Vertical Flap Research Articles

Vertical musculocutaneous trapezius flap for the closure of postpneumonectomy empyema

Vertical musculocutaneous trapezius flap for the closure of postpneumonectomy empyema

Trapezius Island Myocutaneous Flap for Head, Neck, and Facial Reconstruction in Neurofibromatosis Type 1-Associated Plexiform Neurofibromas.

Reconstruction of significant soft tissue defects in the head and neck region after resection of extensive plexiform neurofibromas, as well as preservation and restoration of cosmetic and functional aspects, presents a considerable challenge. The purpose is to evaluate the feasibility of eTMF in repairing substantial defects after the complete resection of NF1 PN. Patients diagnosed with substantial neurofibromatosis (NP) type 1 (NF1), according to the revised criteria, underwent complete resection and remodeling of the facial aesthetic unit. An extended vertical lower trapezius island myocutaneous flap (eTIMF) was used for the defect reconstruction. Perioperative complications were evaluated using the Clavien-Dindo classification. ECOG PS was assessed. Postoperative follow-up at 6 months and completion of UW-QOL. The questionnaire included swallowing, chewing, speech, and quality of life scores. Two patients had pathogenic missense variants: c.5609G>A (p.Arg1870Gln) in exon 38 of NF1 in the first case, and c.4600C>T (p.Arg1534*) in exon 35 in the second case. Two eTMFs were harvested successfully. Five facial esthetic units were remodeled, and 4 units were remodeled. Two extensive tumors were nearly entirely removed. No severe complications were noted. The ECOG PS improved from grade 3 in the first week postsurgery to grade 0 by the eighth week. The UW-QOL results indicated that swallowing, chewing, and speaking functions returned to their preoperative levels, with a 40% improvement in quality of life, reaching 60% and 80%, respectively. eTMF to repair substantial defects following total resection of NF1 PN and facial esthetic unit remodeling enhances appearance, function, and psychosocial outcomes. This technique is safe, efficient, resource-conserving, and simple to implement.

Cost Analysis of Pelvic Exenteration Surgery for Advanced Pelvic Malignancy

BackgroundPelvic exenteration (PE) is a radical procedure involving multi-visceral resection for locally advanced pelvic malignancies. Such radical surgery is associated with prolonged operating theater time and hospital stay, as well as a substantial risk of postoperative complications, and therefore significant financial cost. This study aimed to comprehensively detail the inpatient cost of PE at a specialist center in the Australian public sector.MethodsA retrospective costing review of consecutive PE operations at Royal Prince Alfred Hospital in Sydney between March 2014 and June 2022 was performed. Clinical data were extracted from a prospectively maintained database, and in-hospital costing data were provided by the hospital Performance Unit. All statistical analyses were performed using SPSS.ResultsPelvic exenteration was performed for 461 patients, of whom 283 (61 %) had primary or recurrent rectal cancer, 160 (35 %) had primary or recurrent non-rectal cancer, and 18 (4 %) had a benign indication. The median admission cost was $108,259.4 ($86,620.8–$144,429.3) (Australian dollars [AUD]), with the highest costs for staffing followed by the operating room. Overall, admission costs were higher for complete PE (p < 0.001), PE combined with cytoreductive surgery (CRS) (p < 0.001), and older patients (p = 0.006).DiscussionThe total admission cost for patients undergoing PE reflects the complexity of the procedure and the multidisciplinary requirement. Patients of advanced age undergoing complete PE and PE combined with CRS incurred greater costs, but the requirement of a sacrectomy, vertical rectus abdominal flap reconstruction, major nerve or vascular excision, or repair were not associated with higher overall cost in the multivariate analysis.

Experience in the use of circular incision bi-pedicled vertical flap based mastectomy for grade III gynecomastia: A case series

