Vastus lateralis versus rectus femoris muscle flaps for recalcitrant hip joint infection: An anatomical study comparing the effectiveness of acetabular dead space control.

Eliminating recalcitrant prosthetic hip joint infections remains one of the greatest challenges in orthopedic surgery. In such cases, the salvage procedure of femoral head excision (the Girdlestone procedure) is often performed. There has been emerging surgical interest in filling the resulting acetabular dead space with a pedicled muscle flap, to enable antibiotic delivery. Both vastus lateralis (VL) and rectus femoris (RF) muscle flaps have been described for this purpose with good success. This study is the first anatomical investigation comparing VL and RF as candidates for interposition myoplasty following hip joint excision. Following standard surgical technique, the Girdlestone procedure and interposition myoplasty of both RF and VL were performed on 10 cadavers. The primary aim was to determine which muscle flap eliminated a greater volume of acetabular dead space. Secondary aims were to characterize the blood supply to RF and assess additional metrics indicative of the likelihood of flap success. The VL flap eliminated more dead space than RF. However, the use of the RF flap was feasible in all cases and has several benefits, including ease of harvest, mobility, and aesthetics. The location of the inferior vascular pedicle into RF was relatively consistent and the most effective predictor of flap success. Both VL and RF are effective in reducing acetabular dead space. While VL can fill a greater volume, the RF flap has technical advantages, related to the predictability of the blood supply.

Comparison of patients satisfaction with aesthetic outcomes following lower extremity reconstruction: Muscle vs. fasciocutaneous free flaps.

BACKGROUND: The microsurgical reconstruction of complex lower limb defects has become a routine procedure with high success rates. The emphasis has changed from ensuring flap 'success' to providing a reconstruction, which is also aesthetically pleasing. The aim of this study was to compare patients' satisfaction with aesthetic outcomes, following muscle or fasciocutaneous free flap reconstruction to the lower limb. METHODS: Data were collected retrospectively between July, 2013 and May, 2018 at a single institution. The inclusion criteria were adult patients who had successful free tissue transfers to the lower limb following any aetiology. A Likert Scale questionnaire was sent to all patients who met these criteria. The questionnaire included questions related to the reconstruction and donor site. RESULTS: Questionnaires were sent to 83 patients who met the inclusion criteria. Forty-seven (57%) patients responded, of which 22 (47%) underwent reconstruction with muscular flap and 25 (53%) with fasciocutaneous flap. A statistically significant difference between the two groups was found in relation to flap texture (p = 0.003). Patients with fasciocutaneous flap reconstruction being more satisfied. No significant difference was observed for contour, similarity to the contralateral side, bulkiness of flap, colour match, scar, or overall appearance. The comparison of donor site results revealed no significant difference between the two groups CONCLUSIONS: Despite increase in success in lower extremity reconstruction, many patients still find aesthetic results suboptimal and this affects an individual's global sense of well-being. Aesthetic restoration should be viewed as an integral part of lower limb reconstruction. LEVEL OF EVIDENCE: Therapeutic, III.

Neurovascular Anatomy at the "Box Junction": Considerations in the Anterolateral Thigh Flap.

BACKGROUND: The anterolateral thigh (ALT) perforator flap is one of the most widely used flaps in reconstructive microsurgery. This study investigated a previously unexplored and clinically relevant aspect of perforator anatomy: the "box junction" (BxJn), the point at which the perforator arises from its source vessel. Negotiating the BxJn can be a challenging and time-consuming step in flap harvest, due to the neurovascular structures in the area which must be protected from injury. However, as the presence and location of these structures have yet to be clearly defined, painstaking exploration is necessary on each occasion. Knowledge of BxJn anatomy could allow surgeons to harvest the ALT flap more rapidly and safely. METHODS: We dissected 20 cadaveric thighs and identified perforators to the ALT region and investigated the neurovascular anatomy at their BxJns. RESULTS: In 51 BxJns, two clinically relevant vascular structures were identified: an intramuscular artery arising from the perforator (23, 45% of cases) and a "deep" artery to the underlying muscle arising from the source vessel (29, 57% of cases). We confirmed the consistent presence of motor nerve branches and describe one previously unreported, clinically significant variation, in which the nerve to vastus lateralis crosses the BxJn (12, 24% of cases); 36, 71% of BxJns contained at least one vascular and one neural structure. CONCLUSION: Our study confirms that the BxJn is a site of potentially complex and challenging neurovascular anatomy for the surgeon. Based on these results, we propose an algorithm to guide inexperienced surgeons in negotiating this area.

