Distal profunda femoris artery perforator island flap for distal thigh and knee reconstruction: a CT-based anatomical analysis and a case-series study.

BACKGROUND: Locoregional flap options for reconstructing defects of the anterolateral distal thigh/knee region are limited. The distal profunda artery perforator island (PAPI) flap is a local fasciocutaneous propeller-type flap that utilizes the most distal perforator of the profunda femoris artery. The aim of this study is to conduct a CT-based angiographic analysis of the perforator system of the profunda femoris artery and present outcomes on the application of the PAPI flap in the management of post-oncologic defects of the distal thigh and knee. METHODS: CT angiograms were utilized on the lower limbs of 25 healthy patients (mean age, 57 years; 76% male) and the number and location of septocutaneous perforators with a diameter greater than 1 mm were measured. A case series of patients undergoing reconstruction of post-ablative defects which involved the anterolateral and posterior knee performed by the senior author were reviewed. RESULTS: CT angiography demonstrated a robust collection (mean 3.5, range 2 to 5) of septocutaneous perforators from the profunda femoris artery with the most distal perforator located 3.3 cm from the superior patella border. The PAPI flap was successfully used in 10 patients (6F; 4M; mean age 60.6 years; range 30 to 88 years) with a mean defect size of 87.5 cm2 (range 48 to 150 cm2 ). Hand-held Doppler was used to detect the perforator. No flap loss was encountered, and no knee function limitation was noted at follow-up. Minor complications include seroma (1) and intra-articular infection (2). CONCLUSIONS: We conclude that the distal PAPI flap is a reliable and versatile flap that has potentially wide applications.

Propeller Flaps for Lower Back Defects.

What are the reconstructive challenges of the lumbosacral area?What are the goals and principles of reconstructing the lumbosacral defect?What are propeller flaps?How are propeller flaps used in the lumbosacral region?

Determining functional outcomes after resection and reconstruction of primary soft tissue sarcoma in the lower extremity: A review of current subjective and objective measurement systems.

The surgical management of soft-tissue sarcoma has evolved significantly over the last two decades due to the routine use of adjunct therapies, with an increased focus on postoperative functional outcome. The literature suffers from methodological inconsistency and use of low quality outcome measures to assess an already heterogeneous population. This article aims to review the most frequently used subjective and objective methods of functional outcome assessment and highlight the current benefits and limitations of these.

Patient-reported outcomes post prophylactic risk-reducing mastectomy: improved breast and psychosocial satisfaction yet poorer physical well-being.

BACKGROUND: Few studies have investigated patient-reported outcomes (PROs) for patients with high breast cancer risk undergoing elective risk reduction mastectomy and reconstruction. These patients incur operative risk in the absence of active cancer, which renders their treatment experience unique. This study aimed to identify longer-term quality of life (QoL) issues that persist in this patient cohort. METHODS: A cross-sectional cohort study assessed PROs in 48 women with high breast cancer risk who attended the Royal Melbourne Hospital Risk Management Clinic, at least 12 months post-mastectomy and reconstruction, with surgery between 2011 and 2020, using the BREAST-Q© Likert surveys. The BREAST-Q© internationally validated QoL instrument scales survey data from 0 (worst) to 100 (best) in 14 domains addressing satisfaction and psychosocial issues. RESULTS: There was higher overall breast and psychosocial satisfaction, with scores of 11 and four, respectively, yet lower chest, abdomen and sexual well-being scores with 14, three and four, respectively, in contrast to normative BREAST-Q© data from >1000 women without prior breast cancer or breast operations. High average scores >90 were found for patient satisfaction with surgical, medical and office staff. Twenty-one patients had an average score of 63 for satisfaction with breast implants, while 27 patients post-DIEP had average scores >72 for abdominal well-being, appearance and overall outcomes. Higher mean QoL outcomes were found with DIEP flap in all domains, compared with breast implant reconstruction. CONCLUSION: QoL assessment with PROs 12 months post-risk reduction mastectomy and reconstruction demonstrated higher psychosocial well-being, yet highlights physical implications, with patients experiencing reduced chest, abdomen and sexual well-being, compared with normative BREAST-Q© control data. Higher mean QoL outcomes were found with DIEP flap compared with breast implant reconstruction. PROs studies can identify unmet needs and facilitate change in service provision.

Functional outcomes after single quadriceps muscle resection in patients with soft tissue sarcoma of the anterior compartment of the thigh.