Introduction and importanceSurgical management of grade III gynecomastia with excess redundant skin is challenging. The choice of the surgical technique is mainly decided upon the size of the gynecomastia, the skin redundancy and correction of nipple position. Case presentationWe report our experience in the use of the circular incision bi-pedicled vertical flap based mastectomy for grade III gynecomastia according to Simon classification. This is a retrospective study conducted between January 2022 and April 2023 at two selected units in Sri Lanka. Clinical discussionA total of 7 patients with bilateral grade III gynecomastia were included in this study with a median age of 24 years (range: 18–42 years). The mean BMI was 23.2 kg/m2. All patients exhibited near symmetrical breasts and large areolar diameters. All patients complained of physical and psychological dissatisfaction with their condition and sought an aesthetic correction. Two patients were diagnosed with Klinefelter syndrome and others were apparently healthy. The main complication was seroma formation (7/7). No patients developed haematoma. Nipple hypothesia was noted in two patients which improved on follow up. The mean follow- up duration was 4–9 months. The survey of patient satisfaction showed 9 for contour, 8.6 for wound scars, 9.2 for overall satisfaction and 9.6 for improvement in self-confidence. ConclusionThe above surgical technique achieved satisfactory aesthetic results while avoiding unsightly scars or serious complications and can be considered in the surgical decision making for grade III gynecomastia.

The Vertical Profunda Artery Perforator Flap for Perineal Reconstruction.

Colorectal cancer is a significant cause of cancer-related death in the United States with abdominoperineal resection (APR) remaining a necessary procedure for many patients. The resultant defects of this radical operation are complex and characterized by significant tissue voids. Pedicled vertical profunda artery perforator flaps (vPAP) can be used to obliterate these defects in patients receiving minimally invasive APR or when the abdominal donor site is unavailable. After receiving local institutional review board approval, a single center, retrospective cohort study from January 2020 to December 2021 was performed assessing pedicled vPAP flap reconstruction of APR defects. Age, sex, body mass index, primary diagnosis, comorbidities, concomitant oncologic procedures, radiation, timing, incorporation of gracilis flaps, follow-up, and complications were compared. Ten patients (70% male) with an average age of 56.2 years and BMI of 27.6 were included in the study. Rectal adenocarcinoma (50%) was the most common indication for APR, followed by rectal squamous cell carcinoma (30%), vulvar squamous cell carcinoma (10%), and Crohn disease (10%). Eighty percent of the patients received radiation, and 70% of reconstructions were delayed after the initial resection. The average length of clinical follow-up was 26.1 months. Concerning major complications, 2 patients were required to return to the operating room due to venous congestion (20%), and 2 patients suffered partial flap failure (20%). Minor complications were perineal dehiscence (50%), abscess requiring percutaneous drainage by interventional radiology (30%), and infection requiring antibiotics (20%). Twenty percent of patients developed fistulas requiring surgical excision. There were no instances of donor site dehiscence, and there was no complete flap loss, indicating successful reconstruction in all included cases. vPAP flaps are a reliable method to reconstruct perineal defects with less donor-site morbidity than previous reconstructive options. vPAP flaps should be considered in the setting of delayed reconstruction, minimally invasive APRs, and when the abdominal donor site is unavailable.

Experimental investigation of rear flexible flaps interacting with the wake dynamics behind a squareback Ahmed body

We have conducted an experimental study on the use of rear flexible vertical flaps as adaptive solutions to reduce the drag of a squareback Ahmed body, and on the fluid–structure interaction mechanisms at the turbulent wake. To that aim, wind tunnel experiments were conducted to compare the performance of various configurations including the baseline body, the body with rigid flaps and with flexible flaps. These configurations were tested under different aligned and cross-flow conditions. The results reveal that the flexible adaptive devices effectively reduce the drag within for low values of the dimensionless stiffness quantified through the Cauchy number, Ca. Thus, the two-dimensional deformation of the flexible flaps, which undergo progressive inwards reconfiguration (with an averaged tip deflection angle of Θ≃4°), reduces the bluffness of the flow separation at the body base, thus shrinking the recirculation region. This reconfiguration leads to increased base pressure, resulting into a 8.3% decrease in the global drag, CD, under aligned conditions. Similar drag reductions are observed under yawed conditions.Two regimes are identified in terms of the coupled fluid–structure dynamics. For low Ca, the passive reconfiguration of the flaps include small amplitude, periodic oscillations corresponding to the first free deformation mode of a cantilevered beam. Alongside these weak oscillations, the flaps are deformed guided by the changes in the value of the horizontal base pressure gradient, depicting bi-stable behavior which is caused by the synchronization between the Reflectional Symmetry Breaking (RSB) mode, typically present in the wake of three-dimensional bluff bodies, and the flaps deformation. For higher values of Ca, the flexible flaps deflect inwardly by about Θ≃20° on average, but exhibit vigorous oscillations combining the first and second free deformation modes of a cantilevered beam. These large amplitude oscillations excite the flow separation at the model’s trailing edges, leading to significant fluctuations in the separated shear layers and a consequent 31% increase in the global drag. Under yawed conditions, the flaps responses for large values of Ca are different due to the asymmetry of the corresponding recirculation region.

