Well-vascularized Tissue Research Articles

Internal mammary artery perforator flap for repair of an upper thoracic tracheo-oesophageal fistula

Tracheoesophageal fistulas (TOF) following esophagectomy for esophageal cancer are rare but potentially fatal. There is no consensus on treatment between stenting and surgical repair, although the latter is associated with better distant survival. In surgical repair, the interposition of a flap improves healing by providing well-vascularized tissue and reinforcing the repair zone. The flaps described are usually muscular and decaying. We present the case of a malnourished fifty-year-old man who underwent intrathoracic surgical repair of symptomatic recurrent TOF using a skin flap based on the perforators of the internal thoracic artery (IMAP). The perforator flap was completely de-epidermized and tunneled under the sternum by a proximal and limited resection of the 3rd costal cartilage and placed at the posterior aspect of the trachea, with the excess tissue rolled up on either side. At 9 months, the patient showed no recurrence and improved general condition. The de-epidermized IMAP tunneled under the sternum intrathoracically is a reliable alternative to the conventional muscle flaps described in TOF management and an attractive additional tool in the plastic surgeon's surgical arsenal.

Influence of the Tissue Collection Procedure on the Adipogenic Differentiation of Human Stem Cells: Ischemic versus Well-Vascularized Adipose Tissue.

Clinical and basic science applications using adipose-derived stem cells (ADSCs) are gaining popularity. The current adipose tissue harvesting procedures introduce nonphysiological conditions, which may affect the overall performance of the isolated ADSCs. In this study, we elucidate the differences between ADSCs isolated from adipose tissues harvested within the first 5 min of the initial surgical incision (well-vascularized, nonpremedicated condition) versus those isolated from adipose tissues subjected to medications and deprived of blood supply during elective free flap procedures (ischemic condition). ADSCs isolated from well-vascularized and ischemic tissues positively immunostained for several standard stem cell markers. Interestingly, the percent change in the CD36 expression for ADSCs isolated from ischemic versus well-vascularized tissue was significantly lower in males than females (p < 0.05). Upon differentiation and maturation to adipocytes, spheroids formed using ADSCs isolated from ischemic adipose tissue had lower triglyceride content compared to those formed using ADSCs isolated from the well-vascularized tissue (p < 0.05). These results indicate that ADSCs isolated from ischemic tissue either fail to uptake fatty acids or fail to efficiently convert those fatty acids into triglycerides. Therefore, more robust ADSCs suitable to establish in vitro adipose tissue models can be obtained by harvesting well-vascularized and nonpremedicated adipose tissues.

A Model to Study Wound Healing Over Exposed Avascular Structures in Rodents With a 3D-Printed Wound Frame.

Soft tissue defects with exposed avascular structures require reconstruction with well-vascularized tissues. Extensive research is ongoing to explore tissue engineered products that provide durable coverage. However, there is a lack of controlled and affordable testbeds in the preclinical setting to reflect this challenging clinical scenario. We aimed to address this gap in the literature and develop a feasible and easily reproducible model in rodents that reflects an avascular structure in the wound bed. We created 20 × 20 mm full thickness wounds on the dorsal skin of Lewis rats and secured 0.5-mm-thick silicone sheets of varying sizes to the wound bed. A 3D-printed wound frame was designed to isolate the wound environment. Skin graft and free flap survival along with exposure of the underlying silicone was assessed. Rats were followed for 4 weeks with weekly dressing changes and photography. Samples were retrieved at the endpoint for tissue viability and histologic analysis. The total wound surface area was constant throughout the duration of the experiment in all groups and the wound frames were well tolerated. The portion of the skin graft without underlying silicone demonstrated integration with the underlying fascia and a histologically intact epidermis. Gradual necrosis of the portion of the skin graft overlying the silicone sheet was observed with varying sizes of the silicone sheet. When the size of the silicone sheet was reduced from 50% of the wound surface area, the portion surviving over the silicone sheet increased at the 4-week timepoint. The free flap provided complete coverage over the silicone sheet. We developed a novel model of rodent wound healing to maintain the same wound size and isolate the wound environment for up to 4 weeks. This model is clinically relevant to a complex wound with an avascular structure in the wound bed. Skin grafts failed to completely cover increasing sizes of the avascular structure, whereas the free flap was able to provide viable coverage. This cost-effective model will establish an easily reproducible platform to evaluate more complex bioengineered wound coverage solutions.

