artery (SCIA) perforator flap is a novel, up-and-coming technique for phalloplasty. Here, we present our surgical technique and surgical outcomes for pedicled SCIA-based phalloplasty without urethral lengthening (i.e. shaft-only) in transgender men. Methods All transgender men who underwent shaft-only phalloplasty using SCIA-based perforator flaps between January 2017 and December 2023 were included in the analysis. Participant demographics, surgical characteristics, and postoperative outcomes were assessed, including (partial) flap failure and postoperative complications. Results Forty-seven transgender men were included. Median age at surgery was 30 years (range 19–61 years), and mean BMI 23 ± 2kg/m2. Average flap dimensions were 13 cm in length (range 12–15cm) and 11 cm in width (range 9–13cm). Successful penile reconstruction with a unilateral pedicled SCIA-based flap, without additional flaps or requirements, was achieved in 45 (96%) participants. One participant had total flap necrosis and one had partial flap necrosis. Primary closure was obtained in all participants (100%). Wound dehiscence was frequent at phallus/scrotum junction (n = 17), and infrequent at the donor-site (n = 3), and could be managed conservatively in all cases. Conclusion The SCIA-based perforator flap is a safe and promising pedicled option for shaft-only phalloplasty, with a concealable donor site and without the need for microvascular anastomosis. Therefore, in our center, the SCIA-based perforator flap has become our primary choice for phalloplasty without urethral lengthening in slim patients.

Head and neck free flap reconstruction under the COVID-19 pandemic.

High perioperative mortality and complication rates during the coronavirus disease 2019 (COVID-19) pandemic have been reported. In head and neck reconstruction, not only is patient safety important, but the prevention of infection introduced by the surgical team is also important because the procedure is performed in close proximity to the upper respiratory tract. In addition, recent studies have reported an increased risk for thrombus formation after infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19 vaccination, which is problematic for microsurgical reconstruction procedures. At the authors' institution, patients undergoing head and neck reconstruction are requested to stay home for 2 weeks and undergo screening tests for COVID-19 before admission. Surgeons use standard personal protective equipment during surgery. There was no significant difference in the rate of total flap necrosis between the COVID-19 and non-pandemic periods or large difference of perioperative complication rates between vaccinated and non-vaccinated patients. No surgery-related infections among the surgical staff were also found.

A single-center retrospective comparison of muscle versus cutaneous free flaps for posterior elbow defect reconstruction

IntroductionComparative data regarding free flap outcomes for elbow defect reconstruction is still lacking. This study aims to compare complication rates of free muscle (MFs) versus cutaneous flaps (CFs) for posterior elbow reconstruction. MethodsIn a single-center retrospective analysis, patients with free MFs and CFs for posterior elbow reconstruction from 2000 until 2021 were analyzed. Retrospective chart review included patient demographics, operative details, and postoperative complications. Compared outcomes of interest were microvascular complications, partial or total flap necroses, wound dehiscence, hematoma or flap infection, and donor-site complications. ResultsSixty-six free flaps (CFs: n=42; MFs: n=24) were included, with a trend over time towards using CFs (64%). MFs were used for larger defects (CF: 175 ± 82 vs MF: 212 ± 146 cm2; p=0.13). Outcome analysis revealed an equal distribution of microvascular complications (10% vs 13%; p=0.7), partial flap necrosis (7% vs 8%; p>0.9), wound dehiscence (7% vs 4%; p>0.9), evacuation of hematoma (10% vs 4%; p = 0.7), and infection (0% vs 4%; p = 0.4). Total flap necrosis requiring additional flap surgery was necessary in one CF (2%) and in no MF (0%) (p>0.9). ConclusionSurgical outcomes, flap necrosis rates, and microsurgical complications did not differ between CFs and MFs. Both flap types are safe and effective options. The free anterolateral thigh and latissimus dorsi flaps represent indispensable workhorses for the reconstruction of extensive elbow defects.

The free vastus lateralis-And conjoined vastus lateralis anterolateral thigh/tensor fascia lata flap for oncological chest wall reconstruction.