Soft Tissue Reconstruction After Sacral Neoplasm Resection: The University of California San Francisco Experience.

Resection of sacral neoplasms such as chordoma and chondrosarcoma with subsequent reconstruction of large soft tissue defects is a complex multidisciplinary process. Radiotherapy and prior abdominal surgery play a role in reconstructive planning; however, there is no consensus on how to maximize outcomes. In this study, we present our institution's experience with the reconstructive surgical management of this unique patient population. We conducted a retrospective review of patients who underwent reconstruction after resection of primary or recurrent pelvic chordoma or chondrosarcoma between 2002 and 2019. Surgical details, hospital stay, and postoperative outcomes were assessed. Patients were divided into 3 groups for comparison based on reconstruction technique: gluteal-based flaps, vertical rectus abdominus myocutaneous (VRAM) flaps, and locoregional fasciocutaneous flaps. Twenty-eight patients (17 males, 11 females), with mean age of 62 years (range, 34-86 years), were reviewed. Twenty-two patients (78.6%) received gluteal-based flaps, 3 patients (10.7%) received VRAM flaps, and 3 patients (10.7%) were reconstructed with locoregional fasciocutaneous flaps. Patients in the VRAM group were significantly more likely to have undergone total sacrectomy (P < 0.01) in a 2-stage operation (P < 0.01) compared with patients in the other 2 groups. Patients in the VRAM group also had a significantly greater average number of reoperations (2 ± 3.5, P = 0.04) and length of stay (29.7 ± 20.4 days, P = 0.01) compared with the 2 other groups. The overall minor and major wound complication rates were 17.9% and 42.9%, respectively, with 17.9% of patients experiencing at least 1 infection or seroma. There was no association between prior abdominal surgery, surgical stages, or radiation therapy and an increased risk of wound complications. Vertical rectus abdominus myocutaneous flaps are a more suitable option for patients with larger defects after total sacrectomy via 2-staged anteroposterior resections, whereas gluteal myocutaneous flaps are effective options for posterior-only resections. For patients with small- to moderate-sized defects, local fasciocutaneous flaps are a less invasive and effective option. Paraspinous flaps may be used in combination with other techniques to provide additional bulk and coverage for especially long postresection wounds. Furthermore, mesh is a useful adjunct for any reconstruction aimed at protecting against intra-abdominal complications.

Microsurgical Reconstruction for Advanced Head and Neck Tumors in Africa-Rescued Patients

Although an early diagnosis and treatment would be ideal for head and neck tumors, sometimes it isn´t possible for patients who live in some regions of Africa. We treated some of these patients with tumors rarely seen today in well-developed countries. Materials and Methods: We retrospectively reviewed all free flap reconstructions for advanced head and neck tumors in Africa rescued patients between June 2014 and December 2017. Patient age, surgical treatment and reconstruction, complications and outcomes were analyzed. Results: Twelve patients have been treated. There were 5 fibular bone flaps, 2 anterolateral thigh flaps, 2 profunda artery perforator flaps, 2 vertical rectus abdominal myocutaneous flaps and 1 latissimus dorsi muscle flap. No flap failures have been recorded. Two serious postoperative complications have been detected (one cerebrovascular event and one nosocomial infection) and one patient was diagnosed with distant disease in the follow-up. No locoregional relapse has been detected. Conclusion: Surgical resection and microsurgical reconstruction may be safe and effective in these advanced head and neck tumors, although it isn`t without potential serious complications.

A New Technique for Pelvic and Vaginal Reconstruction in Abdominoperineal Rectal Excision: Combination of Gluteus Maximus Flap and Fasciocutaneous Flap.

Resection of advanced rectal cancer might result in significant tissue loss, including pelvic floor and parts of the vaginal wall. Pelvic floor reconstruction using a musculocutaneous flap offers optimized healing abilities and the possibility of vaginal reconstruction. In Skåne University Hospital, two different flap techniques are used to reconstruct the perineum: the vertical rectus abdominis musculocutaneous flap and the gluteus maximus (GM) flap. A combination of a GM flap and a fasciocutanous flap, referred to locally as a GM special (GMS) flap, is used for posterior vaginal wall reconstruction in women undergoing abdominoperineal resections including parts of or the total posterior vaginal wall. The GMS flap was introduced through a national collaboration in Sweden in 2013. The aim of this article is to offer a detailed description and illustrations of the surgical technique used to construct the GMS flap, focusing on the posterior vaginal wall reconstruction. In our experience, the GMS flap is a resilient and cosmetically appealing choice that is technically easily harvested. The flap has acceptable morbidity and long-term results with adequate neovaginal measurements. Collaborative work is further encouraged.