Extended arc of rotation of Latissimus Dorsi Musculocutaneous Flap providing well-vascularized tissue for reconstruction of complete defects of the sternum: An anatomical study of flap pedicle modification.

Deep sternal wound infections (DSWI) following cardiothoracic surgery represent a life quality endangering sequelae and may lead to sternal osteomyelitis. Radical debridement followed by Negative Pressure Wound Therapy (NPWT) may achieve infection control, provide angiogenesis, and improve respiratory function. When stable wound conditions have been established a sustainable plastic surgical flap reconstruction should be undertaken. This study analyses a method to simplify defect coverage with a single Latissimus Dorsi Myocutaneous Flap (LDMF). Preparation of 20 LDMF in ten fresh frozen cadavers was conducted. Surgical steps to increase pedicle length were evaluated. The common surgical preparation of LDMF was compared with additional transection of the Circumflex Scapular Artery (CSA). Alteration of the surgical preparation of LDMF by sacrificing the CSA may provide highly valuable well-vascularized muscle tissue above the sensitive area of the Xiphisternum. All defects could be completely reconstructed with a single LDMF. The gain in length of flap tissue in the inferior third of the sternum was 3.86±0.9 cm (range 2.2 to 8 cm). By sacrificing the CSA in harvesting the LDMF a promising gain in length, perfusion and volume may be achieved to cover big sternal defects with a single flap.

Local Flaps in Breast-Conserving Surgery in Early Breast Cancer Patients: Armamentarium for Breast Surgeon.

To describe the technique and outcome of local perforator arteries advancement flap in breast-conserving surgeries (BCS) in patient of early breast cancer as our initial experience and review of literature on it. Patients who underwent (BCS) with local perforator artery flap reconstruction were reviewed in terms of their clinical, surgical, and post-operative follow-up details after taking written and informed consent. We have described 4 patients of early breast cancer out of which one patient was post-NACT while 3 were for upfront BCS. We have performed LICAP in 2 patients, AICAP in 1 patient, and IMAP in one patient, depending on the location of primary tumors. None of the patients had any major or minor surgical complications in the post-operative period and drains were removed on post-operative day 2. All patients received post-operative radiotherapy and tolerated well without any loco-regional complications. Patients are in routine follow-up with cosmetic satisfaction without any local recurrence over 1year. The main advantages of pedicled perforator flaps are well-vascularized tissue, spares underlying muscle leading to lesser donor site morbidity like muscle function and seroma formation, easily reach the breast area with good match in terms of skin and subcutaneous tissue, faster recovery, and shorter learning curve in comparison to free flaps. Knowledge and skill about these flaps will help surgeon to give better surgical outcomes and satisfaction to patients.

Evaluation of the non-endoscopic and endoscopic-assisted platysma flap - A randomized control trial.

