Triple-lobe combined latissimus dorsi and scapular flap for reconstruction of a large defect after sarcoma resection.

BACKGROUND: In the setting of the reconstruction for a large defect, we must make the maximum use of the limited human tissue with the minimum damage. In this article, we report on reconstruction using a combination of three-skin paddle latissimus dorsi and a scapular flap for a large defect after soft tissue sarcoma resection to minimize donor site morbidity. METHODS: From 2000 to 2012, six patients underwent primary reconstruction using free or pedicled triple-lobe combined latissimus dorsi and scapular flap after wide resection of soft tissue sarcoma. There were five male patient and one female, and their average age was 66.8 (range, 49-80 years). The location of the defects was the thoracic wall in three, the thigh in one, the knee in one, and the shoulder in one. The average size of the defect was 18.8 × 13.9 cm. RESULTS: The average size of the ascending scapular flap and the skin paddle of the latissimus dorsi flap was 6.8 × 13 cm and 7.3 × 14.7 cm. One patient had partial necrosis of the skin paddle of the latissimus dorsi flap, which was treated conservatively. The triple-lobe combined latissimus dorsi and scapular flaps survived completely in five cases. Neither anastomosis complications nor infections were encountered. The average follow-up period was 63.67 months. All patients were satisfied functionally and esthetically with the reconstruction outcomes at the end of follow-up. CONCLUSION: In conclusion, the triple-lobe combined latissimus dorsi and scapular flap is one of the options for reconstruction of a large defect after sarcoma resection to minimize donor site morbidity.

A Cadaver Study to Assess the Feasibility of a Cross-Nerve Transfer of the Infraorbital Nerve for Patients With Peripheral Infraorbital Nerve Injury.

BACKGROUND: Patients with facial fracture or head and neck surgery sometimes suffer from infraorbital nerve injury. This injury results in severe hemilateral numbness in the midfacial area. The infraorbital nerve ends with two major branches; the infra nasal branch (INB) and superior labial branch (SLB). In this study, we assessed the feasibility of cross-nerve transfer of the INB and SLB based on a cadaver study. METHODS: The INB/SLB from a total 20 sides of 10 cadavers (2 men and 8 women; average age, 79.9 years) were dissected. The distribution patterns of the INB and SLB, the distance between the INB/SLB and the piriform aperture, and the shortest distance between the INB/SLB were estimated. RESULTS: Three distribution patterns of the INB and SLB were observed, that is type A (65%); only the INB is thick enough for a nerve transfer, type B (20%); only the SLB is thick enough for a nerve transfer, and a combination of types A and B (15%). The distance between the INB, SLB and the piriform aperture was on average 8.61 and 10.81 mm in each. The shortest distance between the INB and SLB was on average 11.34 ± 3.7 mm. CONCLUSIONS: The INB and SLB existed in all the specimens and could be found approximately 1 cm below the piriform aperture. The average distance between the INB and SLB was approximately 11 mm. These results imply the feasibility of a cross-nerve transfer of the distal part of the infraorbital nerve.

Vulvar Reconstruction Following Surgery for Vulvar Cancer Using a Stepladder V-Y Advancement Medial Thigh Flap.

OBJECTIVE: The aim of this study was to identify the risks and benefits of the stepladder V-Y advancement medial thigh flap for vulvovaginal reconstruction in comparison to direct skin closure. METHODS: Fifty-four patients with vulvar cancer treated in our hospital between 1992 and 2013 were enrolled in this study. The cohort group (group A) consisted of 25 patients who underwent surgery from August 2006 until April 2013. During this period, we changed our surgical paradigm to incorporate reconstructive plastic surgery immediately following surgery for vulvar cancer performed by gynecologic oncologists. The control group (group B) consisted of 29 patients treated between 1992 and August 2006. During this period, our surgical approach was limited to direct skin closure with no reconstructive plastic surgery. Perioperative findings and clinical outcomes were compared retrospectively. RESULTS: Patient characteristics and surgical procedures, other than the reconstructive surgery, were the same for the 2 groups. The mean blood loss and operative times were similar, and there were no major complications in either group; however, the average length of hospital stay was significantly shorter in group A (P = 0.04). CONCLUSIONS: Stepladder V-Y advancement medial thigh flap lowers posttreatment morbidity and improves quality of life for patients with vulvar cancer. Rapid recovery from surgery is reflected in the short hospital stay, and it enables immediate induction of adjuvant therapy. It may possibly contribute to improved treatment outcome.

Recent advances in reconstructive surgery for bone and soft tissue sarcomas.