The Ergonomic FALD Flap for One-stage Total Breast Reconstruction.

The fat-augmented latissimus dorsi (FALD) flap combines this pedicled flap with immediate intraoperative fat transfer. Very little is described concerning its inset at the mammary site. Our efforts have concentrated on seeking the best flap orientation and skin-adipose paddle shaping, to improve the aesthetic outcome and to obtain a complete breast reconstruction (BR) in one stage. A prospective clinical study was performed in patients who underwent BR with FALD flaps, between December 2020 and March 2022. Patients were randomly enrolled into two groups: ergonomic inset of the FALD flap with vertical orientation of the skin-adipose paddle (group A) and FALD flap with traditional horizontal paddle orientation (group B). The study's endpoints were the evaluation of the aesthetic outcomes (from patients' and surgeon's perspectives) and complications. Thirty-two FALD flaps (23 patients) were performed for group A, and 31 FALD flaps (25 patients) for group B. The two groups were homogeneous in terms of demographic and surgical data (P > 0.05). The overall complication rate was homogeneous among the groups, without statistically significant differences (P = 1.00). The surgeon's assessments showed a statistically significant superior aesthetic outcome in group A regarding volume, symmetry, and shape (P < 0.05). Higher satisfaction was observed in group A patients, in terms of breast size (P < 0.00001), shape (P = 0.0049), and overall satisfaction (P = 0.00061). The ergonomic vertical FALD flap technique enables surgeons to perform one-stage total BR, with excellent breast projection and upper pole fullness. These refinements in flap shaping and molding reduced the need for further autologous fat transfer, obtaining a brilliant totally autologous BR without the need for microsurgical experience.

Comparison of inferior gluteal artery perforator flaps versus vertical rectus abdominis musculocutaneous flaps in the reconstruction of perineal wounds

Achieving a healed perineal wound following chemoradiotherapy and abdominoperineal resection (APR) is challenging for surgeons and patients. Prior studies have shown trunk-based flaps, including vertical rectus abdominis myocutaneous (VRAM) flaps, are superior to both primary closure and thigh-based flaps; however, there has been no direct comparison with gluteal fasciocutaneous flaps. This study evaluates postoperative complications after various methods of perineal flap closure of APR and pelvic exenteration defects. Retrospective review of patients who underwent APR or pelvic exenteration from April 2008 through September 2020 was analyzed for postoperative complications. Flap closure techniques, including VRAM, unilateral (IGAP), and bilateral (BIGAP) inferior gluteal artery perforator fasciocutaneous flaps, were compared. Of 116 patients included, the majority underwent fasciocutaneous (BIGAP/IGAP) flap reconstruction (n = 69, 59.6%), followed by VRAM (n = 47, 40.5%). There were no significant differences between group patient demographics, comorbidities, body mass index, or cancer stage. There were no significant differences between BIGAP/IGAP and VRAM groups in minor complications (57% versus 49%, p = 0.426) or major complications (45% versus 36%, p = 0.351), including major/minor perineal wounds. Prior studies have shown flap closure is preferable to primary closure after APR and neoadjuvant radiation but lack consensus on which flap offers superior postoperative morbidity. This study comparing outcomes of perineal flap closure showed no significant difference in postoperative complications. Fasciocutaneous flaps are a viable choice for the reconstruction of these challenging defects.

Application of vertical transposition flap in closure for large facial soft tissue defects in children.

