Delayed maxillary reconstruction following mucormycosis: A comprehensive analysis of surgical strategies and outcomes.

STUDY DESIGN: This study is a prospective observational study conducted over two years from December 2020 to March 2023 at the Department of Plastic and Reconstructive Surgery. OBJECTIVE: To evaluate the outcomes of delayed reconstruction in patients with maxillectomy defects post-COVID-19 associated mucormycosis, focusing on safety, morbidity, and aesthetic results. METHODS: Fifty patients with post-COVID-19 mucormycosis and maxillectomy defects without skin involvement were included. These patients underwent radical debridement and were treated with Amphotericin B followed by Posaconazole therapy until clinical and radiological resolution of the disease. Reconstruction was performed after a minimum of six months post-maxillectomy. Flaps used for reconstruction included the radial forearm free flap (RAFF), anterolateral thigh flap (ALT), and free fibula osteomyocutaneous flap, planned using a 3D-printed model. Follow-up was conducted weekly for the first month and monthly for the next two months, with semiannual visits thereafter. RESULTS: Of the 50 patients, 42 % were male, and 58 % were female, with a mean age of 43 ± 8.75 years. Most patients (88 %) were diabetic. Maxillectomy defects were categorized as type IIA, IIB, IIIA, IIIB, and IV based on the Cordeiro classification. Four flaps (8 %) required re-exploration, with three salvaged. Complications included marginal flap necrosis (4 %) and oro-nasal fistula (2 %). The average hospital stay was six days, extended to ten days for re-explored cases. Flap dimensions varied with the largest being 62 cm² for the free fibula flap. CONCLUSIONS: Delayed reconstruction using free flaps in patients with post-COVID-19 mucormycosis maxillectomy defects without skin involvement is a safe approach with minimal morbidity. This method allows confirmation of disease resolution before major reconstructive surgery, resulting in excellent aesthetic and functional outcomes.

Reconstruction of Midface Defects after Radical Tumor Resection - a Rare Case Report of Solitary Fibrous Tumour of the Hard Palate.

Introduction- Spindle cell neoplasm is a variant of squamous cell carcinoma. One of its subtypes is solitary fibrous tumor. Its occurrence in head and neck is very rare and rarer in hard palate. But if occurs, radical excision is the only choice as it has malignant potential but coverage of such large mid face defects imposes a challenge in front of a Plastic Surgeon as it demands both soft tissue coverage and skeletal support. Report of the case- A 33 year male presented to our department with swelling of left side face involving the anterior palate, maxilla, nose, and upper lip. With the help of the surgical oncology team, wide local excision of the neoplasm along with bilateral infrastructure maxillectomy, total rhinectomy, total upper lip resection and total hard palatectomy was done. This created large defect in the mid face which was covered with free anterolateral thigh flap. Biopsy was done which revealed the swelling as a solitary fibrous tumor of hard palate. All the margins were free of tumour. The flap settled well. Nostrils were secured with nasal stents. After 3 months, an expander was placed in forehead of the patient for future nasal reconstruction. After 3 months, nasal reconstruction was done using expanded forehead flap and costal cartilage. After 21 days flap detachment and insetting was done. White roll creation was also done. One more secondary procedure was done for flap thinning as patient had complain of nasal obstruction. After 6 months vascularised free fibula bone graft was introduced to reconstruct maxilla for future dental rehabilitation. The patient is in regular follow up and he is satisfied with the results. Discussion- Mid face defects involving perioral and nasomaxillar areas are very uncommon and require composite reconstruction. In such cases, microvascular free flap coverage is an irreplaceable option. Multiple stages might have to be done for further refinement. Conclusion- Reconstruction after oncological resection is always very demanding. With proper preoperative planning and skilled execution, the patient can be benefited functionally, aesthetically and psychosocially.

Optimal Timing for Secondary Reconstruction of Head and Neck Defects after Free Flap Failure.

