Vascularized Tissue Transfer Research Articles

Management of thoracic aortic graft infections with combined omental and bilateral pectoralis major flaps

BackgroundAortic vascular graft/endograft infection (VGEI) has historically been managed through graft removal and re-replacement, but new approaches suggest vascularized tissue transfer is an effective adjunctive treatment. Here we describe our experience with treating thoracic aortic vascular graft infection with combined omental and bilateral pectoralis major myocutaneous (PMM) advancement flaps. MethodsAll patients undergoing combined flap closure by the senior author at a high-acuity cardiac surgery center from 1995-2023 were reviewed. Patients with clinical and radiographic signs of thoracic aortic vascular graft infection were included. ResultsComplete data were available for 598 patients with sternal and mediastinal wounds. Combined PMM and omental flaps were mobilized in 11 thoracic aortic vascular graft infection patients. Indications for flap management included culture-positive infection (8/11; 72.7%), dehiscence (5/11; 45.5%), drainage (7/11; 63.6%), and inability to close the sternotomy due to hemodynamic instability (5/11; 45.5%). During chest exploration, 6/11 (54.5%) underwent complete removal of the infected graft, compared to 5/11 (45.5%) who underwent graft-preserving washout and debridement. Immediate flap closure was performed in 6/11 (54.5%). Post-op complications included dehiscence (2/11; 18.2%), seroma (1/11; 9.1%), hematoma (1/11, 9.1%), abdominal hernia (1/11; 9.1%), and recurrent infection (1/11; 9.1%). One patient (9.1%) died within 30 days of sternal reconstruction from mitral valve failure tachyarrhythmia. None has undergone reoperation for flap-related complications. ConclusionsDespite significant comorbidities, low postoperative morbidity and mortality indicate that combined omental and pectoralis major flaps are a safe and effective adjunctive treatment to the antimicrobial and surgical management of select thoracic aortic vascular graft infections.

Endoscopic endonasal obliteration of the frontal recess and anterior skull base.

Although endoscopic techniques have become more widespread in repair of frontal sinus (FS) defects, certain pathologies still require open approach (extensive trauma or tumors). Under certain circumstances even multiple complex open reconstructive procedures might fail to resolve persistent pneumocephalus or CSF leak and subsequently surgeons tend to escalate the invasiveness and employ even more complex and aggressive approaches. We present our experience treating persistent pneumocephalus or CSF leak after previously failed transcranial reconstruction utilizing an endoscopic endonasal approach (EEA). We retrospectively reviewed a prospectively maintained database of all patients undergoing an EEA for repair of persistent pneumocephalus or CSF leak following FS cranialization between 2016 and 2020. Six patients who underwent cranialization of the FS with subsequent persistent pneumocephalus or CSF leak were identified; two patients suffered a traumatic fracture of the FS, remaining four patients had undergone previous cranial surgery. Clear violation of the FS was not recognized in one patient. All patients underwent cranialization of the FS either directly following initial craniotomy or during open repair of a FS fracture. Two patients underwent multiple transcranial surgeries including using vascularized free tissue transfer. Complete cessation of pneumocephalus/CSF leak was achieved in 83.3% (5/6) after the first and 100% (6/6) after two endoscopic procedures. No morbidity or mortality resulted from the endoscopic procedure. Skull base defects following a failed cranialization of FS are usually located in or in close proximity to the frontal recess. These defects can be safely and effectively repaired via an EEA.

Bilateral Inferior Turbinate Flaps for Salvage Reconstruction after Proton Beam Radiotherapy for Clival Chordoma.

Clival chordoma is a rare, aggressive, notochord-derived tumor primarily managed with surgery via an endoscopic endonasal approach (EEA) and adjuvant proton beam radiotherapy. Reconstruction is commonly performed with a nasoseptal flap (NSF) at the time of initial surgery. While failures of the NSF are rare, they can occur following the initial surgery or in the setting of osteoradionecrosis. Salvage repair typically requires transfer of alternative vascularized tissues outside of the previously radiated field including regional scalp flaps such as pericranial or temporoparietal fascial flaps, or free vascularized tissue transfer. Here we describe the case of a 29-year-old woman with a history of clival chordoma with widespread skull base osteomyelitis secondary to NSF necrosis after proton beam radiotherapy. We describe successful skull base reconstruction with intranasal bilateral inferior turbinate flaps based on the sphenopalatine artery with lateral nasal wall extension, despite prior proton beam therapy and a failed prior vascularized intranasal reconstruction.

