Optimizing Lower Extremity Local Flap Reconstruction in Peripheral Vascular Disease.

BACKGROUND: Local flaps remain a valuable reconstructive tool as a means for limb salvage for patients with advanced arterial disease. Our single-center, retrospective cohort study aims to compare the outcomes of different patterns of blood flow affected by vascular disease to pedicles in local flap reconstruction of the foot and ankle. METHODS: A retrospective review of 92 patients and 103 flaps was performed. On angiograms, pattern of blood flow to the flap pedicle was determined to be direct inline flow (DF) or indirect flow (IF). Patterns of IF were either by arterial-arterial connections (AC) or unnamed randomized collaterals (RC). Primary outcomes were immediate flap success and limb salvage. Comparative analyses were performed using the χ2 and Fisher tests for categorical variables. RESULTS: Among all flaps, 73.8% (n = 76/103) had DF and 26.2% (n = 27/103) had IF. Both groups experienced similar rates of immediate flap success (DF = 97.3% vs IF = 92.6%, P = 0.281) and limb salvage (DF = 75.% vs IF = 66.7%, P = 0.403). However, the rate of contralateral amputation was significantly higher in the IF group (26.9% vs 5.3%, P = 0.006). When comparing the 3 distinct patterns of blood flow (DF vs AC vs RC), pedicled flaps were more commonly supplied by DF and AC, while random pattern flaps were more commonly supplied by RC (P = 0.042). CONCLUSIONS: Alternative routes of revascularization can maintain local flap viability and achieve similar rates of limb salvage but risks contralateral amputation. We found that pedicled and local muscle flaps require inline blood flow or blood supply by ACs. Meanwhile, random pattern flap can be supported by random collaterals.

Pelvic and Perineal Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Classify types of bony pelvic resections. 2. Outline reconstructive options for pelvic and perineal defects. 3. Identify advantages and drawbacks of various reconstructive techniques. 4. Recognize the functional benefits of bony and soft-tissue reconstruction. SUMMARY: Defects of the pelvis and perineum arise from tumors, trauma, infection, congenital differences, and gender incongruence. Pelvic resections can result in bony instability and soft-tissue deficiency. The goals of reconstruction are maintenance of spinopelvic continuity, elimination of dead space, resurfacing of cutaneous defects, and prevention of hernias. Perineal reconstruction has important functional considerations. Abdominoperineal resection and pelvic exenteration defects benefit from flap reconstruction to decrease pelvic wound complications. Vulvovaginal reconstruction is performed with flaps from the perineum, thigh, or abdomen. Scrotal and superficial penile defects are most commonly reconstructed with scrotal flaps and skin grafts. Total penile reconstruction most commonly uses a radial forearm free flap.

The Impact of Increased Body Mass Index on Patient Outcomes and Complications in Microsurgical Lower Extremity Reconstruction.

BACKGROUND: Elevated body mass index (BMI) is a known perioperative risk factor for complications such as delayed wound healing and infection. However, there is a gap in understanding how elevated BMI impacts outcomes after posttraumatic lower extremity (LE) microvascular reconstruction. METHODS: A retrospective review was performed at a level 1 trauma center between 2007 and 2022 of patients who underwent posttraumatic microvascular LE reconstruction. Demographics, flap/wound details, complications, and outcomes were recorded. Patients were stratified into BMI Center for Disease Control categories. RESULTS: A total of 398 patients were included with an average BMI of 28.2 ± 5.8. Nearly half (45%) of LE defects were located in the distal third of the leg, 27.5% in the middle third, and 34.4% in the proximal third. Most reconstructions utilized muscle-containing flaps (74.4%) compared with fasciocutaneous flaps (16.8%). Surgical approaches included free flaps (47.6%) and local flaps (52.5%). Class III obese patients were significantly more likely to be nonambulatory than nonobese patients (OR: 4.10, 95% CI 1.10-15.2, p = 0.035). At final follow-up, 30.1% of patients with Class III obesity were ambulatory, requiring either wheelchairs (42.3%) or assistance devices (26.9%). There were no significant differences in complication rates based on obesity status (0.704). The average follow-up time for the entire cohort was 5.8 years. CONCLUSIONS: BMI is critical for patient care and surgical decision-making in LE reconstruction. Further research is warranted to optimize outcomes for higher BMI patients, thereby potentially reducing the burden of postoperative complications and enhancing overall patient recovery.

Accuracy of the surgical execution of virtually planned deep circumflex iliac artery flaps and their appropriateness for masticatory rehabilitation.

