Well-vascularized Flap Research Articles

Temporoparietal Fascial Flap Combined With Vascularized Outer Table Calvarial Bone Graft and Entire Temporalis Muscle: A Stable Pedicled Flap for Orbital Floor Reconstruction After Total Maxillectomy.

Orbital reconstruction after total maxillectomy is essential to maintain ocular function and facial contour. Free flap transfer with simultaneous orbital bone reconstruction is a straightforward approach; however, it is challenging in medically unstable patients with multimorbidity. The authors developed an easily harvested temporoparietal fascial flap combined with vascularized outer table calvarial bone and entire temporalis muscle. The authors applied this technique in an 81-year-old patient with multiple comorbidities who required orbital floor reconstruction following total maxillectomy. Intraoperative indocyanine green fluorescence imaging confirmed excellent perfusion of the temporoparietal fascia, entire temporalis muscle, and calvarial bone. Although the patient developed postoperative local wound infection, the vascularized bone graft resisted infection and preserved the orbital structure without bone exposure. Our technique is minimally invasive and results in a well-vascularized flap for orbital reconstruction after total maxillectomy involving the orbital bone, and particularly beneficial in patients with multimorbidity or at high risk of local infection.

Difficulties of nasocutaneous fistula repair, following lacrimal outflow system malignancy resection

ABSTRACT Purpose To evaluate the incidence of nasocutaneous fistula (NCF) development, following en bloc resection of lacrimal outflow system malignancies (LOSM), and describe the methods of surgical repair. Methods Retrospective review of all patients who underwent resection of LOSM with reconstruction and post-treatment protocol at the University of Miami between 1997 and 2021. Results Of the 23 included patients, 10 (43%) developed postoperative NCF. All NCFs developed within one year of surgical resection or completion of radiation therapy. NCF was seen more frequently in patients who underwent adjuvant radiation therapy and those who had reconstruction of the orbital wall with titanium implants. All patients underwent at least one revisional surgery to close the NCF, including local flap transposition (9/10), paramedian forehead flap (5/10), pericranial flap (1/10), nasoseptal flap (2/10), and microvascular free flap (1/10). Local tissue transfer, pericranial, paramedian, and nasoseptal forehead flaps failed in most cases. Two patients had long-term closure; one patient who underwent a paramedian flap and a second who underwent a radial forearm free flap, suggesting that well-vascularized flaps may be the most viable option for repair. Conclusions NCF is a known complication, following en bloc resection of lacrimal outflow system malignancies. Risk factors for formation may include adjuvant radiation therapy and use of titanium implants for reconstruction. Surgeons should consider utilizing robust vascular-pedicled flaps or microvascular free flaps for repair of NCF in this clinical scenario.

Treatment of pilonidal sinus with rhomboid excision and Limberg flap operation

Pilonidal sinus is a widespread condition. There have been several surgical methods described for treating the sacrococcygeal pilonidal sinus. The Limberg flap after rhomboid excision is the method that is most frequently utilized. By flattening the natal cleft, a big, well-vascularized flap is used to create a tension-free repair. The best treatment options are said to have a recurrence rate of 0–5% and complication rate during surgery of 0–16%. Aim: This study was held to assess patient characteristics and treatment outcomes for pilonidal sinus patients who had rhomboid excision and reconstruction with Limberg flap in our setting. Methods: Information was collected retrospectively by analyzing the records of patients who were done with rhomboid excision and reconstruction with Limberg flap for sacrococcygeal pilonidal sinus in General Surgery department, Lady Reading Hospital, Peshawar during the period from January 2020 to December 2022. Results: The study included 40 patients in total, 34 (85%) men and 6 (15%) women. The mean age was 25.10. (range 18–45 years). The mean stay in hospital was 4.2 days, with 3 to 7-day of range. The primary disease affected 38 out of the 40 individuals, and a recurring disease affected 2 patients.

Prefabrication-a Vascularized Skin Flap Using an Arteriovenous LoopPrefabricated Flap With Arteriovenous Loop: An Experimental Study in Minipigs.

