Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap.

INTRODUCTION: Achilles tendon rupture and soft tissue infections with wound dehiscence and tendon exposure following the tendon repair are not infrequent. Various procedures have been described for the reconstruction of soft tissue defects at the Achilles tendon region, yet there is lack of consensus on the ideal method. In this article we report our experience using the distally based peroneal artery perforator flap in reconstruction of combined defects of the Achilles tendon and overlying soft tissue. METHODS: 7 patients with Achilles tendon injury and full-thickness soft tissue defects over the Achilles region underwent tendon repair and soft tissue reconstruction with the distally based peroneal artery perforator flap. Perforator vessels were identified at the septum between the peroneus longus and soleus muscles. After choosing the perforator with the largest diameter, meticulous deep dissection of the perforator was performed and completed 6 cm proximal to the lateral malleolus. The peroneal artery was transected and ligated and transposition of the flap to the defect was performed through a subcutaneous tunnel. RESULTS: The size of the soft tissue defects and flaps ranged between 2×3 cm to 4×10 cm and 4×5 cm to 5×12 cm, respectively. Six out of 7 flaps survived completely without any complications. Post-operative venous congestion was observed in one patient which resulted in partial tip necrosis of the flap. The resulting wound healed with conservative treatment. Donor sites healed uneventfully in all patients. All flaps had excellent contour and provided stable soft tissue coverage. CONCLUSION: Distally based peroneal artery perforator flap can be considered as a reliable alternative for the reconstruction of soft tissue defects around the Achilles tendon region. Advantages include (1) extended reach of the flap for the defects around the plantar and dorsal aspects of the foot, provided by the perforator dissection, (2) convenience with footwear and walking, provided by the skin texture similarity with the target region, (3) creating a protective surface to allow tendon gliding and prevent tissue adhesions after the tendon repair, provided by the crural fascia included in the flap, (4) obviating the need for microsurgical anastomosis and associated length of the operation.

Nipple-Sparing Mastectomy and Immediate Implant-Based Reconstruction with or Without Skin Reduction in Patients with Large Ptotic Breasts: A Case-Matched Analysis.

BACKGROUND: Nipple-sparing mastectomy (NSM) and implant-based immediate breast reconstruction are becoming preferred options with improved outcomes. However, reconstruction in patients with large and ptotic breasts is challenging. When mastectomy and skin reduction are combined in a single-staged procedure, the vasculature of the skin is disturbed leading to increased complication rates. This paper aims to compare complication rates of NSM and immediate implant-based reconstruction with or without reduction to determine the safety of reduction in this patient group. METHODS: Breast cancer patients that underwent NSM and implant-based immediate breast reconstruction between November 2010 and 2018 were analyzed. All implants were placed submuscularly. Patients with skin reduction and nipple-areolar complex transposition were matched in a 1:1 fashion with patients without reduction. RESULTS: There were 50 patients (72 procedures) in each group. Demographics of the groups were similar as a part of matching process. Mean implant volume in the reduction group was higher (399.93 ± 97.54 vs. 360.21 ± 82.54, p = 0.009). Full thickness skin necrosis rate was higher in the reduction group [12/72 (%17) vs. 2/72 (3%), p = 0.009], and the most common site was over the suture line [6/12 (50%)]. Complications in the reduction group were more common in reconstructions with implant volumes greater than 500 cc (p = 0.008). CONCLUSIONS: When compared with no reduction, the skin necrosis rate of NSM and immediate implant-based reconstruction with skin reduction is higher. The described technique can only be considered in patients with moderate breast volumes, grade II-III ptosis, and when the planned implant volume is low (< 500 cc). LEVEL OF EVIDENCE: IV. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Factors Associated With Complications in Immediate Breast Reconstruction in 1 Stage With Completely Submuscular Implants.

BACKGROUND: Immediate breast reconstruction in 1 stage using permanent implants is gaining popularity and can be performed with or without the use of acellular dermal matrices. This study aimed to investigate the results of breast implants placed submuscularly without acellular dermal matrix and assess the factors affecting surgical complications. METHODS: From November 2009 to March 2018, 138 patients underwent immediate breast reconstruction with permanent submuscular implants after concomitant skin-sparing or nipple-sparing mastectomies in a single institution. All implants were covered with sufficient soft tissue under a submuscular pocket. RESULTS: One hundred thirty-eight patients were enrolled, and a total of 196 breasts were operated. The average age and body mass index (BMI) of the patients were 44.9 ± 8.8 years and 23.7 ± 3.6 kg/m, respectively. The majority of the mastectomies were therapeutic (81%). The average volume of implants was 389 ± 89 mL, and the mean follow-up was 33 months. The overall complication rate was 17% (n = 23), with skin necrosis being the most common complication followed by infections. Having a BMI equal to or greater than 25 kg/m was found to be a statistically significant predictor for overall complications (P = 0.002), whereas smoking history, age, and implant volume were not statistically significant. CONCLUSIONS: Immediate breast reconstruction in 1 stage using permanent implants can be performed with acceptable complication rates and cosmetic outcomes. Our study demonstrated that high BMI is a risk factor for overall complications. With proper patient selection and surgical technique, implants could be completely covered under a submuscular pocket.