BACKGROUND: Soft tissue sarcoma (STS) occurs most commonly in the anterior compartment of the thigh. Limb salvage surgery is the mainstay of treatment, however, resections frequently involve muscle sacrifice. This study determines the impact of a single quadriceps muscle sacrifice on daily living functions. This is to assist clinical decision-making relating to when a functional reconstruction should be offered over simple soft tissue coverage for these defects. METHODS: Patients who underwent single quadriceps resection as part of the management of STS between 2010 and 2020 were selected. Three functional tests were performed: Time Up and Go (TUG), Timed Up and Down Stairs (TUDS) and Toronto Extremity Salvage Score (TESS). The results were compared with age/sex matched healthy reference values and literature cohorts of lower limb STS patients. Correlations between the tests and age and follow-up duration were determined by the Spearman's test. RESULTS: The mean TESS, TUG and TUDS results of the 13 patients were 89.6%, 9.8 and 1.01 s/step, respectively. These scores were either similar or significantly better than the comparator values. The TESS score showed no statistical significance compared with patients with no muscle resection. TUG and TUDS scores showed significant positive correlation with each other (ρ = 0.885, P = <0.01) and with age (ρ = 0.646, P = 0.017 and ρ = 0.567, P = 0.043, respectively). CONCLUSION: This is the largest documented case series of single quadriceps resection for STS. The study suggests that this group of patients does not show a functional deficit and therefore does not require functional reconstruction.

Use of Closed Incision Negative Pressure Therapy (ciNPT) in Breast Reconstruction Abdominal Free Flap Donor Sites.

BACKGROUND: Closed incision negative pressure therapy (ciNPT) may reduce the rate of wound complications and promote healing of the incisional site. We report our experience with this dressing in breast reconstruction patients with abdominal free flap donor sites. METHODS: A retrospective cohort study was conducted of all patients who underwent breast reconstruction using abdominal free flaps (DIEP, MS-TRAM) at a single institution (Royal Melbourne Hospital, Victoria) between 2016 and 2021. RESULTS: 126 female patients (mean age: 50 ± 10 years) were analysed, with 41 and 85 patients in the ciNPT (Prevena) and non-ciNPT (Comfeel) groups, respectively. There were reduced wound complications in almost all outcomes measured in the ciNPT group compared with the non-ciNPT group; however, none reached statistical significance. The ciNPT group demonstrated a lower prevalence of surgical site infections (9.8% vs. 11.8%), wound dehiscence (4.9% vs. 12.9%), wound necrosis (0% vs. 2.4%), and major complication requiring readmission (2.4% vs. 7.1%). CONCLUSION: The use of ciNPT for abdominal donor sites in breast reconstruction patients with risk factors for poor wound healing may reduce wound complications compared with standard adhesive dressings; however, large scale, randomised controlled trials are needed to confirm these observations. Investigation of the impact of ciNPT patients in comparison with conventional dressings, in cohorts with equivocal risk profiles, remains a focus for future research.

Lymphoedema rates in pedicled anterolateral thigh flaps for coverage of irradiated groin defects.

BACKGROUND: Limb salvage surgery in conjunction with adjuvant radiotherapy is the preferred treatment for soft tissue sarcoma. This study aims to determine if ipsilateral pedicled anterolateral thigh (ALT) flap reconstruction of groin defects post soft tissue sarcoma resection results in acceptable rates of lymphoedema, while also providing good soft tissue cover and minimal donor site morbidity. METHODS: A retrospective chart audit was conducted with ethics approval, obtaining a case series of 16 patients operated on at a single institution by the senior surgeon. Patients who underwent ipsilateral pedicled ALT flap coverage of irradiated groin defects following soft tissue sarcoma resection were included. Comparative six-point limb circumference measurements were utilized to diagnose lymphoedema, with a difference of 10% when compared to the non-operative side being deemed significant. RESULTS: Lymphoedema was noted in three patients (18.8%) with an average follow-up period of 40.9 (range 8-59) months. CONCLUSION: Previously published lymphoedema rates in sarcoma limb salvage surgery of 15.5-30% are comparable to the rates obtained in this cohort. Lymphoedema rates do not appear to be higher in patients undergoing ipsilateral pedicled ALT flap reconstruction, thus making it a useful soft tissue coverage technique in this cohort.

Propeller flap reconstruction of irradiated sarcoma defects: A comparison✰.