Arteriovenous loops have a high potency to induce angiogenesis and are promising to solve the problem of scarce implanted pedicle sources and insufficient neovascularization in flap prefabrication. But there is a lack of large animal experiments to support their clinical application. Therefore, we aimed to explore the feasibility of prefabricating large flaps based on arteriovenous loops in pigs. Five minipigs were used. In the experimental group, a 10-cm-long ear vein graft was microanastomosed with the saphenous artery and vein to form an arteriovenous loop and implanted under the medial thigh flap. A month later, a 10×10cm prefabricated flap pedicled with the arteriovenous loop was elevated and sutured in situ. In the control group, a 10×10cm flap with no vascular pedicle was elevated completely and sutured in situ in the same position. The patency of the arteriovenous loop was evaluated by angiography 30 days after implantation, and the viability of flaps was assessed by macroscopic analysis 10 days after elevation. Three animals received arteriovenous loop flaps unilaterally and no-pedicle flaps unilaterally. Two animals received arteriovenous loop flaps bilaterally. In the experimental group, no thrombi were exhibited in any arteriovenous loop. All 7 prefabricated flaps survived uneventfully. In the control group, 3 flaps were completely necrotic. The arteriovenous loops with long interpositional venous grafts can be used as vascular pedicles to prefabricated large area and well-vascularized flaps. This approach can greatly expand the application of flap prefabrication.

Outcome of Limberg Flap Reconstruction in the Management of Pilonidal Sinus Disease: A Retrospective Study

Introduction: Pilonidal Sinus Disease (PSD) is a tract or cavity commonly seen in the sacrococcygeal region, usually containing a tuft of hair. It is mostly observed in drivers who have excessive hair in the natal cleft region. Although several surgical procedures have been described for the management of PSD, none have been universally accepted as the gold standard. Limberg flap reconstruction, following wide excision, offers a tension-free repair using a well-vascularised flap. This technique flattens the natal cleft, avoiding a midline scar and reducing the chance of recurrence. Aim: The aim of this study was to determine the outcomes of Limberg flap reconstruction in sacrococcygeal PSD. Materials and Methods: A retrospective descriptive study was conducted in the Department of General Surgery at M S Ramaiah Medical College, Bangalore, Karnataka, India. The study duration was six years, from January 2011 to January 2017. The study included a total of 40 patients aged between 15-70 years, with Tezel type III sacrococcygeal Pilonidal Disease (PND), who underwent the Limberg flap procedure. Data was collected and analysed from January to June 2021. Outcome measures such as duration of hospital stay, time required to return to work, and procedure-related complications associated with procedure were analysed and entered into an Excel sheet. Results: The mean age of the study participants was 18.02±6.87 years. Out of the 40 patients, 4 (10%) developed complications. Superficial wound infection was observed in 1 (2.5%) patient, which healed within two weeks. Minimal flap necrosis was observed in 2 (5%) patients, who underwent debridement and dressings on an outpatient basis. The wounds healed within three to four weeks. Recurrence was reported in 1 (2.5%) patient. The mean time to return to work was 18.7±4.88 days. Conclusion: Limberg flap reconstruction for sacrococcygeal PSD is a simple technique with a lower complication rate, faster return to normal activity, and a low recurrence rate.

Treatment of chest wall osteoradionecrosis with a contralateral breast Y-V flap: a case report

Chest wall osteoradionecrosis, one of the most serious complications of radiation therapy for breast cancer treatment, is usually treated by wide debridement followed by coverage with a well-vascularized flap. However, the extent of radiation-induced injury and limits in performing wide resection of the injured bones often present challenges in treatment. Herein, we present our experience treating chest wall osteoradionecrosis with a contralateral breast Y-V flap in an 81-year-old woman. She was diagnosed with chest wall osteoradionecrosis and had grade 3 ptotic breasts. Redundant contralateral breast tissue was used for reconstruction to cover the wound. The flap was elevated in the subfascial plane after an inverted-T incision was made in the lower pole and inframammary fold of the contralateral breast, while preserving the perforators of the left lateral thoracic artery. The flap was spread using the Y-V advancement fashion to cover the wound. The patient was discharged 2 weeks after surgery. At 19 months postoperation, there were no complications or recurrence. The patient was satisfied with the short recovery time and surgical results. The contralateral breast Y-V flap allows simple and quick reconstruction, potentially expanding the available treatment options and therefore increasing flexibility in choosing a treatment plan for patients.

