Pedicle First Anterior Approach to Harvest Anterolateral Thigh Flap-Review of 304 Cases.

Background Although considered as a workhorse flap, the anterolateral thigh (ALT) flap has a steep learning curve that makes it difficult for microsurgeons to perform it early in their practice. In over 85% of patients, the perforator takes an intramuscular course making it difficult for beginners to safely secure the perforator dissection. In this technique, the pedicle is dissected first, utilizing the proximal incision by palpating the groove in between vastus lateralis and rectus femoris on the anterior aspect and extending the incision from 2 to 3 cm distal to the inguinal ligament to the flap markings caudally. Exposing the pedicle first makes it easier to proceed toward the skin perforator due to its easy identification and larger size at its origin. Patients and Methods This retrospective study was conducted from 2005 to 2020 in which 304 ALT flaps were performed by the pedicle first technique. Flap harvest time, incidence of injury to the skin perforator during harvest, flap re-exploration rates, and postoperative complications including incidence of flap necrosis, infection, and bleeding were the parameters that were measured. Results This study included a total of 304 patients of which 220 were male (72.3%). The average flap harvest time was 26 ± 3.2 minutes. Adverse events included perforator injury ( n = 1), flap re-exploration ( n = 15), and complete flap loss ( n = 8). The last eight patients were reconstructed secondarily with ALT flap from the opposite side and free latissimus dorsi flap ( n = 2). Conclusion The pedicle first technique makes ALT flap harvest easy, safe, and faster for plastic surgeons. The chances of injury to the skin perforator are markedly less thereby reducing postoperative complications.

Facial Reanimation Using Free Functional Muscle Transfer: Lessons Learnt From a Long Term Experience Comparing Innervation With Cross Facial Nerve Graft and Masseter Nerve.

BACKGROUND: Facial palsy is a complex problem and goal of reanimation is to achieve symmetric face at rest and spontaneous smile. in our study the authors performed facial reanimation in long standing cases of facial palsy (more than 1 year), gracilis muscle was used as a free functioning muscle transfer. Two motor donor nerves were used: cross-face nerve graft and masseter nerve. MATERIALS AND METHODS: A total of 205 cases of unilateral facial reanimation with free functional muscle transfer (FFMT) were performed between 1998 and 2019. Out of 205 patients, 184 patients were operated by cross facial nerve graft-gracilis, and 21 by masseter nerve-gracilis. Quantitative assessment for outcome was done by measuring the excursion on follow up. Oral competence outcome and satisfaction score calculation was done by questionnaire. Results of spontaneous smile were divided into positive and negative groups. RESULTS: A 2 stage cross facial nerve graft-gracilis FFMT achieved most natural and spontaneous smile when longer observation period (≥2 years) was followed. Masseter nerve-gracilis provided satisfactory results in the shortest rehabilitation period, had more excursion but never obtained spontaneous smile. CONCLUSIONS: The cross facial nerve graft-gracilis FFMT can achieve natural and spontaneous smile and remains our first choice for facial reanimation. Masseter nerve-gracilis can be used if cross facial nerve graft-gracilis fails, patient desires a single stage surgery and in some specific conditions, such as bilateral mobius syndrome.

Perforator propeller flaps for lower extremity soft-tissue defect reconstruction: Shortening the learning curve.

