The accessory vascularization of the tensor fasciae latae muscle: towards a new classification?

PURPOSE: The tensor fasciae latae (TFL) muscle is supplied by the lateral femoral circumflex artery (LCFA), arising from the deep femoral artery. However, it has been noted that there is also a consistent vascular anastomotic network. The aim of this study was to describe the accessory vascularization of the TFL muscle through a descriptive anatomical study, in order to hypothesize the feasibility of harvesting a TFL flap in the event of an injury to the main pedicle. In addition, we illustrate this hypothesis with a successful clinical case of Scarpa freconstruction following ligature of the deep femoral artery. METHODS: The description of the accessory vascularization was obtained by injecting dye into seven lateral femoral circumflex arteries (LCFA), six superficial circumflex iliac arteries (SCIA), and three inferior gluteal arteries (IGA). RESULTS: The TFL muscle was vascularized primarily by the LCFA. A vascular anastomotic network with the SCIA and the IGA was observed. After selective injection to the SCIAs and IGAs, the subsequent injection to the LCFA showed a diffusion of the TFL skin paddle with a perforasome overlapping between the different vascular territories. CONCLUSION: The ascending branch of the lateral femoral circumflex plays a dominant role in the vascularization of the TFL muscle. As a result of a periarticular anastomotic network of the hip, this artery establishes several connections with the proximal arteries. Consequently, in cases where blood flow through the LCFA is interrupted, it should be equally possible to harvest the TFL flap through its accessory vascularization.

An X across the Chest: A Rare Case of a Criss-crossed Sternalis Muscle.

OBJECTIVE: The present case study aims at drawing attention to a very rare presentation of the sternalis muscle noticed during routine dissection, and is intended to highlight the clinical significance and usefulness of this unique muscle in reconstructive surgeries, especially of the breast. CASE REPORT: Though many morphological variants of the muscle have been reported, we came across a unique bilateral sternalis muscle during routine dissection for undergraduate medical teaching, in an 80-year-old male cadaver. The muscle originates on both sides from the external oblique aponeurosis from the fleshy belly, and after becom-ing tendinous, converges in the midline to form a common tendon at the level of the sternal angle, and then splits again into two tendons which become continuous with the ipsilateral sternocleidomastoid. CONCLUSION: Notwithstanding the fact that the presence of a sternalis can be misdiagnosed as a wide range of anterior chest wall lesions and tumors, especially with misdiag-nosis of breast masses in routine mammograms, it has great use as a muscular flap for reconstructive surgeries of the anterior chest wall, head, neck and breast.

[Emergency free flap in reconstruction of the lower limb: About 23 cases over 11 years]. / Reconstruction des pertes de substance des membres inférieurs par lambeau libre en urgence : à propos de 23 cas sur 11 ans.

OBJECTIVES: To study the coverage period influence and various parameters concerning the microsurgical act on the patient clinical outcomes. METHODS: We report 23 cases of reconstruction of lower limb loss of substance by free flap operated from 2010 to 2021. Among them, 9 patients were operated on as an emergency versus 14 in the secondary or late phase of the trauma. RESULTS: The average age of injured patients operated on emergency was 42 years (17-68 years) and 34 years for the patients who undergo deferred surgery (17-57 years). The sex ratio (female/male) was 22% in patients operated on urgently and 7% in patients operated on later. Regarding the type of free flap, it was Serratus anterior muscle flap in 10 cases, Latissismus dorsi flap in 9 cases, ALT flap in 3 cases and Gracilis muscle flap in 1 case. There were 2 failures of vascularized free transfer (8.7%) with complete necrosis of the flap and 3 revision surgeries on venous thrombosis which finally made it possible to obtain 3 flap successes. We analyze the results (complications/osteitis) according to the time to coverage. CONCLUSIONS: In our study, we did not find any significant difference between the groups operated in emergency and at a distance concerning the rate of infection and failure of the flaps.

Twelve-year experience in mandibular reconstruction using osteo-muscular dorsal scapular pedicled flaps.