A reconstructive option for extensive chest wall reconstruction is the free myocutaneous vastus lateralis muscle (VL) flap which can be performed in isolation or in conjunction with a fasciocutaneus anterolateral thigh (cVLALT) and/or myofasciocutaneous tensor fascia lata flap (cVLTFL). We aimed to directly compare the outcomes of these reconstructive options. Patients who underwent oncological chest wall reconstruction with a free VL, cVLALT, or cVLTFL flap between February 2010 and 2022 were included in this retrospective study. Patient demographics, surgical characteristics, as well as medical and reconstructive outcomes, were evaluated. The operative outcomes between myocutaneous VL, cVLALT, and cVLTFL flap reconstructions were compared. A total of 41 patients underwent chest wall reconstruction with a free myocutaneous VL (n = 25; 61%), cVLALT (n = 14; 34%), or cVLTFL Three acute flap thromboses occurred in the entire cohort (3/41, 7%), with one myocutaneous VL flap failing because of recurrent venous thrombosis during the salvage procedure. Total flap necrosis was seen in two cases (5%; VL flap: n = 1; cVLALT flap: n = 1), and partial flap necrosis in one VL flap (1/25, 4%) and in the distal ALT portion of three cVLALT flaps (3/14, 21%). No significant difference was seen between isolated VL and conjoined VL flaps regarding the partial (p = .28) or total flap necrosis rate (p = .9). The free (conjoined) VL flap provides reliable outcomes for obliterating dead space achieving durable reconstruction of complex chest wall defects.

Rate of Free Flap Failure and Return to the Operating Room in Lower Limb Reconstruction: A Systematic Review.

Background: Soft tissue defects of the lower limbs pose significant challenges in reconstructive surgery, accounting for approximately 10% of all reconstructive free flaps performed. These reconstructions often encounter higher complication rates due to various factors such as inflammation, infection, impaired blood flow, and nerve injuries. Methods: A systematic review was conducted following PRISMA guidelines, reviewing literature from 2017 to 2024. Eligible studies included those on free flap reconstruction of lower limb defects in living human subjects, with more than three cases and reported rates of flap failure and return to the operating room. Systematic reviews and metanalysis were excluded. Results: A total of 17 studies comprising 5061 patients and 5133 free flap reconstructions were included. The most common defects were in the lower leg (52.19%) due to trauma (79.40%). The total flap necrosis rate was 7.78%, the partial necrosis rate was 9.15%, and the rate of return to the operating room for suspected vascular compromise was 13.79%. Discussion: Lower limb reconstruction presents challenges due to diverse etiologies and variable tissue requirements. Factors such as recipient vessel availability, flap selection, and multidisciplinary approaches influence outcomes. Muscle and fasciocutaneous flaps remain common choices, each with advantages and limitations. This systematic review underscores the importance of individualized treatment planning. Conclusions: Microsurgical reconstruction of lower limb defects demonstrates safety and reliability, with overall favorable outcomes. Flap selection should be tailored to specific patient needs and defect characteristics, emphasizing meticulous surgical techniques and multidisciplinary collaboration. This systematic review provides valuable insights into current standards and encourages adherence to best practices in lower limb reconstruction.

Evaluating Pedicled Pectoralis Major Myocutaneous Flap Reconstructions for Oral Malignancy and the Influence of Laterally Based Rotational Advancement Flap on Donor Site Integrity and Nipple Position in Male Patients.

Oral cancer poses a significant health burden, particularly in the male population of India. This study focuses on evaluating the outcomes of 48 pedicled Pectoralis major myocutaneous (PMMC) flap reconstructions in male patients with oral malignancy. Given the challenges associated with microvascular flap reconstructions, especially in advanced cancer cases, older patients, and resource-constrained settings, the PMMC flap still serves as a valuable alternative. The study introduces a novel approach by incorporating a laterally based rotational advancement flap (LBRA) to address donor site integrity and decrease the nipple-areolar complex (NAC) displacement. Traditionally, PMMC flap designs tend to cause inward shifting of the NAC during chest donor site closure, impacting the aesthetic outcome. Surgical techniques involved wide local resection, neck dissection, and PMMC flap reconstruction. The Flap design included a horizontal orientation with adjustments based on defect location. Additionally, a laterally based rotational flap from the chest aided in donor site closure. Results demonstrate the versatility and reliability of PMMC flap reconstructions, with no total flap necrosis or major complications observed in the 48 cases. The LBRA technique effectively mitigated NAC displacement. The study contributes to the existing literature by providing insights into the advantages of PMMC flap reconstructions and introducing a technique to optimize donor site closure and decrease the medial shifting of the nipple. The adaptability, reliable vascular supply, and simplified learning curve make the PMMC flap a preferred choice in resource-constrained settings with high patient demand. In conclusion, this research underscores the continued relevance and effectiveness of the PMMC flap in head and neck reconstruction, offering satisfactory cosmetic and functional results. The introduction of the LBRA technique adds a nuanced dimension to improve outcomes, particularly in male patients with oral malignancy.

