Prefabricated fibula free flaps in reconstruction of maxillofacial defects: Two cases of transplanting a fractured fibula.

BACKGROUND: The two-staged prefabricated vascularized fibula free flap is used in maxillofacial reconstruction. We describe the possible cause and management of two cases of fibula fracture after implant placement. METHODS: The patients were treated with two-stage reconstruction with a prefabricated vascularized fibula free flap. Six dental implants were placed in both fibulas. Fibula fractures occurred during the osseointegration period before the second procedure. The reconstruction was continued as planned. RESULTS: Both fibulas fractured in the distal segment, possibly due to a thinner cortex more distally. Harvesting of a fractured fibula flap is more difficult than normally due to callus formation and fibrosis. Both transplants became fully functional with extended healing and additional surgery. CONCLUSION: The fracture apparently did not compromise the vascularisation of the fibula and proved still sufficient for successful harvest and transfer of the flap. The patient should be made aware that additional corrective surgery may be indicated.

Aesthetic Outcomes of Perineal Reconstruction with the Lotus Petal Flap.

The lotus petal flap can be applied for reconstruction of extensive defects in the vulvoperineal area. Studies on aesthetic outcomes are lacking. This study aimed to fill this gap. METHODS: All patients who underwent lotus petal flap reconstruction between October 2011 and December 2015 were asked permission to have their photographs used. Two questionnaires were used: (1) the Strasser score to assess the overall aesthetic results (range 0-15) and (2) the Patient and Observer Scar Assessment Scale (POSAS; range 6-60). Six plastic surgeons and 6 laymen filled in the Strasser score and the Observer scale of the POSAS. Patients filled in the Strasser score, the Patient scale of the POSAS and scored their overall satisfaction with the aesthetic results on a Likert scale (0-10). RESULTS: The photographs of 11 patients were included. The median Strasser score of all observers of 11.9 (range 0.0-75.0) indicated a mediocre aesthetic result. The median total POSAS score of 15.6 (range 6.0-41.0) indicated an aesthetically acceptable scar. Strasser and POSAS scores of the plastic surgeons and laymen did not differ significantly from the patients' scores. The patient satisfaction score with the aesthetic result was a median of 6.0 of 10. CONCLUSIONS: The findings indicate that, overall, patients were moderately satisfied with the aesthetic results of their lotus petal flap reconstructions, as were the plastic surgeons and laymen. For clinical practice, it is important that the plastic surgeon manages expectations carefully before surgery, as it is possible that patients might experience a rather low aesthetic outcome after perineal reconstruction.

Lotus petal flap and vertical rectus abdominis myocutaneous flap in vulvoperineal reconstruction: a systematic review of differences in complications.

BACKGROUND: Vulvoperineal defects resulting from surgical treatment of (pre)malignancies may result in reconstructive challenges. The vertical rectus abdominis muscle flap and, more recently, the fasciocutaneous lotus petal flap are often used for reconstruction in this area. The goal of this review is to compare the postoperative complications of application of these flaps. Methods: A comprehensive literature search of the PubMed, MEDLINE and Cochrane Library databases was performed until 6 June 2020. Search terms included the lotus petal flap, vertical rectus abdominis muscle flap and the vulvoperineal area. Articles were independently screened by two researchers according to the PRISMA-guidelines. Results: A total of 1074 citations were retrieved and reviewed, of which 55 were included for full text analysis. Following lotus petal flap reconstructions, the complication rate varied from 0.0% to 69.9%, with more complications concerning the recipient site compared with the donor site complications (26.0% versus 4.5%). Following vertical rectus abdominis muscle flap reconstructions the complication rate varied between 0.0% and 85.7% with almost twice the number of recipient site complications compared to donor site complications (37.1% versus 17.8%). Conclusions: Overall, the lotus petal flap has lower complication rates at both the donor and the recipient site compared with the vertical rectus abdominis muscle flap. When both options seem viable, the lotus petal flap procedure may be preferred on the basis of the reported lower complication rates. Abbreviations: APE: abdominoperineal excision; ELAPE: extra levator abdominoperineal excision; LP flap: lotus petal flap; NIH: National Institute of Health; NR: not reported; RCT: randomized controlled trial; VRAM flap: vertical rectus abdominis myocutaneous flap.