Management of “Large” Vascular Malformation: An Institutional Review

Background: Large vascular malformations (VM) are complex lesions anatomically, functionally or both. The criteria to define “Large” vascular malformations were unclear. This study aims to retrospectively identify Large VM based on clinical features and discussed about the method we adopted in management. Methods: This is retrospective study of analyzing all patients of vascular malformations treated by us since 2003. The criteria to categorize large vascular malformations were outlined after analyzing the anatomical area of involvement, functional disturbances by these lesions, operability of the lesions, morbidity associated with resection, and the requirement of reconstruction. All cases were managed by a multi-disciplinary team. Various methods utilized to control the bleeding varied from simple wound packing to cardiopulmonary bypass (CPB) assistance. The resection was either curative or palliative. Complete excision in the form of radical resection was carried out in all possible cases intended with curative aim. Vascularized tissue transfer was done to reduce the morbidity following surgical resection. Results: Out of 268 patients, 26 patients fulfilled the criteria for large vascular malformations. The predominant site of involvement is head and neck. 80% had more than one indication for surgery. Majority of the cases 54% were arterio-venous malformations (AVM) followed by 31% of capillary venous malformations (CVM). The commonest indication for surgery is bleeding in 73% followed by cosmetic disfigurement in 61.5%. Compressive wound packing with delayed wound closure and preoperative embolization were the commonly employed methods for bleeding control. CPB assisted resection was carried out in 5 cases. On analysing the recurrence, 7.7% had in complete excision, 36% in incomplete excision and 12% in cases of vascularized tissue transfer. Conclusion: The clinical criteria outlined in our study will be useful in identifying “Large” vascular malformations. Compression wound packing with delayed closure plays a major role in bleeding control immediately after resection. CPB assistance for aiding resection can be considered in selected cases. Complete resection in the form of radical excision will reduce the recurrence. Palliative resection provides symptom free disease when complete resection is not viable. The tissue transfer for the wound cover controls the residual disease in cases of incomplete resection.

Composite TFL flap for reconstruction of knee extension, a case report

Deficiency of the knee extensor mechanism may result from severe injury, loss of structural tissues after tumor resection or complications due to joint replacement surgery. Current treatment options for extensive defects are limited, yielding unsatisfactory functional results and high complication rates. Here, we propose for the first time the use of a free vascularized tissue transfer to reconstruct the extensor mechanism of the knee. The tensor fasciae latae free flap provides sufficient vascularized muscle and fascia as well as a large skin paddle. We present the anatomical concept and long-term outcomes in a patient. • Use of a free, vascularized TFL flap for reconstruction of the knee extensor mechanism is feasible. • A musculotendinous flap can be used to replace the distal quadriceps and patellar tendon, including a skin island if necessary. • Our patient achieved stable ambulation and ability to perform sports such as running or cycling.

A Combined Transoral and Contralateral Submandibular Approach in the Surgical Management of Osteoradionecrosis of the Mandible With Free Flap Reconstruction

We describe a method for performing mandibular resection and vascularized tissue transfer via an intraoral and contralateral submandibular approach to minimize the risk of wound complications in a radiated field. Surgery on radiated tissue associated with osteoradionecrosis of the mandible can present with oral cutaneous fistulas, dense fibrotic skin, and altered tissue planes to make dissection through this tissue tedious and can place the marginal mandibular nerve at increased risk of injury. The use of custom plates allows surgeons to minimize incisions and depend less on anatomic/visual cues during surgery to obtain an accurate result. Our experience in 8 patients has shown a predictable method for resection and reconstruction of the mandible, while minimizing the potential complications associated with previously radiated and operated patients.

Bone Regeneration Exploiting Corticoperiosteal Tissue Transfer for Scaffold-Guided Bone Regeneration.