Reconstruction of extensive scalp defects with anterolateral thigh flap.

BACKGROUND: Extensive scalp defects caused by various etiologies often require free-tissue transfer. We aimed to review our experience in the reconstruction of extensive scalp defects with free anterolateral flaps. METHODS: A retrospective analysis was performed on all patients with extensive scalp defects that were reconstructed with free anterolateral thigh flaps from November 2007 to April 2015. Eleven patients with a mean age of 44 years were included in this study. RESULTS: Eleven free-tissue transfers were used to reconstruct the extensive scalp defects. The flaps were 7-14 cm in width and 10-34 cm in length. CONCLUSION: Microvascular free-tissue transfer is the mainstay for the treatment of extensive scalp defects. We recommend anterolateral thigh free flap use for challenging and complex cases, given the method's numerous advantages, including reliability and safety.

The satisfaction of patients with breast cancer undergone immediate reconstruction with implant and the effect of radiotherapy.

AIM OF THE STUDY: Postmastectomy reconstructive surgery for cosmetic satisfaction of patients is rapidly increasing. Postoperative complications such as infection, capsular contracture, implant loss are more common in patients who receive adjuvant radiotherapy (RT) than those who do not. Satisfaction levels in patients is still a controversial issue. Therefore, we wanted to investigate our patient population for the effects of RT and planned a study evaluating the satisfaction rates of our patients who received implants. MATERIAL AND METHODS: Seventy five breast cancer patients who went through mastectomy and went through reconstruction using expanders or silicone implants were surveyed. Complication and cosmetic satisfaction rates were separately compared between irradiated and nonirradiated implants. Responses of 46 patients who answered the survey were analyzed using χ2 test and Mann Whitney U test. p < 0.05 was considered statistically significant. RESULTS: Thirty-one of the patients received adjuvant RT and 15 did not receive RT (NRT). There was no difference between the RT and NRT groups in the terms of touch, size, shape of silicones, pain and satisfaction level in look of clothing. Only satisfaction in symmetry was significantly lower in the RT group than in the NRT group (p = 0.02). Additionally, patients receiving chemotherapy were less satisfied with silicone size than those who did not (p = 0.02). CONCLUSION: We did not find negative effects, other than symmetry, of adjuvant radiotherapy in breast cancer patients who underwent reconstructive surgery in terms of cosmetic satisfaction.

Risk Factor Analysis for Survival of Becker-Type Expander in Immediate Breast Reconstruction.

BACKGROUND: Breast reconstruction with a Becker-type expander is a common technique following mastectomy. However, inconsistency remains in the literature regarding risk factors for the survival of a Becker-type expander following immediate breast reconstruction. This study's purpose is to investigate possible risk factors for the Becker-type expander survival and to evaluate the complications related to expander removal following immediate breast reconstruction. METHODS: We performed a retrospective chart review of consecutive women who underwent a mastectomy followed by immediate breast reconstruction with a Becker-type expander from November 2010 to November 2016. Electronic medical records were analyzed retrospectively for demographic, clinical, operative characteristics, and outcomes. Univariate Cox regression analysis was performed to determine the risk factors for the survival of the Becker-type expander following immediate breast reconstruction. RESULTS: A total of 74 Becker-type expanders were used in 72 patients who underwent immediate breast reconstruction. The patients' ages ranged from 27 to 71 years, with a mean ± standard deviation age of 44.6 ± 9.1 years. The most frequent complication was capsular contracture which occurred in 25 breasts (33.8%) followed by mastectomy skin flap necrosis in 6 breasts (8.1%), seroma in 4 breasts (5.4%), nipple-areolar complex necrosis in 4 breasts (5.4%), hematoma in 3 breasts (4.1%), and infection in 2 breasts (2.7%). The mean intraoperative expander fill volume (109.6 ± 66.9 cc [p = 0.039]) and mean total volume (386.5 ± 94.7 cc [p = 0.034]) were both significantly lower for patients with capsular contracture compared with those without capsular contracture. In patients with partial NAC necrosis, the mean mastectomy specimen volume (737.5 ± 242.8 cc) was significantly higher compared with patients without partial NAC necrosis (489.8 ± 219.0 cc; p = 0.027). A univariate Cox regression analysis showed that smoking and neoadjuvant therapy were significantly associated with expander removal (p = 0.023 and p = 0.006, respectively). CONCLUSION: The total volume of the expander and intraoperative fill volume of the expander appear to be predictive factors in the development of capsular contracture. However, there is no statistically significant association between radiotherapy and capsular contracture or expander survival in contrast with other published reports. Our findings reveal that the main risk factors for the survival of Becker-type expanders following immediate breast reconstruction are smoking and neoadjuvant therapy. To our knowledge, this is the first study to evaluate the most likely risk factors associated with Becker-type expander survival in immediate breast reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Simple Flap Design for the Salvage of Immediate Implant-Based Breast Reconstruction.

