Vascularized Flap Research Articles

Analysis of changes in bone mineral density and cortical bone thickness after reconstruction of the mandible with fibula, is condyle preservation a critical influence factor?

This study aimed to investigate the features of bone mineral density (BMD) and cortical bone thickness in grafted fibula. Eighty-six patients who underwent mandibular reconstruction using vascularized fibula flaps were enrolled, all of whom were followed up at 3, 6, and 12 months after surgery. The patients were grouped according to whether the condyle was preserved. BMD and cortical bone thickness were also measured. Condyle-preserved group consisted of 65 patients and condyle-unpreserved group consisted of 21 patients. There was a significant correlation between thickness and BMD, which was significantly correlated with follow-up time. One year after surgery, the BMD of the condyle-preserved group decreased from 1029.61 ± 156.01mg/cm3 to 978.6 ± 141.90mg/cm3, and thickness decreased from 3.29 ± 0.65mm to 2.72 ± 0.72mm. BMD of the condyle-unpreserved group decreased from 1062.21 ± 126.01mg/cm3 to 851.26 ± 144.38mg/cm3, and thickness decreased from 3.46 ± 0.89mm to 2.56 ± 0.73mm. In the condyle-preserved and unpreserved groups, the absorption rates of BMD were 3.29 ± 11.97% and 17.09 ± 12.42% at 12 months, respectively, and the rate of thickness was 20.7 ± 11.45% and 26.39 ± 12.23% at 12 months, respectively. BMD and thickness showed a decreasing trend over time. Preserving the condyle can slow bone resorption of the fibula. Regarding implant restoration, we recommend doctors to perform the treatment within 6-12 months after surgery in order to effectively manage bone resorption. Our study found that condylar preservation can decrease the absorption rate of BMD and cortical bone thickness, helping doctors make better clinical decisions. ChiCTR2300069661 (March 22, 2023).

Anterior Skull Base Reconstruction Using a Vascularized Pericranial Flap: A Promising Alternative in Sinonasal Malignancies

Abstract Background As the scope of endoscopic techniques continues to evolve in the treatment of advanced sinonasal malignancies, the primary challenge is the reconstruction of the resulting anterior skull base dural defect. Objective This study aimed to assess the efficacy of vascularized pericranial flap reconstruction in addressing anterior skull base defects in sinonasal malignancies, particularly when alternative reconstructive methods, such as nasoseptal flaps, are not viable. Methods We conducted a retrospective review of nine patients who underwent endoscopic resection of sinonasal malignancy followed by vascularized pericranial flap. Our analysis aimed to evaluate the surgical methods utilized, identify any complications that occurred, and assess the postoperative results of the patients. Results Excluding the singular instance of tension pneumocephalus that emerged during the immediate postoperative period, necessitating surgical intervention, our clinical experience was devoid of any complications, with a median follow-up duration of 18 months. It is worth noting that no cases of cerebrospinal fluid leaks or meningitis were reported. Moreover, the follow-up check endoscopy verified the successful integration of the flap and its efficacious coverage of the resection site. Conclusion This study underscores the benefits of using vascularized pericranial flaps as an alternative solution for anterior skull base reconstruction in sinonasal malignancies. The availability of the pericranial flap in the local region, along with its robust blood supply, and the positive outcomes observed in this preliminary series collectively indicate its potential as an integral component of multi-layered reconstruction techniques for addressing anterior skull base defects.

Comparative Study Between Autologous Platelet-rich Fibrin Membrane and Local Flaps as Intervening Layer in Management of Distal Hypospadias