We present the current perspective on reconstructive surgery for soft tissue tumors, especially in the extremities, based on our large series. A total of 1,813 patients with bone and soft tissue sarcomas underwent surgery at our hospital between 1978 and 2011. Reconstructive operations were performed by plastic surgeons. In such reconstructive surgery, to achieve better quality of life for the patient, great effort was made not only for limb salvage but also for functional reconstruction. Although a few surgeries resulted in limb amputation due to multiple tumors, recurrence, or advanced age of the patient, the rate of limb salvage and/or functional recovery has been increasing dramatically using the method of flap surgery and vascular reconstruction. In fact, over more than 30 years, the limb salvage rate at our hospital has increased from 71.6 % around 1980 to 90.5 % around 2010. In this article, we describe our experience in plastic and reconstructive surgeries after operation for bone and soft tissue sarcomas.

Immediate tendon transfer for functional reconstruction of a dorsal forearm defect after sarcoma resection.

In the treatment of sarcoma, the reconstructive surgeon must consider not only limb salvage but also functional reconstruction. The aim of this study was to evaluate a functional reconstruction of a dorsal forearm defect after sarcoma resection using immediate tendon transfer. Patients who underwent reconstruction of a dorsal forearm defect after sarcoma resection with an immediate tendon transfer between 1997 and 2019 at our hospital were included in this retrospective study. Patient demographics, tumor characteristics, surgical characteristics and functional outcomes were examined. Nine patients were included in this study. Tendon transfer of the flexor carpi radialis (FCR) or the flexor carpi ulnaris (FCU) to the extensor digitorum communis (EDC), the brachioradialis (BR) to the EDC, and the palmaris longus (PL) tendon to the extensor pollicis longus (EPL) was performed in seven, two and five patients, respectively. Seven patients underwent reconstruction using a free flap. Neither anastomosis complications nor infections were encountered. Partial flap necrosis and donor site dehiscence were seen in one case each. The mean distal interphalangeal (DIP), proximal interphalangeal (PIP) and metacarpophalangeal (MP) joint active extension were 4.4°, 6.1° and 11.1° postoperatively. The mean Musculoskeletal Tumor Society (MSTS) score was 26. Immediate tendon transfers of the FCR or the FCU to the EDC and the PL tendon to the EPL can be considered an optimal functional reconstruction of a dorsal forearm defect after sarcoma resection.

Continuous local intraarterial infusion of anticoagulants for microvascular free tissue transfer in primary reconstruction of the lower limb following resection of sarcoma.

In free tissue transfers, preventing microvascular thrombosis is the first priority to achieve a successful result. Numerous protocols exist for preventing thrombosis postoperatively. We performed continuous local intraarterial infusion of anticoagulants in 11 patients undergoing wide resection of malignant soft tissue tumors, followed by primary microvascular reconstruction in the lower limb. A catheter designed for epidural anesthesia was inserted into the femoral artery and connected to a syringe pump. A daily dose of 100 ml comprising 2,000 U of heparin and 40 microg of prostaglandin E(1) was administered by means of continuous infusion for seven consecutive days as a standard regime. There were no cases of thrombosis during the continuous local intraarterial infusion of anticoagulants. There were no serious systemic complications. Although we have described limited cases and supporting data are lacking, we feel that this procedure might be useful for microsurgical reconstruction of the lower limb.

Long-term results of vascularized proximal fibula epiphyseal transfer based on the anterior tibial artery in retrograde fashion.

Injury of bone growth plates can result in severe disability in children. We report the long-term results of successful vascularized proximal fibula epiphyseal transfer based on the anterior tibial artery in retrograde fashion.

A Labia Majora Sharing Perforator Flap for Labial Defect Reconstruction.

Reconstruction of a defect in the labial area has to be performed by taking account of the shape of the labial area and urogenital function. The gracilis myocutaneous flap and the gluteal fold flap are commonly used reconstructive procedures, but sometimes these flaps are too bulky and cause a deviation of the urination stream and/or deformity of the reconstructed site. In this report, we present our unique method of reconstruction using a contralateral labia majora sharing perforator flap. The patient was a 76-year-old woman who presented with squamous cell carcinoma on the left labia majora. Following radical vulvectomy with 2 cm radial margins and left inguinofemoral lymphadenectomy, an 8 × 6 cm2 defect was created. Primary closure was possible, but there was a risk that it might cause an unfavorable deformity and exposure of the urethral and vaginal vestibule. Part of the contralateral side of the labia was used for a dorsal clitoral artery perforator-based transposition sharing flap. The defect was covered without tension, and the donor site was closed primarily. The postoperative course was good. One year after the operation, deviation of the urination stream and severe asymmetry was not observed. This study shows feasibility of perforator-based labia majora sharing flap for contralateral labia majora defect. Our "like with like" reconstruction provides a good functional outcome and less donor-site morbidity to the patient.

A Rare Chest Wall Deformity after Usage of a Tissue Expander for Breast Reconstruction.