Reconstruction of complex orbital exenteration defects: a single center's experience with a five-year follow-up.

BACKGROUND: Orbital exenteration presents a challenge to the reconstructive surgeon. Defects may be treated with split skin grafts, local advancement flaps, or free flap coverage. There are few published series showing the long-term outcomes of reconstruction. Our results, with at least a 5-year follow-up, are presented. METHODS: A retrospective review of 15 immediate reconstructions after orbital exenterations for malignancies in 12 patients at a tertiary referral center over a 5-year period, was done. All flaps were followed up for at least 5 years (mean, 75 months; range, 3-118 months). RESULTS: Malignancies included squamous cell carcinoma, basal cell carcinoma, meningioma, sebaceous gland carcinoma, and rhabdomyosarcoma. Eight cervicofacial rotation-advancement flaps and 4 anterolateral thigh, 1 rectus abdominis, and 1 radial forearm free tissue transfers were used. Aggressive postoperative radiotherapy (9/15) was well tolerated by both regional and free flaps. Both cervicofacial flaps in previously irradiated patients had wound dehiscence or fistula formation. Six (50%) patients died during follow-up, 4 of whom (33%) died of tumor recurrence. CONCLUSIONS: Flap reconstruction after complex orbital exenteration is associated with low morbidity. Cervicofacial rotation-advancement flaps offer reliable, single-stage, aesthetically pleasing reconstructions. They should be avoided in the previously irradiated. Free tissue transfer is indicated for volume replacement, after previous radiotherapy, after tumor recurrence and previous use of locoregional flaps. Reconstruction of complex orbital exenteration defects for malignancies should be undertaken in centers with experience in the management of these procedures.

Cicatricial ectropion: a complication of topical 5-fluorouracil.

Topical 5-fluorouracil (5-FU) is a simple chemotherapeutic treatment that can be used by the plastic surgeon for indicated skin lesions. We present a case of transient, cicatricial ectropion developing secondarily to topical treatment with 5-FU, and propose an algorithm for the management of this significant complication.

Experience with cortical tunnel fixation in endoscopic brow lift: the "bevel and slide" modification.

BACKGROUND: Endoscopic brow lift has become a popular method for rejuvenation of the upper third of the face and in the treatment of functional brow ptosis. Controversy, however, remains over the optimum technique for the fixation of the forehead and brow. This paper presents a single surgeon's experience with a technical modification to McKinney's original description of paramedian cortical tunnel fixation in patients undergoing endoscopic brow lifts. PATIENTS AND METHODS: A case note study of all patients who underwent a modified cortical tunnel endoscopic brow lift fixation by a single surgeon over a 4-year period (2003-2006) was undertaken. The technical modification to cortical tunnel sculpting was introduced to prevent suture associated complications which had occurred in two patients prior to the study. Brow position was maintained with 2/0 polypropylene sutures anchored through modified paramedian cortical bone tunnels. Temporal fixation of superficial parietal to the deep temporal fascia was achieved with the same suture material. RESULTS: Between January 2003 and December 2006, 30 patients had endoscopic brow lifts performed for aesthetic and functional reasons. All cases were bilateral. Twenty-three patients (77%) were female and seven (23%) were male. The median age was 60 years (range: 34-76). Patient follow-up ranged from 3 to 24 months (mean: 12 months). Twelve patients (40%) had another aesthetic procedure carried out at the same time. There were no early postoperative complications (bleeding, VII nerve palsy or infection). One patient had a fixation suture removed under local anaesthetic 6 weeks postoperatively due to ongoing dysaesthesia localised to that particular suture site. A second developed significant intermittent forehead/scalp dysaesthesiae, which was treated conservatively. Notably, there were no cases of alopecia at the incision/fixation sites, relapses of brow ptosis, or troublesome scalp itching. No endoscopic cases were converted to an open/coronal brow lift procedure. DISCUSSION AND CONCLUSION: Cortical tunnel suture fixation provided a simple, stable, and reproducible method of maintaining brow position in endoscopically assisted forehead/brow lift with low morbidity. Our modification introduces a refinement to the technique, which allows easy passage of the fixation suture needle and prevents exposure of suture ends, thereby minimising the risk of knot-associated complications.