Primary mandibular reconstruction after tumor removal or osteoradionecrosis treatment is a standard procedure. The most common reconstruction techniques are fibula, scapula, and iliac crest free flaps. Nevertheless, all patients are not eligible for microsurgery. In this study, we assess 12 years of mandibular reconstruction using an osteo-muscular dorsal scapular pedicled flap (OMDS). We included 40 patients operated on using an OMDS flap. We collected parameters such as length of hospital stay, recurrence risk, and need for secondary flap for oral cutaneous fistula (OCF) treatment. Flap bone volume was assessed by segmenting the scapula on postoperative CT-scans using dedicated software. Forty patients were included. Indications for OMDS flaps were severe cardiovascular history (27%), preoperative radiotherapy with a radiation neck and potentially unreliable blood vessel sutures (20%), previous fibula free flap failure (15%), and patient refusing free tissue transfer (8%). Aside from these medical indications, OMDS flaps were performed in 30% of cases due to organizational concerns. The mean flap length was 73±16 mm, with a maximum of 109 mm. Flap bone volume was stable over time, with negligible resorption (p = 0.761). Secondary pedicled flaps were used to treat OCF in 5 patients (12%). Secondary esthetic procedures were performed in 9 patients (22%). None of the 40 flaps were removed. None of the patients had long-term scarring complications in donor sites. OMDS flaps merit consideration for mandibular reconstruction when free tissue transfer is contraindicated or impossible due to organizational issues.

Soft tissue coverage options around the knee.

Defects around the knee exhibit various etiologies and pose challenges to both orthopedists and plastic surgeons. While a number of reconstructive coverage options are available, flaps are almost always required for complex defects. Many local flaps are easily placed, including muscle and perforator flaps sourced from the thigh to the leg. As the recipient vessels lie deep, free tissue transfers are challenging. Good postoperative management and efficient collaboration between orthopedic and reconstructive surgeons are the keys to successful knee reconstruction, restoring an esthetic contour and preserving joint function.

Study of abdominal wall muscle innervation applied to large-defect closure in congenital diaphragmatic hernia.

In large congenital diaphragmatic hernias (CDHs), direct suture of the diaphragm is impossible. Surgeons can use a triangular internal oblique muscle (IOM) plus transverse abdominis muscle (TAM) flap. Its caudal limit faces the medial extremity of the 11th rib. Clinical studies show that the flap is not hypotonic but that the procedure could expose patients already presenting a hypoplastic lung to external oblique muscle (EOM) hypotonia. The aims of this study were to study EOM innervation by the 10th intercostal nerve (ICN) and ICN innervation to the IOM and TAM. Forty cadaveric abdominal hemi-walls were dissected. The number of branches and the trajectory of each specimen's 10th ICN were studied medially to the medial extremity of the 11th rib (MEK11) using surgical goggles and a microscope (Carl Zeiss®). The 10th ICN was consistently found between the IOM and TAM. There was a median of nine branches from the 10th ICN to the EOM, 77% of them medial to the MEK11. Median values of nine and 12 branches for the IOM and TAM were found, 60% and 51%, respectively, medial to the MEK11. These results argue in favor of good innervation to the IOM plus TAM flap but also indicate postoperative abdominal weakness exposing patients to herniation risks, as more than 75% of the branches from the 10th ICN to the EOM were sectioned or pulled away during flap detachment. Clin. Anat., 33:759-766, 2020. © 2019 Wiley Periodicals, Inc.

Modified suture suspension by annular ligature the frontalis muscle to correct severe congenital blepharoptosis in very young patients / 中华整形外科杂志

Objective@#To explore the effect of the modified suture suspension by annular ligaturing the frontalis muscle to treat severe congenital blepharoptosis in children (age≤3).@*Methods@#From October 2016 to October 2017, 11 patients (16 eyes) with severe blepharoptosis were treated using the modified suture suspension in the Affiliated Hospital of Weifang Medical University. There were 7 males and 4 females, aged from 1 to 3 years old, with the average of 26.3 months. Three suture lines were used in three directions respectively. One end was fixed to the upper edge of the tarsus, the other end was fixed to the frontalis muscle by annular ligation. The operation effect and complications were evaluated 1 week and 6 months after the operation.@*Results@#All the incisions healed well. Hypophasis was observed in 1 eye. The exposed palpebral fissure was less than 3 mm when the eye was closed. No corneal exposure was observed in other cases. One week after surgery, the blepharoptosis of 5 patients were fully corrected (6 eyes, 37.5 %). Blepharoptosis in 5 patients were basically corrected (9 eyes, 56.2 %). One patients was over corrected (1 eyes, 6.3%). Six months after surgery, the blepharoptosis of 5 patients were fully corrected (5 eyes, 31.2 %). Blepharoptosis in 5 patients were basically corrected (9 eyes, 56.3%). However, the blepharoptosis of 1 patient was under corrected (2 eyes, 12.5%).@*Conclusions@#This modified suture suspension by annular ligature the frontalis muscle has the advantages of simple operation, low cost, stable effect, small wound, and satisfactory clinical effect.