Background/PurposeThe most frequent complication following hypospadias correction is fistula formation. Recently, fibrin glue has been employed as a 2nd layer covering the urethroplasty resulting in a reduction in the incidence of fistulas. Platelet-rich fibrin (PRF) is an autologous growth factor-rich source. Although the authors recommend the use of additional layers in hypospadias correction, there remains a controversy. In a trial to address this issue, our research was conducted to compare the accessibility of urethroplasty coverage using PRF to traditional local flaps, aiming to prevent fistula formation in hypospadias repair. Patients and methodsThis is a prospective single-blinded randomized controlled study that involved 60 hypospadias cases admitted to Mansoura University Children Hospital's Pediatric Surgery department between March 2021 and March 2023. These 60 cases were randomly divided into 2 equal groups: (group A platelet-rich fibrin coverage membrane & group B local dartos flap as an additional layer). Both groups were compared regarding the rate of complications. All cases were evaluated regarding age at repair, type of hypospadias, urethral plate width, length of urethroplasty, and size of the 2nd layer. The blood loss and operative time were documented and post-operatively; the cases were assessed for the repair intactness, shape, and size of the neo-meatus, existence of any post-operative problems such as urethral fistula, urethral stricture, meatal stenosis, failure of the repair, or diverticulum. Statistical analysis was carried out following data collection. ResultsThe median length of the 2nd layer in group A was 20 mm (range 15–23 mm) and in group B was 22.5 mm (range 19.5–25 mm) and the difference between the two groups was statistically significant (p = 0.012∗), while its median width in group A was 10 mm (range 10–11 mm) and in group B was 15 mm (range 10–18 mm) and also there was statistically significant difference (p = 0.001∗). The mean operative time in group A was 95.73 ± 11.9 min and in group B was 102.33 ± 10.32 min and there was a statistically significant difference (P < 0.001). The length of hospital stay in group A was 5.47 ± 1.11 days and in group B was 5.47 ± 0.89 days. The urethral fistula was detected in 4 cases of group A (13.3%) and 3 cases of group B (10%). The failure of repair was similar, one case of each group (3.3%). The meatal stenosis was reported in only one case of group A (3.4%) and 7 cases of group B (24.1%) (P = 0.02∗) and the difference was statistically significant. There were no reports of urethral strictures among the cases in either group over the follow-up period (mean 9 months, range 5–17 months). ConclusionPRF patch may be employed as a coverage layer over the urethroplasty in repair of the distal hypospadias, especially in cases without accessible vascular flap with comparable outcome to traditional local flaps. Type of studyA prospective single blinded randomized controlled trial (computer-generated numbers method). Level of evidenceLevel 2.

Preparation of vascularized forearm dermal fat flap and repairing of donor site

Objective:This study prepared vascularized dermal fat flaps and introduced a local split-thickness skin graft from an in situ cutaneous area cutaneous area to manage forearm flap donor sites and evaluated the esthetic and functional outcomes post-operatively. From July 2020 to June 2023, 13 patients with soft tissue defects in Oral and Maxillary Area were repaired with tvascular forearm dermal fat flap. There were 8 males and 5 females, aged from 42-71 years. The flaps ranged from 8 cm×7 cm to 7 cm×5 cm in size. The donor site defects were covered by local split-thickness skin graft from the in situ skins. The color matching degree, surgical scars, ranges of wrist movement and hand sensations in donor forearms were assessed at 6 months after surgery. Results:The tvascular forearm dermal fat flaps for 15 cases all survived. All the local split-thickness skin grafts transplanted with this technique showed primary healing. The follow-up period for 6 months, Donor site exhibited suitabler color matching and there was not severe complications. Conclusion:The vascularized dermal fat flap provides an alternative to conventional forearm flap harvest, which enables primary donor site closure with reduced rates of delayed donor site healing. The vascularized dermal fat flap is a relatively reliable repair method for soft defects in Oral and Maxillary Area.

A Case of Nasoseptal Flap Reconstruction for Refractory Medial Canthal Fistula.

Sino-orbital cutaneous fistulas (SOCFs) are a rare and challenging complication from conditions including granulomatosis with polyangiitis. SOCFs are difficult to manage due to poor vascular supply, compromised tissue, and systemic immunocompromise, which lead to a high rate of recurrence. Given the overall rarity of SOCFs, optimal surgical repair remains controversial, with options ranging from conservative management, onlay grafts, and vascularized flaps. This case report describes a novel one-step approach to SOCF closure using a composite chondral mucosal nasoseptal flap in a patient with a large left medial canthal SOCF that had recurred despite 2 prior attempts at closure including a vascularized paramedian forehead flap. Nasoseptal flaps may provide vascularized mucosal tissue to allow for greater success in closure over traditional, external flaps, and skin grafts.

