Turbocharging as a strategy to boost extended perforator flap vascularity in head and neck reconstruction-A report of two cases.

Perforator flap has been applied as the most common flap for soft tissue defect reconstruction. Here, we presented two cases using turbocharging procedure of perforator to perforator as a salvage strategy. The first case was a 54-year-old male with recurrent squamous cell carcinoma (SCC) in the left buccal area and mouth floor. A 6 × 22 cm posteromedial thigh (PMT) flap was designed for reconstruction. The two eccentric perforators of the PMT flap could not conjoin together during dissection nearby the main pedicle of profunda femoral artery (PFA) resulting in inadequate perfusion. Side branched stump before clipped the branch of distal perforator was preserved, then the proximal perforator was divided and end-to-end anastomosis of side branch of distal perforator was done successfully. The second case was a 52-year-old male underwent wide composite excision of right tongue SCC. After excision, anterolateral thigh (ALT) flap around 7 × 15 cm was harvested from left thigh and two perforators were included which one tiny perforator supplied by the descending branch (DB) and the other major perforator originated from oblique branch (OB) of lateral circumflex femoral artery (LCFA). However, the OB main perforator injury showed inadequate perfusion of flap. We trimmed the injury zone of OB perforator, and shift to re-anastomosis of OB perforators to side branch of DB of LCFA directly. The flap demonstrated excellent perfusion immediately after the operation, and it exhibited complete survival 2 weeks postoperatively. These results indicated that the turbocharging procedure, from perforator to perforator, could serve as a strategy for salvaging perfusion-compromised flaps, especially in cases of eccentric perforators or perforator injury resulting in inadequate perfusion.

High-Fidelity Perforator Visualization for Cadaver Dissection in Surgical Training.

In the first half of the third century B.C., Herophilus and Erasistratus performed the first systematic dissection of the human body. For subsequent centuries, these cadaveric dissections were key to the advancement of anatomical knowledge and surgical techniques. To this day, despite various instructional methods, cadaver dissection remained the best way for surgical training. To improve the quality of education and research through cadaveric dissection, our institution has developed a unique method of perforator-preserving cadaver injection, allowing us to achieve high-fidelity perforator visualization for dissection studies, at low cost and high efficacy. Ten full body cadavers were sectioned through the base of neck, bilateral shoulder, and hip joints. The key was to dissect multiple perfusing arteries and draining veins for each section, to increase "capture" of vascular territories. The vessels were carefully flushed, insufflated, and then filled with latex dye. Our injection dye comprised of liquid latex, formalin, and acrylic paint in the ratio of 1:2:1. Different endpoints were used to assess adequacy of injection, such as reconstitution of eyeball volume, skin turgor, visible dye in subcutaneous veins, and seepage of dye through stab incisions in digital pulps. Dissections demonstrated the effectiveness of the dye, outlining even the small osseous perforators of the medial femoral condyle flap and subconjunctival plexuses. Our technique emphasized atraumatic preparation, recreation of luminal space through insufflation, and finally careful injection of latex dye with adequate curing. This has allowed high-fidelity perforator visualization for dissection studies.

Reconstruction of a massive chest wall defect using a free anterolateral-lower medial thigh flaps: a case report.

Critical defects of the chest wall require robust soft tissue coverage to protect the thoracic viscera. We define massive chest wall defects as larger than two-thirds of the chest wall. For such defects, classic flaps like the omentum, latissimus dorsi and anterolateral thigh flaps are usually insufficient. In our patient, a bilateral total mastectomy for locally advanced breast cancer resulted in a massive chest wall defect (40 by 30 cm). Soft tissue coverage was achieved with a combined anterolateral-lower medial thigh flaps. Revascularization of the anterolateral thigh and lower medial thigh components was via the internal mammary and thoracoacromial vessels, respectively. Post-operative recovery was uneventful and the patient received adjuvant chemoradiotherapy in a timely manner. The total follow up was 24-months. We illustrate the novel use of the lower medial thigh territory in extending the size of the anterolateral thigh flap to reconstruct massive chest wall defects.

Myopericytoma: A Review of Twenty-Three Cases Over Twelve Years and a Case Report of a Rare Neoplasm.

