Autologous coverage for direct-to-implant pre-pectoral reconstruction in large and ptotic breasts: a new technique.

Direct-to-implant (DTI) breast reconstruction after skin reducing mastectomy in large and ptotic breast is characterized by a high rate of complication. The Dermal Sling is commonly used to give extra coverage to the lower pole of the mammary implant to lower the risk of implant exposure in case of wound dehiscence at the T-junction. The aim of the paper is to detail an original technique that combines an inferior dermal sling with pectoral and serratus fascial flaps, to create a pre-pectoral pouch. We retrospectively review the clinical data of the patients who underwent Type IV/V mastectomy and DTI breast reconstruction with the described technique. Minor and major post operative complications were analyzed. Patient satisfaction and aesthetic outcomes were evaluated at one year of follow-up through Breast-Q and Validated Aesthetic Scale. Ten patients (fourteen breasts) were included in the study. Skin and/or NAC necrosis occurred in three breasts. One patient underwent implant removal due to periprosthetic infection. At one of follow-up no capsular contracture nor migration of the implant were clinically detected in all patients. One patient had a visible rippling at the upper quadrants of the new breast. Good patient satisfaction and aesthetic outcomes were reported. The association of fascial flaps and dermal sling is a viable option for breast reconstruction in patients with large and ptotic breasts. Along with providing an autologous coverage for the implant, it allows to maintain a good projection, maximize symmetrization in case of concomitant contralateral reduction mammoplasty and avoid any implant displacement.

Results from a first-in-human phase I safety trial to evaluate the use of a vascularized pericranial/temporoparietal fascial flap to line the resection cavity following resection of newly diagnosed glioblastoma.

PURPOSE: The efficacy of systemic therapies for glioblastoma (GBM) remains limited due to the constraints of systemic toxicity and blood-brain barrier (BBB) permeability. Temporoparietal fascial flaps (TPFFs) and vascularized peri cranial flaps (PCF) are not restricted by the blood-brain barrier (BBB), as they derive their vascular supply from branches of the external carotid artery. Transposition of a vascularized TPFF or PCF along a GBM resection cavity may bring autologous tissue not restricted by the BBB in close vicinity to the tumor bed microenvironment, permit ingrowth of vascular channels fed by the external circulation, and offer a mechanism of bypassing the BBB. In addition, circulating immune cells in the vascularized flap may have better access to tumor-associated antigens (TAA) within the tumor microenvironment. We conducted a first-in-human Phase I trial assessing the safety of lining the resection cavity with autologous TPFF/PCF of newly diagnosed patients with GBM. METHODS: 12 patients underwent safe, maximal surgical resection of newly diagnosed GBMs, followed by lining of the resection cavity with a pedicled, autologous TPFF or PCF. Safety was assessed by monitoring adverse events. Secondary analysis of efficacy was examined as the proportion of patients experiencing progression-free disease (PFS) as indicated by response assessment in neuro-oncology (RANO) criteria and overall survival (OS). The study was powered to determine whether a Phase II study was warranted based on these early results. For this analysis, subjects who were alive and had not progressed as of the date of the last follow-up were considered censored and all living patients who were alive as of the date of last follow-up were considered censored for overall survival. For simplicity, we assumed that a 70% PFS rate at 6 months would be considered an encouraging response and would make an argument for further investigation of the procedure. RESULTS: Median age of included patients was 57 years (range 46-69 years). All patients were Isocitrate dehydrogenase (IDH) wildtype. Average tumor volume was 56.6 cm3 (range 14-145 cm3). Resection was qualified as gross total resection (GTR) of all of the enhancing diseases in all patients. Grade III or above adverse events were encountered in 3 patients. No Grade IV or V serious adverse events occurred in the immediate post-operative period including seizure, infection, stroke, or tumor growing along the flap. Disease progression at the site of the original tumor was identified in only 4 (33%) patients (median 23 months, range 8-25 months), 3 of whom underwent re-operation. Histopathological analyses of those implanted flaps and tumor bed biopsy at repeat surgery demonstrated robust immune infiltrates within the transplanted flap. Importantly, no patient demonstrated evidence of tumor infiltration into the implanted flap. At the time of this manuscript preparation, only 4/12 (33%) of patients have died. Based on the statistical considerations above and including all 12 patients 10/12 (83.3%) had 6-month PFS. The median PFS was 9.10 months, and the OS was 17.6 months. 4/12 (33%) of patients have been alive for more than two years and our longest surviving patient currently is alive at 60 months. CONCLUSIONS: This pilot study suggests that insertion of pedicled autologous TPFF/PCF along a GBM resection cavity is safe and feasible. Based on the encouraging response rate in 6-month PFS and OS, larger phase II studies are warranted to assess and reproduce safety, feasibility, and efficacy. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION FOR PROSPECTIVELY REGISTERED TRIALS: ClinicalTrials.gov ID NCT03630289, dated: 08/02/2018.