The dermal tube: a versatile tool in scar revision.

INTRODUCTION AND AIMS: Tethered scars are a common problem that can have functional and aesthetic consequences. Several approaches which use the dermis have been described for tethered scar correction. The objective of this report is to demonstrate the superior aesthetic outcomes achieved through the introduction of a new, simple dermal technique in scar revision surgery. MATERIALS AND METHODS: From August 2002 through to January 2006, 35 patients were operated on by the senior author for revision of tethered, sunken scars. All scars were considered to demonstrate sunken or depressed characteristics based upon clinical examination and photographic evidence. All patients were operated on by the same surgeon and using the same surgical technique. KEY RESULTS: All the patients were women (age range 17-64 years), with tethered scars affecting the breast (n=10), lower limb (n=5), upper limb (n=6), chest wall (n=4), laparotomy scars (n=8) and tracheotomy scars (n=2). Scars ranged in length from 4 to 30 cm (mean=12 cm). Follow up ranged from 2 to 24 months (median=16 months). At the 12 month follow up, patients were presented with their pre- and postoperative photos and asked to select the overall improvement in aesthetic appearance achieved as either: 'no improvement', 'improved' or 'marked improvement'. These were then ranked to scores of 0, 1 and 2, respectively (0=no improvement; 1=improved and 2=marked improvement). The responses from the questionnaire showed that the median score was 2 with 100% ranking >or=1. Thirty-two patients (91.4%) scored 2. There were no complications reported and the results at 12 months showed that restoration of volume to the scars had been maintained in all patients. To date, no one has had to undergo further revision and there have been no incidences of re-tethering. CONCLUSION: The technique is simple to learn by even junior surgeons. Through following four distinct steps consistent and readily reproducible results are achieved.

Thumb reconstruction following resection for malignant tumors.

BACKGROUND: Although limb salvage is possible for most extremity sarcomas, amputation has often been advocated as the treatment of choice for tumors involving the digits. The thumb poses a dilemma, however, because loss of its function can severely impair the use of the hand and entire upper limb. The authors report their experience with thumb reconstruction following wide excision of bone and soft-tissue tumors of the thumb. METHODS: This was a retrospective review of all patients who underwent excision of thumb or first ray tumors between 1994 and 2005 followed by reconstruction at Memorial Sloan-Kettering Cancer Center. Patient demographics, tumor pathologic findings, ablative and reconstructive operations performed, postoperative adjuvant therapy, recurrence, and survival were analyzed. Function and reconstruction outcomes were assessed. RESULTS: Seventeen patients were identified with bone or soft-tissue sarcomas, melanoma, or squamous cell carcinoma. Median follow-up was 33 months (range, 6 to 105 months; mean, 47 months). Negative resection margins were achieved in all patients. Of the 16 patients who underwent reconstruction, three had a reconstruction using free tissue transfer, four had a pedicled flap, one had an axial based local flap, one had a fillet flap, and seven achieved wound closure directly or with the use of skin grafts. The mean American Musculoskeletal Tumor Society Score following reconstruction was 28.8 (95.8 percent). CONCLUSIONS: Thumb reconstruction and salvage after tumor resection following wide excision is technically possible. Reconstruction following accepted reconstructive principles and techniques can result in acceptable functional outcomes with low risk of complication.

Facial atrophy in HIV-related fat redistribution syndrome: a plastic surgical perspective on treatment options and a look to the future.

Approximately 50% of patients on highly active antiretroviral therapy (HAART) develop lipodystrophy with central and visceral fat accumulation and/or facial and limb atrophy. Although the exact mechanisms of this are not fully understood, the facial atrophy encountered is secondary to atrophy of the subcutaneous fat, and not the deeper fat pads, as has been suggested. More recently, the above features in combination with hyperlipidaemia and insulin resistance have been described and are referred to as HIV-related fat redistribution syndrome. This review looks at treatment options available for this stigmatizing condition.