Contemporary reconstructive approaches for critical size bone defects carry significant disadvantages. As a result, clinically driven research has focused on the development and translation of alternative therapeutic concepts. Scaffold-guided tissue regeneration (SGTR) is an emerging technique to heal critical size bone defects. However, issues synchronizing scaffold vascularization with bone-specific regenerative processes currently limit bone regeneration for extra large (XL, 19 cm3) critical bone defects. To address this issue, we developed a large animal model that incorporates a corticoperiosteal flap (CPF) for sustained scaffold neovascularization and bone regeneration. In 10 sheep, we demonstrated the efficacy of this approach for healing medium (M, 9 cm3) size critical bone defects as demonstrated on plain radiography, microcomputed tomography, and histology. Furthermore, in two sheep, we demonstrate how this approach can be safely extended to heal XL critical size defects. This article presents an original CPF technique in a well-described preclinical model, which can be used in conjunction with the SGTR concept, to address challenging critical size bone defects in vivo. Impact statement This article describes a novel scaffold-guided tissue engineering approach utilizing a corticoperiosteal flap for bone healing in critical size long bone defects. This approach will be of use for tissue engineers and surgeons exploring vascularized tissue transfer as an option to regenerate large volumes of bone for extensive critical size bone defects both in vivo and in the clinical arena.

Retrospective study of the efficacy of vascularized tissue transfer for treating antibiotic-resistant bacteria-infected wound: Comparison with clean and antibiotic-sensitive bacteria-infected wound.

If wounds are infected with bacteria resistant to an empirical antibiotic regimen, effective wound treatment will be delayed. This can delay wound healing and lengthen hospital stays, increasing the costs to patients. Long-term antibiotic use can also result in minor and major complications, such as diarrhea, antibiotic resistance, or life-threatening leukopenia. Multidrug-resistant (MDR) bacteria make wound treatment even more difficult. Traditionally, surgeons thought that adequate infection control should be established before soft tissue coverage. However, wounds infected by MDR do not heal well with this traditional method and there are no optimal treatment guidelines for MDR bacteria-contaminated wounds.We reviewed 203 patients who underwent vascularized flap surgery from 2012 to 2019 to cover wounds. Class IV and I wounds were compared according to the Centers for Disease Control and Prevention classification. Class IV was further classified as antibiotic-resistant (ARB) and antibiotic-sensitive (ASB) bacteria. Wound size, mode, location, pathogens, healing time, and basic demographics were evaluated. Data were compared using Cramer's V and one-way ANOVA or independent t tests.The average healing time was longer in the ARB (19.7 [range 7–44] days) and ASB (17.9 [range 2–36] days) groups than in the Clean group (16.5 [range 7–28] days). Healing time differed in the 3 groups (P = .036). It was longer in the class IV group than in the class I group (P = .01). However, it was not statistically different between the ARB and ASB groups (P = .164).In our study the difference in healing time was small when vascularized tissue transfer was done in ARB-infected wound compared with ASB-infected and clean wound. It is necessary to perform surgery using vascularized tissue for the infected wound of antibiotic-resistant bacteria.

Surgical outcome for colorectal or urinary tract-related fistula: Usefulness of vascularized tissue transfer—a retrospective study⁎

It is challenging to manage colorectal or urinary tract-related fistula. We typically treat colorectal or urinary tract-related fistula with a vascularized tissue transfer. This study aimed to analyze the outcomes of our surgical treatments for colorectal or urinary tract-related fistula. This retrospective review included all patients who underwent surgical repair of a colorectal or urinary tract-related fistula at our institution from October 2004 to September 2019. Patients whose surgical outcomes could not be evaluated were excluded. The primary outcome was the overall cure rate. We also evaluated the complication rate and compared the outcomes for rectovaginal fistula with those for urorectal fistula. The final analysis included 38 cases, of which 17 were rectovaginal fistula and 16 were urorectal fistula. The transperineal approach was used in 28 cases and transperineal and transabdominal combined in nine cases. A gracilis muscle flap was used in 19 cases and a gluteal fold flap in 13 cases. Although a major leak occurred in nine cases, the fistula was finally cured successfully in 31 cases. A comparison of the outcomes for rectovaginal fistula and urorectal fistula showed that complications occurred in 5/17 cases of rectovaginal fistula and 10/16 cases of urorectal fistula (p = 0.056). Fistulae were cured successfully in 13/17 cases of rectovaginal fistula and 14/16 cases of urorectal fistula (p = 0.656). Our surgical treatment for colorectal or urinary tract-related fistula succeeded in 31 of 38 cases. Thus, vascularized tissue transfer is useful for refractory colorectal or urinary tract-related fistula.

Complications in Skull Base Surgery and Subsequent Repair.