One-stage Neurorrhaphy and Posterior Transposition with Gastrocnemius Fascial Flap for Common Peroneal Nerve Injury: Preliminary Results.

OBJECTIVE: Common peroneal nerve (CPN) injury is a frequently encountered lower extremity injury. Furthermore, several previous studies have demonstrated that patients who underwent direct suturing of the CPN following rupture experienced unfavorable postoperative prognoses. Therefore, we aimed to present a novel modified surgical approach for CPN rupture and assess the effectiveness of this technique in restoring lower limb functionality. METHODS: In this retrospective observational study, we included patients with CPN rupture who underwent one-stage neurorrhaphy and posterior transposition combined with nerve wrapping using a gastrocnemius fascial flap for CPN rupture between January 2016 and December 2020. Lower limb function was evaluated using the lower extremity functional scale (LEFS) and British Medical Research Council (BMRC) grading system. We also assessed the influence of age, sex, duration of symptoms, mechanism of injury, and surgical modality on the postoperative recovery of lower extremity function using subgroup and regression analyses. RESULTS: Thirty-seven patients (mean age = 35.76 ± 13.01 years) with at least 2 years of follow-up were included in the final analysis. The LEFS scores significantly improved after surgery at the last follow-up (p < 0.01). Moreover, 67.57% of the patients achieved good or excellent postoperative outcomes (BMRC: M3 or above). Results of the subgroup analysis and regression models suggested that patients who underwent direct suturing showed better recovery of lower extremity function than those who underwent nerve grafting. CONCLUSION: One-stage neurorrhaphy and posterior transposition combined with nerve wrapping using a gastrocnemius fascial flap exhibited encouraging outcomes in restoring lower-limb function among patients with CPN rupture. This novel surgical technique is expected to be an effective method for treating CPN ruptures in the future.

Single Incision Dual Cover with Temporoparietal Fascial Flap for Exposed Cochlear Implant: A Novel Take on a Workhorse Flap.

Cochlear implant surgeries have become increasingly common in India, leading to a rise in complications such as cochlear implant exposure. To address this issue, we present a novel technique involving a single incision dual cover using the temporoparietal fascial flap (TPFF) and skin flap to give durable cover for exposed cochlear implants. Materials and Methods A retrospective study was conducted between December 2019 and December 2022 on patients who underwent the dual flap procedure for exposed cochlear implants. Results The average defect size was 2 × 2 cm, and the average length of hospital stay was 10 days. Fourteen skin flaps were closed primarily, while two required skin grafting for donor site closure. At the time of discharge, all wounds showed successful healing with intact skin coverage over the cochlear implant device site. The average follow-up period was 12 months, during which two patients had donor site scar alopecia, while others had adequate hair growth masking the scar. All patients consistently used their cochlear implants. Conclusion Our single-incision, dual cover TPFF + skin flap technique offers a reliable and innovative solution for managing exposed cochlear implants. With successful implant salvage and favorable postoperative outcomes, this approach demonstrates the versatility and reliability of the TPFF as an excellent option for reconstructive surgeons dealing with cochlear implant complications.

