Management of Through-and-Through Oromandibular Defects after Segmental Mandibulectomy with Fibula Osteocutaneous Flap.

BACKGROUND: Oromandibular defects involving the external skin are a reconstructive challenge. This study aimed to evaluate the use of the fibula osteocutaneous free flap (FOCFF) for through-and-through oromandibular defects by comparing the surgical outcomes and complications of different techniques to close the external skin defect. METHODS: A retrospective analysis was conducted of patients who underwent reconstruction of through-and-through oromandibular defects after oncologic segmental mandibulectomy between January 2011 and December 2014. Five groups were analyzed according to the method of external skin coverage: primary closure, locoregional flaps, deepithelialized double-skin paddle FOCFF (deEpi-FOCFF), division of the skin paddle for double-skin paddle FOCFF (div-FOCFF), and a simultaneous second free flap. Intraoperative and postoperative outcomes along with complications were analyzed between groups. RESULTS: A total of 323 patients were included. The mean total defect area requiring a simultaneous second free flap was larger in comparison to other groups (p < 0.001). Reconstructions performed with div-FOCFF had a higher number of perforators per flap when compared with deEpi-FOCFF (p < 0.001). External defects closed with another free flap exhibited higher intraoperative time for the reconstructive segment in comparison to other groups (p < 0.05). The overall rate of complications was comparable between groups (24%, p = 0.129). CONCLUSION: The FFOCF is a reliable alternative to harvesting multiple simultaneous free flaps for through-and-through oromandibular defects. The authors recommend appropriate curation of the surgical plan based on individual patient characteristics and reconstructive requirements.

Evaluation of the Superficial Collecting Lymph Vessels' Vasa Vasorum in Lymphoedematous Limbs Using Video Capillaroscopy.

OBJECTIVE: The pre-collecting and collecting lymph vessels have smooth muscle cells, and sufficient perfusion is vital to maintain their function. Although the vasa vasorum of the collecting lymph vessels (VVCL) have been histologically investigated, little is known about their physiology. This study aimed to investigate the relationship between morphology and blood flow of the VVCL in lymphoedematous limbs. METHODS: Medical records of lower extremity lymphoedema patients who underwent video capillaroscopy observation during supermicrosurgical lymphaticovenous anastomosis (LVA) surgery were reviewed. The collecting lymph vessels, dissected for LVA, were examined under video capillaroscopy (GOKO Bscan-ZD, GOKO Imaging Devices Co., Japan) with a magnification of 175x and 620x. Blood flow velocity of the VVCL was calculated by measuring the red blood cell movement using software (GOKO-VIP ver. 1.0.0.4, GOKO Imaging Devices Co., Japan). Based on the video capillaroscopy findings, the VVCL were grouped according to their morphology; the VVCL morphology types and blood flow velocity were then compared according to the lymphosclerosis severity grade. RESULTS: Sixty-seven lymph vessels in 20 lower extremity lymphoedema patients were evaluated, including s0 in 19 (28.4%), s1 in 34 (50.7%), s2 in 10 (14.9%), and s3 in four (6.0%) lymph vessels. The VVCLs were grouped into four types: type 1 (n = 4), type 2 (n = 37), type 3 (n = 19), and type 4 (n = 7). Blood flow velocity of the VVCL ranged 0 - 189.3 µm/sec (average 26.40 µm/sec). There were statistically significant differences in VVCL morphology (p < .001) and blood flow velocity (p < .001) according to lymphosclerotic severity. CONCLUSION: Vasa vasorum of the collecting lymph vessels could be grouped into four types with different characteristics. Morphological and physiological changes of the VVCL were related to sclerotic changes of the collecting lymph vessels.

Don't Play It by Ear: Technical Considerations to Optimize Outcome and Procedural Safety of Congenital Microtia Reconstruction in a Dextrocardia Patient With Situs Inversus Totalis, Butterfly Vertebra, and Hemivertebra.