Effect of vascularized jejunal conduit flap on peripheral nerve regeneration in rats.

In the literature, almost all of the nerve conduits proposed for obtaining better nerve recovery were applied as graft materials. In this study, we aimed to propose a new nerve conduit model with a flap pattern and evaluate the effect of a pedicled vascularized jejunal flap on nerve regeneration after wrapping it around a sciatic nerve. A total of 90 Wistar albino rats were randomly divided into nine groups with 10 rats in each. The first three groups constituted the control groups, whereas Groups 4-6 were the jejunum conduit (JC)-applied groups. A mucosa-resected JC (MRJC) was applied in Groups 7 and 8. Epineurial neurorrhaphy was performed in Groups 1, 4, and 7; repair with a nerve graft was applied in Groups 2, 5, and 8; and a 1-cm-long nerve defect was created in Groups 3, 6, and 9. After 2 months of follow-up, nerve regeneration was assessed by statistical analyses of the Sciatic Functional Index (SFI) and histopathological evaluation. The MRJC groups had significantly better results in terms of SFI (p = 0.005). Statistical differences in axonal degeneration, axonal density, myelination, and disorganization were found between all control groups and MRJC groups (p = 0.022, p = 0.001, p = 0.001, and p = 0.039, respectively). In this study, the feasibility of wrapping around the nerve repair zones of pedicled autologous flaps designed in a tubular fashion was observed in a small rat model. The findings must be further validated with larger animals before clinical testing.

Multi-factor early monitoring method based on D-dimer for iliac crest flap loss

BackgroundIn recent years, the utilization of autogenous vascularized iliac crest flap for repairing jaw defects has seen a significant rise. However, the visual monitoring of iliac bone flaps present challenges, frequently leading to delayed detection of flap loss. Consequently, there’s a urgent need to develop effective indicators for monitoring postoperative complications in iliac crest flaps.MethodsA retrospective analysis was conducted on 160 patients who underwent vascularized iliac crest flap transplantation for jawbone reconstruction from January 2020 to December 2022. We investigated the changes in D-dimer levels among patients with or without postoperative complications. Additionally, multivariable logistic regression analysis was performed to explore potential individual risk factors, including surgical duration, age, pathology type, absolute and relative D-dimer levels, and gender, culminating in the development of a nomogram.ResultsOn the first day following surgery, patients who experienced thrombosis exhibited a substantial increase in plasma D-dimer levels, reaching 3.75 mg/L, 13.84 times higher than the baseline. This difference was statistically significant (P < 0.05) compared to patients without postoperative complications. Furthermore, the nomogram we have developed and validated effectively predicts venous thrombosis, assigning individual risk scores to patients. This predictive tool was assessed in both training and validation cohorts, achieving areas under the curve (AUC) of 0.630 and 0.600, with the 95% confidence intervals of 0.452–0.807 and 0.243–0.957, respectively.ConclusionsOur study illustrates that postoperative plasma D-dimer levels can serve as a sensitive biomarker for monitoring thrombosis-induced flap loss. Moreover, we have developed a novel prediction model that integrates multiple factors, thereby enhancing the accuracy of early identification of patients at risk of thrombosis-associated flap loss. This advancement contributes to improving the overall management and outcomes of such procedures.

The lateral based nasopharyngeal flap: A novel vascularized flap for skull base reconstruction.

As the indications for endoscopic skull base approaches have increased, so has the need for more versatile vascularized flaps for skull base reconstruction. Here, we describe a novel lateral based nasopharyngeal flap (LNPF). Two cadaver heads were dissected to elucidate flap anatomy, dimensions, and technique. A retrospective review was performed on two cases where LNPF was used to repair CSF leaks in the nasopharyngeal area, and outcomes reported. The LNPF is an ascending pharyngeal artery myomucosal flap that includes the nasopharyngeal mucosa and the superior pharyngeal constrictor muscle. The flap was 1.2 × 2.2 cm in greatest dimensions. The LNPF was used for salvage CSF leak repair in two cases: one clival and one tubal. Both patients had resolution of leak at 7 months follow-up. The LNPF is a novel flap with reconstruction potential for the nasopharynx, including the lower clivus and the eustachian tube.

