Mental health is strongly associated with capability after lower extremity injury treated with free flap limb salvage or amputation.

BACKGROUND: Knowledge about factors associated with long-term outcomes, after severe traumatic injury to the lower extremity, can aid with the difficult decision whether to salvage or amputate the leg and improve outcome. We therefore studied factors independently associated with capability at a minimum of 1 year after amputation or free flap limb salvage. METHODS: We included 135 subjects with a free flap lower extremity reconstruction and 41 subjects with amputation, between 1991 and 2021 at two urban-level 1 trauma centers with a mean follow-up of 11 ± 7 years. Long-term physical functioning was assessed using the Physical Component Score (PCS) of the Short-Form 36 (SF36) and the Lower Extremity Functional Scale (LEFS) questionnaires. Independent variables included demographics, injury characteristics, and the Mental Component Score (MCS) of the SF36. RESULTS: Greater mental health was independently and strongly associated with greater capability, independent of amputation or limb reconstruction. Mental health explained 33% of the variation in PCS and 57% of the variation in LEFS. Injury location at the knee or leg was associated with greater capability, compared to the foot or ankle. Amputation or limb reconstruction was not associated with capability. DISCUSSION: This study adds to the growing body of knowledge that physical health is best regarded through the lens of the bio-psycho-social model in which mental health is a strong determinant. This study supports making mental health an important aspect of rehabilitation after major lower extremity injury, regardless of amputation or limb salvage.

Predictors of postoperative lumpectomy size in breast-conserving surgery in breast cancer patients: a retrospective cohort study.

BACKGROUND: Oncoplastic reconstructive surgery as an extension of breast-conserving surgery leads to better aesthetic results, an increase in tumor-free margins, and a reduction of re-excision rates. However, oncologic resection is often more extensive than expected, sometimes resulting in the plastic surgeon deviating from the predetermined plan. For optimal planning of the reconstruction, it is mandatory to estimate volume defects after lumpectomy as accurately as possible. This study aims to find preoperative predictors of lumpectomy resection size. METHODS: All consecutive patients diagnosed with invasive breast carcinoma or carcinoma in situ and treated primarily with breast-conserving surgery between 2018 and 2020 at the University Medical Center Utrecht and Alexander Monro Hospital were included. Variables measured were patient characteristics and tumor characteristics. Data was analyzed in a multiple linear regression analysis. RESULTS: A total of 423 cases (410 patients) were included, with a median age of 58 (range 32-84) and a mean BMI of 25.0 (SD=9.3). The mean maximum radiological tumor diameter was 18.0 mm (SD=13.2), and the mean maximum lumpectomy diameter was 58.8 mm (SD=19.2). Multiple linear regression analysis found an explained variance of R 2 = 0.60 (p = < .00), corrected for operating surgeon. Significant predictors for postoperative lumpectomy size were BMI, breast size, and maximum preoperative radiological tumor diameter. Moreover, a predictive tool for lumpectomy size was developed and a web-based application was created on www.evidencio.com under the title ''Predicted lumpectomy size'', to facilitate the use of our tool in a clinical setting. CONCLUSION: Postoperative lumpectomy size can be predicted with BMI, breast size and radiological tumor size. This model could be beneficial for (plastic) breast surgeons in planning reconstructions and to prepare and inform their patients more accurately.

Bulging after DIEP Breast Reconstruction: New Insights Concerning Rectus Diastasis and Medial Perforator Harvest.