BACKGROUND: Breast reconstruction with implants is a real challenge in patients with large breast volume. Skin-reducing inverted-T mastectomy is the best solution for these patients. Delayed wound healing or necrosis at the T-junction area can be seen in this procedure, although it may also lead to severe conditions such as the exposure and loss of implant. In this article, the use of local pedicled flap for the management of these situations was discussed. METHODS: Between April 2010 and July 2015, 54 patients underwent breast reconstruction by inverted-T skin-reducing mastectomy and immediate implant-based breast reconstruction at our clinic. During the postoperative follow-up period, necrosis at the T-junction area was observed in 8 patients. All the patients received proper wound care, and the necrosis was surgically debrided. The defect was closed with Limberg-like rectangular flap. RESULTS: The mean age was 45.2 (range, 33-54) years. The mean body mass index was 25.57 ± 6.53 (range, 21.2-35.2) kg/m. The mean follow-up was 10.9 (range, 4-19) months. Two patients had implant exposure at the defect site after the debridement. There was no implant loss in any of the patients. CONCLUSIONS: The Limberg-like rectangular flap can be used as a salvage option in complicated skin-reducing mastectomies and can be considered as a safe and effective method because of its easy-to-use nature, low cost, and no need for microsurgery experience.

The repair of complex penile defect with composite anterolateral thigh and vascularized fascia lata flap.

One-stage reconstruction of complex penile defects with functional and cosmetic results is a challenging procedure. The selection of proper technique and materials for reconstruction depends on the type of the deficient tissue components, the size of the wound surface, and the donor site. This article presented a case of a partial penile and urethral defect due to an infection in the previous surgical site. The patient was treated with a perforator based pedicled composite anterolateral thigh flap combined with vascularized fascia lata. The urethral defect was reconstructed with the vascularized fascia lata. The remaining part of the flap was used for the resurfacing of the right cavernous body and penile skin defect. There was no fistula and the urinary caliber was accepted as good. The pedicled composite anterolateral thigh flap contains various tissue components suitable for a functional and cosmetic reconstruction of complex penile defects using the one-stage technique.

Selection of recipient vessel in traumatic lower extremity.

The main focus of this paper is the selection of proper vessels for successful free tissue transfer in lower extremities which have suffered extensive trauma. The selection of proper recipient vessels for traumatized lower extremities still presents difficulties for surgeons. This review will provide a general guideline for the selection of proper recipient vessels in traumatic lower extremity reconstruction and describe the possible reasons why some recipient vessels present more problems than others.

Onlay bone grafts in head and neck reconstruction.

BONE GRAFTS ARE USED IN A VARIETY OF CLINICAL SITUATIONS AND CAN BE DIVIDED INTO TWO CATEGORIES: treatment of bone gaps (inlay bone grafting) and bone projection (onlay bone grafting). Cortical grafts are useful in situations requiring immediate mechanical strength. These grafts can survive with or without complete revascularization or resorption and are primarily used by plastic surgeons in the treatment of bone volume deficiency. Cancellous grafts, in contrast, have no mechanical strength and therefore require additional support to bridge bone defects. Thus, they are used primarily for the treatment of bone gaps and in general revascularize quickly, resorb completely, and stimulate significant new bone formation.

Functional reconstruction in large and complex soft tissue defects of forearm and hand with multifunctional anterolateral thigh flap.