Background: Microtia can occur as a standalone condition or as part of a genetic syndrome. We report the first case of microtia presenting in a patient with dextrocardia, situs inversus totalis, butterfly vertebra, and hemivertebra, and we present technical recommendations for optimizing anaesthetic and surgical harmony in this extraordinary case.Patients with situs inversus dextrocardia should be checked for signs of Kartagener syndrome. Dextrocardia requires mirroring the placement of electrocardiogram (ECG) leads and the use of shocking paddles for cardiopulmonary resuscitation. Central venous access should be performed under ultrasound guidance because of varied course. Cervical vertebral deformities necessitate a thorough airway assessment since neck mobility may be limited due to pain or aberrant curvature. Conclusions: In this case, Brent's approach was used to treat the microtia, but rib cartilage was harvested from the ipsilateral side to lessen the chance of damaging the pericardium due to unfamiliar anatomy. These factors must be taken into account to perform a safe surgery on such patients.

Optimal Timing for Secondary Reconstruction of Head and Neck Defects after Free Flap Failure.

BACKGROUND: Finite options exist to address free flap failure. There is a lack of consensus on the gold standard for secondary reconstruction in such cases. Herein, we determined the survival rate of a second flap following a total loss of an initial free flap during head and neck reconstructions and evaluated if there was a difference in the rate of secondary flap necrosis depending on the timing of reconstruction salvage. METHODS: We retrospectively reviewed 1572 free flaps for head and neck reconstruction from 2010-2022. Patients who underwent secondary surgery with flaps after failure of primary free flap were included. Patients were divided into three groups based on the time for secondary flap reconstruction from the time of primary reconstruction (Group A, 0-5 days; Group B, 6-30 days; Group C, >30 days). RESULTS: We identified 64 cases of complete flap loss after primary reconstruction requiring secondary reconstruction. Pedicled flaps were used in 34.4% of the cases, while a second free flap was used in 65.6% of the cases. Overall, the flap failure rate for secondary reconstructions was 6.7% in Group A, 35.3% in Group B, and 6.7% in Group C (p=0.022). For free tissue transfer, the success rate of a secondary reconstruction was 92.3% in Group A, 28.57% in Group B, and 93.3% in Group C. CONCLUSION: We favor an early microsurgical reconstruction (≤5 days) following primary reconstruction in cases of free flap failure. If early reconstruction cannot be performed, a deferred reconstruction with free tissue transfer (>30 days) should be considered.

Empirical Evidence on the Reliability of Lateral Supramalleolar Flap over Reverse Sural Flap for Local Soft Tissue Coverage of Dorsum of the Foot and Ankle Defects.

Background Soft tissue coverage of the distal foot and ankle region has been an area of debate due to the paucity of local flap options. To provide empirical evidence on the reliability of an underreported local alternative for foot and ankle defects, we aim to compare the lateral supramalleolar flap (LSMF) to the reverse sural flap (RSF). Methods During 2016-2019, 48 patients were divided randomly into two equal groups, LSMF and RSF groups respectively. The patients' demographic, surgical, and clinical outcome details were recorded and analyzed. Results Flap necrosis was found in five patients in the group treated with RSF and none in the LSMF group. The mean total number of stages in RSF group was significantly higher than in LSMF group ( p < 0.05). The mean operative time for patients in LSMF group was 85.8 ± 18.5 and 54.2 ± 11.2 in RSF group ( p < 0.05). Five patients in the RSF group needed additional procedures following flap complications. Nine patients in the LSMF group reported satisfaction outcomes to be "excellent," five patients reported "good" whereas, in the RSF group, 14 patients reported "excellent," 5 reported "good," 3 reported "fair," and 2 reported "poor" outcomes. Compared to the RSF (46.4 ± 4.3) group, the LSMF group had significantly better foot function indices (34.03 ± 3.9). Conclusion The lateral supramalleolar flap for foot and ankle defects offers better results, reduced complications as well a lesser number of stages and secondary procedures over the traditionally used reverse sural flap.