Quality of Life, Sexual Functioning, and Physical Functioning Following Perineal Reconstruction with the Lotus Petal Flap.

BACKGROUND: Lotus petal flaps (LPF) may be used for the reconstruction of extralevator abdominoperineal defects that cannot be closed primarily. Limited data are available on how perineal reconstruction with the LPF impacts on patients' quality of life (QoL), sexual functioning, and physical functioning. METHODS: A cross-sectional study was performed following perineal reconstruction with the LPF. The QoL of patients having undergone LPF reconstruction was compared with a control group in which perineal defects were closed without flaps. Sexual and physical functioning (presence of perineal herniation and range of motion [ROM] of the hip joints) could only be evaluated in the LPF group. Psychometrically sound questionnaires were used. Physical functioning was evaluated subjectively with binary questions and objectively by physical examination. RESULTS: Of the 23 patients asked to participate, 15 (65%) completed the questionnaires and 11 (47%) underwent physical examination. In the control group, 16 patients were included. There were no significant differences in QoL between the LPF and control groups. Within the LPF group, 33% of patients were sexually active postoperatively compared with 87% preoperatively. No perineal herniation was found. The ROM of the hip joints was bilaterally smaller compared with the generally accepted values. CONCLUSIONS: Conclusions should be made with care given the small sample size. Despite a supposedly larger resection area in the LPF group, QoL was comparable in both groups. Nonetheless, reconstruction seemed to affect sexual function and physical function, not hampering overall satisfaction.

Quality of Life and Sexual Functioning After Vulvar Reconstruction With the Lotus Petal Flap.

OBJECTIVE: Resection of (pre) malignant lesions in the vulvoperineal area may result in large defects that cannot be closed primarily. The lotus petal flap technique is widely used for reconstruction. The aim of this study was to evaluate both quality of life (QoL) and sexual functioning of patients who underwent the lotus petal flap procedure, because no data are available on this topic. METHODS: A cross-sectional study was performed on all eligible patients (N = 38) who underwent the lotus petal flap procedure between 2005 and 2016. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, Female Sexual Function Index, and Body Image Scale were used to evaluate QoL and sexual functioning. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and Female Sexual Function Index scores were compared with scores of age-matched healthy women. RESULTS: Twenty-six patients (68%) responded. The mean (SD) age was 65.5 (16.3) years, and the median follow-up time was 38.5 months (range 16-141 months). Quality of life scores were lower compared with healthy women in the domains physical, role, and social functioning. Sexual activity rates were comparable with healthy women; however, sexual functioning was worse. Although patients were satisfied about their sexual life, pain was reported. CONCLUSIONS: Patients who underwent vulvar reconstructive surgery with lotus petal flaps seem to have a lower QoL compared with healthy women. Patients report more pain during sexual activity but are satisfied about their sexual functioning. These results should be included in preoperative counseling and follow-up of future patients eligible for vulvar reconstruction with a lotus petal flap.

Complications After Vulvar and Perineal Reconstruction With a Lotus Petal Flap.