As oral submucous fibrosis (OSMF) is a chronic progressive disorder, the treatment is based on the severity of the disease. Surgical treatment is the only choice for grade III and grade IV OSMF cases because the patient can neither clean his/her mouth nor properly chew. The resulting soft tissue defect requires resurfacing with various well-vascularized tissues such as extraoral flaps, intraoral flaps, microvascular flaps, and allografts that have been used. Reconstruction of the resultant defects proved to be challenging. Till date, none of the flaps has been proven to be effective and is universally accepted for the treatment of OSMF because of various drawbacks of the available techniques. This study was conducted to know whether an endoscopic-assisted platysma flap is associated with better outcomes in terms of ease of operation and postoperative function than the conventional approach. This study included 40 patients of grade III and grade IV OSMF reporting to the outpatient department of oral and maxillofacial surgery in a tertiary center of North India. These patients were divided randomly into two groups. Group I and Group II had 20 patients each, undergoing endoscopic-assisted platysma flap and non-endoscopic-assisted platysma flap for reconstruction after resection of OSMF bands, respectively. Data were analyzed for the mouth opening, operating time, flap viability, congestion of neck and oral cavity, signs of inflammation, neurologic assessment, and measurement of the drain. The results showed significant increase in mouth opening from the preoperative value to the values immediately after surgery and at 24 h, 1 week, 15 days, 1 month, 3 months, and 6 months after surgery in both the study groups. Reduced bleeding incidence was found in group I compared to group II, with better postoperative outcomes noted during follow-up. But the mean intraoperative time of the subjects in group I was 130.80 ± 5.5.908 min and in group II was 105.74 ± 2. 491 min. Increased time taken in group I may be due to the long learning curve. The present study concluded that the Endoscope-assisted technique has a key role during supra and subplatysmal dissection to allow for better accessibility, handling, and visibility of the flap and its orientation in relation to the underlying structures to avoid postoperative complications and to overcome the drawback of platysma myocutaneous flap in reconstruction of OSMF defects.

Hemangiossarcoma mamário: Relato de exame histopatológico

Hemangiosarcoma (HSA) is a common form of neoplasm in dogs, characterized by the malignant growth of endothelial cells in blood vessels. This neoplasm is highly aggressive and often shows metastatic behavior, with tropism for well-vascularized tissues and characterized by fragile capillaries, leading to hemorrhagic conditions, causing the death of most affected animals, as well as causing a series of hematological abnormalities. Diagnosis can be made by cytology and confirmed by histopathological examination. Treatment is comprised of surgical removal of the affected nodule or organ, accompanied by chemotherapy protocols. A histopathological examination was carried out on a cutaneous tumor in the mammary area of a seven-year-old Dachshund bitch, which was diagnosed as a hemangiosarcoma. The aim of this paper is to report a case of canine mammary hemangiosarcoma and to show the importance of histopathological examination in routine veterinary medicine diagnoses.

Periosteal Turnover Flap for Coverage and Salvage of Exposed Deep Brain Stimulation Device.

Implanted deep brain stimulation (DBS) devices are crucial in the treatment of movement disorders. Hardware extrusion is among the most frequent complications of the implantation process and requires reconstruction with well-vascularized tissues. The authors present a case of periosteal turnover flap for coverage of an exposed DBS device. An 11-year-old female patient with spastic cerebral palsy presented with an exposed DBS device located in the right parietal area. The exposed device was covered by a proximally based periosteal flap. Postoperative evaluations at months 1, 2, 3, and 8 revealed no signs of infection or dehiscence. This brief clinical study shows that reconstruction with periosteal turnover flaps is both an easy and excellent choice for secondary closure of exposed DBS devices.

Collagen-Derived Dipeptide Pro-Hyp Enhanced ATDC5 Chondrocyte Differentiation under Hypoxic Conditions.

Chondrocytes are surrounded by a lower oxygen environment than other well-vascularized tissues with higher oxygenation levels. Prolyl-hydroxyproline (Pro-Hyp), one of the final collagen-derived peptides, has been previously reported to be involved in the early stages of chondrocyte differentiation. However, whether Pro-Hyp can alter chondrocyte differentiation under physiological hypoxic conditions is still unclear. This study aimed to investigate whether Pro-Hyp affects the differentiation of ATDC5 chondrogenic cells under hypoxic conditions. The addition of Pro-Hyp resulted in an approximately 18-fold increase in the glycosaminoglycan staining area compared to the control group under hypoxic conditions. Moreover, Pro-Hyp treatment significantly upregulated the expression of SOX9, Col2a1, Aggrecan, and MMP13 in chondrocytes cultured under hypoxic conditions. These results demonstrate that Pro-Hyp strongly promotes the early differentiation of chondrocytes under physiological hypoxic conditions. Therefore, Pro-Hyp, a bioactive peptide produced during collagen metabolism, may function as a remodeling factor or extracellular matrix remodeling signal that regulates chondrocyte differentiation in hypoxic cartilage.