While transposition flap is widely used for the repairs of facial defects, few studies has reported its application among children with large defects. In this study, we aimed to investigate the surgical techniques and principles in different locations on face of vertical transposition flap in children. We retrospectively reviewed our hospital database and identified children who were treated with vertical transposition flap for large facial defects between January 2014 and December 2021. Information was collected including patients' demographics, location and dimension of the lesion, surgical procedure, additional surgeries, complications, and outcomes. A total of 122 patients (77 boys, 63.1%) were included in this study. The average age for participants was 3.3 years (3 months to 9 years). One hundred and four (85.3%) patients had melanin nevus and 18 (14.8%) had sebaceous nevus. The average size of defects was 5.8 cm2 (ranging from 0.8-16.5 cm2). Ten patients (8.2%) suffered from dermal layer or full-thickness necrosis in the distal part of their flaps, They all recovered after conservative treatment and there were noticeable scars at discharge. Five patients (4.1%) had slight traction of the mouth and eyelid, all recovered about 2 week after surgery. An acceptable cosmetic outcome was achieved for all the patients at last time follow-up. Repairing large facial defects with vertical transposition flap is effective in Children, especially on forehead, cheek and mandible. However, this technique is far from perfect. Careful selection of appropriate patients and flap design might be needed.

A biomimetic approach to improve convective heat transfer using self-excited flaps

Bio-inspired flexible plates have shown promising results as a passive method to enhance convective heat transfer and mixing in flow. Flap fluttering is a self-excited phenomenon caused by the fluid-structure-interaction between the main flow and the flap. Among all the parameters, the direction of the flap relative to the incoming flow appears to be the key factor in determining the transition into the flapping mode. In this study, flaps made of a 50-micron thick polyester sheet were cut into rectangular shapes and placed at the centerline of the channels of a shrouded straight fin heatsink. Both hanging and vertical positions of the flap in the axial flow were investigated using a custom-built testbed in our lab. We measured the convective heat transfer rates and pressure drop in the heatsink for both arrangements. We observed that: i) the rectangular cantilevered flap is more unstable in the hanging flap configuration compared to the vertically installed flap, i.e., the transition to the fluttering mode occurs at a lower airflow velocity; ii) the critical flow velocity – the velocity at which the flap becomes unstable– is lower for the flap aspect ratio of 0.5. We attribute this behavior to the longer viscous boundary layer around the vertical case, which stabilizes the flap; iii) from a thermal performance point of view, the hanging configuration outperforms the vertical one with the same flap dimensions; iv) at a Reynolds number of 8,940, large amplitude vibrations and coherent fluttering in a hanging configuration render a superior thermal performance of 39 percent improvement in the Nusselt number compared to when bare channels are measured. On the contrary, at higher flowrates, the difference falls in the range of measurement uncertainty; and v) as for the pressure drop, unlike the hanging configuration, the vertical flap creates a higher pressure drop as it tends to block half the channel at the end of the trailing edge stroke. Furthermore, the presence of the flap holder adds to the pressure drop increase, which is eliminated in the hanging position and therefore, flaps could be connected to the shroud directly.

MP42-14 BIOLOGIC MESH BUTTRESS WITH VERTICAL RECTUS ABDOMINIS MUSCLE FLAP TO REESTABLISH PELVIC INTEGRITY DURING CYSTECTOMY FOR ANTERIOR URINARY FISTULA

You have accessJournal of UrologyCME1 Apr 2023MP42-14 BIOLOGIC MESH BUTTRESS WITH VERTICAL RECTUS ABDOMINIS MUSCLE FLAP TO REESTABLISH PELVIC INTEGRITY DURING CYSTECTOMY FOR ANTERIOR URINARY FISTULA Syed M. Alam, Jordan Stiverson, and Hadley Wyre Syed M. AlamSyed M. Alam More articles by this author , Jordan StiversonJordan Stiverson More articles by this author , and Hadley WyreHadley Wyre More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Post-radiation puboprostatic and pubourethral fistulae are devastating conditions, and surgical intervention remains highly morbid. Here, we describe a novel technique using a mesh buttress and vertical rectus abdominis muscle flap (VRAM) to restore pelvic integrity during cystectomy for anterior urinary fistulae. METHODS: Patients having undergone cystectomy with ileal conduit were identified in a prospectively maintained database. Those having undergone VRAM harvest with placement of a mesh buttress for anterior urinary fistula were selected for analysis. Following supratrigonal cystectomy, all patients underwent a left-sided VRAM harvest. After the bladder plate was fulgurated, a biologic mesh was tailored to the pelvic defect and sutured to the posterior trigone. It was then incorporated circumferentially around the levator muscles and anteriorly to the pubic bone and underside of rectus fascia. Prior to circumferential closure of the underlying space, a VRAM flap was secured in the pelvis. The remainder of the mesh was then secured, creating a tunnel for the flap pedicle. Surgical metrics and post-operative outcomes were evaluated using descriptive statistics. RESULTS: Between 2019-2021, eleven patients underwent this technique, of which five carried a diagnosis of post-radiation anterior urinary fistula with pubic osteomyelitis. The median age was 73 years, and all patients were male. Three patients previously underwent radical prostatectomy, all of whom underwent subsequent endoscopic intervention for vesicourethral anastomotic stenosis. One patient underwent transurethral resection of the prostate after radiation. One patient had no prior surgical history. Median operative time was 387 minutes and median blood loss was 500cc. Average length of stay was five days. No patients developed an immediate post-operative complication. All patients had positive intra-operative bone cultures. No patients reported persistent pubic, groin, or thigh pain after surgery. No fistula recurrence occurred at a median follow-up of 264 days. CONCLUSIONS: The use of a mesh buttress in conjunction with pelvic VRAM flap is a novel technique designed to restore pelvic integrity for patients undergoing cystectomy for an anterior urinary fistula. Source of Funding: N/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e573 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Syed M. Alam More articles by this author Jordan Stiverson More articles by this author Hadley Wyre More articles by this author Expand All Advertisement PDF downloadLoading ...