Use of Temporalis Muscle and Temporoparietal Fasciocutaneous Flap (TPPF) for Orbital Exentration Defects: Our Experience of 10 Cases.

Orbital defects represent difficulties in head and neck reconstruction owing to 3-dimensional complexity of the socket with aim to restore form and function. Recommended methods of reconstruction include mucosal and skin grafts free microvascular myofascial or fasciocutaneous flaps. However, most frequently, reconstruction of orbital defects calls for measures somewhere in between. The temporoparietal fascia flap (TPFF) fits well as it provides thin, pliable coverage of defects with dependable blood supply, tolerance for a large degree of rotation and minimal donor site morbidity. We hereby present our experience and results of 10 cases using TPPF and temporalis muscle post orbital exentration defects.Ten patients (7 male and 3 females) age ranging from 25 to 64 years underwent reconstruction of orbital exenteration defects using TPPF and temporalis muscle from June 2019 to June 2020 in our department. The primary disease was squamous cell carcinoma (SCC) of orbital structures (anterior compartment) in all 10 patients. All cases were clinically N0 and M0.All patients had successful transfer of TPFF grafts and temporalis muscle transfer without flap compromise. TPPF was used in all 10 patients while Temporalis muscle flap was used to fill orbital socket in our 9 patients. Temporoparietal fascial flap showed viable option for subtle orbital and malar contour defect. All patients had intact dura with residual orbital cavity after resection reconstructed with TPPF and temporalis muscle without any additional flap usage. No frontal paralysis or orbital fistula was seen but local recurrence occurred in one patient in follow up and managed with RT. The TPFF is one of the most reliable and versatile regional flaps in the head and neck for orbital reconstruction.

Periorbital Facial Necrotizing Fasciitis in Adults: A Rare Severe Disease with Complex Diagnosis and Surgical Treatment-A New Case Report and Systematic Review.

(1) Background: Necrotizing fasciitis (NF) is a severe and aggressive pathology with a rapid progression and high mortality risk. Periocular NF is a rare condition associated with a lower mortality risk but significantly higher disabling sequelae. (2) Methods: We present the case of a 67-year-old homeless patient, a victim of assault, with multiple untreated comorbidities (diabetes mellitus, cardiac conditions, and schizophrenia) and a delayed diagnosis of periocular necrotizing fasciitis. The condition showed a cyclical evolution influenced by the existing comorbidities, and the patient underwent both surgical and medical treatment with a multidisciplinary team. Additionally, we report a systematic review of cases from the literature. (3) Results: The patient's survival outcomes were favorable; however, the sequelae were disabling, not only concerning aesthetic aspects but also due to the loss of the affected eye globe. The systematic review revealed the rarity of such cases and the peculiarities of the presented case compared to those reported in the literature up to this point. (4) Conclusions: Understanding the signs, symptoms, and predisposing factors, as well as the potential rare localizations of NF, including the periocular region, can lead to the early diagnosis and treatment with good functional and aesthetic outcomes, minimizing significant disabilities.

[One-stage repair of full-thickness skin defect at dorsal skin of middle phalanx fingers using artificial dermis combing with digital artery perforator fascial flaps].