Treatment of Rectovaginal Fistula.

Rectovaginal fistula (RVF) is a challenging complication with unsatisfactory success and a significant burden for the patients. With insufficient clinical data due to the rare entity, the present state of treatments for RVFs was reviewed especially form the point of factors to determine management, classifications, principle of treatment, conservative and surgical treatments with outcomes. Size, fistula localization and etiology, type of fistula; "simple" or "complex," status of anal sphincter complex and surrounding tissue, presence or absence of inflammation, presence of diverting stoma, previous attempted repair and radiation therapy, patient's condition with co-morbidities, and surgeon's experience are important factors to determine the management of RVF. The inflammation should initially subside in cases with infection. Starting with conservative surgical options and interposing healthy tissue for complex or recurrent fistulas, invasive procedures will be performed if conservative treatment failed. Conservative treatment may be effective in RVFs with minimal symptoms and should be done for small RVFs for a 36 months usual period. Anal sphincter damage might need a repair of sphincter muscles along with RVF repair. Diverting stoma can initially be constructed in patients with severe symptoms and larger RVFs to relief the patient's pain. Simple fistula is usually indicated for local repair. Local repairs to transperineal and transabdominal approaches can be used for complex RVFs. Interposition of healthy, well-vascularized tissue can be required for more complex fistulas and abdominal procedures for high RVFs.

Regional flap: A reliable coverage for post-radiation ulcer.

Ulcer in radiation-damaged tissue is a dilemma with limited treatment strategies. The study aimed to evaluate the safety and efficacy of regional flaps for patients with post-radiation ulcers through a 10-year experience. A retrospective study of consecutive patients with post-radiation ulcers at a single institute from 2012 to 2022 was conducted. Reconstruction included complete excision of irradiated tissue and coverage with well-vascularised tissue, including local flaps, regional flaps and free flaps. Study outcomes included complications, reoperation rates, overall flap success and recurrence rates. Thirteen patients (six males and seven females; mean age, 56.85 ± 13.87 years) with a mean 10-month history of post-radiation ulcers were enrolled. Ulcers are predominantly located in the chest (n = 3, 23.1%), head (n = 2, 15.4%) and neck (n = 2, 15.4%), with a mean size of 33.1cm2 (range from 1cm2 to 120 cm2 ). Eleven patients underwent reconstruction with 15 regional flaps and three local flaps, one patient received a free anterolateral thigh fasciocutaneous flap and one patient underwent amputation. Among these 15 regional flaps, one (6.7%) had wound dehiscence and four (26.7%) had localised necrosis requiring reoperation. In addition, one patient with a non-healing sinus tract underwent reoperation. The overall success rate of the regional flap was 100% and no recurrence was observed with a mean follow-up of 23.3months. Regional flaps seem a safe and effective reconstructive method for post-radiation ulcers.

Free Anterolateral Thigh Flap in the Repair of Bronchial Stump Blow-outs

A bronchial stump blow-out is a serious complication following pneumonectomy/lobectomy. A blown-out stump requires well-vascularized tissue for healing and successful closure. We illustrate the use of the free anterolateral thigh flap in two patients. For patient 1, a chimeric anterolateral thigh flap was used to seal the bronchial stump following an upper lobectomy for tuberculous bronchiectasis. For patient 2, an anterolateral thigh flap was used to seal the main bronchial stump that had blown-out following pneumonectomy for actinomyces lung abscess. The latissimus dorsi muscle was unavailable in both cases due to a previous thoracotomy. Patient 1 had a persistent bronchial leak post-operatively, which resolved after anti-tuberculous treatment. Patient 2 recovered uneventfully and was discharged 14-days post-operatively. Their follow-ups were 13 years and 4 months respectively. In conclusion, the free anterolateral thigh flap is an alternative option to seal a blown-out bronchial stump in the absence of the latissimus dorsi muscle flap.