Current Fat Grafting Practices and Preferences: A Survey from Members of ISPRES.

Fat grafting has established its niche in a wide spectrum of aesthetic and reconstructive procedures. A consensus-based method of harvest, processing, enrichment, injection, and assessment is lacking, despite the rising trends in its application. We conducted a survey among plastic surgeons to evaluate and identify trends of fat grafting practices. Methods: We conducted an electronic survey with a 30-item questionnaire of 62 members of the International Society of Plastic Regenerative Surgeons. We collected demographic information, techniques, and experiences related to large volume (100-200 ml) and small-volume (<100 ml) fat grafting. Results: The majority of the respondents worked predominantly as aesthetic surgeons. The donor area selection was based on the patient's fat availability (59.7%). For fat enrichment, platelet-rich-plasma and adipose stem cells were routinely used by 12.9% and 9.7% of respondents, respectively. A 3- to 4-mm cannula with three holes was the most preferred instrument for large-volume fat harvesting (69.5%). For small-volume fat grafting, 2-mm cannulas (75.8%) with Mercedes tip (27.3%) were used most commonly. For processing, decantation of fat was performed by 56.5% of respondents (without exclusivity). For handheld injections (without exclusivity), respondents preferred a 1- to 2-mm cannula with a 1 cm3 syringe. The most popular method of outcome assessment was photographic evaluation. Conclusions: The respondents' tendencies were similar to those reported in the previous literature, with some exceptions, such as the technique for preparing fat and enrichment. A wider cross-sectional survey, involving national delegates and global representatives of plastic surgeons, is anticipated.

Clinical applications of the chimeric anterolateral thigh (ALT) flap in head and neck reconstruction.

BACKGROUND: Surgical site infection (SSI) is a common complication following head and neck surgery. Dead space at the excision site can increase the risk of infection, abscess formation, and mortality. Herein, we evaluated the performance of the chimeric anterolateral thigh (ALT) flap in addressing these concerns. METHODS: Patients who underwent oncologic head and neck reconstruction between October 2016 and November 2021 were divided in two groups: a normal ALT flap and a chimeric dead space filling (DSF) ALT-vastus lateralis flap group. We evaluated the postoperative outcomes. RESULTS: Twenty-five patients treated with normal ALT flaps (34.7%) and 47 with DSF ALT flap group (65.2%) were included. Only one ALT per case was necessary. Most of the cases involved tongue (31.9%) and lower gingival reconstruction (27.8%). The time to harvest the DSF ALT flap was 134.3 min when compared to the normal ALT flap (116.2 min, p < .001). Vascular occlusion, flap loss, partial necrosis, and fat necrosis were not observed among the different groups. CONCLUSION: The DSF process can be used as a preventive measure for SSI or vessel exposure due to radiation-induced skin damage. This flap allows same-site reconstruction if the primary tumor recurs by using the pedicle of the chimeric flap for reattachment of another free flap.

Free flap transfer with supermicrosurgical technique for soft tissue reconstruction: A systematic review and meta-analysis.

BACKGROUND: Supermicrosurgery is a technique that allows microsurgeons to accomplish dissections and anastomoses of vessels and nerve fascicles with diameters of ≤0.8 mm. Considering the potential benefits of this technique and limited literature synthesizing the outcomes of supermicrosurgery, the aim of this study was to summarize the available evidence of reconstructive supermicrosurgery and to estimate the success rate. METHODS: We conducted a comprehensive search across PubMed, Scopus, Embase, and Web of Science. We included patient-based studies reporting on procedures for soft-tissue reconstruction with free flaps specifying the use of supermicrosurgery. We excluded studies reporting on lymphatic surgery, solely peripheral nerve surgery, and tissue replantation. Our primary endpoint was to calculate the flap success rate. Pooled estimates were calculated using a random-effects meta-analytic model. RESULTS: Forty-seven studies reporting outcomes of 698 flaps were included for qualitative synthesis. Overall, 15.75% of flaps were used for head and neck, 4.4% for breast and trunk, 9.3% for upper limb, and 69.2% for lower limb reconstruction. The most used flap was the superficial circumflex iliac artery perforator flap (41.5%). The overall flap success rate was 96.6% (95%CI 95.2%-98.1%). The cumulative rate of partial flap loss was 3.84% (95%CI 1.8%-5.9%). The overall vascular complication rate resulting in complete or partial flap loss was 5.93% (95%CI 3.5%-8.3%). CONCLUSIONS: Supermicrosurgery displays a high success rate. Further studies are necessary to explore the true potential of supermicrosurgery. This technique reformulates the boundaries of reconstructive surgery due to its extensive application.