OBJECTIVE: To explore clinical effects of the stageⅠrepair of full-thickness skin defect at dorsal skin of middle phalanx fingers using artificial dermis combing with digital artery perforator fascial flaps. METHODS: From January 2019 to May 2020, 21 patients(27 middle phalanx fingers)with full-thickness skin defect were repaired at stageⅠusing artificial dermis combing with digital artery perforator fascial flaps. All patients were emergency cases, and were accompanied by the exposure of bone tendon and the defects of periosteum and tendon membrane. Among patients, including 11 males and 10 females aged from 18 to 66 years old with an average age of (39.00±8.01) years old;9 index fingers, 10 middle fingers and 8 ring fingers;range of skin defect area ranged from (2.5 to 3.5) cm×(1.5 to 3.0) cm;range of exposed bone tendon area was (1.5 to 2.0) cm×(1.0 to 2.0) cm. The time from admission to hospital ranged from 1 to 6 h, operation time started from 3 to 8 h after injury. RESULTS: All patients were followed up from 6 to12 months with an average of (9.66±1.05) months. The wounds in 26 cases were completely healed at 4 to 6 weeks after operation. One finger has changed into wound infection with incompletely epithelialized dermis, and achieved wound healing at 8 weeks after dressing change. All fingers were plump with less scars. The healed wound surface was similar to the color and texture of the surrounding skin. These fingers have excellent wearability and flexibility. According to the upper limb function trial evaluation standard of Hand Surgery Society of Chinese Medical Association, the total score ranged from 72 to 100. 26 fingers got excellent result and 1 good. CONCLUSION: StageⅠrepair of full-thickness skin defect at dorsal skin of middle phalanx fingers using artificial dermis combing with digital artery perforator fascial flaps is easy to operate with less trauma. It has made satisfactory recovery of appearance and function of fingers. It could provide an effective surgical method for clinical treatment of full-thickness skin loss of fingers with tendon and bone exposure.

Feasibility of a fascial flap to avoid anterior transposition of unstable Ulnar nerve: A cadaver study.

Background: Compression of the ulnar nerve at the elbow is the second most frequent site of nerve compression in the upper limb. Upon release, anteposition of the nerve may be necessary to avoid dislocation of the latter when unstable. Numerous techniques are described in the literature (subcutaneous transposition, intramuscular transposition, subfascial transposition, medial epicondylectomy …), none of which is without complications. Based on Han's work, the authors propose a technique of covering the ulnar nerve with epicondylar fascial flap, avoiding transposition, but ensuring good stability of the ulnar nerve. Methods: As part of the SICM (Italian Society of Hand Surgery) cadaver dissection course (ICLO, Verona, Italy) the authors dissected 36 elbows, of which 20 presented subluxation of the ulnar nerve after its decompression. The fascial flap was therefore made on these 20 elbows, coming from 14 different donors (9 men, 5 women) with an average age of 78 years. The diameter of the ulnar nerve was then measured (at the level of the passage in the cubital canal), the diameter of the newly formed canal, the difference between the two previous measurements (residual space in the flexed elbow canal), and it was verified whether the ulnar nerve was unstable once covered by the flap. Results: The mean diameter of the ulnar nerve was 5.1 mm (range 4-6), while the mean diameter of the neo-canal was 10.1 mm (range 8-11) in elbow extension and 8.9 mm (range 7-10) in elbow flexion. The remaining space in the flexed elbow canal was 3.8 mm (range 3-5).In none of the 20 cases the ulnar nerve was dislocated after having made the fascial flap. Conlusions: In light of the results obtained, the authors think that the use of the epicondylar fascial flap may be a solution to keep in mind to avoid dislocation of the ulnar nerve when it becomes unstable following its decompression. This work obviously needs clinical confirmation on living patients. Level of evidence: V.

Construction of a vascularized fascia-prosthesis compound model with axial pedicle for ear reconstruction surgery.

Background: To design a vascular pedicled fascia-prosthesis compound model that can be used for ear reconstruction surgery. Methods: A vascularized tissue engineering chamber model was constructed in New Zealand rabbits, and fresh tissues were obtained after 4 weeks. The histomorphology and vascularization of the newly born tissue compound were analyzed and evaluated by tissue staining and Micro-CT scanning. Results: The neoplastic fibrous tissue formed in the vascularized tissue engineering chamber with the introduction of abdominal superficial vessels, similar to normal fascia, was superior to the control group in terms of vascularization, vascular density, total vascular volume, and total vascular volume/total tissue volume. Conclusion: In vivo, introducing abdominal superficial vessels in the tissue engineering chamber prepped for ear prosthesis may form a well-vascularized pedicled fascia-prosthesis compound that can be used for ear reconstruction.

