A One-Size-Fits-All Approach to Pressure Ulcers: Whole-Buttock Fasciocutaneous Advancement Flap.

BACKGROUND: Buttock pressure injuries can be difficult to treat. There are many choices of flaps to reconstruct these wounds, but few are large, technically simple, and easily recycled. AIM AND OBJECTIVE: We are presenting our experience on surgical reconstruction of buttock pressure injuries using large whole-buttock fasciocutaneous flaps that are easily designed for ulcers regardless of location and size and are easily recycled for treatment of recurrences. MATERIAL AND METHODS: We conducted a retrospective review of all patients who received reconstruction with fasciocutaneous rotational flaps for buttock region pressure injuries from January 2013 to December 2018. The key steps of this one-size-fits-all flap include elevation of a large, oversized flap to achieve tension-free closure, avoiding fascial incisions over bony prominences, placing the V-Y type closure wound in the posteromedial thigh, and the use of closed incisional negative wound therapy postoperatively. RESULTS: Fifty patients underwent 54 flaps reconstruction for coverage of stage 4 gluteal pressure injuries between January 2013 and December 2018. Seventy-four percent healed without the need for further operation. The average size of the defect was 90 cm2 (maximum = 300 cm2). The average follow-up period was 31 months. Four of the 54 flaps were "recycled" flaps, 3 were performed for the coverage of recurrent ulcers and 1 flap was performed for treatment of a postoperative wound dehiscence. CONCLUSIONS: We recommend this simple, one-size-fits-all approach, whole-buttock fasciocutaneous flap when surgically treating gluteal pressure injuries for selected patients.

Experience on primary closure of fibular flap donor sites and development of an algorithm for closure based on different flap designs.

BACKGROUND: Most skin paddles of the fibula flap are harvested from the distal third of the lower leg, skin grafting for the donor-site is necessary. METHODS: A retrospective review was done on patients with large bony defects using free fibula osteocutaneous flaps (FOSCFF) for head and neck reconstruction. We focus on the techniques for closure of donor sites were skin grafting, primary closure with tear drop design and propeller flap technique on the donor site closure using skin graft, primary closure and local propeller flap based on the different location of perforators of FOSCFF. Postoperative follow up include incidence of wound complications, postoperative days to ambulation and cosmetic outcome. RESULTS: A total of 48 patients were included. Twenty five patients had skin graft (Group A), and 23 patients had primary closure (Group B); in 16 patients tear-drop design was used, 6 had propeller flap, and the remaining 1 patient received a chimeric flap. Group A had more wound complication rates compared to Group B; 20% versus 4.3%, respectively (p = .19). The average postoperative days to ambulation for Group A were 15.1 days versus 7.3 days for Group B (p < .001). The cosmetic score in the B group (2.71) versus A group (4.89) was also statistically significant (p = .007). All the patients ambulated well at follow up. CONCLUSION: Primary closure using the tear drop technique and propeller flap is superior to skin grafting in terms of better cosmetic appearance, earlier postoperative ambulation, and no need for another donor site for skin graft.

The "in situ molding technique: " an accurate and simple way to fix resorbable plates to the facial skeleton.

Bioabsorbable plates developed for use in the facial skeleton have become an integral part of the craniomaxillofacial surgeon's reconstructive armamentarium. They avoid the problems associated with the retention of metal plates and can be easily contoured when heated in a thermobath. The technical process of molding and securing these devices, often through small access incisions, to achieve rigid fixation of facial fractures can be difficult. In this article, we describe a simple, novel technique that we have developed, using hot water suction irrigation, to achieve in situ molding of resorbable plates during facial fracture fixation. We used this technique to fix 123 facial fractures in 110 patients over a 4-year period. No complications secondary to the use of hot water suction irrigation were encountered.

Superficial temporal vessels, both anterograde and retrograde limbs, are viable recipient vessels for recurrent head and neck reconstruction in patients with frozen neck.

BACKGROUND: Reconstruction of recurrent head and neck malignancy especially in the presence of a frozen neck is challenging. The superficial temporal vessels would be ideal as recipient vessels because they lie out of the previous surgical and radiation field. METHODS: We conducted a retrospective case-control study based on our database between January 2013 and June 2016. A total of 581 primary cases were selected as controls. The 60 test group patients had (a) recurrent head and neck reconstruction, (b) previous surgery and irradiation, (c) frozen neck, and (d) superficial temporal vessels as recipients. RESULTS: There was no significant difference between vascular compromise rates of superficial temporal vessels (anterograde and retrograde limbs) and controls (P > .05). Flap success rate of the test and control group is comparable, 95% vs 98% respectively. CONCLUSION: Superficial temporal vessels, both anterograde and retrograde, should be the first consideration for recurrent intraoral, facial, and scalp reconstruction with frozen necks.

Free-style puzzle flap: the concept of recycling a perforator flap.

Theoretically, a flap can be supplied by any perforator based on the angiosome theory. In this study, the technique of free-style perforator flap dissection was used to harvest a pedicled or free skin flap from a previous free flap for a second difficult reconstruction. The authors call this a free-style puzzle flap. For the past 3 years, the authors treated 13 patients in whom 12 pedicled free-style puzzle flaps were harvested from previous redundant free flaps and recycled to reconstruct soft-tissue defects at various anatomical locations. One free-style free puzzle flap was harvested from a previous anterolateral thigh flap for buccal cancer to reconstruct a foot defect. Total flap survival was attained in 12 of 13 flaps. One transferred flap failed completely. This patient had received postoperative radiotherapy after the initial cancer ablation and free anterolateral thigh flap reconstruction. Another free flap was used to close and reconstruct the wound. All the donor sites could be closed primarily. The free-style puzzle flap, harvested from a previous redundant free flap and used as a perforator flap to reconstruct a new defect, has proven to be versatile and reliable. When indicated, it is an alternative donor site for further reconstruction of soft-tissue defects.

Reconstruction of perineoscrotal and vaginal defects with pedicled anterolateral thigh flap.

OBJECTIVE: To present a series of perineoscrotal and vaginal defects reconstruction with the use of anterolateral thigh flap. METHODS: We present a series of 11 patients in whom we used pedicled thigh flaps (10 anterolateral thigh flaps and 1 anteromedial thigh flap) to cover defects of perineum, scrotum, and vagina. Ten patients had perineoscrotal defects and 1 patient had vaginal agenesis. RESULTS: Age group ranged from 26 to 79 years. The size of the flaps ranged from 105 cm² to 220 cm². The vascular pedicle length ranged from 10 cm to 12 cm. Stable closure was achieved in every patient. There were no complications from the donor site. In 1 patient, we found only 1 perforator at the superomedial edge of the flap that originated from the medial circumflex femoral artery; hence, in this patient, we used an anteromedial thigh flap as a salvage procedure. CONCLUSION: With versatility in their design and low donor site morbidity, these flaps present an option in the armamentarium of the reconstructive surgeon for the coverage of defects at the perineoscrotal and vaginal area.