Facial Basal Cell Carcinoma: A Study of Causative Factors and Site-based Algorithm for Surgical Reconstruction.

Background: Basal cell carcinoma (BCC) can be categorized as one of the commonly occurring skin malignancies in the world, with several variations in treatment protocols. Sun exposure has been attributed to its causality; however, other factors such as gender, age, and occupation also affect its incidence. We aimed to characterize the patient population who underwent surgical management for facial BCC at a tertiary referral hospital. Further, we have described an algorithm that may aid in surgical decision-making based on the location of the lesions on the face. Materials and Methods: We performed a retrospective chart review of all patients who presented with a facial BCC to our institution between 2018 and 2019. Data regarding patients' demographic characteristics, skin phototype, average sun exposure, occupation, residence place (rural or urban), and surgical outcomes were recorded. Results: Sixty-eight patients underwent reconstructive procedures after oncologic resection of facial BCC: 41.2% were males and 58.8% were females. Forty-eight (70.6%) patients were from rural areas, and 20 patients (29.4%) from urban areas (P < 0.001). Twenty-six patients reported >2 h of sunlight exposure, 16 reported <2 h of continuous sun exposure, and 26 reported intermittent sun exposure. A significantly higher proportion of patients with facial BCC presented with a Fitzpatrick skin type 4 in comparison to types 3 and 5 (P < 0.001). The most common reconstructive technique was the V-Y advancement flap (n=22, 32.4%), followed by the forehead flap (n=12, 17.6%) and the Limberg flap (n=12, 17.6%). All the flaps were healthy post-operatively and none of them suffered from flap failure, infection, or suture line dehiscence. There was no recurrence at 1-year follow-up. Conclusion: This study gives a correlation between incidence of BCC and age, gender, and sun exposure in Indian population. In our experience, local flaps yield outstanding results and are the first choice for reconstruction of the face when composite defects are not present. Our algorithm aids in surgical decision-making.

Intraoperative Identification of Perforator Spasm and Decreased Pulsation Using Video-capillaroscopy during Free Flap Harvest.

Temporary or prolonged vascular spasm can be appreciated when perivascular dissection is performed for microvascular reconstruction. Due to a lack of reliable assessment modalities, the resolution of spasm at the periphery of perforators cannot be determined by naked eyes or surgical loupes. To address this conundrum, we aimed to observe the state of perforator vessel spasm after flap elevation using video-capillaroscopy. Between November 2021 and February 2022, seven free flaps were evaluated with video-capillaroscopy to determine the incidence of vasospasm in less than 1 mm-diameter perforators. The type of perforator spasm after flap elevation was divided into six types according to the video-capillaroscopy findings: type A, no spasm/decreased pulsation (S/DP); type B, S/DP with recovery within 5 minutes; type C, S/DP requiring papaverine hydrochloride spraying and hot water treatment (PHS+HWT) resulting in recovery within 5 minutes; type D, S/DP requiring PHS+HWT resulting in recovery within 10 minutes; type E, S/DP requiring PHS+HWT resulting in recovery within 15 minutes; and type F, S/DP with no recovery of pulsation even after PHS+HWT. Twenty-five perforators were evaluated, 3.57 perforators (range, 3-4) per flap. Using our classification for perforator vessel spasms on video-capillaroscopy, observations of five perforating branches were classified as type A, seven as type B, six as type C, five as type D, and two as type E. No type F spasm was observed. With video-capillaroscopy it is possible to confirm if blood flow deterioration occurs even in areas that are difficult to determine macroscopically. Video-capillaroscopy, a noninvasive imaging modality, is a useful alternative for the intraoperative evaluation of perforator flow and spasm.