BACKGROUND: Finite options exist to address free flap failure. There is a lack of consensus on the gold standard for secondary reconstruction in such cases. Herein, we determined the survival rate of a second flap following a total loss of an initial free flap during head and neck reconstructions and evaluated if there was a difference in the rate of secondary flap necrosis depending on the timing of reconstruction salvage. METHODS: We retrospectively reviewed 1572 free flaps for head and neck reconstruction from 2010-2022. Patients who underwent secondary surgery with flaps after failure of primary free flap were included. Patients were divided into three groups based on the time for secondary flap reconstruction from the time of primary reconstruction (Group A, 0-5 days; Group B, 6-30 days; Group C, >30 days). RESULTS: We identified 64 cases of complete flap loss after primary reconstruction requiring secondary reconstruction. Pedicled flaps were used in 34.4% of the cases, while a second free flap was used in 65.6% of the cases. Overall, the flap failure rate for secondary reconstructions was 6.7% in Group A, 35.3% in Group B, and 6.7% in Group C (p=0.022). For free tissue transfer, the success rate of a secondary reconstruction was 92.3% in Group A, 28.57% in Group B, and 93.3% in Group C. CONCLUSION: We favor an early microsurgical reconstruction (≤5 days) following primary reconstruction in cases of free flap failure. If early reconstruction cannot be performed, a deferred reconstruction with free tissue transfer (>30 days) should be considered.

Empirical Evidence on the Reliability of Lateral Supramalleolar Flap over Reverse Sural Flap for Local Soft Tissue Coverage of Dorsum of the Foot and Ankle Defects.

Background Soft tissue coverage of the distal foot and ankle region has been an area of debate due to the paucity of local flap options. To provide empirical evidence on the reliability of an underreported local alternative for foot and ankle defects, we aim to compare the lateral supramalleolar flap (LSMF) to the reverse sural flap (RSF). Methods During 2016-2019, 48 patients were divided randomly into two equal groups, LSMF and RSF groups respectively. The patients' demographic, surgical, and clinical outcome details were recorded and analyzed. Results Flap necrosis was found in five patients in the group treated with RSF and none in the LSMF group. The mean total number of stages in RSF group was significantly higher than in LSMF group ( p < 0.05). The mean operative time for patients in LSMF group was 85.8 ± 18.5 and 54.2 ± 11.2 in RSF group ( p < 0.05). Five patients in the RSF group needed additional procedures following flap complications. Nine patients in the LSMF group reported satisfaction outcomes to be "excellent," five patients reported "good" whereas, in the RSF group, 14 patients reported "excellent," 5 reported "good," 3 reported "fair," and 2 reported "poor" outcomes. Compared to the RSF (46.4 ± 4.3) group, the LSMF group had significantly better foot function indices (34.03 ± 3.9). Conclusion The lateral supramalleolar flap for foot and ankle defects offers better results, reduced complications as well a lesser number of stages and secondary procedures over the traditionally used reverse sural flap.

Mucormycosis Management in COVID-19 Era: Is Immediate Surgical Debridement and Reconstruction the Answer?

Background Excessive use of corticosteroids therapy along with gross immunocompromised conditions in the novel coronavirus disease 2019 (COVID-19) pandemic has raised the risks of contracting opportunistic fungal infections. Here, we describe our experience with the implementation of a surgical protocol to treat and reconstruct rhino-orbital-cerebral mucormycosis. Methods A retrospective review of our prospectively maintained database was conducted on consecutive patients diagnosed with mucormycosis undergoing immediate reconstruction utilizing our "Mucormycosis Management Protocol." All patients included in this study underwent reconstruction after recovering from COVID-19. Wide local excision was performed in all cases removing all suspected and edematous tissue. Reconstruction was done primarily after clear margins were achieved on clinical assessment under a cover of injectable liposomal amphotericin B. Results Fourteen patients were included. The average age was 43.6 years and follow-up was 24.3 days. Thirteen patients had been admitted for inpatient care of COVID-19. Steroid therapy was implemented for 2 weeks in 11 patients and for 3 weeks in 3 patients. Eight patients (57.1%) had a maxillectomy and mucosal lining resection with/without skin excision, and six patients (42.8%) underwent maxillectomy and wide tissue excision (maxillectomy and partial zygomatic resection, orbital exenteration, orbital floor resection, nose debridement, or skull base debridement). Anterolateral thigh (ALT) flaps were used to cover defects in all patients. All flaps survived. No major or minor complications occurred. No recurrence of mucormycosis was noted. Conclusion The approach presented in this study indicates that immediate reconstruction is safe and reliable in cases when appropriate tissue resection is accomplished. Further studies are required to verify the external validity of these findings.