Reconstruction of Hand and Foot Defects with Free Serratus Carpaccio Flap and Free Serratus Fascia Flap: A Comparative Retrospective Study of Surgical Outcomes.

BACKGROUND: Defects of the hand and foot often require an individualized reconstructive approach, due to their unique functional and aesthetic characteristics. Transferred tissues should be thin, pliable, and durable, with free fascial flaps meeting these requirements. This study aimed to evaluate the serratus fascia flap and the serratus carpaccio flap, which is a modification of the fascia flap, by including a thin muscle layer, with the goal of enhancing flap resilience and lowering morbidity rates. METHODS: Between January 2000 and December 2017, 31 patients underwent microsurgical reconstruction of the hand or foot either by serratus fascia flap (fascia group) or serratus carpaccio flap (carpaccio group). The serratus fascia flaps were mainly harvested between 2000 and 2012, and the serratus carpaccio flaps between 2013 and 2017. Patient records were reviewed retrospectively, regarding demographics, complications, overall flap survival, additional revision surgeries, and surgical outcome. Categorical variables were compared using Fisher's exact test and continuous data with the Mann-Whitney tests. Logistic regression was used to examine the correlation between comorbidities and postoperative complication rates. Differences were considered significant when p < 0.05. RESULTS: The fascia group consisted of 17 patients and the carpaccio group of 14 patients. The average patient age in the fascia group was 39.2 ± 10.5 years, and it was 39.1 ± 14.7 years in the carpaccio group. Overall complication rates were significantly lower in the carpaccio group than in the fascia group (28.6% vs. 70.6%, p = 0.03). The rates of overall flap survival (85.7% in the carpaccio group vs. 74.5% in the fascia group, p = 0.66) and partial flap loss (14.3% in the carpaccio group vs. 47.1% in the fascia group, p = 0.07) did not differ significantly among both groups. One postoperative hematoma of the donor site requiring revision surgery was reported in the carpaccio group (7.1%, p = 0.45) while no donor-site morbidity was reported in the fascia group. CONCLUSIONS: Our findings indicate that the serratus carpaccio flap presents a promising alternative to the serratus fascia flap. This modification has proven to be effective in substantially reducing postoperative complications requiring additional surgical interventions. Therefore, the serratus carpaccio flap can be considered a dependable reconstructive option for addressing complex soft tissue defects of the hand and foot, with complication rates that are within an acceptable range.

Reconstruction of Extensive Diaphragmatic Defects Using the Rectus Abdominis Muscle and Fascial Flap.

Diaphragmatic reconstruction is required for extensive diaphragmatic defects associated with tumor resection. Methods using artificial mesh and autologous tissues, such as pedicled flaps, have been reported predominantly for diaphragmatic reconstruction. We present the case of a 61-year-old woman who presented with a 14 × 13 × 12 cm tumor in the abdominal cavity of the upper left abdomen on computed tomography. The diaphragm defect measuring 12 × 7 cm that occurred during excision of the malignant tumor was reconstructed using the rectus abdominis muscle and fascial flap. The flap has vertical and horizontal vascular axes; therefore, blood flow is stable. It also has the advantage of increasing the range of motion and reducing twisting of the vascular pedicles. Fascial flap does not require processing such as thinning and can be used during suture fixation. This procedure, which has rarely been reported so far, has many advantages and may be a useful option for diaphragm reconstruction.

Endonasal skull base repair with a vascularised pedicled temporo-parietal myo-fascial flap.