ABSTRACT: Myopericytoma is a rare soft tissue tumor with a predilection for the distal extremities. It is commonly found in the skin and subcutaneous tissues and usually takes a benign course. Current knowledge is limited to isolated case series and reports; hence, this study aims to report our tertiary institution's experience with this uncommon entity. A review of our institution's pathology records for cases of myopericytoma was performed. From January 2009 to September 2020, 23 cases of myopericytoma were identified and their clinicopathologic features were reported. A unique case of myopericytoma of the ankle from the series was also highlighted as a case report. Among the 22 cutaneous cases, 18 were in the extremities and 4 in the head and neck. One patient had an intracranial lesion. Most patients developed asymptomatic nodules (72.2%), but 1 patient had a locally aggressive tumor on presentation. None recurred despite marginal excision in some patients (80.0%). In conclusion, pathologists and surgeons who encounter this rare neoplasm can reassure patients of its benign tendency.

Hepatic Artery Reconstruction in Living Donor Liver Transplantation With the Radial Artery Interpositional Graft.

INTRODUCTION: Reconstitution of hepatic artery inflow is essential for a successful liver transplantation. Living donor transplantation presents additional challenges in the form of a short and small donor vessel stump, exacerbating the poor surgical access for microsurgery. Few reports have described the use of the radial artery as an interposition graft in liver transplantation; we present a series of 6 cases and discuss the technical merits of this procedure. METHODS: Retrospective review of consecutive patients undergoing living donor liver transplantation from December 2015 to December 2019 was performed. Demographics, operative details, and postoperative outcomes were reviewed. RESULTS: Twenty-two patients underwent living donor liver transplantation. Radial artery interposition grafting was used in 6 cases, including 1 salvage case for hepatic artery thrombosis. One patient developed hepatic artery stenosis (2 weeks postoperatively) that was conservatively managed. After radial artery grafting, all patients had normal resistive indices on duplex ultrasonography at up to 20 months postoperatively. The mean follow-up was 15.2 months. CONCLUSION: When faced with a significantly short vessel stump or caliber mismatch, radial artery interpositional grafting is a safe and useful technique for reducing tension and overcoming vessel size mismatch in hepatic artery reconstruction.

Anatomical Study of the Medialis Pedis Flap and its clinical applications in Asian Singaporean Patients.

PURPOSE: The purpose of this study was to revisit the medial plantar artery's anatomy and study its distribution for raising the medialis pedis flap. Several investigators have reported their clinical experience with the use of this flap for reconstruction of soft tissue defects of the hand. However, many have reported difficulty raising the flap due to variations in its arterial anatomy and the confusion that exists with respect to the nomenclature in our literature. METHODS: This study was divided into 2 parts: an anatomic study and clinical application. In the anatomic study, 12 cadaveric feet specimens from 6 patients were injected with latex and barium-gelatin injections and the medial branch of the deep division of the medial plantar artery distribution was studied. We then described the use of a medialis pedis flap in four clinical cases to cover defects of the digits. RESULTS: The anatomic study revealed that the average pedicle length of the deep division of the medial plantar artery was 1.94cm. In the four illustrative clinical cases where the flap was used, the average flap size was 4.5 × 3.75cm. Donor sites were either closed primarily or with skin grafts. The vessels used for this flap were the medial branch of the deep division of the medial plantar artery and venae commitantes, or subcutaneous veins which provided the superficial drainage. All flaps were successful without any significant complications. The study is novel in that it describes the anatomic variability of length of the medial branch of the deep division of the medial plantar artery that exits in nature. CONCLUSIONS: This paper describes the medial branch of the deep division of the medial plantar artery and the anatomic variations that exist in the raising of the medialis pedis flap. We have shown how a medialis pedis flap is an ideal option for reconstructing soft tissue defects of the hand because of its texture, bulkiness and pliability in the context of like for like reconstruction.

Coverage of anterior mediastinal tracheostomy with bipedicled anterolateral thigh flap.