Formulating an Easy, Affordable, and Reproducible Method for Virtual Planning and 3D Reconstruction: A State Institution's Approach for Mandibular Reconstruction.

INTRODUCTION: Free fibula flap is now regarded as the criterion standard for mandibular reconstruction after oncological resection. However, the results are often confounded due to inappropriate estimate of defect or inappropriate angulation of osteotomy. Three-dimensional (3D) printing and virtual planning can be an effective tool to help in planning osteotomies, therefore simplifying the process. Unfortunately, in developing countries, it is considered to be an expensive and a time-consuming affair, refraining the surgeons to use this technology. We have devised a cheap (less than $35), rapid, and reproducible method for this process that can be performed by residents with the help of the operating surgeon using a freely available software. MATERIALS AND METHODS: The study was conducted over a span of 5 years from 2016 to 2020. Forty patients were randomly categorized into 2 groups of 20 each, one of which underwent conventional free fibula flap and the other group consisted of those for whom 3D printing and virtual planning were used. Aesthetic outcome was measured by preoperative and postoperative CT scans with 3D reconstruction. Furthermore, the reconstruction time and total operative time were also measured in both these groups. RESULTS: Comparative study clearly demonstrated a significantly better aesthetic outcome in the 3D printing and virtual planning group. The use of this modality significantly reduced the reconstruction time, which was 83.9 minutes in the cases group and 124 minutes in the control group. CONCLUSIONS: Three-dimensional printing and virtual planning help to improve the quality of mandibular reconstruction giving a better aesthetic outcome. Besides, it also reduces the operative time and gives us a chance to use prebent implants used for reconstruction. Our methodology is simple, quick, and cost-effective; therefore, we believe that this tool can be incorporated often in free fibula flaps for mandibular reconstruction in developing countries such as ours.

Comparison of the outcomes of adipofascial and two-staged fasciocutaneous reverse sural flap in patients with lower leg trauma.

BACKGROUND: Distal one - third trauma of the lower limb is a complex condition to treat. The reverse sural flap is a time tested procedure for reconstruction of such defects especially in patients where free flaps are ruled out due to comorbidities. The purpose of this study is to compare the two modifications of the classical technique of reverse sural flap (adipofascial and fasciocutaneous) which is lacking in the literature. MATERIAL & METHODS: In this study, the authors conducted a retrospective analysis of 67 patients with lower one-third leg defects reconstructed with either adipofascial reverse sural flap (Group A, n = 37) or two-staged fasciocutaneous reverse sural flap (Group B, n = 30) in a tertiary care hospital in North India between 2015 and 2019. An evaluation of the different flap characteristics of the two variants of the reverse sural flap was done and compared. Mean follow up period was 12 months. RESULTS: The adipofascial group showed shorter operative time, was a single-stage and with better reach and aesthetic outcome. The complications did not differ except that for the adipofascial group was associated with unstable skin graft over the flap initially which did not require any treatment. DISCUSSION: Lower one-third defect of the lower limb has been a challenge for reconstructive surgeons all over the world. The goal of reconstruction is a functional lower limb. Although free tissue transfer is the preferred modality of treatment of such cases but it may not be possible in all cases due to various reasons. Reverse sural flap is a very lucrative local option for such reconstructions as it is easy to perform, reliable, low profile and bulk, require minimal facilities with less operative time. Adipofascial flaps represent an extremely useful modification of the reverse sural flap which is quick to perform with minimal donor site morbidity. CONCLUSION: Adipofascial reverse sural artery flap is a good option for patients with lower limb trauma with the added advantage of being single-stage and with better donor site cosmesis as compared to the fasciocutaneous reverse sural artery flap.