Characteristics and Limitations of Video-capillaroscopy in Reconstructive Microsurgery for Different Histologic Components of Flaps.

Indocyanine green, ultrasonography, and handheld Doppler can be used to evaluate blood flow at the donor and recipient site during microvascular reconstruction. However, these methods do not provide direct visualization and assessment of real-time blood flow. Video-capillaroscopy has been shown to be useful in clinical practice to assess microcirculation in rheumatologic disorders. In this report we used video-capillaroscopy to assess different tissue components involved in microvascular surgery. Seven patients who underwent head and neck oncologic microvascular reconstruction between November 2021 and February 2022 were included in this study. Video-capillaroscopy (GOKO-BscanZD, GOKO Imaging Devices Co., Ltd., Japan) was used to evaluate the donor-site and recipient-site tissue components. Optimal red blood cell movement was graded with a score of four, while no flow was graded with a score of 0. Seven myocutaneous flaps and seven recipient sites were evaluated. For the donor-site, our analysis demonstrated a significantly higher video-capillaroscopy quality for skin (3.43), adipose tissue (3.7) and perforators (3.7) when compared with muscle (0.429), muscle fascia (0.857), and de-epithelialized skin (1) (P < 0.001). For the recipient-site, a significantly higher video-capillaroscopy quality for skin (2.7), adipose tissue (3.5), and the periosteum (2.1) was noted when compared with muscle (0) (P < 0.001). Video-capillaroscopy efficiency is limited in the muscular component and injured (de-epithelialized) skin surface areas of flaps. Herein, we provide evidence that assessment of flap perfusion with video-capillaroscopy can be reliably achieved in the skin, periosteum, perforators, and adipose tissue. Video-capillaroscopy is expected to be applied for intraoperative real-time blood flow evaluation.

Combined ALT, Estlander, and Upper Lip Flap for Defects Involving the Oral Commissure.

Lip defects (including the corners of the mouth) are a reconstructive challenge in terms of both aesthetic and functional outcomes. When oral cancer resection results in defects that extend beyond the corners of the mouth to the buccal mucosa and buccal skin, it is difficult to perform reconstructive surgery using only a local flap, and a free flap must be used in combination. In this report, we present a case of reconstructive surgery of the corners of the mouth, buccal mucosa, and buccal skin after tumor resection for buccal mucosal squamous cell carcinoma in a 70-year-old man. The patient presented with a change in an oral mucosal ulcer for a period of 1 year. After biopsy of the ulcerated area, he was pathologically diagnosed with squamous cell carcinoma. After tumor resection, including the corners of the mouth, lips, and cheek skin, and neck dissection, the patient underwent reconstructive surgery using an extended upper lip flap combined with an Estlander flap and a free anterolateral thigh flap. Two months after surgery, the patient was able to consume regular food. At 24 months of follow-up, the patient was able to speak normally without any restrictive symptoms such as fluid leakage from the corner of the mouth. Lip sensation restoration was optimal. This method using the combination of an anterolateral thigh flap and extended Estlander flap is a markedly useful option for reconstructive surgery of defects around the corner of the mouth caused by wide excision of invasive cancer.

Definitive Closure of the Tracheoesophageal Puncture Site after Oncologic Laryngectomy: A Systematic Review and Meta-Analysis.