Alberta reconstructive technique (ART): An innovative approach using digital surgical design and simulation in advanced jaw reconstruction with occlusion-based prefabricated vascularized fibular flaps and primary osseointegrated implant installation.

The Alberta reconstructive technique (ART) is an innovative surgical procedure performed on patients undergoing primary jaw resection and reconstruction. The ART procedure was developed in collaboration with the Institute for Reconstructive Sciences in Medicine and the Division of Otolaryngology-Head and Neck Surgery, University of Alberta.

Comparative Study between Vascularized Flap and Free Graft in CSF Rhinorrhoea (success rate): Meta-Analysis Study

Abstract Background CSF rhinorrhea refers to CSF leakage into the nasal cavity. Most commonly, CSF enters the nasal cavity through defects in the anterior skull base. CSF leak is a serious condition occurring spontaneously or as a result of increased ICP, head trauma, surgery, neoplastic invasion, inflammatory erosion of the skull base, or congenital malformations. Objective Our meta-analysis study is to compare between free grafts and prdicled nasal flaps in repairing CSF rhinorrhea regarding success rate, complications, operative time and hospital stay. Methodology The total number of patients in all the included studies was 524 patients; 339 in the free graft group and 185 in the vascularized flap group. Results Our meta-analysis study showed that success rate in free graft group was 88.5%, while, in vascularized flap group was 93% and the complications rate in free graft group was 39%, while, in vascularized flap group was 39.3%. The result of our meta-analysis showed no significant difference between free grafts and vascularized nasal flaps in reconstruction of skull base in CSF rhinorrhea regarding success rate and complications rate. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2021. Conclusion We found no significant difference between free grafts and vascularized nasal flaps in reconstruction of skull base in CSF rhinorrhea regarding success rate and complications rate. Choosing between them depends on the surgeon’s experience and the location and the size of the defect.

Continuous oxygen monitoring to enhance ex-vivo organ machine perfusion and reconstructive surgery

Continuous oxygenation monitoring of machine-perfused organs or transposed autologous tissue is not currently implemented in clinical practice. Oxygenation is a critical parameter that could be used to verify tissue viability and guide corrective interventions, such as perfusion machine parameters or surgical revision. This work presents an innovative technology based on oxygen-sensitive, phosphorescent metalloporphyrin allowing continuous and non-invasive oxygen monitoring of ex-vivo perfused vascularized fasciocutaneous flaps. The method comprises a small, low-energy optical transcutaneous oxygen sensor applied on the flap's skin paddle as well as oxygen sensing devices placed into the tubing. An intermittent perfusion setting was designed to study the response time and accuracy of this technology over a total of 54 perfusion cycles. We further evaluated correlation between the continuous oxygen measurements and gold-standard perfusion viability metrics such as vascular resistance, with good agreement suggesting potential to monitor graft viability at high frequency, opening the possibility to employ feedback control algorithms in the future. This proof-of-concept study opens a range of research and clinical applications in reconstructive surgery and transplantation at a time when perfusion machines undergo rapid clinical adoption with potential to improve outcomes across a variety of surgical procedures and dramatically increase access to transplant medicine.

Conversion Total Hip Arthroplasty After Pedicled Peri-Hip Bone Flap Grafting: The Chinese Experience