Autologous Platelet Rich Plasma As A Preparative for Resurfacing Burn Wounds with Split Thickness Skin Grafts.

BACKGROUND: Split thickness skin graft is a widely accepted technique to cover large defects. Shearing, hematoma and infection have often been attributed as major causes for graft loss. Autologous platelet rich plasma (PRP) has been used in various treatment modalities in the field of plastic surgery for its healing, adhesive and hemostatic properties owing to the growth factors that are released. This Study primarily throws light on the usage of PRP over difficult Burn wound beds to augment graft uptake and attenuate complications. METHODS: The patients were divided into two groups of those who were subjected to use of autologous PRP as a preparative burn surfacing and the control group who underwent standard method of treatment. RESULTS: Patients in PRP group significantly showed a higher graft adherence rate as compared to those with other method. It also reduced pain, and hematoma formation. CONCLUSION: Application of PRP is a safe, cost effective, easy method to increase graft adherence rate in patients with burns where graft loss is noticed and there is shortage of donor sites.

Reverse pedicle-based greater saphenous neuro-veno-fasciocutaneous flap for reconstruction of lower leg and foot.

INTRODUCTION: Paucity of soft tissue available locally for reconstruction of defects in leg and foot presents a challenge for reconstructive surgeon. The use of reverse pedicle-based greater saphenous neuro-veno-fasciocutaneous flap in reconstruction of lower leg and foot presents a viable alternative to free flap and cross-leg flap reconstruction. The vascular axis of the flap is formed by the vessels accompanying the saphenous nerve and the greater saphenous vein. We present here our experience with reverse saphenous neurocutaneous flap which provides a stable cover without the need to sacrifice any important vessel of leg. PATIENTS AND METHODS: The study is conducted from March 2003 through Dec 2009 and included a total of 96 patients with defects in lower two-thirds of leg and foot. There are 74 males and 22 females. Distal pivot point was kept approximately 5-6 cm from tip of medial malleolus, thus preserving the distal most perforator, and the flap is turned and inserted into the defect. Donor site is covered with a split thickness skin graft. Postoperative follow-up period was 6 weeks to 6 months. RESULT: The procedure is uneventful in 77 cases. Infection is observed in 14 cases. Partial flap necrosis occurs in 2 cases. Total flap necrosis is noted in 3 cases. CONCLUSION: Reverse pedicle saphenous flap can be used to reconstruct defects of lower one-third leg and foot with a reliable blood supply with a large arc of rotation while having minimal donor site morbidity.

Microsurgical reconstruction of major scalp defects following scalp avulsion.

INTRODUCTION: Total scalp avulsion is a serious injury, commonly occurring in Indian females working with industrial and agricultural machines. Their long hairs often get caught in a rapidly revolving machines, resulting in total avulsion of scalp. Lack of education and awareness in Indian villages often result in these patients coming late to the hospitals when replantation is not possible and scalp reconstruction remains the only available option. MATERIALS AND METHODS: We performed our study on 22 cases of scalp avulsion injury presented to us between June 2007 and April 2012 at Department of Burn, Plastic & Reconstructive Surgery, SMS Hospital, Jaipur. In all of them a free tissue transfer was performed as an elective procedure. RESULTS: Twenty two patients underwent free tissue transfer and followed up for an average period of 6 months. All patients included in this study were females with mean age of 28 yrs. Five patients in our study reported with partial necrosis of the free flaps which were subsequently managed with split-thickness skin graft (STSG). Two patients reported total necrosis of the flap which was re-operated using latissimus dorsi along with serratus anterior muscle (LDSA) from the contralateral side. CONCLUSION: As scalp avulsion because of rapidly rotating machine leads to large size defect not amenable for local tissue reconstruction. We performed reconstruction using LDSA and omental free flaps with split thickness skin graft (STSG) for large scalp defect and achieved good and stable soft tissue cover with satisfactory cosmesis.