Tracheoesophageal puncture (TEP) and voice prosthesis insertion following laryngectomy may fail to form an adequate seal. When spontaneous closure of the fistula tract does not occur after conservative measures, surgical closure is required. The purpose of this study was to summarize the available evidence on surgical methods for TEP site closure. A comprehensive search across PubMed, Web of Science, SCOPUS, and Cochrane was performed to identify studies describing surgical techniques, outcomes, and complications for TEP closure. We evaluated the rate of unsuccessful TEP closure after surgical management. A meta-analysis with a random-effect method was performed. Thirty-four studies reporting on 144 patients satisfied inclusion criteria. The overall incidence of an unsuccessful TEP surgical closure was 6% (95% confidence interval [CI] 1-13%). Subgroup analysis showed an unsuccessful TEP closure rate for silicone button of 8% (95% CI < 1-43%), 7% (95% CI < 1-34%) for dermal graft interposition, < 1% (95% CI < 1-37%) for radial forearm free flap, < 1% (95% CI < 1-52%) for ligation of the fistula, 17% (95% CI < 1-64%) for interposition of a deltopectoral flap, 9% (95% CI < 1-28%) for primary closure, and 2% (95% CI < 1-20%) for interposition of a sternocleidomastoid muscle flap. Critical assessment of the reconstructive modality should take into consideration previous history of surgery or radiotherapy. Nonirradiated fields and small defects may benefit from fistula excision and tracheal and esophageal multilayer closure. In cases of previous radiotherapy, local flaps or free tissue transfer yield high successful TEP closure rates. Depending on the defect size, sternocleidomastoid muscle flap or fasciocutaneous free flaps are optimal alternatives.

Calf augmentation and volumetric restoration: A systematic review and meta-analysis.

BACKGROUND: Because of the recent attention focused on the aesthetics of the leg, outcomes in the literature are under-reported and require further investigation. We summarized the available evidence on the surgical techniques to augment the volume and dimension of the calf based on clinical outcomes and satisfaction rates. METHODS: An electronic search was conducted across PubMed MEDLINE, Web of Science, Scopus, and Ovid MEDLINER(R) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Data collection included the patients' characteristics, surgical techniques, and postoperative outcomes. Pooled estimates were calculated with a random-effect meta-analysis using the DerSimonian-Laird model. RESULTS: This review included 48 articles reporting outcomes of 2455 patients. The average age and follow-up were 33.15 years and 33.58 months, respectively. The most common indications for calf augmentation were esthetic concerns (48.7%). Most patients underwent subfascial implant placement (70.2%) followed by fat transfer (17.6%), submuscular implant placement (10.1%). Overall, the pooled satisfaction rate following calf augmentation was 95.4% (95% CI: 93.7%-97%). The pooled satisfaction rate for implant placement and fat transfer was 96.7% (95% CI: 94.4%-97.9%) and 87.2% (95% CI: 78.5%-96%), respectively. The pooled incidence of implant removal was 1.3% (95% CI: 0.7%-2%). The pooled estimate for additional fat grafting procedures following initial fat transfer was 54.1% (95% CI: 38.3%-70%). CONCLUSIONS: While fat transfer has an exceptional safety profile, additional procedures to achieve satisfactory outcomes are usually necessary. Subfascial implant placement provides the best volumetric expansion with a lower implant removal rate and optimal safety profile.

Mucormycosis Management in COVID-19 Era: Is Immediate Surgical Debridement and Reconstruction the Answer?

Background Excessive use of corticosteroids therapy along with gross immunocompromised conditions in the novel coronavirus disease 2019 (COVID-19) pandemic has raised the risks of contracting opportunistic fungal infections. Here, we describe our experience with the implementation of a surgical protocol to treat and reconstruct rhino-orbital-cerebral mucormycosis. Methods A retrospective review of our prospectively maintained database was conducted on consecutive patients diagnosed with mucormycosis undergoing immediate reconstruction utilizing our "Mucormycosis Management Protocol." All patients included in this study underwent reconstruction after recovering from COVID-19. Wide local excision was performed in all cases removing all suspected and edematous tissue. Reconstruction was done primarily after clear margins were achieved on clinical assessment under a cover of injectable liposomal amphotericin B. Results Fourteen patients were included. The average age was 43.6 years and follow-up was 24.3 days. Thirteen patients had been admitted for inpatient care of COVID-19. Steroid therapy was implemented for 2 weeks in 11 patients and for 3 weeks in 3 patients. Eight patients (57.1%) had a maxillectomy and mucosal lining resection with/without skin excision, and six patients (42.8%) underwent maxillectomy and wide tissue excision (maxillectomy and partial zygomatic resection, orbital exenteration, orbital floor resection, nose debridement, or skull base debridement). Anterolateral thigh (ALT) flaps were used to cover defects in all patients. All flaps survived. No major or minor complications occurred. No recurrence of mucormycosis was noted. Conclusion The approach presented in this study indicates that immediate reconstruction is safe and reliable in cases when appropriate tissue resection is accomplished. Further studies are required to verify the external validity of these findings.