Surgical management of tracheal anastomosis failure and risk of arterial bleeding

To determine the optimal algorithm for tracheal anastomotic insufficiency and prevention of arterial bleeding. We present 2 patients with defects of tracheal anastomosis after tracheal resection and divergence of tracheal edges. We primarily analyzed appropriate emergency care and prevention of subsequent severe complications such as arterial bleeding and respiratory insufficiency. Tracheostomy may be preferable for complete late tracheal anastomotic insufficiency to restore breathing. However, surgery should be accompanied by prevention of arterial bleeding. Isolation of damaged area, particularly tracheostomy tube, from the mediastinum by well-vascularized tissues can prevent bleeding from major vessels (for example, innominate artery). Follow-up is unreasonable due to worsening of clinical situation, risk of hemorrhagic complications and fatal outcomes. General satisfactory clinical status of the patient is not of matter. Repeated tracheal anastomosis is justified only for early insufficiency, i.e. within 2-3 days when postoperative inflammation is mild.

Free extended anterolateral thigh myocutaneous flap versus combined pedicled pectoralis major–latissimus dorsi myocutaneous flaps in deep and extensive sternal wound reconstruction

The combined pedicled pectoralis major-latissimus dorsi (PM-LD) and free extended anterolateral thigh (ALT) myocutaneous flaps provide well-vascularized tissues for extensive sternal wound reconstruction. However, the outcomes and postoperative complications between the two surgical techniques are different. Thus, the aim of this study is to evaluate the feasibility of these two reconstructive options. This single-center, retrospective study was conducted between August 2011 and May 2019. Forty-four patients diagnosed with deep sternal wound infection (DSWI) and presented with grade four complications (sternal instability and necrotic bone tissue) were enrolled. Two reconstructive strategies, namely, combined pedicled PM-LD (n=24) and free extended ALT (n=20) myocutaneous flaps, were used according to the patients' hemodynamics. Data including age, gender, body mass index (BMI), hospital stay, follow-up, defect/flap size, number of surgical procedures before reconstruction, duration from the last debridement to flap coverage, comorbidities, and postoperative complications, were obtained for statistical analysis. The mean defect size in the combined PM-LD myocutaneous flap group was 188.4 (5*17-10*23) cm2 , and the mean flap size was 150.0 (8*12-15*15) cm2 and 205.0 (8*15-10*25) cm2 in PM and LD flap, respectively. The mean defect size in the free extended ALT myocutaneus flap group was 202.5 (6*16-10*21) cm2 , and the mean flap size was 285.2 (9*30-12*25) cm2 . No significant differences were observed between the free extended ALT and the combined pedicled PM-LD myocutaneous flaps in relation to age, gender, BMI, hospital days, follow-up, defect size, preoperative procedures, and comorbidities, except for the average operative time (443.2 ± 31.2 vs. 321.3 ± 54.3 mins, p=.048). The combined pedicled PM-LD myocutaneous flap had significantly more donor site complications, including seroma (21% vs. 0%, p=.030), bilateral nipple-areolar complex asymmetry (100% vs. 0%, p < .0001), and skin graft loss with infection (33% vs. 0%; p=.044) than the free extended ALT myocutaneous flap. The free extended ALT and the combined pedicled PM-LD myocutaneous flaps were both feasible and effective options for sternal wound reconstruction. Our findings suggested that the free extended ALT myocutaneous flap may be a better alternative for a comprehensive and extensive reconstruction of sternal wounds. Further studies based on these findings can be conducted.