BACKGROUND: Tumorous diseases of the jaw demand effective treatments, often involving continuity resection of the jaw. Reconstruction via microvascular bone flaps, like deep circumflex iliac artery flaps (DCIA), is standard. Computer aided planning (CAD) enhances accuracy in reconstruction using patient-specific CT images to create three-dimensional (3D) models. Data on the accuracy of CAD-planned DCIA flaps is scarce. Moreover, the data on accuracy should be combined with data on the exact positioning of the implants for well-fitting dental prosthetics. This study focuses on CAD-planned DCIA flaps accuracy and proper positioning for prosthetic rehabilitation. METHODS: Patients post-mandible resection with CAD-planned DCIA flap reconstruction were evaluated. Postoperative radiograph-derived 3D models were aligned with 3D models from the CAD plans for osteotomy position, angle, and flap volume comparison. To evaluate the DCIA flap's suitability for prosthetic dental rehabilitation, a plane was created in the support zone and crestal in the middle of the DCIA flap. The lower jaw was rotated to close the mouth and the distance between the two planes was measured. RESULTS: 20 patients (12 males, 8 females) were included. Mean defect size was 73.28 ± 4.87 mm; 11 L defects, 9 LC defects. Planned vs. actual DCIA transplant volume difference was 3.814 ± 3.856 cm³ (p = 0.2223). The deviation from the planned angle was significantly larger at the dorsal osteotomy than at the ventral (p = 0.035). Linear differences between the planned DCIA transplant and the actual DCIA transplant were 1.294 ± 1.197 mm for the ventral osteotomy and 2.680 ± 3.449 mm for the dorsal (p = 0.1078). The difference between the dental axis and the middle of the DCIA transplant ranged from 0.2 mm to 14.8 mm. The mean lateral difference was 2.695 ± 3.667 mm in the region of the first premolar. CONCLUSION: The CAD-planned DCIA flap is a solution for reconstructing the mandible. CAD planning results in an accurate reconstruction enabling dental implant placement and dental prosthetics.

The Lateral Antebrachial Neurocutaneous Flap: Case Series.

BACKGROUND: The neurocutaneous flap was developed based on the understanding that every superficial cutaneous nerve includes vessels, also known as vasa nervorum or paraneural vessels, which run around and inside the nerves and deliver blood to the skin above. A cutaneous perforator connected to paraneural vessels that vascularize the skin and nerves is referred to as a neurocutaneous perforator. The lateral antebrachial cutaneous nerve (LACN), the most dependable blood supply from the primary underlying veins of the neurocutaneous flap, is the subject of this study. METHODS: We reviewed the results of 30 flap coverage procedures in 10 children. The applied flap was based distally along the radial aspect of the hand and wrist. The pivot point of the flap was located dorsally. This study considered patients with posttraumatic tissue loss, vital structure exposure, or hand contractures with an LACN flap. There was a case-by-case assessment. RESULTS: Thirteen male patients were included; their ages ranged from 6 to 65 years. Demographic data, preoperative cause of trauma, and postoperative complications were collected. Statistically significant improvements were observed after flap healing. CONCLUSIONS: The LACN flap is a more versatile flap with less morbidity than other alternative flaps for coverage of soft tissue defect restoration around the hand, wrist, and distal forearm.

Modern Oncologic Maxillary Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Have a broad understanding of the oncological principles relating to cancers involving the maxilla. (2) Define anatomically the various types of maxillectomy defects and their associated morbidity. (3) Understand the goals and principles of maxillary reconstruction. (4) Demonstrate an understanding of the strengths, limitations, and alternative reconstructive options for the various types of maxillectomy defects. SUMMARY: Reconstruction of the maxilla following cancer resection has evolved over the past decade. Underpinned by advances in virtual surgery technology and an increased focus on dental rehabilitation, more sophisticated workflows using free bone flaps have become more commonplace. There are few reconstructions anywhere in the body that require the restoration of similarly intricate bone and soft-tissue relations with implications for both form and function, like the maxilla. Success demands careful anatomical definition of the defect, an understanding of the goals and principles of reconstruction, and the understanding of relative strengths and limitations of the various reconstructive options. Equally, as no one technique is without shortcomings and maxillary surgery can be associated with a significant complication profile, it is just as important to match the patient and oncologic context to the reconstruction. This article is intended to provide the reader with a broad overview of these core factors.

Preservation of the native urethral plate and corpus spongiosum combined with buccal mucosa graft plus Orandi's penile skin flap as an alternative to staged urethroplasty for narrow penile strictures.