Dental Silicone-based Surgical Guides to Harvest the Chimeric Scapular Flap: Preventing Iatrogenic Vascular Injury.

The angular branch of the thoracodorsal artery and the periosteal branches of the circumflex scapular artery can be easily injured while harvesting a chimeric scapular flap. Thus, we reported the use of 3D printed scapular models using CT angiography to prepare inexpensive surgical guides from autoclavable dental silicone impressions for scapular flap harvest. Mandibular and scapular models were prepared using a 3D printer for 11 patients undergoing chimeric scapular flap transfer following mandibular resection. During preoperative simulation surgery, we molded dental silicone accordingly with scapular models to produce surgical cutting guides. Six men (54.5%) and five women (45.5%) were included. The average age of patients was 65.4 years. Fourteen bone units were reconstructed as three patients needed two bone segments (27.3%) whereas eight patients required reconstruction of one bone segment (72.7%). The mean flap harvest time and total surgical time were 52.1 min and 633.8 min, respectively. The mean duration for osteotomies and bone plate fixation was 26.2 min. The difference between the length of the preoperative surgical model (64.92 mm) and the postoperative 3D-CT measurements (64.48 mm) was not statistically significant (0.95 mm, P = 0.397). No injuries were caused to the angular and periosteal vessels. Four patients exhibited donor-site seroma (36.4%). The cost of the dental silicone for surgical guide was only $5 per patient. Dental silicone-based surgical guides help minimize the risk of vascular injury while harvesting chimeric scapular flaps. The osteotomies were performed with precision and in a time-efficient manner.

Dynamic Changes on Video-capillaroscopy and Potential Microsurgical Application: Temperature and Skin Surface Readings.

Video-capillaroscopy is being explored as a potential tool for microsurgical flap monitoring. A detailed examination of the effect of temperature on capillary changes using video-capillaroscopy is yet to be investigated. We analyzed the video-capillaroscopy findings on different skin areas often used for flap harvest at normal body temperatures and at lower temperatures. Skin capillaries at the lateral thigh, anterior forearm, mid-axillary line, abdomen, and fingertips were observed using video-capillaroscopy in 20 healthy Japanese individuals. Further, ImageJ software was used to measure the blood vessel area and blood flow velocity, and comparisons were drawn between normal body temperature and lower body temperature states. All measures of blood vessel area and average blood flow velocity for the different anatomical regions were significantly different before and after cooling (P < 0.001). The mean reduction rate of the vessel area was significantly different among anatomic regions (P < 0.001). Post-hoc analysis revealed a significant difference in the vessel area reduction rate between anatomic areas (P < 0.05); except when comparing the thigh versus finger, the forearm versus abdomen, and the mid-axillary line versus abdomen. The mean blood flow velocity was significantly different among anatomic regions (P < 0.001). Post-hoc analysis revealed a significant difference between the thigh and forearm (P = 0.009), the forearm and fingertip (P = 0.001), and the abdomen and fingertip (P = 0.004). Decreasing the skin temperature resulted in a significant vasoconstriction and reduction in capillary flow velocity. It is imperative to keep the monitored area warm during video-capillaroscopy assessment to avoid false diagnosis of vascular occlusion.

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.