Enhanced Recovery After Surgery in Immediate DIEP Flap Breast Reconstruction: Reducing Length of Stay and Opioid Use.

Background: To improve patient outcomes amid reduced healthcare resources during the COVID-19 pandemic, a single Canadian cancer center implemented an Enhanced Recovery After Surgery (ERAS) protocol for autologous DIEP flap breast reconstruction. Methods: This retrospective cohort study included 100 consecutive patients undergoing microsurgical breast reconstruction with DIEP flaps using the ERAS protocol and 100 patients using a standard protocol. Primary outcomes were the hospital length of stay and opioid use. Secondary outcomes included postoperative complications, laxative and antiemetic consumption. Results: In this study, 80% of the patients had immediate reconstruction, while the remaining patients received either delayed immediate or delayed reconstruction. Patients in the ERAS group had shorter hospital stays (2.8 vs 4.5 days; P < 0.001) and lower total opioid use (50.2 vs 136.3 mg; P < 0.001). This reduction was also observed when breaking down opiates per day of hospitalization (30.2 vs 18.2 mg; P < 0.001), and in the first 24 postoperatively hours (35.7 vs 67.6 mg; P < 0.001). The control group had a higher incidence of postoperative complications, including seroma, partial and total flap necrosis, compared to the ERAS group. However, readmission rates were similar between the two groups. Conclusion: Implementing the ERAS protocol for DIEP flap breast reconstruction can significantly reduce hospital length of stay and postoperative opioid requirements without increasing the risk of adverse events. This pattern holds true for immediate reconstructions with DIEP flaps.

Reverse Sural Artery Flap – A Versatile Option in Distal Lower-limb Reconstruction

Abstract Background: The biggest barriers to the reconstruction of soft-tissue defect in the distal part of the lower limb are the paucity of local vascularized soft tissue and the mechanical demands of the region. Advancements in microsurgery techniques and low complication rates have made free tissue transfer the method of choice. However, the option of microsurgery may not be available at all centers. The reverse sural artery flap (RSAF) provides a reliable alternative for covering soft-tissue defects of the distal parts of the lower extremity. Objective: The aim of this study was to assess the versatility and efficacy of RSAF for providing coverage for soft-tissue defects over the distal parts of the lower limb. Materials and Methods: A retrospective, observational, and descriptive study was performed through a data survey of medical records of patients treated between August 2020 and January 2023. Results: A total of 25 patients underwent surgery, 21 males and 4 females. The age range of patients was from 18 to 55 years. Tissue defects following trauma constituted majority of the cases. Four patients had partial flap necrosis. No case of total necrosis of flap was recorded. The average duration of hospital stay was 15.6 days. Conclusion: The reverse-flow fasciocutaneous sural flap proved to be a feasible, easily reproducible, and reliable option for reconstruction of distal lower-limb defects.

Postoperative infections associated with microvascular free flaps in head and neck reconstruction: Analysis of risk factors and results with a standardized prophylaxis protocol