OBJECTIVE: In narrow anterior urethral strictures, the combined buccal mucosa graft (BMG) with pedicled penile skin flap (PSF) represents a well-known effective alternative to staged urethroplasty. We hypothesized that if the native urethral plate and adjacent corpus spongiosum were preserved, a narrower flap would be needed, and reinforced ventral stability could be achieved without compromising the surgical outcome. METHODS: Twelve patients with narrow penile urethral strictures underwent single-stage augmentation urethroplasty using a combined technique. A BMG was quilted to the corpora cavernosa in a dorsal onlay approach, and a longitudinal ventral PSF was transposed ventrally and sutured to the scarred native urethral mucosa on one side and to the BMG on the other side to form a neourethra of triangular form. The preserved corpus spongiosum was wrapped and fixed around the flap ventrally. RESULTS: The median age was 47 years (IQR 35-59), and the median stricture length was 5 cm (IQR 3, 8-7). The median surgical time was 205 min (IQR 172-236). The overall success rate (SR) was 91.7% without sacculation or diverticula formation after a median follow-up period of 38 months (IQR 33-40). Three transient fistulas healed through prolonged urinary diversion. Five patients (41.7%) reported postvoid dribbling following urethroplasty. CONCLUSION: Preservation of the native urethral plate is a valuable adjunct to the combination of graft and flap for single-stage augmentation urethroplasty for narrow urethral strictures, with satisfactory mid-term success and an acceptable complication rate.

Oronasal Fistula Closure and Defect Reconstruction: Two Case Reports Using Periodontal Plastic Surgery Principles.

OBJECTIVES: Oronasal fistulas are common sequelae following cleft lip and palate surgery and can significantly impact a patient's quality of life. They result from various factors, including surgical techniques, tissue management, and patient-specific factors. This case report explores the modern approach to oronasal fistula closure using periodontal plastic surgery principles. MATERIALS AND METHODS: The report presents two cases of patients with oronasal fistulas due to previous maxillofacial surgical intervention. These patients underwent microsurgical procedures that involved partial flap thickness preparation of the fistula areas, the use of connective tissue grafts from the palate, and meticulous suturing techniques to ensure graft integrity. The procedures were performed in stages, and postoperative care was provided. RESULTS: Both cases demonstrated successful fistula closure and graft survival. The patients reported improvements in breathing, speech, aesthetics, and quality of life. The second case also included guided bone regeneration and implant placement. CONCLUSIONS: Oronasal fistulas resulting from maxillofacial surgery can be effectively treated using periodontal plastic surgery techniques, significantly improving patients' quality of life and aesthetic outcomes. This approach represents a valuable addition to the existing repertoire of oronasal fistula closure methods.

What's New in Cleft Palate and Velopharyngeal Dysfunction Management: An Update.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Describe the pathology of velopharyngeal dysfunction (VPD) as it relates to patients with a cleft palate. (2) Use the perceptual speech assessment and objective diagnostic tools to determine the presence or absence of VPD. (3) Describe the surgical options available for the treatment of patients with VPD. (4) Develop an evidence-based, customized treatment plan for VPD founded on objective considerations. SUMMARY: To treat patients with cleft palate effectively, the surgeon must understand the diagnosis and surgical management of cleft-associated velopharyngeal dysfunction. The authors review diagnostic modalities including perceptual speech assessment, video nasendoscopy, fluoroscopy, magnetic resonance imaging, and nasometry. Surgical treatments including palatal lengthening with buccal myomucosal flaps, conversion Furlow palatoplasty, sphincter pharyngoplasty, and pharyngeal flap are discussed. Selection of an optimal surgical treatment is addressed.

Treatment of Patients With Electrical Injury by Using Modified Forearm Venous Flap: Retrospective Case Series Study.

OBJECTIVE: Severe hand electrical injuries often occur in functional areas such as joints; the repair requires attention to both appearance and function due to the visibility of the hand. This study aimed to present the clinical experience of successfully repairing hand electrical injuries using improved forearm venous flaps. METHODS: From 2020 to 2022, 15 cases of severe hand electrical injuries were diagnosed, including 10 males and 5 females. Among them, 6 cases were repaired in the first web space, 4 in the thumb, 3 in the index finger, 2 in the middle finger, 2 in the ring finger, and 2 in the little finger. The size of venous flaps ranged from 2.0 cm × 1.8 cm to 12 cm × 4.0 cm. All patients underwent repair using improved forearm venous flaps. The follow-up period ranged from 5 to 8 months. RESULTS: All flaps survived without serious complications. All patients were satisfied with the postoperative aesthetics and function of their hands. CONCLUSION: The improved forearm venous flap is a simple and reliable method for repairing hand electrical injuries.

Comparison of instep and non-instep flap in the reconstruction of the weight-bearing portion of the forefoot and heel.