The aim of this study was to evaluate the association between flap harvest technique and occurrence of abdominal bulging. Methods: A retrospective analysis of 159 patients undergoing DIEP flap breast reconstruction between 2014 and 2021 in the University Medical Center Utrecht was conducted. Outcomes measured were preoperative rectus diastasis, flap weight, laterality of flap harvest (unilateral or bilateral), timing of the harvest (immediate or delayed), number of perforators harvested (single or multiple), and location of the harvested perforator (medial, lateral, or both). Results: In 159 patients, 244 DIEP flaps were performed, 16 of these donor-sites (6.6%) developed a clinically evident abdominal bulge. When preoperative rectus abdominis diastasis was found (n = 97), postoperative bulging occurred significantly more often (P < 0.01). Patients in whom the medial perforator artery was harvested for reconstruction (n = 114) showed less abdominal bulging than patients in whom the lateral (n = 92) was harvested (P = 0.02). Using single versus multiple perforators for the DIEP flap, bilateral versus unilateral reconstruction or timing of the operation showed no significant difference in outcome of bulging (P = 1.00, P = 0.78, P = 0.59, respectively). Conclusions: The incidence of bulging in our study cohort is comparable to the literature. Harvesting the medial perforator artery for the DIEP flap showed less abdominal bulging than using the lateral perforator artery in a DIEP flap breast reconstruction. Also, preoperative rectus diastasis was found to be an important risk factor for the occurrence of bulging.

Single-Admission, Staged Restoration of Gastrointestinal Continuity After Right Gastroepiploic Artery Damage.

A case of iatrogenic right gastroepiploic artery injury during laparoscopic transhiatal esophagectomy is reported. This case report describes microvascular repair of the right gastroepiploic artery and vein. Subsequent intraoperative decision making with regard to a staged, single-admission successful esophagectomy is discussed. In this case of a single-admission, staged esophagectomy, the gastric conduit was be preserved after transection of the right gastroepiploic artery and vein.

Is dangling of the lower leg after a free flap reconstruction necessary? Study protocol for a large multicenter randomized controlled study.

BACKGROUND: Within the field of plastic surgery, free tissue transfer is common practice for knee and lower leg defects. Usually, after such free flap reconstruction, patients undergo a dangling protocol in the postoperative phase. A dangling protocol is designed to gradually subject the free flap to increased venous pressure resulting from gravitational forces. Worldwide there are multiple variations of dangling protocols. However, there is no evidence available in the literature that supports the use of a dangling protocol. METHODS: This is a multicenter randomized controlled trial that includes patients with a free flap lower leg reconstruction. The primary outcome is to assess whether a no-dangling protocol is not inferior to a dangling protocol, in terms of proportion of partial flap loss, 6 months after surgery. Secondary objectives are to identify differences in major and minor complications, length of stay, and costs, and to objectify blood gaseous changes during dangling. Furthermore, at 2 years we will assess difference in physical function, infection rates, and osseous union rates. DISCUSSION: The primary outcome of this study will give a more decisive answer to the question of whether a dangling protocol is necessary after a free flap reconstruction of the lower leg. The secondary outcomes of this study will provide a better insight into the physical functions, infection rates, and union rates in these patients. TRIAL REGISTRATION: Central Committee on Research Involving Human Subjects (CCMO), NL63146.041.17. Registered on 11 July 2018. Netherlands Trial Register, NTR7545 . Registered on 10 October 2018.

Resuscitating extremities after soft tissue sarcoma resections: Are functional reconstructions an overlooked option in limb salvage? A systematic review.

BACKGROUND: Although resection of extremity soft tissue sarcomas can occasionally lead to large disabilities, literature regarding the necessity and outcome of functional reconstructions are scarce. The goal of this review is to assess outcomes and usage of functional reconstructions in light of multimodal treatment. METHODS: A systematic search was performed in July 2018 in PubMed and Embase databases according to the PRISMA guidelines. Search terms related to 'soft tissue sarcoma' and 'functional reconstruction' were used. Case series evaluating outcomes of functional reconstructions after STS resection were included. Functional reconstructions were limited to free functioning muscle transfers, tendon reconstructions, and nerve reconstructions. Qualitative synthesis was performed on all studies. Tumor grade, multimodal treatment, reconstruction, outcomes, and complications were collected from individual patient data. Results were summarized by tumor site. RESULTS: Fourteen studies were included after full-text screening. A total of 134 patients were described, of which the majority (74.9%) had functional reconstructions in the lower extremity. Radiotherapy and chemotherapy were administered in 60.3% and 49.4% respectively. Free functioning muscle transfers were used in 41.0% of all cases, tendon reconstructions in 58.2%, and nerve reconstructions in only 12.7%. A wide variety of outcome measures were used. Most patients regained good functionality, also after multimodal treatment. Unfavorable outcomes were often related to flap failure or allograft tendon rupture. CONCLUSION: Functional reconstructions in extremity STS are rarely described, but generally result in good functionality in spite of multimodal treatment. Early participation of reconstructive surgeons may help achieve ideal functional and oncological outcomes.