BackgroundThis study investigated the perioperative outcomes of patients undergoing conversion total hip arthroplasty (THA) after failed peri-hip bone flap grafting (PBFG) and compared them with those patients undergoing primary THA for osteonecrosis of the femoral head (ONFH). MethodsFrom January 2010 to December 2021, 163 Chinese patients (163 hips) were treated by conversion THA after failed PBFG (containing 94 patients who had pedicled vascularized iliac bone flap grafting and 69 patients who had pedicled vascularized greater trochanter bone flap grafting), and 178 Chinese patients were treated by primary THA. The preoperative baseline data and perioperative indicators in both groups were compared. ResultsIn the conversion group, patients had significantly greater blood loss, a longer length of stay, and greater changes in serum hemoglobin than those in the primary THA group (P < 0.05). The operative room time, transfusion volume, calculated blood loss, changes in serum hematocrit, and increased superficial infection (P > 0.05) in the conversion group were greater compared with the primary cohort; however, the difference was not statistically significant. The mean postoperative Harris Hip Scoring system (HHS) of the PBFG group at the 1-month follow-up was 81, and the control group had a score of 82. Importantly, subgroup analysis of the PBFG group indicated that there was no significant difference between patients who had prior pedicled vascularized iliac bone flap grafting and pedicled vascularized greater trochanter bone flap grafting (P > 0.05), except for the operative room time (P = 0.032). ConclusionsHip-sparing surgery of ONFH did not make THA more difficult or lead to more perioperative complications, but increased blood loss and extended hospital stay from a prior PBFG are still notable problems in clinical practice. Thus, it is necessary for surgeons to focus attention on the improvement of the preoperative condition and prepare for any specific intraoperative challenges.

Lower Eyelid Reconstruction with Mustardé Flap

Restoring defects in the lower eyelids, particularly those that extend beyond two-thirds, can be challenging, especially after tumor resection. Basal cell carcinoma (BCC) is the most common form of skin cancer, affecting the lower eyelid and inner canthus. Grafts are often combined with flaps for replacing the posterior lamella or anterior lamella. The Mustardé rotational cheek flap is a popular choice for reconstructing the anterior lamella of the lower eyelid, as it meets the basic requirements of an ideal cutaneous flap. This wide-based pedicle flap can support free grafts needed to line the inside of the flap. Other autogenous grafts, such as labial mucosa, hard palate mucoperiosteum, auricular cartilage, and nasoseptal cartilage, have also been used in eyelid reconstruction. However, hard palate mucosa transplants provide uniformity and can be expensive. Hughes procedures are not suitable for individuals with amblyogenic age or one-seeking eyes. Combining a vascular flap with a superior graft like pericranium may provide a viable surgical option for enduring functional and aesthetic outcomes.

Comparison of limb reconstruction with vascularized fibula flap versus induced membrane technique in 54 pediatric cases over 16 years

BackgroundChildren's bone loss of limbs represents a significant challenge for surgeons, especially given that children are growing individuals. In the pediatric population, we compared bone reconstruction using vascularized fibula flaps with the induced membrane technique. The primary purpose of this study was to evaluate the delay and quality of consolidation. Methods.Data from patients who underwent limb reconstruction using either the fibula flap or the induced membrane were retrospectively collected from files across two centers. Perioperative and long-term complications were documented, along with functional and aesthetic outcome. ResultsBetween 2004 and 2020, 31 children underwent limb reconstruction using a fibula flap, and 13 patients were treated using the induced membrane technique. The etiologies included 76% tumors, 20% congenital pseudarthroses, and 3.7% infections. The median size of the bone resection was 12.5cm (range: 1.8 to 31cm). The median time to consolidation after free fibula flap transfer was 10 months (range: 2 to 55 months) versus 7.5 months (range: 1 to 64 months) for the Masquelet technique (p=0.54). Limb length inequality occured in 52% of fibula cases and 39% of the induced membrane cases (p=0.55). ConclusionsBoth of free fibula flap and the induced membrane technique are effective options for bone reconstructing long bones in children. These techniques yield good functional outcomes and have comparable consolidation times.

Multiple Buttresses Reconstruction of Maxilla with Fibular Flap Using Computer-aided Design/Computer-aided Manufacturing after Maxillectomy.