BACKGROUND: Instep flaps are commonly used for the reconstruction of weight-bearing areas of the foot. However, in cases of large defects or damage to the instep area, non-instep flaps such as reverse sural flaps (RSF) or free anterolateral thigh flaps (ALTF) can be employed. Previous studies have primarily focused on heel reconstruction when comparing different flaps, without considering the forefoot. This study aims to verify the clinical outcomes of these flaps and determine the appropriate donor site for weight-bearing areas of the foot including forefoot reconstruction. METHODS: In a retrospective study, 39 patients who had undergone flap reconstruction of weight-bearing area defects in the foot with a follow-up period of ≥1 year were included. The patients were categorized into two groups: Group A (n = 19) using instep flaps, and Group B (n = 20) using non-instep flap including RSFs and ALTFs. Surgical outcomes were assessed based on the success of the flap, the presence of partial necrosis, the number of additional surgeries, and complications related to the donor site. Clinical evaluation included visual analogue scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) score, and the occurrence of ulcers. RESULTS: All flaps were successful, while partial necrosis occurred in one case in Group B. There were three reclosures after flap border debridement in both groups and one donor site debridement in Group A. The VAS scores during weight-bearing were 2.0 ± 1.1 and 2.2 ± 1.5 for Groups A and B, respectively (p = .716). The AOFAS scores were 52.8 ± 6.8 and 50.2 ± 12.7 for Groups A and B, respectively (p = .435). The occurrence of ulcers was 0.4 ± 0.9 times for Group A and 0.3 ± 0.7 times for Group B, with no significant difference between the two groups (p = .453). CONCLUSION: There was no difference in clinical outcomes between the types of flaps after reconstruction of the forefoot and hindfoot. Therefore, it is recommended to choose the appropriate flap based on factors such as the size of the defect, its location, and vascular status rather than the type of flap.

Single-staged revascularization and reconstruction after crush injury of the wrist and distal forearm: A protocolized approach.

BACKGROUND: Amputation of the wrist or distal forearm after high-energy trauma due to a crushing mechanism is associated with complex tissue defects, making repair, and reconstruction challenging. Given the difficulty of this type of salvage, patients unfortunately experience a high revision amputation rate. However, a higher quality of life has been reported in patients with successful reconstructions. Herein, we described a protocolized approach for revascularization and reconstruction for functional hand salvage after traumatic amputation from a crushing mechanism using an anterolateral thigh flap (ALT). METHODS: A retrospective review was performed between October 2016 and October 2023 for all patients who underwent single-stage emergent debridement, revascularization, and soft tissue coverage using the ALT after amputation at the level of the wrist or distal forearm secondary to high-energy crush injury. Charts were reviewed for the preoperative Mangled Extremity Salvage Score, intraoperative details including what structures were injured and the reconstructive method performed, and postoperative data such as follow-up duration, outcomes, and complications. RESULTS: Eleven patients met the inclusion criteria with an average age of 35.5 (21-49) years old. The average size of the skin soft tissue defects was 17.3 × 8 cm (range, length: 13-25 cm, width: 6-13 cm), and all cases had associated injury to the underlying bone, nerves, and blood vessels. The average size of the ALT flap used for reconstruction was 19.2 × 9.8 cm (range, length: 14-27 cm, width: 7-15 cm). All patients had survival of the replanted limb. One patient experienced partial flap necrosis that required secondary debridement and skin graft. Nine patients healed without requiring any additional debridement procedures. Patient follow-up averaged 24.6 (12-38) months. All patients achieved satisfactory functional recovery with Grade II to III of Chen's criteria. CONCLUSIONS: For patients with traumatic crush amputation to the wrist with surrounding soft tissue injury, thorough debridement, revascularization, and reconstruction of amputated limbs can be performed in a single stage using the ALT. A protocolized approach from two institutions is presented, demonstrating improved survival and reduced complications of the traumatized limb with improved long-term patient outcomes.

Transsphincteric Repair of Rectourethral Fistulas in Combination With Dartos Muscle Flap Interposition Following Radical Prostatectomy.

OBJECTIVE: To present our experience with a novel technique that combines the York-Mason transsphincteric approach with dartos muscle flap interposition to treat rectourethral fistulas. METHODS: We extracted records from our prospectively kept database of 35 procedures conducted for treating rectourethral fistulas during 2002-2023; the York-Mason approach was combined with dartos muscle flap interposition in 5 cases, performed for treating rectourethral fistulas due to radical prostatectomy, all of which were referral cases. RESULTS: All 5 patients were successfully treated and followed up for a median of 70.0 months without recurrence. Before the fistula repair, all had a diverting stoma. In all cases, the first voiding cystourethrogram revealed a healed fistula. The posterior and the scrotal incisions healed uneventfully. All patients reported normal voiding and no urinary incontinence. To date, the stoma has closed in 3 patients, all of whom had intact fecal continence and no postoperative anal stenosis. CONCLUSION: The transsphincteric modified York-Mason approach combined with dartos muscle flap interposition resulted in complete healing of rectourethral fistulas.