Surgical treatment of vulvar cancer with perineal defect reconstruction using a VRAM flap. Clinical case

The article presents a clinical case of perineal defect reconstruction using a VRAM flap in a patient with vulvar cancer. Stepwise surgical treatment method is described. A multidisciplinary meeting allows to realize a plan of surgical help for such patients with the goal of treating oncological process and its complications.We have proposed a variant of perineal defect reconstruction through transfer of a vertical rectus abdominis musculocutaneous flap with a vascular pedicle.

Aesthetic Management of Peri-Implant Soft Tissue Dehiscence. A Case Report of a Combined Perio Restorative Approach

This case report designates a combined perio restorative technique in the management of peri-implant 3-dimensional soft tissue defects in an esthetic zone. A staged approach was implemented to treat this case; the first stage was planned to treat the horizontal defect around the implant, in which crown was removed, and coronally advanced flap with connective tissue graft were used to treat the soft tissue defect. At the second stage, a modified coronally advanced flap with connective tissue graft was used to augment the vertical defect, and no vertical releasing incision was made in this stage to maximize the blood supply to the advanced flap. De-epithelized free gingival graft was harvested from the palate to obtain better fibrous connective tissue graft . Graft was placed over the site to compensate for the vertical defect and flap was advanced to ensure primary closure without tension. Resin-bonded bridge was used as a provision after modification to avoid any soft tissue contact. Healing by primary intention was attained providing a clinically healthy soft tissue surrounding a well-functioning restoration, and periapical radiographs showed a stable crestal bone level without presence of mucositis or peri-implantitis. Within the limitations of this clinical case report, it revealed the possibility of fully restoring severe horizontal and vertical peri-implant soft tissue defects and at the same time attaining high level of patient satisfaction via a combined mucogingival and prosthetic approach; nevertheless, the long-term preservation of this successful outcome needs to be monitored.

Revisiting Vertical Flap Pyeloplasty in Pelviureteric Junction Obstruction: A Case Series

Pelviureteric Junction Obstruction (PUJO) can cause recurrent Urinary Tract Infections (UTIs), pain, and loss of renal unit function. Surgical intervention is often required, and numerous treatment strategies have been employed. Vertical flap pyeloplasty was initially described as the technique of choice in PUJO patients with the large box-shaped extra-renal pelvis and longer segment strictures (usually &gt;2 cm). In the present case series, 11 patients underwent vertical flap pyeloplasty for PUJO with a large extrarenal box-shaped pelvis. Demographic, perioperative, and follow-up data were recorded. Success was defined as symptomatic improvement and an improvement in early Diethylenetriamine Pentaacetate (DTPA) renogram at six months. In the present series, all 11 patients showed an improvement in Glomerular Filtration Rate (GFR) with an average improvement of 11.9 mL. The procedure was technically easier, less time-consuming, and produced acceptable results. Vertical flap pyeloplasty could be considered as a practical, technically easier, and effective treatment option in PUJO with a large extrarenal pelvis and long segment strictures.

Flap Coverage of Infected Ventricular Assist Devices Influences Patient Outcomes.