Motor Innervation of the Corrugator Supercilii Muscle in Relation to Orbital Landmarks: Guidelines for Surgical Denervation.

Precise knowledge of the nerve supply of the corrugator supercilii muscle (CSM) is a prerequisite for performing a selective denervation of the CSM. The authors' goal was to determine the course and variability of the motor nerves of the CSM in relation to fixed orbital landmarks. The facial nerve branches toward the CSM were identified during microscopic dissection of 9 Caucasian formaldehyde-fixed cadaver half-heads. The distances between the branches and defined landmarks were measured. All branches to the transverse head of the CSM ran between 15 and 32 mm superior to the lateral orbital margin. Medially the CSM was supplied by a superficial zygomatic, buccal, or bucco-zygomatic branch, which was much smaller than the temporal branches. This branch ran 4 to 7 mm medial to the medial canthus. This anatomical knowledge can be applied for surgical denervation of the corrugator supercilii muscle. The authors suggest a surgical procedure for corrugator denervation through a blepharoplasty incision.

Degloved foot sole successfully reconstructed with split thickness skin grafts.

INTRODUCTION: The current opinion is that split thickness skin grafts are not suitable to reconstruct a degloved foot sole. The tissue is too fragile to carry full bodyweight; and therefore, stress lesions frequently occur. The treatment of choice is the reuse of the avulsed skin whenever possible, or else the use of a full thickness fascio-cutaneus flap. PRESENTATION OF THE CASE: A young male sustained a crush injury to his right foot with deglovement of the plantar surface and part of the dorsum. DISCUSSION: Split thickness skin grafts are not suitable for full weight bearing, but in special circumstances, certain patients, a lot of time and patience, early mobilization and gradual increasing partial weight bearing it is worthwhile to try. To toughen the foot sole pressure distribution is necessary and can be reached in several ways, soft and springy materials of the inlay, but also socks, orthopedic shoes, casting, orthotics or walking aids. CONCLUSION: This case-report illustrates that the reconstruction of a degloved foot sole with split-thickness skin grafts can be successful; a silicon inner sole was used to prevent stress lesions.

The split radial forearm flap for lower leg defects.

The conventional free radial forearm flap is a very reliable, long-pedicled flap with thin, pliable skin. These properties make it an excellent choice for high-risk reconstructions or defects requiring only a thin cover. The split radial forearm flap allows primary closure of the donor site and has a large variability in shape and size. In this report, the cutaneous perforators of the radial artery were investigated in fresh cadavers and we present our clinical experience with the split radial artery flap in 9 patients with lower leg defects. Sufficient perforators exist to safely divide the flap proximally and distally into segments. In all clinical cases, the donor site could be closed primarily. All flaps remained viable and 8 of 9 patients obtained an esthetically pleasing result. The split radial forearm free flap is an elegant option for reconstruction of small- to moderate-sized soft tissue defects in the lower extremity.

Can previous diagnostic examinations prevent preoperative angiographic assessment of the internal mammary perforators for (micro)surgical use?

BACKGROUND AND AIM: Preoperative assessment of the internal mammary artery perforating (IMAP) branches enhances IMAP-based reconstructive procedures. Conventionally, color-flow Doppler, selective catheter arteriography, or CT angiography is used for such assessment. We studied how often these examinations may be rendered superfluous by assessment of previously performed diagnostic examinations. METHODS: A radiologist and a plastic surgeon jointly assessed whether information on the dominant IMAP could sufficiently be obtained from the thoracic CT scans of 12 head and neck cancer patients and 12 breast cancer patients, and from the mammary MRI of 12 breast cancer patients. Secondly, we retrospectively assessed in how many of the 10 patients who underwent an IMAP-flap head and neck reconstruction, and in how many of the 10 women who consecutively underwent a deep inferior epigastric perforator (DIEP) flap mammary reconstruction such previous diagnostic examinations were available and informative regarding the level of the dominant perforator. RESULTS: All 24 CT scans and 11 of the 12 MRI scans sufficiently allowed assessment of the level of the dominant IMAP. Previous information had already been available in all 10 DIEP flap patients and 6 of the 10 IMAP-flap patients. The distribution of IMAP dominance over the intercostal levels on the scans differed from that found by cadaveric or intraoperative assessment. CONCLUSIONS: Previously performed diagnostic CT scans and MRI scans that included the parasternal region usually allow sufficient preoperative assessment of the internal mammary perforators for reconstructive procedures. We advocate re-assessment of such previous examinations before ordering additional angiography. Additionally, we suggest to include the parasternal region in diagnostic scans.