Over the past several decades, endoscopic sinus surgery has revolutionized the approach to skull base surgery. Open skull base approaches remain a viable option for advanced skull base tumors. Complications have gone down with increased reliability of vascularized tissue transfer. In this article, the authors explore the various complications that can present following skull base surgery and review the approaches for repair when such issues are encountered.

Systematic review of negative pressure wound therapy for head and neck wounds with fistulas: Outcomes and complications.

Fistula formation in head and neck wounds is considered one of the most challenging complications that a head and neck reconstructive surgeon may encounter. The current mainstay of treatment is aggressive surgical debridement followed by vascularised soft tissue coverage. Negative pressure wound therapy (NPWT) has been successfully used for the closure of complicated wounds for decades. This study analysed the outcomes and complications of NPWT in the management of head and neck wounds with fistulas. A systematic search of studies published between January 1966 and September 2019 was conducted using the PubMed, MEDLINE, EMBASE, and SCOPUS databases and using the following key words: "negative pressure wound therapy," "head and neck," and "fistula." We included human studies with abstract and full text available. Analysed endpoints were rate of fistula closure, follow-up duration, and complications if present. Nine retrospective case series (Level IV evidence) that collectively included 122 head and neck wounds with orocutaneous fistulas, pharyngocutaneous fistulas, and salivary contamination were examined. The number of patients included in each study ranged from 5 to 64. The mode of NPWT varied among the included studies, with most adopting a continuous pressure of -125 mm Hg. Mean durations of NPWT ranged from 3.7 to 23 days, and the reported fistula closure rate ranged from 78% to 100%. To achieve complete wound healing, six studies used additional procedures after stopping NPWT, including conventional wound dressings and vascularised tissue transfer. Information regarding follow up was provided in only three of the nine studies, where patients were followed for 5, 10, and 18 months. No serious adverse events were reported. NPWT for head and neck wounds with fistulas may be considered a safe treatment method that yields beneficial outcomes with a low risk of complications. The current data originated mainly from studies with low levels of evidence characterised by heterogeneity. Therefore, definitive recommendations based on these data cannot be offered. Additional high-quality trials are warranted to corroborate the findings of this systematic review.

Microsurgery in musculoskeletal oncology.

Sarcomas are rare mesenchymal bone and soft tissue tumors of the musculoskeletal system. In the past, the primary treatment modality was amputation of the involved limb and the 5-year survival was very low for high-grade tumors. During the last three decades, limb salvage has become the rule rather than the exception and the use of neoadjuvant and adjuvant therapies (radiation and chemotherapy) has dramatically increased disease-free survival. Reconstruction of large bone and soft tissue defects, though, still remains a significant challenge in sarcoma patients. In particular, vascularized tissue transfer has proved extremely helpful in dealing with complex bone and soft tissue or functional defects that are frequently encountered as a result of the tumor or as a complication of surgery and adjuvant therapies. The principles, indications and results of microsurgical reconstruction differ from trauma patients and are directly related not only to the underlying disease process, but also to the local and systemic therapeutic modalities applied to the individual patient. Although plastic reconstruction in the oncological patients is not free of complications, usually these complications are manageable and do not jeopardize oncological outcome. The overall treatment strategy should be tailored to the patient's and sarcoma profile.

Peroneal Vascularized Tissue Transfer

Peroneal Vascularized Tissue Transfer

Incisions and reconstruction approaches for large sarcomas.

Large intraabdominal, retroperitoneal, and abdominal wall sarcomas provide unique challenges in treatment due to their variable histology, potential considerable size at the time of diagnosis, and the ability to invade into critical structures. Historically, some of these tumors were considered inoperable if surgical access was limited or the consequential defect was unable to be closed primarily as reconstructive options were limited. Over time, there has been a greater understanding of the abdominal wall anatomy and mechanics, which has resulted in the development of new techniques to allow for sound oncologic resections and viable, durable options for abdominal wall reconstruction. Currently, intra-operative positioning and employment of a variety of abdominal and posterior trunk incisions have made more intraabdominal and retroperitoneal tumors accessible. Primary involvement or direct invasion of tumor into the abdominal wall is no longer prohibitive as utilization of advanced hernia repair techniques along with the application of vascularized tissue transfer have been shown to have the ability to repair large area defects involving multiple quadrants of the abdominal wall. Both local and distant free tissue transfer may be incorporated, depending on the size and location of the area needing reconstruction and what residual structures are remaining surrounding the resection bed. There is an emphasis on selecting the techniques that will be associated with the least amount of morbidity yet will restore and provide the appropriate structure and function necessary for the trunk. This review article summarizes both initial surgical incisional planning for the oncologic resection and a variety of repair options for the abdominal wall spanning the reconstructive ladder.