Currently, large defects of the head and neck regions are mainly reconstructed using microvascular free flap. Postoperative infections, including surgical site infections (SSIs) and medical postoperative infections (MPI), are important causes of morbidity and worsening of surgical outcomes. The authors aimed to analyze the results obtained using a standardized prophylaxis protocol in a series of 100 consecutive patients who underwent microvascular reconstruction surgery between 2016 and 2021 at a single institution, to identify the risk factors, which could be overcome, to minimize the incidence of infectious complications. In this study, 24 patients developed infectious complications. Higher American Society of Anesthesiologists(ASA) score was statistically associated with higher risk of infectious complications (p=0.01), need for postoperative transfusions (p=0.01), and higher T and N stage (p=0.03 and p=0.02, respectively) in patients with cancer. We also found a correlation between the increase in surgery duration, hospitalization, and intensive care unit (ICU) stay with higher risk of infection (p=0.03, p=0.01, and p=0.001, respectively). Nine patients reported partial or total flap necrosis and in this group of patients, a higher incidence of infectious complication was recorded (p=0.001). Our experience shows that SSIs and MPIs affect the global and surgical outcomes of patients and both their incidences can be reduced by correcting potential risk factors preoperatively (e.g., anemia), intraoperatively (amount of blood loss and duration of surgery), and postoperatively (duration of hospitalization and ICU stay and early elimination of potential sources of infection).

Diagnostical accuracy of hyperspectral imaging after free flap surgery.

Microsurgical free-tissue transfer has been a safe option for tissue reconstruction. This study aimed to analyze the diagnostic accuracy of hyperspectral imaging (HSI) after free-tissue transfer surgery. From January 2017 to October 2019, 42 consecutive free-flap surgeries were performed, and their outcomes were analyzed via HSI. Clinical examination of free-flap perfusion was initially performed. Clinical examination findings were subsequently compared with those of HSI. Potential venous congestion with subsequent necrosis was defined as a tissue hemoglobin index of ≥53%. Student's t-test was used to compare the results of the analysis. The evaluation of sensitivity and specificity for flap failure detection was time dependent using the Fisher's exact test. A p-value of ≤0.05 was considered statistically significant. Microsurgical tissue transfer success rate was 84%. Seven patients presented with venous congestion that caused total flap necrosis. Overall, 124 assessments were made. HSI accurately identified 12 out of 19 pathological images: four as false positive and seven as false negative. The sensitivity and specificity of HSI were 57 and 94%, respectively, compared to those of clinical examination that were 28 and 100%, respectively, within 24 h following tissue transfer. The sensitivity and specificity of HSI were 63 and 96%, respectively, compared to those of clinical examination that were 63 and 100%, respectively, within the first 72 h. A tissue hemoglobin index of ≥53% could predict venous congestion after free-flap surgery. HSI demonstrated higher sensitivity than clinical examination within the first 24 h; however, it was not superior compared to clinical findings within 72 h.

Experience of using a supraclavicular flap in reconstruction of oral cavity defects

Introduction. In case of cancer of the oral mucosa at the first stage, the standard treatment approach is radical surgical intervention, with the formation of extensive defects leading to aesthetic and functional disorders. Taking into account the characteristics of defects, choosing a flap is a difficult task. Currently, there is a wide selection of regional and microvascular free flaps. However, not all flaps meet the requirements. The supraclavicular fasciocutaneous flap, being a regional flap, has a number of advantages: easy to harvest, reliable due to the constancy of the vascular pedicle, primary closure of the donor site, scarcity of hair, the possibility of closing various defects of the oral cavity. Aim. To evaluate the possibility of using a supraclavicular flap in patients with oral cancer to restore the defects after surgical treatment.Materials and methods. The study included 10 patients with malignant tumors of the oral cavity who underwent surgical intervention with defect replacement using supraclavicular flap at the N. N. Blokhin National Medical Research Center of Oncology between February of 2015 and May of 2021. In 4 cases, buccal mucosa was affected; in 3 cases, the retromolar area; in 1 case, oral floor mucosa; in 1 case, mandibular alveolar ridge; in 1 case, mobile tongue. Flap sizes were 5–10 × 5–8 cm. Three (3) patients had history of radiotherapy, and 1 of them had a radical dose.Results. In 4 patients without previous radiotherapy, partial flap necrosis was observed. In 1 patient, sutural diastasis in the oral cavity after partial flap necrosis was diagnosed. There were no cases of total flap necrosis and fistula formation. Suture dehiscence in the donor bed was observed in 1 patient only.Conclusion. Use of supraclavicular flap is an option for oral cavity defect replacement after surgical intervention in patients with malignant tumors of the oral cavity producing satisfactory esthetic and functional results. The advantages of this flap are simple flap dissection, reliability of vascular pedicle, flexibility, possibility of replacing large defects, scant hair coverage.

Twelve Years of Establishing the Strategies for Tongue Reconstruction.