The use of left ventricular assist devices (LVADs) for patients with end-stage cardiac failure awaiting heart transplantation has become increasingly common. However, ventricular assist device-related infections remain a major problem complicating their long-term use. Poor data exist to determine how to manage these infections after operative debridement. Patients who underwent insertion of a ventricular assist device and had a subsequent readmission for LVAD infection at the University of Rochester Medical Center from 2012 to 2022 were identified through accessing the medical records archives of the hospital. Patients were followed retrospectively for an average of 3.2 years. Patient demographics, preoperative diagnosis/disease state, type of ventricular assist device inserted, postoperative day of ventricular assist device infection onset, infectious organism identified at initial washout, infectious organism identified at time of definitive device coverage, timing of coverage procedure after the initial washout for infection, type of flap used for coverage, 90-day complications after definitive coverage, and lifetime return to operating room for infection were reviewed. Comparison analysis with a χ 2 test was used to analyze outcomes. Of 568 patients admitted with an LVAD-related infection 117 underwent operative debridement. Of these, 34 underwent primary closure, 31 underwent closure with secondary intention (negative pressure wound therapy with split thickness skin grafting), and 52 were closed with a flap (pectoralis, omental, latissimus, or vertical rectus abdominus musculocutaneous flap). There was a statistically significant higher incidence of return to the operating room (RTOR) for infection over a lifetime with primary closure compared with secondary intention and flap reconstruction ( P = 0.01, 0.02), but no difference in 90-day complications ( P = 0.76, P = 0.58). Eighty-three patients had a positive culture upon definitive coverage with 24 having a postsurgical complication, 15 of which required lifetime RTOR for infection. Thirty four were closed with negative cultures with 9 having a complication and 4 requiring RTOR for infection. This was not statistically significant for complications or RTOR ( P = 0.79, 0.40). Culture data were further substratified into bacterial cultures (n = 73) versus fungal cultures (n = 10), and there was no statistically significant difference between these compared with complications or RTOR ( P = 0.40, 0.39). Coverage of infected LVADs with locoregional flaps or allowing to granulate using wound vac therapy has a decreased lifetime RTOR for future infections for these patients without increase in 90-day complications. Timing of RTOR should not be impacted by positive cultures provided there is healthy granulation tissue in the wound.

Soft tissue reconstruction strategy for sacral tumor resection

Objective: To investigate the clinical strategy and effect of soft tissue reconstruction after sacral tumor resection in different planes. Methods: The data of 27 consecutive patients who underwent primary or secondary sacral tumor resection and soft tissue reconstruction from June 2012 to June 2021 at Dongnan Hospital of Xiamen University (the 909th Hospital) were retrospectively analyzed. There were 11 males and 16 females, aged (M(IQR)) (46.2±23.6) years (range: 16 to 72 years). Sacrospinous muscle, gluteus maximus and vertical rectus abdominis muscle flap were selected for soft tissue reconstruction according to the tumor site and the size of tissue defect. the postoperative follow-up was performed. The operative methods, intraoperative conditions, complications and disease outcomes were summarized. Results: Among the 27 patients with sacral tumor, the tumor plane was located in S1 in 8 cases, S2 in 5 cases and S3 or below in 14 cases. There were 12 patients with tumor volume≤400 cm3 and 15 patients with tumor volume>400 cm3. Operation time was 100(90) minutes (range: 70 to 610 minutes), intraoperative blood loss was 800(1 600) ml (range: 400 to 6 500 ml). Soft tissue reconstruction was performed by transabdominal rectus abdominis transfer repair in 2 cases, extraperitoneal rectus abdominis transfer repair in 1 case, gluteus maximus transfer repair in 5 cases, gluteus maximus advancement repair in 13 cases, and sacrospinous muscle transfer repair in 6 cases. Postoperative complications occurred in 6 cases, including 1 case of incision infection, 4 cases of skin border necrosis, and 1 case of delayed infection due to fracture of internal fixator 3 years after operation, all of them were cured. The follow-up time was (35±21) months. Among the patients, 6 patients had recurrence, 2 patients with Ewing sarcoma died of lung metastasis 1 year after operation, 4 patients with metastatic cancer died of primary disease, and the remaining patients survived without disease. Conclusion: Choosing different soft tissue reconstruction strategies according to sacral tumor location and tissue defect size can effectively fill the dead space after sacral tumor resection, reduce postoperative complications and improve the prognosis of patients.

Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis

BackgroundRadical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm. MethodsA decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature. ResultsGluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates. ConclusionOur data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.