Symptomatic varix of the facial vein.

Varices of the facial and neck region are extremely rare, and the most prevalent varices in this region affect the orbital vein. To date, no report on a patent and symptomatic varix of the facial vein has been published, because these varices are particularly rare and most often thrombosed at the time of diagnosis. We present a patient with a prominent patent varix of the right facial vein. After a magnetic resonance imaging scan and duplex ultrasonography, the lesion was treated via surgical exploration, ligation, and complete excision. At 6 months of follow-up, no signs of recurrence were noted.

A cadaver study of the vascular territories of dominant and nondominant internal mammary artery perforators.

The perfusion territory of the pedicled internal mammary artery perforator flap has been described, but the number of perforators to be included in the flap's pedicle is controversial. We studied the vascular territory of the dominant perforator and the contribution of additional nondominant perforators to it. Therefore, the dominant perforators in 9 fresh cadavers and the nondominant perforators in 4 of these, were injected with water-based ink. The dominant perforator vascularized a territory extending from the superior border of the clavicle to the xiphoid, and from midsternal to the anterior axial fold, with a mean craniocaudal length of 19.4 cm (range, 17.0-24.0) and a mean mediolateral width of 18.6 cm (range, 16.0-22.5). Additional injection of nondominant perforators did not lead to any substantial enlargement of this territory. One single dominant perforator vascularizes a large part of the hemithorax, allowing for various flap designs. Nondominant perforators do not have to be included in the vascular pedicle of the internal mammary artery perforator flap, which leads to less donor-site morbidity.

Anatomy of the vascular pedicle of the internal mammary artery perforator (IMAP) flap as applied for head and neck reconstruction.

INTRODUCTION: The vascular pedicle of the internal mammary artery perforator (IMAP) flap and its enhancement by inclusion of the internal mammary vessels up to the level of the first rib have not been systematically assessed anatomically, to date. This study assesses these features of this pedicle in light of the flap's application in head and neck reconstruction. MATERIAL AND METHODS: The length of the dominant perforator and the enhanced vascular pedicle of the IMAP flap were measured in 27 fresh cadaveric hemi-thoraxes. RESULTS: In 18 out of 27 cadaveric cases (0.67) the second perforator was dominant. The mean length of the 27 dominant perforators was 47 mm (range: 30-66 mm). By enhancement up to the level of the first rib, the mean length of the vascular pedicle could be doubled to 92 mm when based on the second perforator (0.67). In the five cases (0.19), where the third perforator was dominant, the mean length of the enhanced pedicle was 104 mm, whereas it was 61 mm in the four cases (0.15) where the first perforator was dominant. CONCLUSION: This is the first study that assessed the enhanced length of the vascular pedicle of the IMAP flap. Our results show that the mean length of the dominant second perforator may be doubled by such enhancement and that the arc of rotation to the head and neck region may, then, be doubled again. Hereby, even high-located defects in the head and neck region can be reached. This provides a better understanding of the feasibility of the pedicled IMAP flap in head and neck reconstruction.

Vulva reconstruction after pelvic exenteration, using a unique combination of two flaps.