Lower Extremity Reconstruction with Vascularized Free-Tissue Transfer: 20 Years of Experience in the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Objective: The reconstruction of extensive soft-tissue defects in the lower extremity still poses a great challenge to plastic and reconstructive surgeons. The ideal approach is to achieve a proper soft-tissue coverage with a well-vascularized flap, which results in a durable weight-bearing surface and permits normal joint motion. This study aims to retrospectively analyze the outcomes of lower-extremity reconstruction with vascularized free-tissue transfer performed at our plastic surgery division. Materials and Methods: A retrospective chart review was performed regarding 58 patients with defects in the lower extremity which were reconstructed with vascularized free-tissue transfers between 2000 and 2019. Forty-four of the patients were male, and 14 were female. The mean age was 44.4 years (range: 6-89 years). The most common indication for free-flap surgery was a secondary reconstruction after tumor eradication (23 cases, 39.7%), and 84.8% of the defects were exposed bare bones, tendons, or joints.Results: In our 58 reviewed cases, the foot was the most common area requiring reconstruction with a free flap (68.9%), and the mean defect size was 12.5 x 8.1 cm. The most commonly used free flap was the Anterolateral thigh free flap (39.7%), followed by the Gracilis free flap (29.3%), and the Superficial circumflex iliac artery-perforator free flap (10.4%). The recipient vessels most frequently used were posterior tibialis vessels (53.4%). The overall flap-survival rate was 75.9%, though there was an increased survival rate of up to 85.7% in the last five years of the period studied. The flap-salvage rate was 40.9%, and arterial thrombosis was the major cause of flap loss (50%). Factors associated with free-flap failure were re-exploration and free flap surgery after tumor or cancer eradication. The most common post-operative complication was flap-wound dehiscence (10.3%). Two patients received a flap correction due to bulkiness, and three had recurrence of ulceration. Conclusion: Microvascular free-tissue transfers for lower- extremity-defect reconstructions are reliable and valuable as a surgical technique. In over 20 years of experience in our division, we’ve had an overall flap-survival rate of 75.9%. Our flap of choice was the Anterolateral thigh free flap.

Coverage of anterior mediastinal tracheostomy with bipedicled anterolateral thigh flap

BackgroundCancer defects requiring anterior mediastinal tracheostomy (AMT) are complex, often accompanied by tracheo-laryngeal and pharyngeal defects with exposure of the great vessels and mediastinal cavity. The trachea has to be mobilised and exteriorised as an end-tracheostome through the anterior chest. A well-vascularised flap that can resurface skin defects, obliterate dead space and allow maturation of a reliable anterior mediastinal tracheostome is required. We describe a modification of using a centrally fenestrated bipedicled chimeric anterolateral thigh flap (ALT) to address these challenges. MethodsA free chimeric bipedicled ALT flap was designed. The skin defect was resurfaced by a vertically-oriented skin paddle. Two chimeric muscle components were used to partition the mediastinum and the great vessels of the neck from the tracheostome. The mediastinal trachea was mobilised and matured through a centrally-fenestrated opening in the flap. Layered fascial sutures were employed to minimize dehiscence. Results/ComplicationsTwo patients with AMT underwent the modified ALT. No major complications such as flap-tracheostomy dehiscence occurred. One patient had a small peripheral demarcation of the flap which required revision and secondary closure. ConclusionThe bipedicled design of the modified ALT flap provided robust blood supply to the central fenestration through dual perforators, avoiding flap-tracheostomy separation. The chimeric muscle components obliterate dead space and protect the great vessels of the neck and mediastinum. The thin pliable nature of the anterolateral thigh skin also allowed for tensionless inset of the trachea.

Closure of Irradiated Tracheocutaneous Fistula with Pectoralis Major Muscle Flap and Split Skin Graft

Abstract Tracheocutaneous fistula in an irradiated neck is often difficult to manage. Simple closure often leads to dehiscence and recurrence. We present a patient with supraglottic carcinoma, postradiotherapy, who presented with a persistent trachea-cutaneous fistula. We excised the fistula along with surrounding indurated tissue and covered the defect adequately with skin graft for tracheal lining and pectoralis muscle flap as a muscle cover. Fistula was closed and wound healed well. There was no recurrence of fistula as evidenced with indirect laryngoscopy. Pectoralis major flap is a well-vascularized flap that can be used to cover defects in anterior lower neck. Simple skin graft with a cover of muscle flap was enough to give adequate tracheal lining.

A cover flap reduces the rate of fistula after urethroplasty whatever the severity of hypospadias.