Factors predictive of relapse in adult bacterial osteomyelitis of long bones.

BACKGROUND: Osteomyelitis is a difficult-to-cure infection with a high relapse rate despite combined medical and surgical therapies. Some severity factors, duration of antimicrobial therapy and type of surgical procedure might influence osteomyelitis relapse. METHODS: 116 patients with osteomyelitis were followed for ≥1 year after hospital discharge. Demographic, microbiological and clinical data, eight severity factors and treatment (surgical and antibiotic) were analyzed. RESULTS: Mean age was 53 years and 74.1% were men. Tibia (62.1%) and S. aureus (58.5%) were the most commonly involved bone and bacteria, respectively. Mean follow-up was 67.1 months. Forty-six patients underwent bone debridement, 61 debridement plus flap coverage and 9 antimicrobial therapy only. Twenty-six patients (22.4%) relapsed, at a mean of 11.2 months since hospital discharge. Duration > 3 months (p = 0.025), number of severity factors (P = 0.02) and absence of surgery (P = 0.004) were associated with osteomyelitis relapse in the univariate analysis. In the Cox regression analysis, osteomyelitis duration > 3 months (P = 0.012), bone exposure (P = 0.0003) and type of surgery (P < 0.0001) were associated with relapse. Regarding the surgical modalities, bone debridement with muscle flap was associated with better osteomyelitis outcomes, as compared with no surgery (P < 0.0001) and debridement only (P = 0.004). CONCLUSIONS: Osteomyelitis extending for > 3 months, bone exposure and treatment other than surgical debridement with muscular flap are risk factors for osteomyelitis relapse.

The ongoing emergence of robotics in plastic and reconstructive surgery.

Robot-assisted surgery is more and more widely used in urology, general surgery and gynecological surgery. The interest of robotics in plastic and reconstructive surgery, a discipline that operates primarily on surfaces, has yet to be conclusively proved. However, the initial applications of robotic surgery in plastic and reconstructive surgery have been emerging in a number of fields including transoral reconstruction of posterior oropharyngeal defects, nipple-sparing mastectomy with immediate breast reconstruction, microsurgery, muscle harvesting for pelvic reconstruction and coverage of the scalp or the extremities.

Application of muscular flap and induced membrane technique in the emergency treatment for limb salvage for Gustilo type Ⅲ B and Ⅲ C open fracture of lower leg / 中华显微外科杂志

Objective To investigate the clinical effectivity of the muscular flap transposition and induced membrane technique in the emergency treatment for the limb salvage of Gustilo type Ⅲ B/C open fracture of lower leg. Methods From July, 2015 to December, 2017, 10 cases of Gustilo type Ⅲ B/C fracture of lower leg with bone defects were performed limb salvage surgery. Induced membrane technique was used to fill the bone defects in the emergency room.The gastrocnemius and/or soleus muscular flaps were transposed to cover the bone cement or ex-posed bone simultaneously in emergence treatment. After the wound healed completely, traditional bone grafting was used to repair the bone defects. There were 4 cases of Gustilo type Ⅲ B and 6 cases of Gustilo type Ⅲ C. The aver-age length of bone defect was (5.25±1.70) cm ranging from 3.0 cm to 11.0 cm. The gastrocnemius medial head flaps were performed in 5 cases, the combined application with the gastrocnemius medial head flaps and the medial hemimuscular flaps of soleus were performed in 2 cases, and medial hemimuscular flaps of soleus were transposed in 3 cases. Results The wounds in 6 cases were healed at one stage, but 2 cases healed by dressing because the exudate after skin grafting.In 1 case, the cross-leg flap was used to cover the exposed bone cement due to the necro-sis of soleus flap. The other 1 was performed the transposition of the lateral gastrocnemius flaps because the exposure of bone cement after the necrosis of the upper and lateral muscles in lower leg. In the second-stage, the bone defects were reconstructed by traditional bone grafting. The average healed time of bone was 7.2 months ranging from 5 months to 9 months. At the last followed-up time, all patients recovered their function of weight-bearing. The Paley's score of the adjacent joints: excellent in 8 cases and good in 2 cases. Conclusion The combination with induced membrane technique and local muscular flap transposition in emergency surgery is an effective method to limb salvage for the Gustilo type Ⅲ B/C open fracture of lower leg.