Background: The perforator propeller flap is an advantageous option for soft tissue reconstruction in the lower limb as it ensures the preservation of the main artery and muscle, eliminates the need for microsurgical reconstruction as well as provides "like with like" resurfacing of the defects. Despite this, it remains a technically demanding reconstructive option for residents and surgeons with little experience in perforator dissection. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects were addressed with propeller flaps. Methods: A retrospective study of all propeller flap based reconstruction done on patients with soft tissue defects involving the distal third of the leg was undertaken from August 2018 to December 2020. Results: 28 patients were treated with propeller flaps for various lower extremity defects. The median defect size was 12 cm2. The posterior tibial artery (PTA) was used in eleven cases (39.3%) and the peroneal artery (PA) in seventeen of the cases (60.7%). The complication rate was 28.6% (n = 8). The complete flap necrosis rate was 10.7% (n = 3) and partial flap necrosis rate was 7.1% (n = 2), The rate of venous congestion was 7.1% (n = 2) and wound dehiscence occurred in 3.5% (n = 1). There was a significant negative correlation between the number of cases performed by a resident and the operative time. Conclusion: Although propeller flaps are a reliable option to address lower extremity defects, they have a long learning curve and require a good amount of experience and perforator dissection skills to reduce the probability of flap failure. We are of the opinion that residents should be adequately trained in this procedure to ensure optimal outcome delivery.

Long Arm Double Asymmetrical Sliding Flaps: A Technique to Treat Flexion Contractures of Digits.

Contracture involving flexor aspect of the fingers is one of the common sequelae encountered after burns, infection, and trauma. In the treatment of contractures, the surgeon is often challenged by the paucity of skin flaps to cover the joint area. It is then covered with skin grafts, leading to recurrence. When there is a large discrepancy between the required and the available length of skin, traditional Z-plasty techniques fail to overcome this deficiency of the skin. We employ 2 long skin flaps to cover the joint, using all the available skin around the contracture and leaving areas on the sides of the digit that are covered by full-thickness skin grafts.

Abdominal Wall Reconstruction Using Pedicled Antero Lateral Thigh Flap.

Background: Reconstructing abdominal wall defects has been a difficult task for surgeons. The abdominal wall defects range from defects of only soft tissue to full thickness defects including all the three layers of the abdomen. Only soft tissue defects are commonly caused by peritonitis and laparotomies, and full thickness defects can occur from en bloc resection of tumours as well as trauma. Treatment options available include component separation, partition technique, flap coverage, and more recently acellular dermal matrix. Methods: This retrospective study done between 2016 and 2020 where 20 patients were operated for abdominal wall defect using Pedicled ALT flap in the Department of Plastic and Reconstructive Surgery, Sawai Man Singh Hospital, Jaipur, Rajasthan, India. Results: The study consisted of total 20 patients, 14 males and 6 females. Eight patients were post electric burn, 5 patients had suffered trauma, 4 patients underwent resection of abdominal wall tumour and 3 patients were post laparotomy for peritonitis. Mean age of patients was 48 years (range from 36 to 62 years). Mean fascia defect size was 14.2 cm (range 12.2 to 16.4 cm). Mean operative time was 170 minutes (range from 140 minutes to 220 minutes). Postoperative hospital stay ranged from 8 days to 24 days (mean- 12 days). Conclusion: Pedicled ALT flap has expanded the armamentarium of plastic surgeons for reconstruction of abdominal wall defects.

Resurfacing in Facial Burn Sequelae Using Parascapular Free Flap: A Long-Term Experience.

It is difficult to treat large postburn sequelae (scars and defects) over the face. Available methods include skin grafts, local flaps, tissue expansion, and free flaps. These surgical options should be chosen wisely, depending on individual patient requirements and the area involved. In patients with large postburn scars and defects in which the surrounding tissue is also involved, use of free tissue transfer is extremely useful. A retrospective analysis was done between 2011 and 2019 of 52 cases with extensive facial burn deformities in whom secondary reconstruction was done with free parascapular flap cover in our department. Outcome was assessed by a direct questionnaire. There was no complete flap loss in the series. Two cases were re-explored for venous insufficiency and suffered partial marginal necrosis. Twenty patients had to undergo further debulking procedure. Forty-seven patients were satisfied by the final outcome. Postburn facial deformities are difficult to treat; in many cases, there are no local options, and tissue from different regions is to be used for reconstruction. Free parascapular flaps can be used as an effective method in such cases with a high level of patient satisfaction.