BACKGROUND: Cancer defects requiring anterior mediastinal tracheostomy (AMT) are complex, often accompanied by tracheo-laryngeal and pharyngeal defects with exposure of the great vessels and mediastinal cavity. The trachea has to be mobilised and exteriorised as an end-tracheostome through the anterior chest. A well-vascularised flap that can resurface skin defects, obliterate dead space and allow maturation of a reliable anterior mediastinal tracheostome is required. We describe a modification of using a centrally fenestrated bipedicled chimeric anterolateral thigh flap (ALT) to address these challenges. METHODS: A free chimeric bipedicled ALT flap was designed. The skin defect was resurfaced by a vertically-oriented skin paddle. Two chimeric muscle components were used to partition the mediastinum and the great vessels of the neck from the tracheostome. The mediastinal trachea was mobilised and matured through a centrally-fenestrated opening in the flap. Layered fascial sutures were employed to minimize dehiscence. RESULTS/COMPLICATIONS: Two patients with AMT underwent the modified ALT. No major complications such as flap-tracheostomy dehiscence occurred. One patient had a small peripheral demarcation of the flap which required revision and secondary closure. CONCLUSION: The bipedicled design of the modified ALT flap provided robust blood supply to the central fenestration through dual perforators, avoiding flap-tracheostomy separation. The chimeric muscle components obliterate dead space and protect the great vessels of the neck and mediastinum. The thin pliable nature of the anterolateral thigh skin also allowed for tensionless inset of the trachea.

Current operative management and therapeutic algorithm of lymphedema in the lower extremities.

Lymphedema is defined as the abnormal accumulation of interstitial fluid in subcutaneous tissues resulting from cancer, cancer treatment (surgery and/or radiotherapy), infection, inflammatory disorders, obesity, and hereditary syndromes. Surgical management of lymphedema can be broadly classified into two categories, reductive surgical techniques such as direct excision, suction assisted protein lipectomy (SAPL) or radical reduction with perforator preservation (RRPP); and physiological surgical procedures such as lymphaticovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT). These techniques and their various combinations were evaluated. The results revealed patients with reversible lymphedema (ISL stage I, mild severity) benefit most from physiological procedures (LVA or VLNT) which can reduce the chance of disease progression to the chronic, solid phase. Reductive techniques such as SAPL, RPPP, or direct excision procedures should be reserved for patients with advanced - severe lymphedema (ISL stages II and especially stage III) as the surgical treatment of choice. In this study, current literature on the surgical treatment of lower extremity lymphedema is reviewed and discussed in conjunction with authors' clinical experiences. An algorithm is presented, based on clinical evidence and experience which aims to provide a structured approach to managing lower limb lymphedema.

The use of negative-pressure wound therapy over a cultured epithelial autograft for full-thickness wounds secondary to purpura fulminans in an infant.

Purpura fulminans is a serious condition that can result in severe morbidity in the pediatric population. Although autologous skin grafts remain the gold standard for the coverage of partial- to full-thickness wounds, they have several limitations in pediatric patients, including the lack of planar donor sites, the risk of hemodynamic instability, and the limited graft thickness. In Singapore, an in-house skin culture laboratory has been available since 2005 for the use of cultured epithelial autografts (CEAs), especially in burn wounds. However, due to the fragility of CEAs, negative-pressure wound therapy (NPWT) dressings have been rarely used with CEAs. With several modifications, we report a successful case of NPWT applied over a CEA in an infant who sustained 30% total body surface area full-thickness wounds over the anterior abdomen, flank, and upper thigh secondary to purpura fulminans. We also describe the advantages of using NPWT dressing over a CEA, particularly in pediatric patients.

Impact of Microsurgical Anastomosis of Hepatic Artery on Arterial Complications and Survival Outcomes After Liver Transplantation.