To determine which patients should benefit from the interposition of a well-vascularized flap between the neourethra and the penile skin and if it should be performed even in mild hypospadias. A retrospective study on patients with a primary hypospadias repair was performed (2003-2017). Only patients undergoing urethroplasty based on the principle of a tubularization were selected to ensure comparable groups. Patients were assigned in two groups according to the use or not of a cover flap. Univariate analysis and adjusted logistic regression were used to evaluate the relation between postoperative complications, the severity of hypospadias, the use of flap and patients' characteristics. Three-hundred and seventy-six patients were included with anterior (59.3%), midshaft (27.4%) and posterior hypospadias (13.3%). The median follow-up was 54months (24months-17years). The overall rate of fistula was 11.7% (n = 44). Comparing the outcome in children with flap (n = 217) to controls (n = 159) showed that the use of a flap reduces the rate of fistula (6.5 vs 18.9%, p < 0.001). Stratification of the study according to the phenotype reveals that the more severe the hypospadias, the more protective was the flap (OR = 2.6 for anterior, 5.5 for midpenile, 7.1 for posterior hypospadias). The flap remains nevertheless significantly effective whatever the phenotype (p < 0.05 for anterior, p = 0.01 for midpenile, p = 0.02 for posterior hypospadias). The more severe the hypospadias, the more effective is the cover flap to avoid fistula. It remains nevertheless suitable even in anterior hypospadias and the use of a cover flap should not be limited to the surgery of severe phenotypes.

Urogenital Fistulas and Female Urethral Diverticula

Urogenital fistulas are a group of conditions in which the urinary tract is apparently connected to another organ system. Causes of fistula range from congenital anomalies, malignancy, trauma, infection or inflammatory conditions, ischemia, parturition, and iatrogenic sources – including surgery and radiation. Signs and symptoms of urinary tract fistula are variable and depend on the organ system involved and the size of the fistula. For patients who are appropriate surgical candidates, elective surgical repair is the mainstay of treatment of urinary tract fistula. Surgical techniques can be complex, but rely on the same key concepts: adequate exposure of the fistula tract; careful dissection and separation of the tissue layers, while minimizing cautery; multi-layer closure; watertight closure of each layer; meticulous hemostasis to prevent hematoma formation, but preserve vascular supply of tissues; use of well-vascularized tissue flaps; tension-free, non-overlapping suture lines; biopsy of tissues concerning for malignancy. This review contains 6 figures, 5 tables, and 82 references. Keywords: urogenital fistula, female bladder, vesical fistula, urinary bladder fistula, vesicovaginal fistula, urethrovaginal fistula, vaginal fistula, urethral diverticulum, urethral diverticulectomy, female urethra

Urogenital Fistulas and Female Urethral Diverticula

Urogenital fistulas are a group of conditions in which the urinary tract is apparently connected to another organ system. Causes of fistula range from congenital anomalies, malignancy, trauma, infection or inflammatory conditions, ischemia, parturition, and iatrogenic sources – including surgery and radiation. Signs and symptoms of urinary tract fistula are variable and depend on the organ system involved and the size of the fistula. For patients who are appropriate surgical candidates, elective surgical repair is the mainstay of treatment of urinary tract fistula. Surgical techniques can be complex, but rely on the same key concepts: adequate exposure of the fistula tract; careful dissection and separation of the tissue layers, while minimizing cautery; multi-layer closure; watertight closure of each layer; meticulous hemostasis to prevent hematoma formation, but preserve vascular supply of tissues; use of well-vascularized tissue flaps; tension-free, non-overlapping suture lines; biopsy of tissues concerning for malignancy. This review contains 6 figures, 5 tables, and 82 references. Keywords: urogenital fistula, female bladder, vesical fistula, urinary bladder fistula, vesicovaginal fistula, urethrovaginal fistula, vaginal fistula, urethral diverticulum, urethral diverticulectomy, female urethra

