Locoregional Flap Reconstruction of the Distal Third of the Leg - What Role Does it Have in a Modern Reconstructive Algorithm?

ABSTRACT: Reconstruction of traumatic defects of the lower third of the leg poses a challenge due to limited locoregional options. Failed coverage can be associated with prolonged hospital stay, infection, loss of function, and unplanned return to surgery. Over the last few decades, free tissue transfer has dominated reconstructive algorithms for such defects; however, locoregional flaps may provide equally effective coverage in select patients. In the wake of the CODID-19 pandemic, locoregional flaps gained more consideration due to limited resources. We present a literature review and discussion of locoregional flaps, with emphasis on the quality and efficacy of these reconstructive modalities compared with free tissue transfer and surgical indications.Soleus flaps, reverse sural flaps, and cutaneous perforator-based flaps are workhorses for small to medium size defects of the distal third of the leg, even in the setting of concomitant orthopedic trauma and exposed vital structures. It is important to consider such alternatives an integral part of the reconstructive algorithm as they can provide durable coverage with a favorable complication profile with less resource utilization. Appropriate patient selection requires consideration of the character of the defect, smoking status, preexisting vascular disease, and the zone of injury.

Allograft as an Adjunct for Free Omental Flaps for Lower Extremity Coverage of a Mangled Lower Extremity.

The utility of allograft for temporary coverage of soft tissue defects is well-established, most notably in the burn literature. Its utility as an adjunct to free tissue transfer for soft tissue defects has been described, but literature on the effectiveness of this hybrid approach for lower extremity salvage is limited. We present a series of two patients who underwent lower extremity salvage using an omental free flap and allograft followed by staged split-thickness skin grafting at our institution. Patient characteristics analyzed included age, smoking status, comorbidities, mechanism of injury, wound class, and wound surface area. Endpoints included partial or complete flap loss, number of days from allograft to autograft, postoperative infection, unplanned reoperation, and successful, functional extremity salvage.  Both patients were male, ages 50 and 35, with a BMI of 31 and 19.2 kg/m2, respectively. Both were active smokers and had contaminated Gustilo IIIB wounds with areas of over 300 cm2. Both flaps had partial necrosis, averaging 6cm2, that was debrided at the planned second stage. Neither had an unplanned return to surgery, and both patients returned to ambulation.  Allograft skin as a practical and effective adjunct to omental free flap for post-traumatic lower extremity reconstruction. It can facilitate the resolution of edema and prevent flap desiccation, allowing time demarcation of partial flap necrosis and confirmation of flap viability prior to definitive skin autograft. This is particularly useful for large surface area contaminated highly irregular traumatic lower extremity wounds.

Oncoplastic Breast Reduction: A Systematic Review of Postoperative Complications.

Background: Breast-conserving therapy with oncoplastic reduction is a useful strategy for partial mastectomy defect reconstruction. The most recently published systematic review of oncoplastic breast reduction outcomes from 2015 showed wound dehiscence in 4.3%, hematoma in 0.9%, infection in 2.8%, and nipple necrosis in 0.9% of patients. We performed a systematic review of oncoplastic breast reduction literature, comparing outcomes and complication rates reported over the past 8 years. Methods: Studies describing the use of oncoplastic breast reduction and discussion of postoperative complications were included. The primary outcome assessed was the postoperative complication rate; secondary outcomes analyzed were rates of margin expansion, completion mastectomy, and delays in adjuvant therapy due to complications. Results: Nine articles met inclusion criteria, resulting in 1715 oncoplastic breast reduction patients. The mean rate of hematoma was 3%, nipple necrosis was 2%, dehiscence was 4%, infection was 3%, and seroma was 2%. The need for re-excision of margins occurred in 8% of patients, and completion mastectomy in 2%. Finally, delay in adjuvant treatment due to a postoperative complication occurred in 4% of patients. Conclusions: Oncoplastic breast reduction is an excellent option for many patients undergoing breast-conserving therapy; however, postoperative complications can delay adjuvant radiation therapy. Results of this systematic literature review over the past 8 years showed a slight increase in complication rate compared to the most recent systematic review from 2015. With increased popularity and surgeon familiarity, oncoplastic breast reduction remains a viable option for reconstruction of partial mastectomy defects despite a slight increase in complication rate.

Multi-modal data integration platform combining clinical and preclinical models of post subarachnoid hemorrhage epilepsy.