The maxilla comprises horizontal and vertical buttresses, each with specific functions, supporting various organs, such as the eyes, nose, and oral cavity. Notably, they combine to form a three-dimensional structure, which enables the buttresses to provide their inherent support strength. However, reconstructing the maxilla after maxillectomy by assembling new buttresses is challenging. We successfully reconstructed all the buttresses crucial for facial appearance and dental rehabilitation using a vascularized fibular flap. Four patients underwent maxillary buttress reconstruction with a fibular flap after total or subtotal maxillectomy. We used computer-aided design/computer-aided manufacturing digital technology to osteotomize the fibula into multiple segments and assemble them to reconstruct the maxillary buttresses. Each buttress was assembled based on a preoperative simulation. All patients underwent immediate one-stage maxillary reconstruction. They had good maxillary buttress alignment and acquired good facial appearance, eye position, nasal airway, and prosthetically suitable maxillary alveolus ridge. The combination of computer-aided design/computer-aided manufacturing digital technology and surgical techniques has enabled novel maxillary reconstruction, providing great hope to patients experiencing facial disfigurement and loss of function after maxillectomy.

Surgical Reconstruction of Type IV Hypoplasia of the Thumb (Floating Thumb) in Infants: A Retrospective Analysis of Functional Outcomes and Radiographic Alignment.

BACKGROUND Congenital hypoplasia of the thumb type IV, also known as floating thumb, is a condition in which 2 small phalanges are attached to the hand with a thin skin bridge. Surgical management options for this condition vary from amputation to flap reconstruction. MATERIAL AND METHODS This retrospective study analyzed 11 infants with congenital hypoplasia of the thumb type IV who underwent surgical reconstruction using a modified vascularized polydactylous hallux flap. The study included 6 male and 5 female infants, aged 6 to 24 months. Functional evaluations and radiographic studies were conducted postoperatively. RESULTS All 11 patients underwent the complete surgical protocol. Successful vascular and nerve anastomoses were performed during the initial procedure, ensuring sufficient blood supply and neural connectivity to the transferred toes. The second operation showed promising outcomes, including improvements in thumb opposition, grasp strength, and overall function. Postoperative assessments demonstrated satisfactory radiographic alignment and no major complications during the follow-up period. CONCLUSIONS The modified vascularized polydactylous hallux flap reconstruction is a viable surgical option for managing congenital hypoplasia of the thumb type IV in infants. This technique effectively restores thumb opposition, grasp strength, and overall hand function, with satisfactory radiographic alignment and minimal complications. The study findings support the efficacy and safety of this surgical approach in addressing this rare congenital anomaly.

Frontal sinus reconstruction with overlapping sinus mucosa and vascularized pericranial flap Coverage after modified transbasal bifrontal craniotomy: Novel technique and clinical outcomes

BackgroundThe modified transbasal bifrontal craniotomy is a variant of the bifrontal craniotomy with a wider surgical corridor than the standard approach. There are several methods for frontal sinus repair in bifrontal craniotomy. This study reports a novel method for frontal sinus repair in the modified transbasal interhemispheric approach by precisely overlapping the frontal sinus mucosa margin (without frontal sinus mucosa exenteration) with packing the frontal sinus with povidone-soaked gel foam and covering it with a vascularized pericranial flap. MethodsIn this case series, we retrospectively collected the clinical outcomes regarding cerebrospinal fluid (CSF) leakage, meningitis, and mucocele formation of patients who underwent modified transbasal bifrontal craniotomy at Vara Hospital. ResultsFrom January 2016 to December 2021, 65 patients with anterior skull-base lesions were treated with a modified transbasal interhemispheric approach with frontal sinus repair by overlapping frontal sinus mucosa with gel foam packing and vascularized pericranium flap covering. There was no case of postoperative CSF leakage, meningitis, or mucocele formation during the follow-up period of 19.2 months (min 1, max 73). ConclusionsWe demonstrated that the modified transbasal interhemispheric approach with frontal sinus repair using gel foam packing and pericranial flap is effective in preventing postoperative CSF leakage and meningitis.