Reconstruction after resection of malignant tongue tumors remains one of the most difficult problems in head and neck oncology. Recent trends in tongue reconstruction have focused on optimizing speech and swallowing functions and maximizing quality of life. In the recent literature, several reconstructive strategies including regional flaps and free flaps have been described. A case series of 328 patients underwent oral tongue reconstruction between March 2011 and March 2022. Functional evaluation was performed in all patients 3 months after reconstruction (where the patients required no adjuvant radiotherapy) or after radiotherapy. Total flap necrosis was seen in 5 patients with free flap reconstruction (2 radial forearm flaps, 1 lateral arm flap, and 2 anterolateral thigh flaps), 5 patients with infrahyoid myocutaneous flap, and 1 patient reconstructed with a supraclavicular flap. Our success rate is 96.6%; partial flap necrosis was observed in 11 patients with infrahyoid myocutaneous flap and 2 patients with a supraclavicular flap. Most patients with subtotal glossectomy or smaller defects (type II-IVA defects) could communicate on the phone and had the near-normal capacity for an oral diet. The remaining patients (type IVB-V defects) had significantly lower speech scores. The majority of patients could eat liquid and semiliquid foods. Tongue cancer surgery and subsequent reconstruction posed exciting challenges for the surgeon to optimize tongue function and quality of life for patients. Attention to the principles of tongue reconstruction and choosing appropriate flap for each defect achieve better functional results.

A META-ANALYSIS STUDY: RISK FACTORS OF TOTAL FLAP NECROSIS IN MICROSURGERY

Background: Total flap necrosis as flap failure can cause burdensome problems for both the surgeon and patient. We performed a meta-analysis to analyze several risk factors for total flap necrosis in free flap surgery. Age, gender, diabetes mellitus (DM), hypertension (HT), duration of surgery, blood transfusions, and intraoperative intravenous fluids are discussed. Methods: We used the PubMed, Science Direct, Proquest, and Web of Science databases from January 2019 to December 2020. The selected articles described free flaps and included the number of cases according to variables and the incidence of total flap necrosis. Results: From thirteen articles, we documented 2,063 free flaps. Most of the patients were male (65,9%), and the defects were caused by malignancies (75.4%). The most common location was the head and neck (72.7%). Lateral circumflex femoral system and radial forearm are the two most common types of free flaps. Overall success free flap in this study was 93.45%, while the failure rate was 6.55%. Total necrosis was found in 23% of all postoperative complications. No significant differences in criteria for old age (> 60 years), female gender, DM, HT, and duration of surgery were found. Transfusions or intraoperative fluid administration cannot be concluded. Conclusions: The causes of free flap failure are multifactorial and no absolute contraindications to surgery are mentioned in the literature. Some of the factors analyzed in this study were not significant as the risk of total free flap necrosis but could lead to other surgical or medical complications. However, further studies are needed.

Extensive Defect Reconstruction With Pre-expanded Anterolateral Thigh Flap: Tissue Expansion of the "Outskirts".

Previously reported pre-expansion techniques of the anterolateral thigh flap are mainly perforator-based. The expansion will interfere with the flap harvest if the requisite perforator is found unsuitable as a pedicle. Expansion of the peripheral territories of the flap donor site can minimize the interference from the expansion. Forty-eight peripheral pre-expansions of the anterolateral thigh flap were retrospectively reviewed in 38 patients from 2012 to 2021. The reconstructive outcomes, including flap success, increase in flap size, donor-site closure, and complications, were assessed. In addition, subgroup analysis was performed based on the expanded territories. Rate of successful flap elevation of 100% and flap survival rate of 97.9% were achieved. One patient had total flap necrosis, which was salvaged with skin grafting. Peripheral expansion attained a mean 55.5% ± 19.6% increase in flap width. Primary donor-site closure was accomplished in 95.8% of flaps and fascial restoration in 97.9% of the donor sites. Three patients developed major expansion-related complications, which required surgical intervention. One patient had wound dehiscence in the donor site, which healed by secondary intention. Compared with other subgroups, the lateral-and-medial-side expansion provided a larger flap for reconstruction (P = 0.001). If time is not of the essence, peripheral pre-expansion permits direct donor-site closure with size augment of the anterolateral thigh flap. In addition, it preserves the reliability and versatility of the anterolateral thigh flap.