Objective: Expanded endonasal approaches (EEAs) to the skull base have increased the scope and extent of pathologies that can be treated endoscopically. The trade-off is creation of large skull base bone defects requiring reconstruction to re-establish barriers between the sino-nasal mucosa and subarachnoid space to prevent CSF leak and infection. A popular reconstructive technique is the local vascularized pedicled naso-septal flap, an option that may not always be possible when there is disruption of the vascular pedicle from multiple previous surgeries, adjuvant radiotherapy or extensive tumor infiltration. An alternative is the regional temporo-parietal fascial flap (TPFF) transposed via the trans-pterygoid route. We implemented a modification of this technique incorporating contralateral temporalis muscle at the tip of this flap and deeper vascularised pericranial layers within the pedicle to provide a more robust flap in selected cases. Study design/methods: A retrospective review of two cases is presented with both patients having undergone multiple EEAs to resect skull base tumors with adjuvant radiotherapy, their postoperative courses complicated by recalcitrant CSF leaks resistant to multiple surgeries. Results: Our patients had their persistent CSF fistulae repaired using infra-temporal transposition of the TPFF modified to include some of the contralateral temporalis muscle with optimisation of a vascular pedicle: a temporo-parietal temporalis myo-fascial flap (TPTMFF). Both CSF leaks resolved without further complication. Conclusion: In situations where local flap repair to reconstruct skull-base defects following EEA may not be viable or has failed, a modified regional flap incorporating temporo-parietal fascia with a preserved vascular pedicle along with attached temporalis muscle plug may provide a robust alternative option.

Modified pedicled temporoparietal fascial flap combined revascularization in adult moyamoya angiopathy.

Background: Pedicled temporoparietal fascial flaps (TPFF), which are flexible, thin, and highly vascularized, have been tried for the moyamoya angiopathy (MMA) treatment. To reduce postoperative complications and improve prognosis, we performed surgical modification and followed up to observe the efficacy. Methods: From February 2018 and June 2022, the clinical data of 31 adult MMA patients who underwent the modified TPFF combined revascularization were collected. The clinical outcomes and complications of the patients were recorded until the cut-off date of follow-up. The primary endpoints were the magnetic resonance perfusion (MRP), modified Rankin Scale (mRS) scores, and Matsushima Grade; the secondary endpoints were the clinical symptom outcome and Postoperative complications. Descriptive statistics and rank sum test to assess the therapeutic effect of the modified TPFF combined revascularization for adult MMA treatment. Results: The clinical symptoms of MMA were alleviated in 26 patients and disappeared in five. In all patients, MRP showed improvement in cerebral perfusion on the operated side, and no deterioration or new cerebral infarction occurred during follow-up. Postoperative digital subtraction angiography (DSA) showed that the anastomotic site was patent, and the MMA collateral was decreased in all patients. Only 1 case (3%) of Matsushima grade C showed poor collateral compensation. The admission mRS score (1.54±0.66) of the ischemic MMA was significantly reduced compared with ≥6 months postoperatively (0.54±0.72, P<0.01). The admission mRS score (0.57±0.53) of the hemorrhagic MMA was reduced compared with ≥6 months postoperatively (0, P<0.05). Postoperative complications included epileptic seizures in 2 cases, a cerebral hyper-perfusion syndrome in 2 cases, intracranial rebleeding in 2 cases, skin necrosis in 1 case, and skin maceration in 1 case. Conclusions: Modified TPFF combined revascularization might be a feasible and safe surgical technique for MMA, but it is still necessary to increase the sample size and extend the follow-up time to evaluate its efficacy. Ischemic MMA may have a more significant prognostic benefit than hemorrhagic MMA by this surgery.

Cranial transposition and revascularization of autologous omentum: a novel surgical technique for resection of recurrent glioblastoma multiforme.