Cubital fossa defect- our reconstructive experience with pedicle flaps

IntroductionCubital fossa wounds can be complicated by the non-availability of reliable, well-vascularized donor tissue. Closure with pliable and readily available donor tissue for cubital defect and early mobilization of the elbow joint is essential for better results. The authors did this study to see how best the results of cubital fossa defect cover can be achieved by pedicle flaps in a single stage without compromising the donor areas. Material and methodPatients having deep elbow wounds in which vital structures were lying exposed in the cubital region were included in this study. The patients were assessed for the availability of tissue for cover, reliability of flaps, flap pliability, the functional outcome of the elbow and donor site morbidity. ResultsA total of 17 cases of cubital region defects are presented wherein closure of the wound by means of primary closure was not possible. Out of these, eight were covered with Pedicled Thoracodorsal Artery Perforator (TDAP) flaps, five with Pedicled split Latissimus Dorsi Muscle (SLDM) flaps and four with reversed lateral arm flaps (RLA). Post-operatively all the flaps were healthy, patients attained a good range of elbow joint movements with no clinically evident morbidity of the donor site. ConclusionCubital fossa defect coverage needs dedicated planning to obtain a sturdy tissue for cover. In the presence of local tissue damage or scarring, we have looked elsewhere to bring pliable and well-vascularized tissue which is reliable. The flaps we used have allowed single-stage reconstruction and early mobilization of the elbow joint with good functional recovery.

Cross-sectional Vascularization Pattern of the Adipofascial Anterolateral Thigh Flap for Application in Tissue-engineered Bone Grafts.

Background:As part of the engineering of bone grafts, wrapping constructs in well-vascularized tissue, such as fascial flaps, improves bone formation. Our aim was to understand the cross-sectional vascularization pattern of human adipofascial flaps for this application.Methods:Seven adipofascial anterolateral thigh (ALT) flaps were harvested from five human cadaveric specimens. Axial vessel density was analyzed by immunohistochemistry and quantitative histology.Results:We found a high density of blood vessels directly superficial to and close to the fascia. A secondary plexus in between this first suprafascial plexus and the subdermal plexus was also identified. In all specimens, this second plexus showed less vascular density, and appeared to be at a constant level within the suprafascial fat throughout the flaps. The peak measurements for this secondary plexus varied between 1.2 and 2 mm above the deep fascia, depending on the donor’s body mass index.Conclusions:Quantitative immunohistochemistry is a reliable method to quantify and locate vessel density in an adipofascial flap. This is vital information before wrapping nonvascularized material into such a flap to estimate the inosculation potential of these vessels and likelihood of survival of the tissue. To profit from both suprafascial vascular plexuses, a correlation between subcutaneous tissue thickness and distance of the second plexus to the fascia should be further investigated. For the moment, we recommend maintaining at least 2–3 mm of subcutaneous fatty tissue on the fascia, to profit from both plexuses. Engineered constructs should be wrapped on the superficial medial side of the fascial flap to enhance vascularization.

Speech and swallowing function following microsurgical reconstruction of palatal defects in a series of six pediatric patients.

Reconstruction of extensive palatal defects in growing patients aims to restore speech intelligibility and swallowing function while avoiding excessive scarring formation that may cause growth disturbances in the palate and midface region. Free flaps transfer healthy, well-vascularized tissue to the defect area, and their combination with pharyngeal flaps allow for restoration of the velopharyngeal function. We examined speech and swallowing after microsurgical palate reconstruction in a series of six pediatric patients. Radial forearm free flaps were used in all cases, in combination with a superiorly based pharyngeal flap in five cases. Mean age at surgery was 10.7 years. Etiologies included recurrent oronasal fistula due to failed primary cleft palate repair (n=4), embryonal rhabdomyosarcoma of the maxilla (n=1), and inflammatory fibrous hyperplasia (n=1). Speech evaluations (with the Hirose standard and listener ratings) and swallowing assessments (based on videofluoroscopy swallowing studies and patient-reported swallowing and diet) were performed in average 44 months postoperatively. All flaps survived without major postoperative complications. Speech intelligibility was graded as "excellent" in four patients and "moderate" in two. Hypernasality and nasal obstruction were each judged as "none/minimal" in five cases and "moderate" in one case. All patients tolerated oral diet without significant nasal regurgitation. In five of six patients, the swallowing assessment showed good motion and velopharyngeal closure. Microsurgical reconstruction of extensive palatal defects using radial forearm free flap, with or without a superiorly based pharyngeal flap, is a reliable technique that can deliver substantial improvement of speech and swallowing in pediatric patients.