Treatment strategy for severe lepharoptosis / 中华整形外科杂志

Objective@#To establish a treatment protocol for severe blepharoptosis. This protocol helps to achieve better accuracy and more stable result.@*Methods@#Evaluate levator muscle function pre-operatively. When levator function ≤ 1 mm, frontalis suspension technique was performed. When levator function more than 1 mm, technique of levator resection, combining excision of tarsus and levator, and tarsus-levator-CFS suspension was performed accordingly until it reaches adequate correction result during the surgery.@*Results@#A total of 275 severe ptosis patients was included from January 2015 to June 2016. 52 cases (388 eyes) received levator resection. 162 cases received combining excision of tarsus and levator. 24 cases received tarsus-levator- CFS suspension. 37 cases received frontalis suspension. 326 eyes achieved adequate correction results. 62 cases were still undercorrected. The asymmetry result showed that 76 cases presented good symmetry. 142 cases presented moderate asymmetry and 57 showed severe asymmetry.@*Conclusions@#The new treatment protocol shows a satisfactory result with better accuracy and more stable correction for severe ptosis correction.

Application of prefabricated reconstructive titanic plate combined with vascularized iliac bone-muscular flap in repairing and remodeling mandibular defects / 中国医学装备

Objective: To investigate the application effect of prefabricated reconstructive titanic plate combined with vascularized iliac bone-muscular flap in repairing and remodeling mandibular defects. Methods: This study is a prospective study, and 50 patients with mandibular tumor were enrolled in the research. And all of them were divided into observation group (25 cases) and control group (25 cases). The patients of observation group were implemented precise remodeling of mandible by using prefabricated reconstructive titanic plate combined with vascularized iliac bone-muscular flap, and that of control group were implemented remodeling of mandible by using virtual surgery assisted to vascularized iliac bone-muscular flap. And the occurrences of surgical effect and adverse reaction between the two groups were compared and analyzed. Results: The surgical effect of observation group (24 cases, 96%) was significantly higher than that of control group (20 cases, 80%) (x2=10.951, P<0.05). And the adverse reaction rate of observation group (5 cases, 20%) was significantly lower than that of control group (13 cases, 52%) (x2=10.624, P<0.05). Conclusion:Prefabricated reconstructive titanic plate combined with vascularized iliac bone-muscular flap can obtain better effect in repairing and reconstructing mandibular defects, and its postoperative adverse reactions are less.

Pelvic floor reconstruction by modified rectus abdominis myoperitoneal (MRAM) flap after pelvic exenterations.

OBJECTIVE: To describe the technique and report experiences with pelvic floor reconstruction by modified rectus abdominis myoperitoneal (MRAM) flap after extensive pelvic procedures. METHODS: Surgical technique of MRAM harvest and transposition is carefully described. The patients in whom pelvic floor reconstruction with MRAM after either infralevator pelvic exenteration and/or extended lateral pelvic sidewall excision was carried out were enrolled into the study (MRAM group, n=16). Surgical data, post-operative morbidity, and disease status were retrospectively assessed. The results were compared with a historical cohort of patients, in whom an exenterative procedure without pelvic floor reconstruction was performed at the same institution (control group, n=24). RESULTS: Both groups were balanced in age, BMI, tumor types, and previous treatment. Substantially less patients from the MRAM group required reoperation within 60days of the surgery (25% vs. 50%) which was due to much lower rate of complications potentially related to empty pelvis syndrome (1 vs. 7 reoperations) (p=0.114). Late post-operative complication rate was substantially lower in the MRAM group (any grade: 79% vs. 44%; grade≥3: 37% vs. 6%) (p=0.041). The performance status 6months after the surgery was ≤1 in the majority of patients in MRAM (81%) while in only 38% of patients from the control group (p=0.027). There was one incisional hernia in MRAM group while three cases were reported in the controls. CONCLUSIONS: Pelvic floor reconstruction by MRAM in patients after pelvic exenterative procedures is associated with a substantial decrease in postoperative complications that are potentially related to empty pelvis syndrome.