Subarachnoid hemorrhage (SAH) is a devastating neurological injury that can lead to many downstream complications including epilepsy. Predicting who will get epilepsy in order to find ways to prevent it as well as stratify patients for future interventions is a major challenge given the large number of variables not only related to the injury itself, but also to what happens after the injury. Extensive multimodal data are generated during the process of SAH patient care. In parallel, preclinical models are under development that attempt to imitate the variables observed in patients. Computational tools that consider all variables from both human data and animal models are lacking and demand an integrated, time-dependent platform where researchers can aggregate, store, visualize, analyze, and share the extensive integrated multimodal information. We developed a multi-tier web-based application that is secure, extensible, and adaptable to all available data modalities using flask micro-web framework, python, and PostgreSQL database. The system supports data visualization, data sharing and downloading for offline processing. The system is currently hosted inside the institutional private network and holds [Formula: see text] of data from 164 patients and 71 rodents. Clinical Relevance-Our platform supports clinical and preclinical data management. It allows users to comprehensively visualize patient data and perform visual analytics. These utilities can improve research and clinical practice for subarachnoid hemorrhage and other brain injuries.

A Comparison of Complication Rates in Wise Pattern Versus Vertical Breast Reduction.

BACKGROUND: Breast reduction has a well-chronicled history and remains a common reason for patients to seek plastic surgery consultation. The Wise pattern is the most common skin reduction pattern in the United States. Vertical pattern reduction is also widely used and offers the potential for decreased scar burden. Both patterns have been used with a variety of pedicles for preservation of the nipple areolar complex, which may also impact complication rate and patient satisfaction. There is a preponderance of literature on breast reduction surgery but limited comparative data on the safety profile of these patterns. The purpose of this article is to review the comparative literature, with emphasis on the overall risk of complications. METHODS: OVID and PubMed were used to query the literature for articles comparing complication rates in both Wise pattern and vertical breast reduction. Inclusion criteria were case series that encompassed both vertical and Wise pattern reductions and cited the rate of complications. Complications included in our analysis of total complication rate were as follows: hematoma, seroma, infection, dehiscence, fat necrosis, skin necrosis, and nipple areolar complex necrosis. We excluded standing cutaneous deformity as a complication. Articles that included oncoplastic breast reductions were also excluded. The primary analysis was an inverse variance-weighted random-effect meta-analysis of overall complication rate, with the association between the technique and overall complication rate quantified using odds ratios. RESULTS: Eight articles were identified that met inclusion criteria, representing 963 patients (525 Wise pattern and 438 vertical pattern). The overall complication rate pooled across the studies favored vertical pattern reduction, but the result was not definitive. CONCLUSIONS: Vertical pattern breast reduction can be done safely. Our statistical analysis found a trend toward decreased complications with vertical reductions, but did not reach statistical significance. Patients seeking breast reduction are a heterogeneous population with respect to breast size, degree of ptosis, body habitus, body mass index, comorbidities, and acceptance of scars. It remains important to individualize the approach to the patient and their needs. More quantitative, comparative data, especially from randomized controlled trials, would be useful to further evaluate the relative safety profiles of the 2 patterns.

The Safe Gluteoplasty: Anatomic Landmarks to Predict the Superior and Inferior Gluteal Veins.

Objective: The increase in demand for gluteal fat grafting seen in recent years in the United States has not been met with an equal gain in knowledge of the perils of this anatomic territory. The purpose of this study was to identify anatomic landmarks that can be readily used by surgeons to identify the takeoff of the superior and inferior gluteal veins. Method: Six fresh cadaveric gluteal specimens were dissected at the University of Louisville anatomy laboratory. A question mark incision was made for exposure, followed by identification of the sciatic nerve in the proximal thigh. This was traced retrograde to the sciatic forearm. The piriformis muscle was identified dividing the foreman into superior and inferior portions, which corresponded to the takeoff of the superior and inferior gluteal vessels, respectively. The distance of the gluteal vessels from the one-third point of a line from the mid-sacrum to the greater trochanter was measured. Result: Our cadaveric dissection series demonstrated that the superior and inferior gluteal veins were on average 3.28 cm (2-5.9 cm) and 1.25 cm (0-3.5 cm) away from the point one third the distance from the mid-sacral border to the greater trochanter. Conclusion: The mid-sacrum and the trochanter of the femur are the anatomic landmarks used to identify the large gluteal vein trunks. Understanding the location and trajectory of these deep gluteal structures with use of readily identifiable landmarks may assist surgeons in avoiding inadvertent injection of fat to these veins during fat grafting.