V06-07 ROBOTIC ASSISTED BUCCAL MUCOSA GRAFT POSTERIOR URETHROPLASTY

You have accessJournal of UrologyLower-Tract Reconstruction I: Sling/ Sphincter/ Penile & Urethral Reconstruction (V06)1 Apr 2020V06-07 ROBOTIC ASSISTED BUCCAL MUCOSA GRAFT POSTERIOR URETHROPLASTY Min Suk Jun*, Michael Siev, and Lee Zhao Min Suk Jun*Min Suk Jun* More articles by this author , Michael SievMichael Siev More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000885.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic-assisted posterior urethral reconstruction has shown great promise in early series with excellent patency rates. While Y-V or T plasty remains useful for short supra-sphincteric stenoses, longer stenoses, especially those that are trans-sphincteric, pose a great surgical challenge. The standard approach usually involves urethral transection, often including the bulbar arteries. This increases the risk for incontinence, bulbar urethral necrosis, and future AUS erosion. A buccal mucosa graft posterior urethroplasty may obviate the need for urethral transection, potentially avoiding the aforementioned complications. We present our technique of robotic assisted buccal mucosa graft posterior urethroplasty (RBMGPU). METHODS: This is a retrospective chart review of men who underwent RBMGPU by a single surgeon with the Da Vinci SP robot during 2019. Indications included vesicourethral anastomotic stenosis, radiation induced stenosis, and fistula. Nonobliterative stenoses were approached retropubically or transvesically, while obliterative stenoses were approached posteriorly. A simple prostatectomy was performed if the prostate was in situ. If the stenosis spanned both sides of the sphincter, a perineal dissection was performed. When a well-vascularized flap was required for graft backing or interposition, a rectus or omental flap was used. The primary endpoint was surgical success defined by the absence of obstructive voiding symptoms or urethral patency >16 French. The secondary endpoint was de novo incontinence. RESULTS: 7 men with mean age of 65 years (range 49-72) underwent RBMGPU. Mean operative time was 512 minutes with mean estimated blood loss of 185 mL. Average length of stay was 1.4 days. At a mean of 2.2 months follow up (range 0.8-4.5), 6 of 7 patients reached the primary endpoint while 1 patient experienced de novo incontinence. There was 1 major complication (Clavien > 2), which was a Richter hernia related to the rectus flap. CONCLUSIONS: RBMGPU is a feasible approach to posterior urethroplasty, while minimizing known risk factors for future incontinence surgery. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e557-e558 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Min Suk Jun* More articles by this author Michael Siev More articles by this author Lee Zhao More articles by this author Expand All Advertisement PDF downloadLoading ...

Rhomboid excision and Limberg flap operation for managing pilonidal sinus: our experience at Patan Hospital, Patan Academy of Health Sciences

Introduction: Pilonidal sinus is a common disease. Various surgical techniques for management of sacrococcygeal pilonidal sinus have been described. Among them, the most commonly used is the rhomboid excision with the Limberg flap. With this technique of flattening the natal cleft and tension-free repair is made using a wide, well-vascularized flap. It is reported the best treatment methods, with 0-16 % of surgical area-related complications and a recurrence rate of 0-5 %. We conducted a study to evaluate the patient’s profile and outcomes of the patients of pilonidal sinus treated with rhomboid excision and Limberg flap reconstruction at our center.&#x0D; Methods: Data were recorded retrospectively by reviewing the charts of patients who underwent rhomboid excision and Limberg flap operation for sacrococcygeal pilonidal sinus from September 2015 to September 2019.&#x0D; Results: Thirty-four patients were included in the study. Twenty-nine (85.4%) were males and 5 (14.7%) were females. The mean age was 25.29 years (range 17-40 years). Mean hospital stay was 4.5 days (range 3 – 7 days. Nine (26.5%) patients had surgical site infections. Two patients (5.9%) had a recurrence.&#x0D; Conclusion: Limberg flap for reconstruction after rhomboid excision of pilonidal sinus is an effective and feasible technique with good outcome.

The pedicled temporoparietal fascial flap

The pedicled temporoparietal fascial flap has played a role in reconstructive strategies for defects of the head and neck for well over a century. Although partially succeeded by more recent microvascular free tissue transfer techniques, this well-vascularized and pliable flap has remained an important tool in the reconstruction of locoregional defects of the temporal bone, orbitomaxillary complex, and anterior skull base. Furthermore, with little donor site morbidity and relative ease of harvest this flap is likely to remain a key tool in the reconstructive armamentarium of head and neck and skull base surgeons. In this article we review the anatomy, operative technique, potential complications, and applications of the pedicled temporoparietal fascial flap.