Pharyngo-oesophageal perforation following anterior cervical discectomy and fusion: management and results.

OBJECTIVES: Pharyngo-oesophageal perforation is a rare, life-threatening complication of anterior cervical discectomy and fusion surgery; its management remains poorly defined. We reviewed our experience to understand the treatment of this dreadful complication. METHODS: Data regarding the demographics, clinical course, diagnosis, management and outcomes of 15 cases of pharyngo-oesophageal perforations in 14 patients were collected during the period from 2003 to 2016. RESULTS: Pharyngo-oesophageal perforation occurred at a median of 32 days (range 1 day-102 months) after anterior cervical discectomy and fusion surgery. Clinical manifestations included neck abscesses and cutaneous fistulas (10 cases), cervical swelling (two cases), salivary leakage from cervicotomy (two cases), dysphagia, halitosis and regurgitation (one case). In all cases, conservative management was utilized. Two patients affected by minor external fistulas were successfully managed conservatively. In 13 cases, the following surgery was performed: (i) radical bone debridement, total or partial removal of spine fixation devices, autologous bone graft insertion or plate/cage replacement in one case each; (ii) anatomical suture of the fistula; or (iii) suture line reinforcement with myoplasty (in 11/13 cases). Perforation recurred in three cases. One patient underwent reoperation. The other two patients were treated conservatively At a median follow-up of 82 months (range 1-157 months), all patients exhibited permanent resolution of the perforation. CONCLUSIONS: Patients with minimal leaks in the absence of systemic infection can be managed conservatively. For cases of large fistulas with systemic infection, we recommend partial or total removal of the fixation devices, direct suture of the oesophageal defect and coverage with tissue flaps.

Total lower lid reconstruction: clinical outcomes of utilizing three-layer flap and graft in one session.

AIM: To report the clinical outcomes of utilizing a three-layer flap and graft in reconstruction of the lower lid in one session. METHODS: Seventeen patients with total or near total lower eyelid defect were included. The defects were reconstructed in three layers. Posterior lamella was reconstructed by using tarsoconjunctival free graft from the ipsilateral upper lid and periosteal flap from lateral orbital rim. Mobilization of residual orbicularis muscle provided a rich blood supply; and the anterior lamella was reconstructed by skin flap prepared from upper lid blepharoplasty as a one-pedicular or bipedicular bucket handle flap. RESULTS: The cause of lower eyelid defect was basal cell carcinoma in 15 patients and trauma in two of them. No intraoperative and postoperative complication occurred. Patients were followed from 10 to 15mo postoperatively. Cosmetic results were favorable in all patients and we had acceptable functional results. Thickness of the reconstructed tissue was a concern in early postoperative period. CONCLUSION: Three-layer lower lid reconstruction in one session is an effective technique for total lower lid reconstruction with minimal complications and acceptable functional and aesthetic outcomes and can be considered as a safe alternative for the preexisting techniques.

Reconstruction of soft tissue defect of the foot dorsum with trimmed latissimus dorsi free muscle flap with skin grafting / 中华显微外科杂志

Objective To discuss the clinical application of using trimmed latissimus dorsi free muscle flap together with skin grafting to resurface soft tissue defects on the dorsum of the foot. Methods From June 2005 to October 2011,eleven patients (8 males and 3 females,aged from 4-46 years) with large soft tissue defects of the foot dorsum were treated in our department. The size of the defects after debridement ranged from 5.0 cm × 6.0 cm-8.0 cm × 12.0 cm,all with exposed tendons or bones.Trimmed free latissimus dorsi muscular flap with split thickness skin grafting was used for reconstruction for all the 11 patients. Results All the flaps survived with no complications after surgery.During 3-10 months' follow-up,the appearance and walking function were satisfying, no further debulking procedures were needed. Conclusion Trimmed latissimus dorsi free flap with skin grafting is a good option for dorsal defect reconstruction.