A 2-stage breast reconstruction using a breast tissue expander and prosthesis is a simple method of breast reconstruction with little donor-site morbidity and short surgery time. In this report, we present a rare case of chest wall deformity, which appeared during breast skin expansion with tissue expander. We present a case of a 31-year-old woman who underwent a 2-stage breast reconstruction with a tissue expander and breast prosthesis. She had a former history of autologous microtia reconstruction using costal cartilages to create a framework of the ear at the age of 10. During expansion, the woman developed an abnormal hollowing of the chest wall. Even though it was difficult to select an ideal size for the breast prosthesis, an excellent breast shape was obtained by measuring the actual breast projection that we needed, using ultrasound sonography. The patient was satisfied with the final result. In this case, the patient suffered from a postoperative chest wall deformity due to cartilage harvesting. This unfavorable result highlights the need for careful preoperative evaluation of risk factors that may lead to chest wall deformity when patients will have tissue expansion as a part of breast reconstruction. When thoracic deformity occurs, surgeons should realize that choosing an adequate implant becomes rather difficult. Ultrasound sonography helps surgeons in measuring the actual breast projection preoperatively.

Use of Laser Speckle Contrast Imaging for Successful Fingertip Replantation.

Fingertip replantation is a technical challenge for microsurgeons. For successful fingertip replantation, it is important to monitor the replanted fingertip vascularity for the early detection and revision of vascular compromise. Laser speckle contrast imaging (LSCI) is a camera-based technique that measures the perfusion by illuminating the tissue with a 785-nm-wavelength divergent laser beam. This creates a speckle pattern over the illuminated area. We present a case in which postoperative monitoring of the replanted fingertip microcirculation using LSCI allowed for successful Tamai zone I fingertip replantation. Postoperative monitoring using LSCI has 3 main advantages. First, this method is harmless to the patient and the replanted fingertip. A camera-based technique enables microcirculation monitoring without touching the patient or the replanted fingertip. Second, tissue perfusion is measured in real time and recorded continuously, allowing for the rapid response to the arterial or venous occlusion to be observed. Third, using LSCI, the skin perfusion can be measured quantitatively. Although further clinical investigations will be required to confirm its efficacy, LSCI has the potential to be a useful monitoring device.

A Breast Reconstruction Using a Breast Prosthesis and Capsular Flap for a Lymphocele Patient.

We encountered a very rare condition where the patient had a lymphocele under the skin envelope of the breast following mastectomy during the course of breast reconstruction with a tissue expander. The incidence rate of axillary lymphoceles is reported as 2.2-50% in breast cancer patients, but there have been no reports mentioning lymphoceles under the breast skin during the course of breast reconstruction with a prosthesis. The patient had a lymphocele in the lower lateral part of the breast following mastectomy and had multiple cellulitis-like inflammations. These inflammations were treated with conservative therapy such as administration of antibiotics, resting, and cooling. After 6 months of the initial surgery, the patient underwent complete resection of the lymphocele, preventative elimination of a possible lymphatic leakage, and breast reconstruction using a prosthesis combined with a capsular flap. The capsular flap is a transposition flap that uses capsular tissue around the expander to cover adjacent thinned skin. There were no postoperative complications such as breast skin necrosis, exposure of the prosthesis, or recurrence of the lymphocele and cellulitis. The patient had a successful breast reconstruction even though a lymphocele of the breast was observed. Even though a patient may have a lymphocele in the breast following mastectomy, with careful resection of the lymphocele, complete elimination of possible lymphatic leakage, and by performing the capsular flap technique, complete breast reconstruction with a breast prosthesis may be successful.

Reconstruction following resection of soft-tissue sarcomas at the ankle region in seven patients.

The defects following soft-tissue or bone malignancies resection tend to be wide and composite at the region of ankle, and reconstruction of the defects is a difficult task. Between 1982 and 2007, we performed reconstruction for the defects of the ankle region in seven patients. All of the patients underwent free tissue transfer, and the selected methods are different for each case. No perioperative complications have occurred in any patients. All flaps survived completely. Two patients had local recurrence and amputation was carried out. Functional and aesthetical improvement is desirable for reconstruction of the ankle. We consider it important to select reconstructive options based on the size and volume of the defects and tissue deficiency; and free tissue transfer is useful for the reconstruction of the wide and composite defects at the ankle region.

Stepladder V-Y advancement medial thigh flap for the reconstruction of vulvoperineal region.

Many surgical procedures have been reported for vulvoperineal reconstruction following cancer resection. These include the use of skin grafts, local skin flaps, muscle flaps and fasciocutaneous flaps. Among them, V-Y advancement flap from the medial thigh region has been widely used. However, at times a scar contracture occurs, caused by the long, straight suture line. From September to October 2007, we performed vulvoperineal reconstruction following cancer resection using stepladder V-Y advancement medial thigh flaps in three patients. All flaps survived completely and no scar contracture was observed in all the patients. No surgical revisions were needed. This flap is reliable, easy to be elevated and allows immediate repair of deep defects. This technique can be useful for the reconstruction of the vulvoperinela region because zigzag scars are inconspicuous, diminish the postoperative scar contracture and achieve normal urination.