Head and Neck Reconstruction With 2-Stage External Pectoralis Major Myocutaneous Flap Transfer.

In head and neck surgery cases where skin is severely scarred or adhered to surrounding tissue, reconstruction can be difficult to perform using microsurgical tissue or conventional pedicled pectoralis major myocutaneous flap (PMMF) transfer given the risks, which include damage to major vessels when manipulating scarred skin. For such cases, we perform a 2-stage external PMMF transfer, whereby the PMMF is directly sutured to the defect over the neck skin (without manipulation the hardened skin), and the flap division is then performed secondarily. A total of 30 patients who had histories of radiotherapy (60-70 Gy) and prior neck dissection received the 2-stage external PMMF transfer procedure. Indications for the flaps included pharyngeal fistula closure in 12 patients, reconstruction for mandibular necrosis after radiotherapy in 8 patients, salvage surgery for partial or total necrosis of the free flap in 4 patients, and simultaneous reconstruction after tumor excision in 6 patients. Two patients underwent a second external PMMF transfer from the contralateral side because of postoperative complications, yielding a total of 32 flap transfers. Twenty-nine flaps showed complete flap survival, whereas 3 had partial necrosis. Other complications, despite complete flap survival, included large fistulas requiring additional surgery for fistula closure (1 patient) and small fistulas that were closed without requiring reoperation (7 patients). External PMMF transfer offers a safe, simple, and effective option in cases where free flap surgery is considered difficult or the risks associated with neck manipulation are high.

Is Supraclavicular Artery Island flap (SAI) a viable alternative to Free Tissue Transfer (FTT) in head and neck reconstruction? A systematic review and meta-analysis.

PurposeThe aim of this study is to compare the outcomes of Supraclavicular Artery Island (SAI) Flap versus Free Tissue Transfer for head and neck reconstruction. MethodsWe performed a systematic review of MEDLINE (via PubMed), Scopus and Cochrane Library database according to the PRISMA guidelines. Only comparative studies between the two techniques were included. Random-effects model meta-analyses were performed. ResultsEight studies, reporting a total of 402 patients and same number of flaps, 165 of which underwent reconstruction using supraclavicular artery island flap and 237 reconstructed with free tissue transfer were identified. No statistically significant differences were observed regarding major complications, total flap necrosis, partial flap necrosis, post operative fistula formation, donor site dehiscence, recipient site dehiscence and total flap area. ConclusionSupraclavicular artery island flap and free tissue transfer seem to be comparable when used in head and neck reconstruction.

Interpolation sural flap in acute trauma patients

Objectives: Distal lower leg wounds, regardless of cause, and acute trauma wounds, regardless of site, are difficult. Reconstruction of both situations are much more challenging. Interpolation sural flap is a good alternative for this type of reconstruction. Methods: Fourteen interpolation sural flap were harvested to reconstruct for distal leg region wounds due to acute trauma. Ten male and four female patients aged from 10 to 59 years old were included this study. Results: All flaps survived. No venous congestion and total flap necrosis was seen. There were 4 complications, and all of them were corrected with short interventions. After second stage, no complication was seen. Conclusions: Interpolation sural flap modification has many advantages including reliability, no venous congestion, immediate reconstruction without a surgical team. However, it is a two-staged reconstruction and its donor site scarring can be serious.

Lateral supramalleolar flap for soft-tissue coverage of ankle and foot defects

The reconstruction of soft tissue defects in the foot and ankle remains a big challenge due to the anatomical characteristics of this area. This study evaluated the long-term effectiveness of covering by lateral supramalleolar flap in patients with soft tissue defects around the ankle and foot. We conducted a retrospective study from January 2017 to December 2020 at the Hospital for Traumatology and Orthopedics, Ho Chi Minh City, Vietnam. Data about patients’ characteristics, detailed injuries, perioperative information, intraprocedural dossier, and complications of this method were recorded and analyzed. There were 31 male and 17 female patients, with an average age of 39.8 (ranging from 11 to 77) years. The skin defects ranged from 8 cm2 to 120 cm2. The blood supply for the flap included a mixed-flow pattern (n = 30) and retrograde flow (n = 18). The success rate was 94%. Forty-two patients had been successfully covered, five patients had partial flap necrosis (in which two cases needed skin graft afterwards and three cases got spontaneous healing), only one patient had total flap necrosis. In conclusion, the lateral supramalleolar flap can cover the soft tissue of ankle and foot defects in both mixed-blood supply pattern or retrograde pattern with high success rates. However, the risk of venous congestion should be considered, particularly when using the retrograde pattern flap.