Glioblastoma multiforme (GBM) patients continue to suffer a poor prognosis. The blood brain barrier (BBB) comprises one of the obstacles for therapy, creating a barrier that decreases the bioavailability of chemotherapeutic agents in the central nervous system. Previously, a vascularized temporoparietal fascial scalp flap (TPFF) lining the resection cavity was introduced in a trial conducted in our institution, in newly-diagnosed GBM patients in an attempt to bypass the BBB after initial resection. In this paper, we report on a new technique to bypass the BBB after re-resection and potentially to allow tumor antigens to be surveilled by the immune system. The study aims to assess the feasibility of performing a cranial transposition and revascularization of autologous omentum after re-resection of GBM. Laparoscopically harvested omental free flap was transposed to the resection cavity by a team consisting of neurosurgeons, otolaryngologists, and general surgeons. This was done as part of a single center, single arm, open-label, phase I study. Autologous abdominal omental tissue was harvested laparoscopically on its vascularized pedicle in 2 patients, transposed as a free flap, revascularized using external carotid artery, and carefully laid into the tumor resection cavity. Patients did well postoperatively returning to baseline activities. Graft viability was confirmed by cerebral angiogram. Omental cranial transposition of a laparoscopically harvested, vascularized flap, into the cavity of re-resected GBM patients is feasible and safe in the short term. Further studies are needed to ascertain whether such technique can improve progression free survival and overall survival in these patients.

Secondary surgery for the unsatisfactory auricle after auricular reconstruction.

OBJECTIVES: Complications, including framework exposure, infections, and reconstructed auricle deformation, may occur after auricular reconstruction. However, reports on surgical methods for cases with unsatisfactory outcomes after auricular reconstruction using an autologous costal cartilage are insufficient. Herein, we summarized retreatment casesfor poor ear morphology in patients who had undergone auricular reconstruction in our department for 5 years and discussed other techniques. METHODS: Between September 2014 and September 2019, 24 ears of 24 patients with poor morphology, unsatisfactory macroscopic characteristics and anatomical structures, and unsatisfactory outcomes of local repair after auricular reconstructive surgery were treated. Patients were divided into the following three groups: type 1 (9 ears), with intact and sufficient hairless skin in the mastoid region behind the reconstructed ear; type 2 (7 ears), with intact, but insufficient, hairless skin in the mastoid region behind the reconstructed ear; and type 3 (8 ears), with hairless skin in the mastoid region behind the reconstructed ear with impaired skin integrity. RESULTS: Twenty-two (91.6%) patients successfully completed the surgical treatment and recovered well; one experienced delayed wound healing and another developed hypertrophic scarring at the incision site at 3 months postoperatively. All patients were followed for 0.5-4 (mean, 2.8) years. The macrostructure of the reconstructed ear post-revision was stable and significantly improved in terms of morphology and structure. CONCLUSIONS: In patients with unsatisfactory outcomes after auricular reconstruction, the appropriate technique for the revision surgery should consider the local soft tissue conditions of the reconstructed ear to obtain satisfactory results.

Vascularized Prelaminated Thermoplastic Bioabsorbable Scaffold in Tracheal Reconstruction.

Successful tracheal reconstruction remains a challenging task for the reconstructive surgeon. A variety of techniques have been previously employed, using both autografts and allografts. The authors present a novel method for tracheal reconstruction utilizing a prelaminated fascial flap in conjunction with a bioabsorbable scaffold. Laryngoscope, 132:550-553, 2022.

Anterolateral Thigh Fascia Lata Rescue Flap: A New Weapon in the Battle Against Osteoradionecrosis.