Hepatic artery (HA) complications after liver transplant (LT) can lead to biliary complications, graft failure, and mortality. Although microsurgery has been established to improve anastomotic outcomes, it prolongs surgical time and has not reached widespread adoption at all transplant centers. We investigated the incidences of arterial, biliary complications and outcomes after using microsurgery to anastomose HA during LT. Retrospective cohort of consecutive LT performed from 2006 to 2018 was reviewed for operative details and postoperative outcomes. Cox-regression models were used to investigate the relationship between variables and outcomes. Eighty (62.5%) LTs (Group 1) were performed without and compared with 48 (Group 2) with microsurgical anastomosis of HA. Both groups were comparable in terms of arterial and biliary anastomoses performed. Incidence of early HA thrombosis was similar (6.2% vs 2.1%, P = .28). Group 2 had lower incidence of short- and long-term arterial complications, especially amongst living donor liver transplantations (LDLT) (5.3% vs 35.0%, P = .022). On multivariate analysis, microsurgery was associated with lower risk (hazard ratio [HR] 0.09, 95% confidence interval [CI] 0.01-0.71) of, and LDLT had higher risk (HR 4.23, 95% CI 1.46-12.27) of arterial complications. Biliary complications were associated with LDLT (HR 3.91, 95% CI 1.30-11.71) and dual biliary anastomoses (HR 5.26, 95% CI 1.15-24.08) but not with occurrence of HA complications. Worse patient survival was associated with the occurrence of any HA complication (HR 4.11, 95% CI 1.78-9.48). Hepatic arterial complications can be reduced using microsurgical techniques for the anastomosis, resulting in improved patient survival outcomes after liver transplantation.

Pulmonary mucormycosis with diaphragm and liver involvement in a patient with haematopoietic stem cell transplant.

Pulmonary mucormycosis is a rare but life-threatening fungal infection. We report a post-haematopoietic stem cell transplant patient with pulmonary mucormycosis that extended to the diaphragm and subphrenic space. He underwent lung and diaphragm resection, debridement of liver capsule and diaphragm reconstruction using a pedicled latissimus dorsi flap. Following surgery, the patient remained well and has resumed his regular daily activities.

Outcome predictors in elderly head and neck free flap reconstruction: A retrospective study and systematic review of the current evidence.

Free flap tissue transfer has become the gold standard for reconstruction of composite head and neck defects. We sought to investigate the efficacy and morbidity of these procedures in the elderly. We retrospectively reviewed 245 head and neck free flap procedures (234 patients). Patients were stratified by age group (≥ or <65 years). Univariate and multivariate analyses were used to evaluate the following primary outcomes - free flap survival, postoperative medical and surgical complications and 30-day mortality. We found that free flap success and surgical complication rates were similar between the two age groups. Overall flap success and perioperative mortality rates were 94.3% and 2.1% respectively. Medical complications were significantly more common in the elderly group (p <0.001) and this correlated with comorbidity (OR = 2.81, p = 0.044) and advanced tumour stage (OR = 10.20, p= 0.029). Age was not independently associated with poor outcomes in our cohort. We then performed a systematic review of similar case-control studies worldwide and compared their findings with our results. We conclude that advanced age does not preclude free flap success in head and neck reconstruction. Rather, the presence of comorbidity appears to predict the development of medical complications postoperatively. Elderly patients with low comorbidity scores may be offered free flap reconstruction with less reservation.

Two-Blade Guillotine Technique for Nipple Graft Harvest.

The nipple-sharing technique for nipple reconstruction offers excellent tissue matching. The method used for nipple graft harvesting determines the quality of the graft and hence, the success of nipple sharing. Here, we described a guillotine technique wherein the nipple is first transfixed with 2 straight needles to stabilise it. Two No. 11 blades are then inserted in the center and simultaneously swept outwards to amputate the distal portion of the nipple. This technique provides good control, resulting in a very evenly cut base. The recipient bed is deepithelialized thinly, and the nipple graft is inset with interrupted 8-0 nylon sutures under magnification. Being a composite graft, it is protected with splint dressings for 6 weeks, and the dressing is regularly changed by the surgeon. The height of the nipple grafts ranges from 4 to 8 mm. This technique was performed in 9 patients with an average follow-up of 2.9 years (range, 1-4.5 years). Apposition between the nipple graft and its bed is crucial for the success of this technique. When correctly applied, we observed rapid revascularization of the graft.

Dermatofibrosarcoma protuberans in children and adolescents: Clinical presentation, histology, treatment, and review of the literature.