Predictors of Adverse Outcomes in Free Flap Reconstruction: A Single-Institution Experience.

Understanding the independent predictors of poor outcomes in free flap surgery is essential for patient selection. We aim to determine the independent predictors of major complications, flap survival, and extended hospital stays. Retrospective cohort study. Tertiary medical center. We reviewed medical records from all vascularized tissue transfers in the head and neck between 2007 and 2014 at our institution. We recorded demographics, medical comorbidities, disease characteristics, flap characteristics, and intraoperative events. We defined outcomes as major complications in the 30-day postoperative period, flap death or partial flap survival, and a length of stay ≥14 days. We used bivariate and multivariate methods to test for associations. Of 170 free flap operations, 44% had major complications; 11% fully or partially failed; and 27% required an extended hospital stay. Independent predictors of major complications were age ≥60 years (odds ratio [OR], 3.7; P = .001), revision surgery (OR, 3.5; P = .004), and a prior neck dissection (OR, 3.5; P = .004). Independent predictors of flap failure were revision surgery (OR, 4.1, P = .01) and the use of a plate (OR, 3.7; P = .03). Revision surgery was independently associated with a longer stay (OR, 3.0; P = .01), and the use of a radial forearm flap was associated with a shorter stay (OR, 0.3, P = .047). These results underscore that caution is warranted in revision flap surgery, patients with prior neck operations, and patients aged ≥60 years.

Surgical resection and vascularized bone reconstruction in advanced stage medication-related osteonecrosis of the jaw

A retrospective review of all patients with stage 3 medication-related osteonecrosis of the jaw (MRONJ), treated by surgical resection and immediate vascularized bone reconstruction at a tertiary care medical center, was performed. Eleven patients were included, seven female and four male; their mean age was 65.8 years (range 56–73 years). Mean follow-up was 25 months. Ten patients had received intravenous bisphosphonates. The most common pathology was breast cancer (4/11). Pain (n=8) and pathological fracture (n=7) were the most common presenting symptoms. Microvascular free flaps consisted of seven fibula osteocutaneous flaps and four scapula osteocutaneous free flaps. All patients reported resolution of symptoms, with complete bone union identified radiographically (100%). Complications occurred in three patients (27%). One patient required removal of hardware at 8 months postoperative. Dental implant rehabilitation was completed in two patients. Ten patients are tolerating an oral diet. Ten patients are alive without evidence of MRONJ at any of the surgical sites. One patient died 28 months after surgery from progression of metastatic disease. Advanced MRONJ can be successfully treated in patients using vascularized tissue transfer, including those patients with significant peripheral vascular disease. Dental rehabilitation is a viable option for advanced MRONJ patients treated by vascularized flap reconstruction.

Orbital Floor Reconstruction Using a Dynamic Titanium Mesh Following a Total Maxillectomy

When a total maxillectomy is performed in patients with maxillary cancer, it is important to preserve visual function and maintain the patient’s facial features, since both orbital floors are removed. Various reconstruction methods have been reported. We have performed reconstructions of the orbital floor using a dynamic titanium mesh. The results have been satisfactory in terms of function and cosmetic appearance, since neither diplopia nor infectious symptoms have been observed and minimal post-surgical cheek deformation has occurred. The prosthesis were prepared so as to cover the resected area of the hard palate. The removal of the prosthesis facilitated observations of the cavity. Also, the presence or absence of recurrences and the condition of the reconstruction site could be assessed visually. The titanium mesh that was employed was useful for preserving postoperative visual function, since it has a high biological affinity and can be easily used to replicate the 3D structure of the orbital floors. Compared with a vascularized composite-free tissue transfer, surgery using this mesh requires only a short operative time and the sacrifice of fewer autografts. In contrast to bone grafting, the restoration of ocular alignment is possible, since the mesh can easily replicate the 3D structure of the orbital floors. The mesh, however, may be exposed on the surface of the skin or cause infection if used over a wide area extending to the zygomatic bones, since it is an artificial material. It is important to take the area of reconstruction into consideration when using this mesh, as in the present cases. Here, we report three postoperative cases with follow-up periods of more than 5 years. A lengthy and meticulous follow-up period is necessary for such cases.