OBJECTIVES: The aim of this study was to evaluate the results of free anterolateral thigh (ALT) flap reconstruction for large and complex soft tissue defects of forearm and hand. PATIENTS AND METHODS: Thirteen patients (11 males, 2 females; mean age 32.5 years; range 18 to 55 years) underwent free ALT flap reconstruction for forearm and hand defects. The etiology of defects was crush injury in nine patients, tumor excision in two patients, electric burn in one patient, and unstable scar excision in one patient. In five patients a flow through ALT flap was used to reconstruct vascular defects. In tree patients a vascularised fascial ALT flap was used to reconstruct the tendon defects and in five patients neurosensory ALT flap was used. Patients were followed for 44+/-14.6 months. Chen classification was used to evaluate functional outcomes at the end of the postoperative first year. RESULTS: All flaps survived completely in 11 patients. In the other two patients marginal necrosis was observed. These areas with necrosis healed after debridement and daily dressings. The functional results were satisfactory in 11 patients according to Chen classification (6 patients Chen I and 5 patients Chen II) and poor in two patients (Chen III). CONCLUSION: The anterolateral thigh flap represents an excellent option for covering various complex defects in the forearm and hand. The flap provides a thin, pliable, vascularized tissue for covering the exposed tendons, nerves, bones, and reconstruct deficiencies.

Tissue plug technique for management of large chronic empyema defects and bronchopleural fistulas.

After multiple thoracotomies, local muscles are often transected or sacrificed for the treatment of intrathoracic infection. In these conditions, free tissue transfers are described as an alternative. Five anterolateral thigh musculocutaneous free flaps were used for the treatment of complicated large chronic empyema defects and bronchopleural fistulas with a special flap inset and gauze-packing method, the so-called tissue plug technique. All flaps survived completely without complication. There was no sign of recurrent infection, and the bronchopleural fistulas were sealed and the empyema cavities completely obliterated. We concluded that the tissue plug technique is an alternative for the management of difficult empyema cavities and bronchopleural fistulas in selected patients where the soft tissue flap is not enough to fill the complete dead spaces.

Assessment of fibula osteoseptocutaneous flap donor-site morbidity using balance and gait test.

To assess the functional deficits in gait and balance after fibular osteoseptocutaneous flap harvest, a case-control study in a hospital-based biomechanical laboratory was conducted. Eleven patients receiving fibula osteoseptocutaneous flaps were enrolled as study group and 10 age-matched and healthy subjects as a control group. The average postoperative period at the time of evaluation was 27.4 months (range: 10 to 68 months) and the average age at the time of evaluation was 52.1 years (range: 38 to 76 years). The balance test by Smart Balance Master and gait analysis were used for objective assessment of the donor leg function postoperatively. No statistical differences were observed in the kinetic and kinematic variables of gait analysis except double support time in both the groups. There were also no significant differences in simple static balance test (eyes open, eyes closed, swaying vision, eyes open with swaying surface, and sway-referenced vision and support). Significant differences were observed in more difficult task (eye closed with swaying support) and in the use of ankle strategy for maintaining maximum balance. In the dynamic balance test only specificity of the forward left direction determined significant difference in reaction time of movement control of gravity. The results of ankle strategy usage and dynamic balance indicated deficits of ankle muscle torque. Necessary postoperative physical training is required for ankle muscle torque and vestibular sense.

Augmentation of venous drainage by a venous anastomosis for pedicled flaps.

Recently several studies have addressed the venous problem and confirmed that venous ischemia is more injurious to tissue viability than arterial ischemia of equivalent duration. There are different methods of managing venous-compromised pedicled flaps. Between June 1996 and November 2003, our center treated two submental, five Becker, nine posterior interosseous, three distally based sural, and three colon pedicled flaps (22 flaps in total), which had venous congestion either at the time of flap elevation or immediately after inset of the flap. These cases of venous congestion were managed with an immediate additional venous anastamosis. After vein anastomosis, venous congestion reduced gradually, then improved, and finally disappeared completely in the postoperative follow-up days with all flaps surviving in their entirety. Reexploration was not required for the microsurgical venous anastomosis. In conclusion, flap necrosis resulting from venous congestion causes prolonged hospitalization, multiple debridements, and additional procedures to cover the exposed structures. Additional vein anastomosis, which is a simple, rapid, and reliable auxiliary procedure, may increase complete flap survival and lead to successful end results, both functional and cosmetic.

The use of free flaps in the management of type IIIB open calcaneal fractures.

