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.

Maximizing Micrograft Take in Extensive Back Burns.

Extensive burns involving the back pose unique challenges. Offloading in the prone position is not possible with concomitant deep facial and neck burns. We describe our experience in maximizing graft take in a patient who had extensive back burns with concomitant anterior body burns. The two main goals in graft fixation for extensive back wounds are mechanical stabilization of micrografts to reduce shearing and prevention of water logging from exudates or bleeding to optimize contact with wound bed. Guided by the stages of wound healing, graft take, and burn care, we describe three stages of postoperative negative pressure wound therapy (NPWT) in a patient with 54% TBSA burns treated with micrografting. After complete excision of the deep dermal burns of the entire back, the wounds were covered with micrograft-allograft composites. In phase I, days 1 to 3, conventional topical negative pressure dressing with a thin sponge was applied and a leak-proof seal was achieved with gel sealant and high tack adhesive drapes. In phase II, days 4 to 5, foam dressings with topical negative pressure were applied, but with a less stringent seal, supported by wall suction. In phase III, the selective removal of allografts was initiated to facilitate expansion of micrografts. Negative pressure was continued for another 2 weeks at the most dependent site to prevent wound maceration from exudates. Micrograft take was optimized with the patient in the supine/semirecumbent position. The back wounds healed completely between 60 and 70 days without repeat micrografting. Since prone positioning was not possible in this patient, clearance of exudates and maintenance of micrograft contact with the wound bed using this technique proved successful.

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.

Use of the Descending Branch of the Lateral Circumflex Femoral Artery as an Arterial Graft in Living Donor Liver Transplant.

BACKGROUND: Reconstructing the hepatic artery in living donor liver transplantation presents the challenges of a short and small donor vessel stump, which is compounded by poor surgical access for microsurgical anastomosis. Arterial interpositional grafts (eg, the radial artery) have been used to overcome these problems. The purpose of this presentation is to describe the use of the descending branch of the lateral circumflex femoral artery (DLCFA) as an alternative when the patient has had an abnormal Allen's test precluding the use of the radial artery or if a Y-graft is needed. METHODS: The DLCFA resides in the septum between the rectus femoris and vastus lateralis muscles. A linear incision made over the proximal third of this septum exposed the avascular plane in which the vessel resides. A graft exceeding 10 cm could be harvested with diameters ranging between ≤2 and 7 mm. There were several muscular branches emanating from the profunda femoris artery system that could be dissected to the required length for a Y-shaped graft. Three cases of living donor liver transplantation using the DLCFA (straight and Y grafts) are described. RESULTS: After DLCFA interpositional grafting, all patients had normal resistive indices on duplex ultrasonography of the intrahepatic arterial system. Follow-up of the 3 patients was between 2 and 6 months. There was no donor site morbidity. CONCLUSIONS: The DLCFA graft was a useful arterial graft for hepatic artery reconstruction. It was easily harvested with minimal donor site morbidity.

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.

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.

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.

Surgical planning using facial fracture 3D models: The role of cyanoacrylate glue and miniplating for anatomical reduction.

BACKGROUND: In comminuted facial fractures, peri-operative use of 3D-printed life size models is increasingly a useful adjunct. It allows for preoperative surgical rehearsal and plate bending, to achieve anatomical reduction with reduced operative time and cost. One problem encountered is difficulty contouring the fixation plate whilst maintaining the relative spatial orientation of comminuted fragments. This paper shares an effective method of overcoming this problem. METHODS: All comminuted facial fracture patients underwent counselling for 3D printing. Pre-printing thresholding and segmentation of each fragment (as directed by the surgeon) were done by the radiologist and the engineering team, using the multi-slice CT Face DICOM data. Life-size 3D-resin models of the fractures were printed. Fast-acting medium consistency cyanoacrylate glue (Zap-A-GapⓇ) and miniplates were used to assemble the printed model segments in 'anatomic reduction'. Aerosolized alcohol accelerator facilitated immediate glue curing, providing a stable model. The plates were adapted over this restored neonative 3D construct with bending inserts, sterilized and used intraoperatively. The 3D model was used to guide the operative sequence. Intraoperative CT was used in select cases to confirm anatomic reduction. RESULTS/COMPLICATIONS: All patients (n = 5) had comminuted fractures in at least one of the bony units (mandible, maxilla or orbits) and one was a pan-facial fracture case. 3D printed models aided fracture reduction and fixation, whilst avoiding the guesswork in ascertaining the contour of the mandibular arch. In addition, the pre-contoured mandible plates restored premorbid occlusion and projection, without the need for long-term archbars in all cases. Operative time was estimated to be reduced by 0.5-1 h. Resident teaching was enhanced by this approach. CONCLUSION: The application of medium consistency fast-acting cyanoacrylate glue and miniplates facilitated the creation of the premorbid facial skeletal model and allowed pre-bending of the plates, thus saving operative time and cost.

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.

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.

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.

Shaping of the abdominal flap in breast reconstruction: The coning technique in muscle sparing TRAM.

In the setting of autologous breast reconstruction, achieving an aesthetic outcome through shaping of the flap is of the upmost importance. We describe the abdominal flap folding technique of 'coning' and the indications. We define 'coning' as the technique of folding the abdominal flap in a circular fashion to create a conical breast mound, with the line of fusion forming a pillar of tissue for structural integrity. A retrospective study of 34 patients undergoing unilateral muscle-sparing TRAM flap was performed. Of these patients, the majority (79.4%) underwent immediate reconstruction, with the thoracodorsal vessels largely acting as the recipients (94.1%). Three (8.8%) patients were noted to have a contour defect secondary to incomplete folding of the flap. Two (5.9%) patients had partial skin envelope necrosis. One patient had 50% flap loss, requiring return to theatre for excision. In conclusion, coning was used exclusively in the muscle-sparing TRAM flap. This cuff of muscle protected the pedicle during folding through cushioning the perforators at their most vulnerable points. This technique allowed for muscle cuff harvest whilst minimising anterior sheath sacrifice. Coning achieved long-term maintenance of shape, volume and projection.

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.

Antimicrobial-impregnated dressing combined with negative-pressure wound therapy increases split-thickness skin graft engraftment: a simple effective technique.

OBJECTIVE: Immobilization and adequate surface contact to wounds are critical for skin graft take. Techniques such as the tie-over dressing, cotton bolster, and vacuum-assisted closure are used to address this, but each has its limitations. This study is designed to assess the effect of antimicrobial-impregnated dressing (AMD) combined with negative-pressure wound therapy (NPWT) on skin graft survival. DESIGN: Retrospective case-control study PARTICIPANTS: : Patients with chronic or contaminated wounds treated with split-thickness skin graft. A broad spectrum of wounds was included, from causes such as trauma, burns, chronic diabetic ulcers, and infection. INTERVENTIONS: Antimicrobial-impregnated dressing, which contains 0.2% polyhexamethylene biguanide, with NPWT MAIN OUTCOME MEASURE:: Success of skin graft MAIN RESULTS: : In the AMD group, all skin grafts achieved 100% take without secondary intervention. No infection or graft failure was observed in any patients, and no complications, such as hematoma or seroma formation, were noted, although in the control group partial loss of skin grafts was noted in 3 patients. Infection and inadequate immobilization were thought to be the main reasons. There were no hematoma or seroma formations in the control group. CONCLUSION: Use of an AMD dressing with NPWT after split-thickness skin grafting can be an effective method to ensure good graft to wound contact and enhances skin graft take in chronic and contaminated wounds.