PURPOSE: Dermatofibrosarcoma protuberans (DFSP) is a rare, low-grade malignant tumor. It is characterized by aggressive local infiltration, leading to a propensity for recurrence. In children, DFSP is even less common and likely misdiagnosed or underdiagnosed. This study is a review of DFSP in the pediatric population and aims to identify factors for successful treatment. MATERIALS AND METHODS: From July of 1986 to 2011, a total of 159 patients were diagnosed with dermatofibrosarcoma protuberans at Kaohsiung Chang Gung Memorial Hospital, Taiwan. Subject to the age classification of our institution, patients under the age of 18 are defined in the pediatric category, of which159 cases were identified as our research subjects. Detailed data, including demographic data, imaging studies, pathology, treatment methods, and outcomes, of these identified patients were collected, reviewed, and analyzed. RESULTS: A total of 13 patients, consisting of six male and seven female patients, were identified based on our criteria. Two had the lesions noticed at birth. Most patients experienced a variable period of quiescence, followed by a rapid growth phase. All 13 patients underwent wide excisions. Post-excision reconstruction included direct closure in three cases, skin grafting in three cases, and local or free flap reconstruction in seven cases. Of 13 patients, four received postoperative radiotherapy. All patients survived without recurrence up to July 2011, with follow-up periods ranging from 20 months to 19 years. CONCLUSION: Clinicians should be aware that DFSP is known to occur among children. Owing to its relatively low incidence, its presence may be confused with commoner lesions such as hemangioma, fibroma, or atrophic plaques without nodule. The confusing situation, as a result, frequently leads to delayed diagnosis. Vigilance in its diagnosis allows for treatment at manageable sizes as well as ensures complete excision. Reconstructive options, such as skin grafting, and modalities, such as adjuvant postoperative radiotherapy, are suggested to best complement each other. The former minimizes disfigurement while the latter minimizes recurrences.

Influence of neck dissection and preoperative irradiation on microvascular head and neck reconstruction-Analysis of 853 cases.

BACKGROUND: Previous neck dissection and irradiation is believed to affect the success of free tissue transfers in head and neck reconstruction, but evidence is scarce and conflicting. This study seeks to evaluate flap success rates in the presence of these two factors. METHODS: Over a ten-year period, a total of 853 free flap cases were evaluated. Success rates were compared between a control group with no prior intervention (non-irradiation and neck dissection, NRTND) against three other groups: irradiation only (RT), previous neck dissection only (ND), and both (RTND). The choices of recipient vessel used were also compared. RESULTS: The flap failure rate was 6.3% (4/63) in the RTND group; 4.8% (1/21) in the ND group; 5.2% (6/115) in the RT group; and 2.1% (14/654) in the NRTND group. There was no statistical significance among the four groups (P = 0.254). Ipsilateral neck vessels (92.7%) were more frequently used in the NRTND group. In contrast, the superficial temporal vessels, contra-lateral neck vessels were more likely to be selected in the groups with irradiation and/or neck dissection. CONCLUSIONS: Free tissue transfer in head and neck patients with previous irradiation and neck dissection is feasible and can be safely done. In addition, superficial temporal vessel could be the first choice in patients with previous radiotherapy and neck dissection.

Comparison of outcomes of pressure sore reconstructions among perforator flaps, perforator-based rotation fasciocutaneous flaps, and musculocutaneous flaps.

BACKGROUND: Pressure sore reconstruction remains a significant challenge for plastic surgeons due to its high postoperative complication and recurrence rates. Free-style perforator flap, fasciocutaeous flap, and musculocutaneous flap are the most common options in pressure sore reconstructions. Our study compared the postoperative complications among these three flaps at Kaohsiung Chang Gung Memorial Hospital. METHODS: From 2003 to 2012, 99 patients (54 men and 45 women) with grade III or IV pressure sores received regional flap reconstruction, consisting of three cohorts: group A, 35 free-style perforator-based flaps; group B, 37 gluteal rotation fasciocutaneous flaps; and group C, 27 musculocutaneous or muscle combined with fasciocutaneous flap. Wound complications such as wound infection, dehiscence, seroma formation of the donor site, partial or complete flap loss, and recurrence were reviewed. RESULTS: The mean follow-up period for group A was 24.2 months, 20.8 months in group B, and 19.0 months for group C. The overall complication rate was 22.9%, 32.4%, and 22.2% in groups A, B, and C, respectively. The flap necrosis rate was 11.4%, 13.5%, and 0% in groups A, B, and C, respectively. There was no statistical significance regarding complication rate and flap necrosis rate among different groups. CONCLUSIONS: In our study, the differences of complication rates and flap necrosis rate between these groups were not statistically significant. Further investigations should be conducted.