Carcinoma espinocelular como complicação tardia em doença pilonidal sacrococcígea: relato de caso / Squamous cell carcinoma as a late complication of sacrococcygeal pilonidal disease: case report

A malignização é uma ocorrência rara na evolução tardia de cistos pilonidais, tendo sido descrito menos de 70 casos até 2007. Assim como em outras etiologias, a ocorrência de malignidades em feridas crônicas é chamada de úlcera de Marjolin. Normalmente, observa-se a ocorrência de tumores de baixo grau e bem diferenciados, sendo o carcinoma espinocelular o mais frequente. Entretanto trata-se de tumores de comportamento agressivo, com elevado índice de recidivas e metástases linfonodais. Relatamos o caso de um paciente masculino, 41 anos, com cerca de 23 anos de evolução de doença pilonidal sacrococcígea, que evoluiu com malignização para carcinoma espinocelular, submetido a tratamento cirúrgico e radioterápico.

Malignancy occurs ever so rarely on pilonidal cyst late evolution, so much so that less than 70 cases have been described until 2007. As in other etiologies, malignancy in chronic wounds is named Marjolin’s ulcer. Generally, the incidence of low grade and differentiated tumors is most frequently noticeable. Squamous cell carcinoma is the most frequent one. However, these are aggressive tumors, with high rates of recurrence and lymph node metastasis. We report the case of a male patient, 41 years-old, about 23 years of sacroccygeal pilonidal disease evolution, whose has developed malignancy (squamous cell carcinoma), submitted to surgical and radiotherapic treatment.

Selecting flap repaire hemifacial atrophy by digital technology / 中华显微外科杂志

ObjectiveTo explore clinical application of selecting flap by using of digital technique in treatment of hemifacial atrophy.MethodsSeven patients with hemifacial atrophy were selected,preoperative CT angiography was performed,deformity and flap three-dimensional reconstruction and design bone and soft tissues using Mimics 14.3 software, latissimus muscular flap or femur anterolateral flap were selected,according to tilt donor area and recipient area blood vessel diameter. Defect model were printed using rapid prototyping. ResultsHemifacial atrophy had a good postoperative shape,and the flaps survived in all the 7 cases.Follow-up 3 years,the flaps look well and the patients get expecting results. ConclusionsThe digital technique was a relatively useful tool that can assist surgeons with reconstruction of the flap,and accurate marking of the extent of the flap to be harvested.Therefore avoiding intraoperative injuries to the blood vessels to better survival of the flaps.

Medial gastrocnemius muscle transferring reconstruction the patella tendon with long following-up / 中华显微外科杂志

Objective To evaluate the long following-up outcome of the medial gastrocnemius muscle transferring reconstruction the patella tendon after the wide resection of aggressive bone tumors in the proximal tibia. Methods With the 69 patients of the osteogenetic sarcoma in the proximal tibia were treated with the wide resection and reconstruction the patella tendon. After the long following up the knee extensor,function and complications were evaluated. Results With the 69 patients, the 45 survival patients were followed up for the average 68.6 (24-128) months. The local recurrence rate was 8.7%(6/69). The strength of knee extending was in the average of grade 4.2(3.6-5.0), the degree of knee flexion was in the average of 95°(75°-135°), the degree of knee extension was in the average of-2°(0°-12°), the knees of five patients cannot fully extension. The MSTS functional score was in the average of 77% (23.1/30). Conclusion During the limb salvage of the proximal tibial aggressive bone tumors, the medial gastrocnemius muscle transferring reconstruction the patella tendon could offer the knee extension strength; improve the soft tissue coverage and functional results.

Treatment of large defects in the pelvic limb by dorsal vascularized muscular flaps or myo-cutaneous flaps

25 patients with defects of soft tissue or complex defects of soft tissue and bone joint in the pelvic limbs received the dorsal vascularized myocutaneous transplantation and monitored continuously within 3 months - 9 years. The results have shown that the operations had a good outcomes, even complex lesions of soft tissue and bone such as open bone fracture, osteitis, bone defect. The dorsal vascularized myocutaneous flaps had a good viability and high antisepsis so that can be used in the bone operation or plastic reconstruction for defects of soft infected subchronically or chronically