BACKGROUND: Lotus petal flaps are often used to reconstruct defects in the vulvoperineal area. Wound complications occur more often after surgery in the vulvoperineal area than in other areas of the body. Postoperative complications have a great impact on patients' well-being, length of hospital stay, care needed, and return to participation in daily life. Therefore, it is important to determine which patients are more prone to develop complications. METHODS: All lotus petal flap reconstructions in our center between January 2004 and August 2014 were retrospectively reviewed. Complications were categorized by the Clavien-Dindo classification. RESULTS: Ninety-three patients with 137 flaps were reviewed. The complication rates did not differ significantly between the reconstruction areas. In 30.1% of subjects, no complications were reported. A total of 51.7% of the subjects experienced Clavien-Dindo grade I or II complications, which required no or minor intervention. In 18.3% of subjects, intervention was required under general anesthesia (Clavien-Dindo grade IIIb complications), usually for debridement (64.7%). Donor site morbidity occurred in 14.0% of the subjects. The age group younger than 60 years showed a significantly higher rate of complications compared with the group older than 60 years (P = 0.015; odds ratio, 0.235; 95% confidence interval, 0.073-0.754). CONCLUSIONS: This is the largest study to date on the complications of the lotus petal flap reconstruction. Complication rates did not differ between vulvar, perineal, and vulvoperineal reconstruction. Young patients seem to have a higher risk of developing complications.

Functional outcome after one-stage flap reconstruction of the hypopharynx following tumor ablation.

The main objective of this study was to evaluate functional outcome in terms of food passage of the three different reconstruction techniques that are currently most often used for hypopharyngeal reconstruction in our institution. A retrospective observational database research was conducted of all patients that underwent hypopharyngeal reconstruction for carcinoma of the hypopharynx or larynx from 1992 until 2014 in the University Medical Center Groningen. The following techniques were most commonly used and therefore analyzed: the pedicled pectoralis major flap, the radial forearm free flap and the anterolateral thigh free flap. Our primary outcome food passage was measured after 1 year and classified in gastric tube fed, fluids, semisolid or solid. Complications were registered according to the Clavien Dindo classification in five different grades. Comorbidity was scored using the Adult Comorbidity Evaluation Index. 58 patients were included. 51 patients survived one year follow up, 25 % returned to a solid diet, 40 % returned to a semi-solid diet and 20 % remained feeding tube dependent. Overall flap success rate was 88 and 35 % developed a pharyngocutaneous fistula. Multivariable ordinal regression showed that reconstruction with free flaps, a near-circumferential surgical defect, a higher body mass index and no comorbidity showed significantly better functional outcomes in the food passage. For recipient site complications, both free flaps and a shorter surgery time resulted in less severe complications. This study shows that the use of free flaps is superior to the use of the pectoralis major flap, and that it should therefore be reserved as a second choice.

Fasciocutaneous Lotus Petal Flap for Perineal Wound Reconstruction after Extralevator Abdominoperineal Excision: Application for Reconstruction of the Pelvic Floor and Creation of a Neovagina.

BACKGROUND: The extralevator abdominoperineal excision (ELAPE) procedure creates an extensive soft tissue defect of the pelvic floor. It has been suggested that primary reconstruction reduces the risk of wound infection and delayed wound healing in this high-risk area. Use of myocutaneous flaps or omentoplasty are associated with functional limitations and complications. We performed the perineal variant of the lotus petal flap, which was originally described for vulvar reconstruction. We aimed to verify if application of the lotus petal flap in pelvic floor reconstruction after ELAPE meets the goals of an ideal reconstruction. METHODS: We performed a retrospective study of 28 patients who underwent the lotus petal flap procedure for pelvic floor reconstruction after ELAPE between January 2011 and March 2014. RESULTS: Median age was 62.1 years and 78.6 % of patients were female. In most patients the tumor was preoperatively irradiated (89.3 %) and in 28.6 % of the reconstructions a biological mesh was applied. No total flap loss occurred. Six (21.4 %) patients had no complications, while 13 (46.4 %) patients had minor complications (Clavien-Dindo grade I-II). Reoperation (Clavien-Dindo grade IIIb) was performed in nine patients (32.1 %), three of whom required a second lotus petal flap reconstruction. Median time until wound healing was 14 weeks. No additional surgery was performed for aesthetic problems. CONCLUSIONS: Reconstruction of the pelvic floor after ELAPE using the fasciocutaneous lotus petal flap has limited major complications, but still with a high incidence of minor wound complications. This retrospective cohort study shows limited consequences on form and function.