OBJECTIVES: To demonstrate that the anterolateral thigh fascia lata (ALTFL) rescue flap may be effectively used for management of osteoradionecrosis (ORN) in selected patients. STUDY DESIGN: Retrospective case review. METHODS: Retrospective chart review was performed on patients who underwent ALTFL free flap repair to various sites of ORN in the head and neck between 2011 and 2018. Inclusion criteria were patients with radiographic and clinical evidence of head and neck ORN who either failed previous hyperbaric oxygen (HBO) therapy or with extensive disease, which was unlikely to respond to conservative management. RESULTS: Twenty-three patients with average age of 63 years (40-78) who underwent 24 ALTFL free flap procedures were reviewed. ORN sites were the mandible (n = 16), palatomaxilla (n = 4), skull base and cervical spine (n = 3), and calvarium (n = 2). Recipient vessels used were superficial temporal (n = 11), common facial (n = 10), and angular (n = 3). Average hospital stay was 3.0 (1-10) days. Prior HBO therapy was performed in 13 (57%) patients. There were four major complications: flap failure, recurrent mandibular infection resolved with IV antibiotic course, mandibular fracture with malunion requiring occlusal adjustment, and unresolved sequelae of ORN requiring fibular free flap. There were four minor complications: thigh hematoma, thigh seroma, and intraoral scar formation causing trismus (n = 2). The procedure was successful in 22 of 23 (95.7%) patients with radiographic arrest of ORN, resolution of symptoms, and elimination of antibiotic requirements. CONCLUSION: The ALTFL rescue flap merits strong consideration in ORN management and appears to prevent progression to more extensive disease, which would require full segmental bone resection and reconstruction. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2688-2693, 2021.

The Infratemporal Retro-Eustachian Transposition of the Temporoparietal Fascial Flap for Clival Reconstruction After Endoscopic Endonasal Approach: An Anatomic Conceptual Technique.

BACKGROUND: Reconstruction after endoscopic endonasal approaches is a key element. Lower clivus reconstruction is difficult and most of the times a pedicled flap is not available. As the complexity and the dimensions of the exposure increase, a reliable reconstruction technique becomes more and more important. OBJECTIVE: To describe the anatomic and technical nuances of the transposition of the temporoparietal fascial flap for lower clivus reconstruction. METHODS: A specific temporoparietal fascial flap (TPFF) design and tunneling technique has been studied using 4 head specimens, microscopic and endoscopic surgical techniques, and neuronavigation. RESULTS: The L-shaped flap offers several advantages. It can be tunneled directly toward the lower clivus passing through the infratemporal fossa. CONCLUSION: The infratemporal retro-eustachian transposition of an L-shaped TPFF provides a vascularized tissue virtually without dimension limits. This is the only technique that allows the flap to be tunneled directly in the lower clivus with the most vascular portion being at the bottom of the defect. Clinical validation is still required since more issues may become relevant in a real-surgery setting. Though, due to its possible complications, this methodology needs further testing and should not be attempted in less experienced hands.

The Adipo-Fascial ALT Flap in Lower Extremities Reconstruction Gustillo IIIC-B Fractures. An Osteogenic Inducer?

RESULTS: Mean time from injury to flap coverage was 72 hours. The mean size of bone defects was 4-7,6 cm. All flaps were Antero Lateral Tight flaps, and the fracture sites did not have any evidence of infection. None of the patients was a smoker. A solid bone union was reached, and full wearing was in a mean of 11 (4-20) weeks after the injury. The lower limb was saved in 100% of the cases. CONCLUSION: Despite the goods results, further studies applied on a large number of patients are needed to confirm authors theory, however, we can consider the fascial ALT flap as a valid help for bone healing in 3B-C open tibial fractures.

Retrospective analysis of free temporoparietal fascial flap for defect reconstruction of the hand and the distal upper extremity.

INTRODUCTION: Soft tissue reconstruction of the hand and distal upper extremity is challenging to preserve the function of the hand as good as possible. Therefore, a thin flap has been shown to be useful. In this retrospective study, we aimed to show the use of the free temporoparietal fascial flap in soft tissue reconstruction of the hand and distal upper extremity. METHODS: We analysed the outcome of free temporoparietal fascial flaps that were used between the years 2007and 2016 at our institution. Major and minor complications, defect location and donor site morbidity were the main fields of interest. RESULTS: 14 patients received a free temporoparietal fascial flap for soft tissue reconstruction of the distal upper extremity. Minor complications were noted in three patients and major complications in two patients. Total flap necrosis occurred in one patient. CONCLUSION: The free temporoparietal fascial flap is a useful tool in reconstructive surgery of the hand and the distal upper extremity with a low donor site morbidity and moderate rates of major and minor complications.