A 64-year-old woman with recurrence of carcinoma of the vulva in an irradiated area received an en-bloc total pelvic exenteration. Reconstruction of the pelvic defect was performed with an anterolateral thigh (ALT) flap and a rectus abdominis muscle (RAM) flap (PM/RAM). This combination of flaps is unique, with excellent results. In a large defect, often irradiated in advance, well-vascularised tissue should be placed. Multiple flaps can be used to reconstruct these large pelvic defects, each with their own advantages and disadvantages. The combination of flaps used in this case uses the good properties of both flaps: the reliable and well-vascularised PM/RAM in combination with the ALT flap to provide much bulk in extreme large defects.

Clinical application and outcome of the internal mammary artery perforator (IMAP) free flap for soft tissue reconstructions of the upper head and neck region in three patients.

BACKGROUND: The fasciocutaneous internal mammary artery perforator (IMAP) island flap allows for superior esthetical and functional skin cover in the head and neck region in combination with limited donor site morbidity. Its modification as a free flap allows reconstruction of more cranial defects. PATIENTS AND METHODS: Three IMAP free flaps varying from 7 × 4 cm² to 10 × 6 cm² were transplanted in three patients with a mean age of 59 years (range, 54-69 years). Enhancement of the flap's vascular pedicle at least doubles the diameter of the internal mammary vessels to be anastomosed. RESULTS: Coverage with excellent texture and color match was uneventfully obtained and the flaps' donor sites were primarily closed in all three cases. CONCLUSIONS: Our experience proves the consistent feasibility of successful transplantation of the IMAP free flap. Because of its characteristics, we suggest contemplating the use of this flap in the upper head and neck region.

Clinical outcome after pedicled segmental pectoralis major island flaps for head and neck reconstruction.

The pectoralis major is reliable for reconstruction of large defects in the head and neck area. In 2001, we introduced a muscle-sparing technique with preservation of the clavicular part of the muscle. So far, we did not report on its reliability and clinical outcome at the receptor site.Fifty-four pedicled segmental pectoralis major island flaps were used in 53 patients, from 2001 through 2006. As outcome measures, we studied the overall rate of complications, the rate of major complications, and the final outcome at the receptor sites. We differentiated for the types of complications and assessed operation indication (primary vs. salvage procedure), site of reconstruction, previous radiotherapy, and completeness of tumor excision as possible risk factors for complications. We compared our findings to those of a meta-analysis of 16 other studies.Complications at the receptor site were observed after 21 of the 54 operations (0.39). Eleven of these cases (0.52) required repeated surgery that was successful in 8 cases (0.72). Conservative treatment was successful in 8 cases (0.80). Final outcome was successful in 49 of the 54 operations (0.91). Previous radiotherapy was a significant risk factor for persisting complications. Salvage procedures were a significant risk factor for developing clinical fistulas and the risk of partial flap loss was significantly correlated with nonhypopharyngeal reconstructions. Our results were comparable with those found in the meta-analysis.Our muscle-sparing technique proved to be reliable with clinical results comparable with conventional techniques in addition to function preservation at the donor site.

Clinical application and outcome of the segmental pectoralis major free flap in five head and neck patients.

BACKGROUND: Although microsurgical transplantation of the sternocostal segment of the pectoralis major muscle shares most of the advantages of the latissimus dorsi free flap, the latter has become a workhorse of microsurgery and the segmental pectoralis major free flap has not. By presenting their clinical experience with primary transplantations of this free flap to reconstruct craniofacial defects, the authors intend to draw more attention to its application and promote its use in reconstructive surgery. METHODS: Segmental pectoralis major free flaps were used for reconstruction of craniofacial defects in four male oncologic patients and one female trauma patient with a mean age of 55 years (range, 37 to 68 years). The donor-site morbidity was limited by preserving the clavicular muscle segment and its innervation. In one patient, only part of the sternocostal segment of the muscle was harvested, whereas in another, the free flap's vascular pedicle was anastomosed to the vascular pedicle of the contralateral pedicled pectoralis major flap. RESULTS: Total flap loss occurred in the one trauma patient and repeated surgery for wound-healing problems was required in one of the oncologic patients. Still, final flap outcome was favorable in four of the five patients. CONCLUSIONS: The segmental pectoralis major free flap is a useful and justifiable adjunct to the microsurgical techniques available for flat or wide craniofacial defects. It has the advantage over the latissimus dorsi flap of allowing a simultaneous two-team approach with the patient in supine position.