Abstract: Nasal Lining Flaps for Closure of the Nasal Floor in Unilateral and Bilateral Cleft Lip and Palate Repairs Reduces the Rate of Alveolar Fistula Formation

INTRODUCTION: This study was performed to assess the efficacy of the nasal lining flaps for closing the nasal floor in unilateral and bilateral cleft lip and palates. We believe this technique is superior to traditional techniques, resulting in a low rate of fistula formation at the alveolus. Some surgeons do not close the nasal floor during primary cleft lip repair, leaving a symptomatic alveolar fistula that is present until the alveolar bone grafting. The traditional approach for closure involves the use of anteriorly-based medial (M-flap) and lateral (L-flap) skin flaps. However, these skin flaps are thin and provide notoriously unreliable coverage. The nasal lining flaps were devised to reconstruct the nasal floor with robust, well-vascularized flaps. These flaps create an anatomic reconstruction of the nasal floor while providing support for the alar base(s). The undersurface of the one-layer repair eventually fills in secondarily. METHODS: Cleft repairs performed by two craniofacial surgeons at a university children’s hospital were identified. One surgeon used the nasal lining flaps while the other used primarily M- and L-flaps to close the nasal vestibule. Patients were included in the study if they had a complete cleft lip and palate and at least 6 months of follow-up. RESULTS: There were 64 patients in the study. Thirty-seven (37) underwent closure with nasal lining flaps while 27 underwent closure using traditional techniques. The rates of alveolar fistula formation were 3% (1/37) and 30% (8/27), while the rates of non-alveolar fistula formation were 16% (6/37) and 15% (4/27), respectively. The lower rate of alveolar fistula formation in the group that underwent closure with the nasal lining flaps was statistically significant (p=0.003, Fisher’s exact test). There was no statistically significant difference in rates of non-alveolar fistula formation (p=1, Fisher’s exact test). CONCLUSION: The nasal lining flaps have multiple advantages. This technique closes the nasal floor at the time of primary lip repair, when visualization is easiest. The repair is simple to perform and has a high success rate. Closure of the alveolar region with soft tissue likely improves quality of life by preventing fluid or food regurgitation into the nose. The nasal floor closure does not prevent the need for bone grafting, but can make the surgery easier since the nasal side is already closed.

Salvage surgery after high-dose radiotherapy.

Salvage surgery is a relatively new entity in thoracic surgery and oncology. Salvage resection after radiotherapy refers to surgery as only remaining therapeutic option in patients who were treated with high-dose stereotactic radiotherapy (SRT) for early-stage lung cancer or full-dose chemoradiation for locally advanced lung cancer. Indications include locally progressive tumors, recurrent local or locoregional disease, or specific complications after radiotherapy such as lung abscesses or infected, necrotic cavities. Small, retrospective series demonstrate that salvage surgery after high-dose radiotherapy is feasible and may yield good long-term results. A clear distinction should be made between salvage surgery after SRT for early-stage lung cancer and salvage procedures after full-dose chemoradiation for lung cancers with locoregional extension into the mediastinum. Salvage surgery after SRT may be rather straightforward and in specific cases even feasible by a minimally invasive approach. In contrast, surgery after a full dose of chemoradiation delivered several months or years earlier, can be quite challenging and the dissection of the pulmonary artery and mediastinal lymph nodes technically demanding. Due to the more central irradiation an intrapericardial dissection is often required. To prevent a bronchopleural fistula protection of the bronchial stump with well-vascularized flaps is recommended. Each individual patient in whom salvage surgery is considered, should be discussed thoroughly within a multidisciplinary board, detailed cardiopulmonary functional evaluation is required, and the operation should be performed by an experienced team including a thoracic surgeon, anaesthesiologist and intensive care physician. At the present time only retrospective series are available. Carefully designed prospective studies are necessary to more precisely define indications and results of salvage surgery not only after SRT for peripherally localized lesions but also following full-dose chemoradiation for locoregionally advanced disease.

Limited Bilateral Advancement of the Sternocostal Head of Pectoralis Major for Sternal Reconstruction: Preserving the Axillary Fold

The introduction of well-vascularized flaps for infected sternotomy wound reconstruction has improved mortality rates dramatically. Multiple variations of the pectoralis major flap have been described in this context. However, unresolved limitations of this flap include poor cosmesis and problematic coverage of the inferior third of the sternotomy wound. We describe an approach to address these issues. The humeral attachments are preserved and bilateral muscles are advanced in a limited fashion. The left sternocostal head is advanced medially and rotated anticlockwise, using this portion to fill the upper half of the sternum while the caudal portion of the right pectoralis muscle is used as a turnover flap at the lower half of the wound. In all 25 patients, the anterior axillary fold was preserved bilaterally and the infection completely resolved. Complications included 3 cases of hematoma, 2 cases of coagulopathy, and 1 late bone sequestrum (aseptic). Although the study had a limited sample size, we had a high rate of success and few complications. With the preservation of bilateral axillary folds, good cosmesis, and adequate wound coverage, we recommend this modification of the pectoralis major flap in even complicated cases of mediastinitis.