Collagenase Treatment for Dupuytren Disease of the Thumb and First Web.

PURPOSE: To evaluate the short-term effectiveness of collagenase Clostridium histolyticum to treat thumb and first web contractures in Dupuytren disease. METHODS: We prospectively included 14 thumbs in 12 patients with a contracture at the metacarpophalangeal or interphalangeal joint of at least 20° with a palpable cord in the thumb (n = 8) or an adduction contracture of the thumb with palpable cords in the first web (n = 6). They received an injection containing 0.58 mg of collagenase Clostridium histolyticum in the fibrous cord divided over 3 spots. The contracture was released by carefully manipulating the thumb under local anesthesia 1 day later. The extension and abduction deficits were measured before and after the intervention (follow-up at 7 and 30 days and 6 months). Wilcoxon signed rank test was used to analyze the data. RESULTS: In the total sample, postintervention extension deficits were statistically significantly lower than preintervention deficits except in one patient who had a recurrence at 6 months compared with the 30-day posttreatment result. Intermetacarpophalangeal head distance (IMD) also improved significantly. In an analysis of subgroups, we compared the separate contributions of treatment of a pretendinous cord and a first web cord on both extension deficit and IMD. Treatment of pretendinous cords significantly affected both extension deficit and IMD. However, treatment of first web contractures did not significantly improve extension or IMD. CONCLUSIONS: Collagenase Clostridium histolyticum is a good treatment option for pretendinous cords in thumbs affected with Dupuytren disease because it provides good results, is minimally invasive, and has minor adverse events. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Accuracy of fibula reconstruction using patient-specific CAD/CAM reconstruction plates and dental implants: A new modality for functional reconstruction of mandibular defects.

BACKGROUND: The purpose of this study was to analyze the accuracy of mandibular reconstruction using patient-specific computer-aided designed and computer-aided manufactured (CAD/CAM) reconstruction plates as a guide to place fibula grafts and dental implants in a one-stage procedure using pre-operative 3D virtual planning. METHODS: Seven consecutive patients were analyzed retrospectively, the 3D accuracy of placement of the fibula grafts and dental implants was compared to the virtual plan. RESULTS: Six out of seven flaps survived for an average follow-up time of 9.4 months. The outcome was compared to the virtual plan, superimposed on the mandible. For the fibula segments, the mean deviation (SD) was 3.0 (1.8) mm and the mean angulation (SD) was 4.2° (3.2°). For the implants, the mean deviation (SD) was 3.3 (1.3) mm and the mean angulation (SD) was 13.0° (6.7°). The mean (SD) mandibular resection plane deviation was 1.8 (0.9) mm. CONCLUSIONS: A patient-specific reconstruction plate is a valuable tool in the reconstruction of mandibular defects with fibula grafts and dental implants. Implant angulation showed a greater deviation from the virtual plans in patients with a sharp ventral fibula rim, where the guide is removed after pilot drilling of the implants.

Paralytic ectropion treatment with lateral periosteal flap canthoplasty and introduction of the ectropion severity score.

BACKGROUND: Paralytic ectropion patients suffer from impairment of function and appearance of the lower eyelid and are at high risk of developing an exposure keratitis. A canthoplasty procedure can reduce the horizontal eyelid laxity and elevate the lower eyelid. We used a periosteal flap from the outer orbit to create a new canthal ligament. This study investigates the long-term outcomes of this technique. METHODS: Cross-sectional outcome study in which 30 cases of paralytic ectropion are treated with a lateral periosteal flap canthoplasty after adequate eyelid shortening. At the desired canthal height, a periosteal flap from the outer temporal orbital rim is mobilized around the rim and sutured in a double-breasted fashion to a tarsal strip. Effect of the operation is measured by comparing preoperative and postoperative photographs for signs of ectropion. For this purpose, a new photograph-based scoring method [the Ectropion Severity Score (ESS)] was developed and evaluated. RESULTS: The ESS proved to be reliable and sensitive to the presence of ectropion. Significant improvement of the ectropion sequelae was measured after a mean follow-up period of 2 years. In 3 cases (13%), a revision procedure was necessary because of relapse of lower eyelid sagging after a mean time of 1.9 years. In these cases, the periosteal flap could be reused. CONCLUSIONS: The ESS is a useful instrument to score the severity of paralytic ectropion. The periosteal flap canthoplasty is an effective procedure, with durable results in paralytic ectropion patients. The same periosteal flap can be used in a revision procedure.