Revisiting the Use of Deep Temporalis Fascia Grafts in Ophthalmology

ABSTRACT Purpose To report new indications for deep temporalis fascia (DTF) grafts in the ophthalmic field. Methods Monocentric retrospective interventional case series study. All the patients who underwent a DTF graft in an unpublished new indication over the study period (May 2020–October 2023) were included. For each patient, gender, age, graft indication, outcomes, complications, and follow-up duration were collected. In most cases, the DTF graft was covered by a vascularized flap. Results Eight patients underwent a DTF graft over the study period. The indications were: radiotherapy-induced scleral necrosis in three cases, tendinoplasty to replace the inferior rectus muscle tendon invaded by a locally advanced conjunctival carcinoma in one case, Ahmed glaucoma valve tube exposure in one case, intraocular lens with scleral fixation exposure in one case, orbital cerebrospinal fluid fistula (orbitorrhea) in one case, and post-traumatic complete corneal graft loss in one case. The DTF graft was successful in 87.5% of cases after a mean follow-up of 11.4 months. No complications were observed. Conclusions DTF graft is a highly versatile graft that can be easily harvested. New indications for DTF grafts may include the repair of radiotherapy-induced scleral necrosis, the creation of oculomotor tendon and the temporary packing of large ocular tissue loss in an emergency context. Further studies with a longer follow-up are needed to confirm our preliminary results.

Long-Term Treatment Outcome of a Patient with Extensive Circular Soft Tissue Defect of the Distal Third of the Lower Extremity: A Case Report

Background. Open fractures of the lower leg bones associated with extensive soft tissue defects are among the most challenging in trauma surgery.&#x0D; Aim of the study is to demonstrate the possibilities of modern reconstructive surgery in the treatment of severe polystructural trauma of the lower limb using a unique clinical example.&#x0D; Case description. An 18-year-old patient sustained a polytrauma which included head and extremities injuries as a result of a fall under a moving train. Due to the signs of uncompensated ischemia of the left lower limb at the first stage of treatment the patient underwent emergency left tibial artery thrombectomy, repeated debridement of the left lower leg wound, remounting of the external fixator, and lumbar sympathectomy. The second stage of surgical treatment included free transplantation of a vascularized anterolateral flap of the right thigh. The third stage included staged necrectomies; replacement of the soft tissue defect of the posteromedial surface of the distal lower leg with a sural fasciocutaneous vascularized flap on the distal vascular pedicle from the contralateral tibia; the fourth stage included cutting off the fasciocutaneous cross flap. At the follow-up, 2 years after the end of the treatment the patient complained of persisting swelling of the foot, which occurred during prolonged standing in the upright position and required elastic compression of the ankle joint. The cause of the swelling was impaired lymphatic outflow due to the damage to all venous collaterals in the injury area. She walks with full load on the injured limb without additional support. There is no pain syndrome, foot sensitivity is fully preserved.&#x0D; Conclusion. Presented clinical case demonstrates the possibility of successful replacement of an extensive circular defect of the distal lower leg using sequentially free and non-free vascularized tissue complexes.

Vascularized fascial flap for reconstruction of combined oral mucosa-mandibular defects: The multi-modal biological assessment

ObjectiveThe reconstruction of composite defects in the oral and maxillofacial region using vascularized fascial flaps, such as the fibular, iliac, and temporal fascial flaps, has gained increasing attention among surgeons. However, there remains uncertainty regarding the suitability of fascial flaps as transplants, as well as their healing processes and outcomes, due to their non-mucosal nature. This study aims to comprehensively assess the biological aspects of vascularized fascial flaps at clinical, histological, and genetic levels, with the goal of providing essential biological references for their clinical application. Study DesignThis study enrolled three patients who underwent reconstruction of combined oral mucosa-mandibular defects using fibular vascularized fascial flaps between 2020 and 2023. Data regarding changes in the appearance of the fascial flaps, bulk-RNA sequencing, and histological slices of initial fascia, initial gingiva, and transformed fascia were collected and analyzed. ResultsWithin three months, the fascial flaps exhibited rapid epithelial coverage and displayed distinct characteristics resembling mucosa. High-throughput RNA sequencing analyses and histological slices revealed that the transformed fascia exhibited tissue structures similar to mucosa and demonstrated unique advantages in promoting blood vessel formation and reducing scarring through the high-level expression of relevant genes. ConclusionThese findings emphasize the potential and feasibility of utilizing vascularized fascial flaps for oral mucosa reconstruction, establishing their unique advantage as transplant materials, and providing significant biological information and references for their selection and clinical application.