A novel technique for repair of mid-penile hypospadias using a preputial skin flap: results of 110 patients.

Several techniques have been used to repair mid-penile hypospadias; however, high failure rates and major complications have been reported. In this study, we describe a novel technique using a well-vascularized flap of the inner and outer preputial skin. A total of 110 male children with hypospadias underwent repair by our technique between 2008 and 2015. The inclusion criteria were children with mid-penile or slightly more proximal hypospadias, with or without ventral chordae, and an intact prepuce of the cobra eyes variety. Recurrent cases, patients with other preputial types, and circumcised children were excluded from this study. The prepared flap was sutured in its natural longitudinal orientation to the created urethral plate strip to form a neo-urethra over a urethral catheter. Outcome measures included surgical success without the formation of a urethra-cutaneous fistula, no ischaemia of the flaps, glans dehiscence or infection and functional outcome and cosmetic appearance. The median follow-up duration was 3.3years. There were 63 cases of mid-penile hypospadias (57.3%), and in 47 cases (42.7%), the meatus was slightly more proximal. The age of the patients ranged from 1.1 to 8.0years, with a mean age of 4.6±1.2years. Surgery was successful in 106 (96.4%) cases. Minor complications occurred in 11 patients (10%) and included oedema of glans in ten patients and bluish discoloration on the ventral aspect of the glans close to the suture line in three patients. All patients improved within 2weeks after surgery. Long-term follow-up revealed a properly functioning urethra with a forward, projectile, single, compact, and rifled urinary stream of adequate calibre and cosmetically acceptable repair. No cases of meatal retraction, meatal stenosis, urethral stricture, or acquired urethral diverticulum occurred. Our technique is different from the split prepuce in situ technique. We create a narrow strip of the urethral plate that facilitates glanular closure, and we use the inner and adjacent outer skin in a vertical manner to preserve excess skin for penile coverage. Prepuce is split at midline to preserve more preputial skin with favourable dartos tissue for penile skin coverage. The glans is closed using a stitch-by-stitch method that has not been described previously. This study presents a novel technique for mid-penile hypospadias repair using a preputial skin flap with excellent results in terms of short- and long-term outcomes.

The T-plasty: a modified YV-plasty for highly recurrent bladder neck contracture after transurethral surgery for benign hyperplasia of the prostate: clinical outcome and patient satisfaction.

To describe a modified surgical technique for treatment of highly recurrent bladder neck contracture (BNC) after transurethral surgery for benign hyperplasia and to evaluate success rate and patient satisfaction of this novel technique. Ten patients with highly recurrent BNC and multiple prior attempts of endoscopic treatment underwent the T-plasty. Perioperative complications were recorded and classified according to the Clavien classification. Patient reported functional outcomes were retrospectively analysed using a standardized questionnaire assessing recurrence of stenosis, incontinence, satisfaction and changes in quality of life (QoL). The questionnaires included validated IPSS and SF-8-health survey items. Mean age at the time of surgery was 69.2 years (range 61-79), and the mean follow-up was 26months (range 3-46). No complications grade 3 or higher according to the Clavien classification occurred. Success rate was 100%. No de novo stress incontinence occurred. Urinary stream was described as very strong to moderate by 80% of the patients, mean post-operative IPSS-score was 11.3 (range 4-29), and mean post-operative IPSS-QoL was 2.4 (range 1-5). Patients satisfaction was very high or high in 90%, and QoL improved in 90%. The SF-8-health survey showed values comparable to the reference population. The T-plasty represents a safe and valuable option in treating highly recurrent BNC after surgery for benign hyperplasia. It offers multiple advantages compared to other techniques such as a single-staged approach and the opportunity for reconstruction of a reliable wide bladder neck by usage of two well-vascularized flaps. Success rate, low rate of complications and preservation of continence are highly encouraging.