Patient and Surgical Factors Contributing to Perioperative Infection in Complex Lower Extremity Trauma

Infections in the traumatized lower extremity are a significant source of morbidity and expense. Outcomes after vascularized soft tissue reconstruction were analyzed to determine impact on infection rates. A retrospective review of a prospectively maintained database was performed, including 114 trauma patients requiring soft tissue reconstruction of lower extremity injuries at an urban Level I tertiary referral center from 2008 to 2015. Patient characteristics and perioperative outcomes were analyzed. After trauma, 39 (34.2%) patients developed wound infections, of which 74.4 per cent of infections occurred before soft tissue coverage. Isolated lower extremity injury yielded a 4-fold increase in the incidence of infection. Infection rates doubled in patients who smoked, sustained a fall, had a proximal third of the lower leg wound, or underwent external fixation. Comorbid diabetes, underlying fracture, and wound size were not predictive of infection. Overall, there was a 97.4 per cent rate of limb salvage after soft tissue reconstruction. In patients with infection before soft tissue reconstruction, a salvage rate of 96.6 per cent was achieved. Soft tissue reconstruction in the traumatized and infected lower extremity resulted in high limb salvage success rates, demonstrating vascularized tissue transfer in lower extremity injuries is effective in treating lower extremity infection.

Integra-based Reconstruction of Large Scalp Wounds: A Case Report and Systematic Review of the Literature.

Background:Large complex scalp wounds that have traditionally required free vascularized tissue transfer have been successfully reconstructed with skin substitutes such as Integra. Although there are multiple reports of Integra-based reconstructions of scalp wounds, there has not been a comprehensive assessment of this body of literature that critically examines this method. Our goal was to conduct a systematic review to determine the effectiveness of Integra-based reconstructions of scalp wounds, with emphasis on large defects.Methods:A comprehensive systematic review was completed using key search terms, including Integra, dermal regeneration template, bovine collagen, skin substitute, forehead, and scalp. Selected articles reported characteristics of patients and their reconstructions. The primary outcome measures were wound complications and percent graft take.Results:Thirty-four articles were included in this systematic review. Wound sizes ranged from 5.7 to 610 cm2, with 35.3% of articles reporting a mean defect size >100 cm2. Thirty-two articles reported mean percent take of skin graft ≥90%. Sixteen articles reported a minor complication. There were no major complications associated with the reconstructions.Conclusions:There is a substantial evidence base for the use of Integra to reconstruct scalp wounds. To date, the dermal regeneration template is generally reserved for salvage procedures or when the patient cannot tolerate free tissue transfer. Based on the findings of this systematic review and the authors’ clinical experience, Integra can be used to achieve predictable results in large complex scalp defects.

Results of surgical closure of bronchopleural fistula with vascularized tissues

BackgroundBronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree or lung parenchyma resulting in air leak in the chest tubes. Chronic BPF is a serious complication of several pulmonary and postoperative conditions, as it carries a high morbidity and mortality and is associated with prolonged hospital stay and thus high resource consumption. Till date surgical intervention has been the main stay of management of chronic BPF.This study was carried out to assess the efficacy of surgical closure of the chronic BPF using vascularized tissue transfer into the pleural cavity. Patients and methods28 patients were operated upon primarily due to chronic BPF with or without empyema. All patients were selected and subjected to surgical intervention using vascularized tissue transfer into the pleural cavity. The vascularized tissues had been used were: Intercostal muscle flap, Latissmus dorsi muscle transposition, Omental flap, and Pericardial pad of fat. ResultsThe mean hospital stay postoperatively was 4 ± 1 day. There was immediate or early stoppage of air leak after the intervention in all patients. No patient had prolonged postoperative air leak (≥5 days). One patient required negative suction for 2 days to help stoppage of the leak. No patient required instillation of sealants through the tubes. ConclusionOnce the BPF has developed, early recognition, drainage of the pleural space and control of the inflammatory process are critical. Surgical closure of BPFs with proper vascularized tissues is an effective technique associated with low cost and lower hospital stay.