Analysis of epidemiological characteristics and surgical treatment of patients with pressure ulcer

Introduction/Objective A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence. It appears as a result of pressure or the combination of pressure and shear. Pressure ulcers can be identified within a wide variety of patient subpopulations and epidemiological and etiological aspects play a major role in their treatment. Methods A retrospective study of data analysis included 72 patients with pressure ulcers that were hospitalized and surgically treated in our institution over a five-year period. Main data features used in the analysis were sex, age, principal diseases, comorbidities, and biochemical indicators of malnutrition. The patients? data was obtained from the existing patients? records. Additionally, the study analyzed the method of treating pressure ulcers, types of reconstructive methods in surgical treatment, as well as the incidence rate of partial osteotomy. Results A total of 72 patients with pressure ulcers were included in this study, with a mean age of 54.7 ? 16.1 years. Three times more patients injured in traffic accidents were male (75% vs. 25%), while most of the patients with multiple sclerosis were female (85.7%). More than 95% of patients who had pressure ulcers of stage III or IV were treated surgically with a reconstructive method of transposition or rotation myocutaneous flap. Patients with stage IV pressure ulcer were usually treated with partial osteotomy. Conclusion Surgical reconstructive treatment with fasciocutaneous and myocutaneous flaps represents the gold standard for treating patients with pressure ulcers. These procedures provide reconstruction with adequate flap coverage and obliteration of dead space with well-vascularized tissue but with necessity of further implementation of antidecubitus measures.

The unilateral reverse latissimus dorsi flap for soft tissue coverage of midline thoracal defects after spine surgery procedure: A case report

IntroductionThe thoracolumbal region is often a difficult area to reconstruct for orthopaedic surgeons. Reconstruction of this area with a standard free tissue transfer is not always possible, and locoregional flaps are often failed due to poor quality outcome and mobilization difficulty.Case reportA case was presented with unilateral distally based latissimus dorsi flaps reconstruction in patient with midline thoracal soft tissue defect underwent kyphosis deformity correction surgery. This study reported a patient, male, 33 years old who was diagnosed with ankylosing spondylitis and kyphosis deformity. The patient underwent surgical correction of the kyphosis deformity. After 1 month, the patient complained about his open surgical wounds.Clinical discussionIn our institution, this patient underwent second debridement surgery and unilateral reverse latissimus dorsi flap for thoracal soft tissue defect coverage to obtain well-vascularised tissue, with good resistance to bacterial contamination and easy to shape into such defect. After follow-up for 6 months, the patient shows good outcome and postoperative wound healing was favorable.ConclusionWe believe that the “reverse” latissimus dorsi flap is a good option to cover this particular region. It is simple, safe, and reliable. It also provides a backup plan for the microsurgery in this region.

Obliteration and Contouring of Comminuted Anterior Wall Frontal Sinus Fracture Using Pericranial Flaps.

Summary:One of the common postoperative complications of comminuted fractures of frontal sinus are contour deformity, hardware extrusion, adherence and/or palpability, and skin thinning. We are presenting our novel technique with pericranial flaps to decrease these complications. The study was performed from January 2019 to January 2020, on 40 cases of comminuted fractures of anterior wall of frontal sinus, 28 men and 12 women, with an average age of 41 years. Injury resulted from motor vehicle crashes (n = 25), motorcycle crashes (n = 11), and falling from heights (n = 4). Our novel technique involves the use of two anteriorly based pericranial flaps; one flap is used for obliteration of the frontal sinus and the other is used to overlay the hardware used to restore forehead contouring and to eliminate the possibility of early extrusion or late plates or mesh palpability. Two patients had postoperative minimal disruption of forehead lacerations healed with secondary intention and minimal scarring. Excellent patient compliance without any complaint of mesh palpability. No adherence occurred and no skin thinning. This technique (two anteriorly based pericranial flaps) may be more reliable to obliterate the frontal sinus also overlaying the hardware used to improve forehead contour and decrease the incidence of mesh palpability and skin adherence than using hardware without flap coverage.