INTRODUCTION: The treatment for soft tissue sarcomas has evolved to include radiotherapy, wide local excision and plastic surgical reconstruction. Goals for the reconstruction of these irradiated defects are the introduction of non-irradiated healthy tissue, tension-free closure and obliteration of potential dead space. Although many defects once required free tissue transfer for reconstruction, greater knowledge of anatomical vascular pattern has led to the increasing use of propeller perforator flaps, islanded and transposed into the defect. Propeller flap outcomes for the reconstruction of irradiated skin defects have only been reported in case reports. We evaluated the use of propeller perforator flaps at St Vincent's Hospital Melbourne in a series of patients for the reconstruction of irradiated sarcoma defects. METHODS: All patients who underwent sarcoma resection with plastic surgical reconstruction at St Vincent's Hospital from January 2009 to February 2017 were identified from unit audits and medical record data and compared depending on the type of reconstruction. Propeller perforator flaps were evaluated compared to other methods of reconstruction. RESULTS: Thirty-nine cases involved single perforator propeller flaps for reconstruction. The frequency of propeller flap reconstruction has greatly increased from 3 in their first year of use in 2013 to 12 in 2015. Most propeller flaps were used to reconstruct thigh defects (43.6%) followed by shoulder defects (17.9%). Generally the defects were smaller (138.7 cm2) than free flaps (214.2 cm2), and the usual composition of the defect was skin and subcutaneous tissue only. Patients who underwent propeller flap reconstruction had a significantly short length of inpatient stay (p < 0.01), and there were no total failures. CONCLUSION: Propeller perforator flaps are useful for the reconstruction of irradiated defects in sarcoma reconstruction surgery, particularly small- to moderate-sized fasciocutaneous defects. They offer less morbidity, faster recovery and better aesthetic results than free or standard pedicle flaps. The success of propeller flaps has changed the algorithm for how we approach towards the reconstruction of irradiated sarcoma defects to consider their use as the first reconstructive option for superficial sarcoma defects.

Orbital floor reconstruction: a case for silicone. A 12 year experience.

INTRODUCTION: Controversy still exists regarding the choice of implant material for orbital floor reconstructions, in particular the use of silicone. We aimed to evaluate the long-term outcomes of orbital floor reconstructions with silicone versus other non-silicone implants. PATIENTS AND METHODS: We conducted a 12 year retrospective review of patients who had orbital floor reconstructions for fractures at the Royal Hobart Hospital, Tasmania, Australia, from 1995 to 2007. Surgical admission notes, CT reports, operation records, outpatient notes, and complications were recorded. Long-term follow-up consisted of a structured telephone interview assessing patient outcomes and satisfaction, including ongoing disability, following orbital floor repair. RESULTS: Eighty one patients were identified as having had orbital floor reconstruction with an implant. Mean long-term follow-up was 63 months. Outcomes of Silicone implants (n=58) were compared to non-silicone implant materials (n=23) including titanium mesh, 'Lactasorb', 'Resorb-X', autologous cartilage, and bone graft. Statistically significant advantages in the silicone group were found in the number of patients with palpable implants (24% vs 63%, p=0.005), the number of patients without any complaint (67% vs 32%, p=0.004), and the number of patients requiring subsequent surgery for complications related to their implants (5% vs 23%, p=0.046). CONCLUSION: The appropriate use of silicone implants for orbital floor reconstruction can have good results, contrary to much of the literature, with low complication rates including an acceptably low rate of infection and extrusion, as well as high patient satisfaction. To establish definite guidelines for best surgical practise, particularly amongst synthetic implant materials, prospective study is required.

Extended medial gastrocnemius myocutaneous flap in repair of the quadriceps extension mechanism.

The gastrocnemius muscle is versatile in flap repair of defects from anterior knee to lower leg. We describe a case of extensor reconstruction using an extended medial gastrocnemius myocutaneous flap. A medial gastrocnemius flap was raised distal to its musculotendinous insertion. At its point of rotation, it was anchored to the anterior periosteum of the tibia, hence obliterating dead space and recreating the extensor mechanism of the knee. The patient had no flap loss and was able to ambulate independently. He showed no extensor lag. Our flap is unique in that it is the only medial gastrocnemius flap that has shown no extensor lag as well as complete flexion of the knee following a disrupted entire quadriceps mechanism. It is also the first myocutaneous gastrocnemius flap that has been described for this purpose.

Cerebral metastases in malignant mesothelioma: case report and literature review.

Malignant mesothelioma is an uncommon tumour with an inevitably poor outcome. Statistics from the US National Cancer Institute reveal a steady rise in its incidence over the past 25 years. It typically arises from the pleura, but can also originate in the peritoneum, pericardium, genital tracts and tunica vaginalis. Previously considered a local disease with low incidence of metastasis, there is increasing evidence suggesting otherwise. Reported cases of cerebral metastasis are rare and the vast majority are postmortem findings. This report documents a patient with symptomatic cerebral metastasis from malignant mesothelioma, who underwent craniotomy and excision of two cerebral lesions. It is one of a handful of case reports in the literature in which histological confirmation has been obtained ante-mortem and where surgical treatment of the intracranial mesothelioma was undertaken.