Function of the clavicular part of the pectoralis major muscle after transplantation of its sternocostal part.

BACKGROUND: Muscle-sparing transplantation of the sternocostal part of the pectoralis major muscle while preserving the clavicular part of the muscle may reduce donor-site morbidity, particularly in cases where dissection of the lymph nodes of the neck has been performed. The nerve supply and motor function of the clavicular part is alleged to be preserved when the sternocostal part is transposed through the deltopectoral groove. This study aims to objectify such preservation. METHODS: Muscle activity of the remaining clavicular and abdominal muscle parts was determined electromyographically, dynamometrically, and goniometrically on 17 sides in 16 patients after head and neck reconstruction. Subjective assessment was obtained by use of a structured questionnaire. RESULTS: The electromyogram proved preservation of innervation of 16 of 17 clavicular parts. The electromyogram of the abdominal part showed no signs of denervation on 10 sides and normal, full interference patterns at maximum voluntary effort in all patients. Selective functional testing of the clavicular part revealed decreased force in horizontal adduction in 11 out of 15 patients. Still, the isolated effect of the pectoralis major transposition on shoulder function could not be objectified statistically. Subjective evaluation yielded that shoulder disability was more likely to have been correlated with loss of trapezius muscle function. CONCLUSION: We conclude that the innervation of the clavicular part, indeed, is preserved by transposition of the sternocostal part through the deltopectoral groove. This supports the validity, effectiveness, and functional acceptability of our muscle-sparing technique of partial pectoralis major transplantation.

The segmental pectoralis major free flap: anatomical features of its vascular pedicle.

BACKGROUND: The pectoralis major muscle may be suited for free transplantation of a segment of the muscle. We investigated the length and diameter of its vascular pedicle to determine its feasibility. METHODS: The length of the pedicle, its arterial diameter, and its entry point into the muscle were determined in 17 cadaveric flaps. RESULTS: The pedicle length up to the medial border of the pectoralis minor muscle averaged 6.6 cm. The mean external arterial diameter was 1.8 mm, and the venous diameter was consistently larger. The vascular pedicle consistently entered the muscle lateral to the midpoint of, and a mean of, 8.8 cm caudal to the clavicular line. CONCLUSION: The vascular length and diameter are sufficient for microvascular anastomosis. Although an anatomic landmark for the cranial border of the flap could not be defined, the sternocostal part of the pectoralis major muscle may potentially be used as a segmental free flap.

The nerve supply to the clavicular part of the pectoralis major muscle: an anatomical study and clinical application of the function-preserving pectoralis major island flap.

The purpose of this study was to investigate the nerve supply to the clavicular part of the pectoralis major muscle so that the innervation to this part can be maintained in the muscle-preserving pectoralis major island-flap transfer. Although methods have been described that include a limited portion of the muscle while leaving the upper parts undisturbed with an intact motor innervation, reports on anatomical studies of this nerve supply are brief. The distal distribution of the nerves, the spatial relationship to the main vascular pedicle, and the ways to preserve them during surgical procedures remain unclear. Surgically relevant features of the clavicular part of the pectoralis major muscle were studied by dissection. The nerve supply to this part was examined on 11 sides of eight formalin-fixed cadavers. Two fresh cadavers were used for dissection, intraarterial polymer injection, and application of a nerve-preserving surgical technique. In all subjects, a separate nerve innervated the clavicular and upper medial sternocostal portions of the pectoralis major muscle. This nerve arises craniomedial to the main vascular pedicle of the flap and divides into several branches. These branches run in a fascia on the deep surface of the pectoralis major muscle, superficial to the origin and distal course of the vascular pedicle. Most branches to the clavicular part end medial to the coracoid process. The course of the branches to the upper sternocostal part is more medial. Based on their anatomical findings, the authors propose a surgical technique for transfer of the pectoralis major island flap to the head and neck area through a tunnel in the deltopectoral groove, lateral to the origin of the vascular pedicle. Head and neck reconstruction was performed using this technique. The presented method is a muscle-preserving procedure that maintains maximal donor-site function and morphology.