BACKGROUND: There have been a limited number of reports regarding calcaneal open fractures so far. Thus, the debate regarding treatment is continuing. Type IIIB open calcaneal fractures are often associated with the possibility of chronic osteomyelitis that may cause severe complications, including amputation. METHODS: Between the years 1990 and 2001, 27 free tissue transfers were performed in 25 patients for reconstruction of soft-tissue defects complicated by calcaneal fracture. All of the patients underwent debridement and bone fixation procedures at the initial operation in the acute phase. Ten patients with comminuted fractures were treated by means of external fixation and 15 patients had intraarticular fractures that required internal fixation in addition to external fixation. After several aggressive debridements, free tissue transfers were performed subacutely for primary wound coverage. Muscle flaps were used in the majority of cases (n = 21). The mean follow-up period was 7 years 8 months. RESULTS: Complete flap survival occurred in 93 percent of flaps. There was one partial and one total flap failure. The overall infection rate was 12 percent (n = 3). Two of these patients were treated successfully and one required partial calcanectomy. In all cases, solid bone union was achieved. However, 72 percent of the patients suffered from pain or degenerative changes. CONCLUSIONS: Type IIIB open calcaneal fractures require systematic and meticulous treatment. Free tissue transfer is the essential component of providing healthy tissue for achieving adequate wound healing with reduced infection rates.

Demonstration of circulation haemodynamics in random pattern thinned skin flap (an experimental study).

BACKGROUND: Clinical applications and indications of the thin skin flap have been widely documented but its circulation haemodynamics are still controversial. An experiment was conducted on pigs to show the survival and circulation haemodynamics of random pattern thinned skin flap. METHODS: Group I: Random pattern standard skin flaps; 5 x 5 cm (n=20 flaps), and 5 x 10 cm (n=20 flaps). Group II: Random pattern thin skin flaps; 5 x 5 cm (n=20 flaps), and 5 x 10 cm (n=20 flaps). Group III: Random pattern thin skin flaps with silicone sheet underneath; 5 x 5 cm (n=20 flaps), and 5 x 10 cm (n=20 flaps). RESULTS: The mean surviving skin area of the 5 x 10 cm flaps was 95.5% in Group I, 64.9% in Group II, and 33.67% in Group III. A statistically significant difference (P<0.05, ANOVA) was found between the groups. The mean surviving skin area of the 5 x 5 cm flaps was 100% in Groups I and II, and 68.2% in Group III. A statistically significant difference (P<0.05, ANOVA) was also found between Groups I and III, and Groups II and III. In microangiographical studies, the distribution of subcutaneous plexuses was clearly visible in Group I. In Group II the subdermal vascular plexus was observed less frequently and was thinner, particularly on the distal part of the flaps. In Group III dilatation of the subdermal vascular plexus was evident, particularly on the proximal section of the flaps. In the technetium-99m-labelled microspheres uptake of the 5 x 10 cm flaps, there was no statistically significant difference between the first segments in Groups I and II, Groups II and III (P>0.05, ANOVA). A significant difference was found between the second segments in Groups I and III (P<0.05, ANOVA). CONCLUSION: The results obtained in this study show that the effect of subdermal vascular plexus in the survival of the random pattern thinned skin flaps is supported by flap bed osmosis and plasma imbibition.

Safety and reliability of microsurgical free tissue transfers in paediatric head and neck reconstruction--a report of 72 cases.

Although many large series of free tissue transfers for head and neck reconstruction have been reported in adults, there are few studies in paediatric patients. Seventy-three free tissue transfers for reconstruction of various defects of the head and neck were performed in 72 paediatric patients between January 1990 and September 2002, at our centre. The average age at the time of reconstruction was 11.8 years (range: 2 to 17 years). Thirty-eight patients were girls and 34 were boys. There were 19 tumour resection defects, 18 congenital oro-nasal fistula defects (cleft palate), 11 posttraumatic defects, nine corrosive pharyngo-oesophageal injuries, eight burn contractures, six hemifacial atrophies and microsomia, and one facial paralysis. Thirty-nine fasciocutaneous flaps, 16 osteoseptocutaneous flaps, 10 muscle or myocutaneous flaps, and eight jejunal flaps were transferred. The mean operative time was 8 h 20 min. All flaps survived, except one partial necrosis, with 98.6% success rate. Five patients (6.8%) required re-exploration. There were two venous and three arterial thromboses. All five flaps were successfully salvaged. The average hospital stay was 18 days. This study confirmed free tissue transfer as a safe, reliable, cost- and time-effective method for the reconstruction of various head and neck defects in children.