Early Reconstruction Delivered Better Outcomes for Severe Open Fracture of Lower Extremities: A 15-Year Retrospective Study.

Background: The principle of early flap reconstruction for high-grade traumatic lower-extremity injuries established in 1986 by Godina has been widely accepted. However, the lack of an orthoplastic center in China makes early reconstruction not accessible for all patients with a Gustilo IIIB fracture. This study aimed to analyze the impact of timing on outcomes in lower-extremity traumatic free-flap reconstruction. Methods: A retrospective review identified 394 free-flap reconstructions performed from January 2005 to January 2020 for Gustilo IIIB tibial fractures. Patients were stratified based on the number of debridements: two times or less (early) and more than two times (delayed). The interval between injury and reconstruction, surgery time, hemorrhage volume, length of hospitalization (LoS), wound and bone healing time, flap outcomes, and function restoration were examined based on times of debridement. Results: The mean interval between injury and flap reconstruction in the early-repair group with 6.15 ± 1.82 postoperative days (PODs) was significantly shorter than that of the delayed-repair group with 16.46 ± 4.09 PODs (p < 0.001). The flap harvest time, reconstructive time, and intraoperative blood loss were also significantly less in the early-repair group compared to the delayed-repair group. Interestingly, we observed an 8.20% enlargement of wound size due to multiple debridements in the delayed-repair group. Most importantly, the early-repair group had better outcomes with a decreased risk of total or partial flap necrosis, lower incidence of flap complications, and fewer overall late complications than the delayed-repair group. In addition, the LoS, as well as wound and bone healing time, were notably shorter in the early-repair group. Furthermore, 4.85% of cases in the delayed-repair group experienced additional operations on bone, while no additional operations were performed in the early-repair group. All cases in both groups obtained satisfying functional results, while the early-repair group showed better functional recovery. Conclusions: Early repair with free flaps performed within two instances of debridement had superior outcomes when compared with delayed reconstruction after multiple debridements, consistent with Godina’s findings. We recommended early referral to a higher-level hospital with orthoplastic capabilities after an aggressive and thorough initial debridement carried out by senior surgeons.

Utility of Indocyanine Green Angiography for Preventing Pre-expanded Extended Lower Trapezius Myocutaneous Flap Necrosis: How to Make the Correct Decision for Hypoperfused Areas.

Designing a skin flap that perfectly covers the anatomical and dynamic territories is challenging. Tissues capturing territories beyond may be insufficiently perfused, and these hypoperfused areas can lead to partial flap necrosis. Indocyanine green angiography (ICGA) is an effective tool for identifying hypoperfused areas. This retrospective study proposes a standardized strategy for managing the hypoperfused areas identified by ICGA in pre-expanded extended lower trapezius myocutaneous (e-LTMC) flaps. Patients who underwent pre-expanded e-LTMC flap surgery with perfusion assessment using ICGA between June 2016 and January 2022 were identified. A standardized protocol was applied, and patients were divided into four groups according to different management options for hypoperfused areas detected by ICGA. Preoperative and operative variables of interest and postoperative outcomes, including flap necrosis and flap survival length, were collected and analyzed. Sixty-nine flaps were included in the study. No total flap necrosis was observed. Partial necrosis occurred in 10 flaps. Significant differences were observed in the incidence of full-thickness necrosis between the management groups. The incidence of flap necrosis in cases where management relied on ICGA findings was significantly lower than that of cases where management did not rely on ICGA findings. There were no differences in the relative survival length of the flap between cases with and without intervention for the hypoperfused areas. The proposed standard strategy effectively reduced the necrosis rate of the pre-expanded e-LTMC flap, thus it is sensible to act on the ICGA findings. Prophylactic resection of the hypoperfused area should be recommended. Where resection may lead to poor reconstructive outcomes, flap trimming or a second flap should be the preferred option.