Rare causes of closed rupture of the flexor tendon.

Closed injuries to the flexor tendon are relatively rare. We present three rare causes of closed injury to the flexor tendon. Early recognition and adequate treatment by a specialised hand surgeon are crucial for the prognosis of such cases. Delayed diagnosis and treatment often require secondary reconstruction of the flexor tendon, which results in a worse functional outcome.

Effects of motor imagery on hand function during immobilization after flexor tendon repair.

OBJECTIVE: To determine whether motor imagery during the immobilization period after flexor tendon injury results in a faster recovery of central mechanisms of hand function. DESIGN: Randomized controlled trial. SETTING: Tertiary referral hospital. PARTICIPANTS: Patients (N=28) after surgical flexor tendon repair were assigned to either an intervention group or a control group. INTERVENTION: Kinesthetic motor imagery of finger flexion movements during the postoperative dynamic splinting period. MAIN OUTCOME MEASURES: The central aspects of hand function were measured with a preparation time test of finger flexion in which subjects pressed buttons as fast as possible following a visual stimulus. Additionally, the following hand function modalities were recorded: Michigan Hand Questionnaire, visual analog scale for hand function, kinematic analysis of drawing, active total motion, and strength. RESULTS: After the immobilization period, the motor imagery group demonstrated significantly less increase of preparation time than the control group (P=.024). There was no significant influence of motor imagery on the other tested hand function (P>.05). All tests except kinematic analysis (P=.570) showed a significant improvement across time after the splinting period (P

Kinematic analysis of hand movements after tendon repair surgery: a new assessment using drawing movements.

OBJECTIVE: Although several hand outcome tests exist to judge skill level after hand injury, currently none give insight into how tasks are performed by looking at kinematic parameters. In this article, the clinical value of analyzing kinematic parameters related to the drawing of a triangle on a graphics tablet by healthy subjects and patients with hand injury is discussed. DESIGN: In a first experiment 10 healthy subjects drew the triangles as accurately as possible at various speeds. In a second experiment, 67 healthy subjects and 12 patients with flexor tendon injury were measured repeatedly. RESULTS: In the first experiment, the analysis showed a high linear correlation between speed and accuracy for each individual (Pearson correlation coefficient >/=0.762, P

In vivo three-dimensional reconstruction of human median nerves by diffusion tensor imaging.

The in vivo assessment of axonal projections of the peripheral nervous system has been severely limited by the lack of noninvasive techniques. We examined whether MR diffusion tensor imaging with fiber tracking of the human median nerve is feasible. The median nerve was examined with a 3-T MRI scanner in wrists of three healthy volunteers and the wrist of a patient after median nerve repair. In vivo three-dimensional (3D) reconstruction of axonal projections of the median nerve could be achieved in healthy volunteers with intact median nerves and a patient with a transected median nerve using diffusion tensor imaging combined with fiber tracking. The median nerve could be visualized and correlated well to the expected location on T1-weighted images in the patient and all volunteers. The transected median nerve in the patient could be detected up to the site of repair one month postoperatively, whereas the nerve could not be detected more distally immediately after repair. Two months postoperatively, it could clearly be tracked more distally, indicating nerve regeneration. Diffusion tensor imaging can detect the median nerve in healthy individuals as well as up to the lesion site in a patient with a complete transection of the median nerve.