The outcome of free tissue transfers in patients with hematological diseases: 20-year experiences in single microsurgical center.

BACKGROUND: Free tissue transfers performed in patients with hematological diseases represent significant challenges for micro-surgeons. There are rare literatures that address the outcome in these patients. Therefore, we collected our database, analyzed the outcome, reliability, and related-management of microsurgical technique in the patients with hematological diseases. METHODS: A retrospective chart review of 20 patients with hematological disorders who received free tissue transfers during 20-years period in a single microsurgical center was done. Eleven patients who received head and neck reconstruction were found to have hyperfibrinogenemia. Seven patients with reactive thrombocytosis after trauma, and two patients with leukemia had soft tissue defects in the upper and lower extremities. Twenty-six flaps were used for free tissue transfers. Intra-operatively all patients received intravenous 5,000 Ud of heparin post immediate reperfusion. Anti-coagulant medication such as Dextran-40 or prostaglandin-E1 (PGE1) was given postoperatively. RESULTS: Twenty-three of the 26 free flaps survived without vascular compromise. Intra-operatively all patients received intravenous 5,000 Ud of heparin post immediate reperfusion, and anti-coagulant medication such as Dextran-40 or prostaglandin-E1 was given to the patients postoperatively. The three failed cases were found in patients with hyperfibrinogenemia and needed further reconstruction with another flap. The overall success rate was 88.5% (23/26). CONCLUSIONS: Hematologic disorder is not a predicted factor of free flap failure. The key factors for success flap survival in patients with hematologic disorders include preoperative knowledge of the medical condition and monitoring potential post-operative complications, aggressive hematologist consultations, and meticulous non-traumatic surgical anastomosis.

The role of the anterolateral thigh flap in complex defects of the scalp and cranium.

In this study, we introduced scalp reconstruction using free anterolateral thigh (ALT) flaps and evaluated postoperative outcomes in nine patients between March 2000 and April 2012. Five patients had problems of exposed prosthesis, three required reconstruction after resection of scalp tumor and one patient presented with third degree flame burns of the scalp. All flaps survived without re-exploration, except three flaps with tip necrosis requiring secondary procedures of debridement and small Z-plasty reconstructions. The superficial temporal artery and its concomitant vein were used as recipient vessels, apart from two cases where previous surgery and flame burns excluded these choices, for which facial arteries and veins were used instead. Primary closure of the donor-site was possible in six cases; with skin grafting performed for the other three patients. All donor sites healed without complications. The ALT flap offers the advantage of customizable size, option of fascia lata as vascularized dural replacement, and minimal flap atrophy typical of muscle flaps. Indications include very large defects, defects with exposed prosthesis, or defects with bone or dural loss. Our experience lends credible support to the use of customized free ALT flaps to achieve functional and cosmetically superior result for the reconstruction of large scalp defects, especially with bone exposure.

Free tissue transfers in head and neck reconstruction: complications, outcomes and strategies for management of flap failure: analysis of 2019 flaps in single institute.

BACKGROUND: Free tissue transfer has become the preferred option for complex reconstructions in head and neck cancer ablation. This study reviewed the surgical outcome and analyzed the evolution of microsurgical head and neck reconstruction over 20 years in single institute. PATIENTS AND METHODS: A total of 1,918 patients underwent microsurgical head and neck reconstructions in 20-year period. The surgical outcome and complications among these 2,019 flaps (1,223 anterolateral thigh flaps, 372 fibula flaps, 353 radial forearm flaps, 12 jejunal flaps, and 59 others) were retrospectively reviewed and analyzed. RESULTS: A total of 201 cases required emergent surgical re-exploration and the overall flap success rate was 96.2%. Venous insufficiency was the most common cause for re-exploration. Other major complications included fistula formation (5.4%), partial flap necrosis (7.5%), and infection (17.8%). The fibula flap had frequent complications compared with soft tissue flaps. The familiarity to the ALT flap had minimized complications and allowed for widely versatile uses. CONCLUSION: Free tissue transfer is shown to be highly reliable option for head and neck reconstruction. For soft tissue defect, ALT flap is the first choice. Fibula flap is ideal for bone defect reconstruction. In case of complex composite defects, double flaps, which include ALT and fibula flaps could reconstruct bone and soft tissue defects simultaneously with high success rate.