Nuances in Forehead Flap Reconstruction for Large Nasal Defects.

The forehead flap is a time-tested and robust resurfacing flap used for nasal reconstruction. Owing to its excellent color and texture match, acceptable donor site morbidity, and robust and independent blood supply that can support both structural and internal lining grafts, this flap remains the workhorse flap for resurfacing large nasal defects. Various nuances of this technique relating to defect and template preparation, flap design, flap elevation, flap inset, donor site closure, and pedicle division are discussed in this article. These nuances are the guiding principles for improved outcomes using a forehead flap for the reconstruction of large nasal defects.

[Research progress in surgical treatment of avascular necrosis of talus].

Objective: To summarize the surgical treatment methods for avascular necrosis of the talus. Methods: The recent domestic and international literature related to avascular necrosis of the talus was extensively conducted. The pathogenesis, surgical treatment methods, and prognosis were summarized. Results: The clinical symptoms of avascular necrosis of the talus at early stage are not obvious, and most patients have progressed to Ficat-Arlet stages Ⅲ-Ⅳ and require surgical treatment. Currently, surgical treatments for this disease include core decompression, vascularized bone flap transplantation, arthroplasty, and arthrodesis, etc. Early avascular necrosis of the talus can be treated conservatively, and if treatment fails, core decompression can be considered. Arthrodesis is a remedial surgery for patients with end-stage arthritis and collapse, and in cases of severe bone loss, tibiotalocalcaneal arthrodesis and bone grafting are required. Vascularized bone flap transplantation is effective and plays a role in all stages of avascular necrosis of the talus, but the appropriate donor area for the flap still needs further to be studied. Conclusion: The surgical treatment and the system of treatment for different stages of avascular necrosis of the talus still need to be refined.

The use of vascularized fibula flap with allograft in post-oncologic microsurgical bone reconstruction of lower limbs in pediatric patients.

BACKGROUND: Post-oncologic surgical reconstruction of lower limbs in pediatrics remains a challenging topic. Microsurgical techniques allow reconstructions of large bony defects. The use of vascularized fibular flap with allograft has proven to be an ideal biologic construct. We aim to assess the success rate of this operation, including flap survival, bony union, weight-bearing ambulation, and complications in a long-term follow-up in our case series compared to the literature. PATIENTS AND METHODS: Our case-series includes 18 femoral resections (9 osteosarcomas, 8 Ewing sarcoma, and 1 desmoid tumor) and 15 tibial resections (10 osteosarcoma, 4 Ewing sarcoma, and 1 Malignant Fibrous Histiocytoma). We collected patients' demographics, type of tumor, type of resection, defect size, fibula-flap length, method of fixation, anastomosis site, follow-up data, complications, and their management. All survivals were examined by X-ray and CT-scan to evaluate the morphological changes of the vascularized fibula and follow-up. The functional evaluation was performed by the 30-point Musculoskeletal Tumor Society Rating Score (MSTS) for the lower limb (Enneking et al., Clinical Orthopaedics and Related Research 1993(286):241-246). RESULTS: The mean age of the femur resection patients' group was 11.2 years with a mean defect size of 14 cm and a mean length of the fibular flap of 18 cm; for the tibia the mean age was 12 years with a mean defect size of 14 cm and a mean length of the fibular flap of 16.6 cm. The overall survival of the reconstructions at 5 years follow-up was 17 out 18 cases for the femur and 13 out of 15 cases for the tibia. MSTS score was 28.2 for the femur and 23.7 for the tibia. The average time of union of the fibula was seen after 5 months, while allograft consolidation was observed around 19.7 months. The mean time of follow-up was 144.5 months for the femur and 139.2 months for the tibia. The complication rate observed was 7 out of 18 for the femur and 7 out of 15 for the tibia reconstructions. CONCLUSIONS: The viability of the fibula is a cornerstone in the success of reconstruction as well as the successful management of complications in intercalary defects after tumor resection in pediatrics to restore good functionality. Our results are in line with those reported in the literature in terms of overall complication rates. The high primary union of allograft, the high MSTS score obtained, and the low rate of severe complications reflect the mechanical role of this reconstructive technique over a long follow-up.

[Application and research advances of delayed sural neurotrophic vascular flap for diabetic foot ulcers].

Diabetic foot ulcer is one of the serious complications of diabetes. Diabetic wounds are of great difficulty to repair, causing a high amputation rate and a great burden to patients and their family members and society. Researches showed that the delayed sural neurotrophic vascular flap has a great effect in repairing diabetic foot ulcers. This article mainly reviewed the clinical status and research advances of the delayed sural neurotrophic vascular flap in repairing diabetic foot ulcers, intending to provide a reference for its application and research.

"Extra-anatomical Pedicle Rerouting" An alternative technique to obtain new recipient vessels for microsurgical reconstruction in unfavorable clinical situations.

BACKGROUND: Lack of adequate recipient vessels in certain anatomically unfavorable locations or in complex clinical situations is still a limitation to successful microsurgical transfer. To address such complex cases, advanced microsurgical techniques should be applied. In this paper, the authors describe their experience with the Extra-anatomical Pedicle Rerouting (EPR) technique, an alternative approach that was used in selected cases throughout the body to obtain healthy recipient vessels for microsurgical reconstruction in unfavorable clinical situations where suitable recipient vessels were difficult to find. PATIENTS AND METHODS: Fifteen patients with defects of variable etiology (oncological resection, trauma, previous surgeries) located in the trunk or upper and lower extremities received EPR free flap reconstruction at our Institution. Operative data, postoperative course, and complications were recorded. Clinical and photographic follow-ups were also documented. RESULTS: A total of 15 flaps (6 antero-lateral thigh (ALT), 6 latissimus dorsi/thoracodorsal artery perforator flap (LD/TDAP), 3 deep inferior epigastric artery perforator flap (DIEP)) were transferred adopting the EPR technique for oncological (11) and post-traumatic (4) defects. According to the different clinical scenarios, the rerouted vessels were the thoraco-acromial, posterior circumflex humeral, thoracodorsal, deep inferior epigastric, lateral circumflex femoral, anterior tibial, and medial sural pedicles. Mean length of the rerouted vascular conduits was 6.53 cm. Mean operative time was 420 minutes. No major complications were registered. Minor wound dehiscence was observed and managed conservatively in 3 patients. CONCLUSIONS: The EPR technique proved to be useful in a reliable and reproducible manner in different regions of the body as an alternative solution to obtain healthy recipient vessels in anatomically and surgically unfavorable clinical situations.

"Boot-on-Donut" procedure for anterior and large septal perforation.

BACKGROUND: Surgical closure of large nasoseptal perforation (NSP) is challenging. The use of an extended anterior ethmoidal artery (eAEA) flap to reconstruct NSP may present with difficulties for NSPs which have their upper edge in a high position. METHOD: We propose adding a "donut-shape" flap from surrounding septal tissue to the eAEA flap. Thus, the inverted edges of this flap allow to cover the uppermost aspect of the NSP. A series of 18 patients with complete closure of NSPs was included. CONCLUSION: This novel "Boot-on-Donut" technique consisting of the eAEA flap (Boot) and inverted edges (Donut) is a feasible procedure that allows to reconstruct large NSP located superiorly.

Anatomical variant of the superficial temporal artery in temporoparietal fascia flap for microtia reconstruction.

BACKGROUND: Single-stage microtia auricular reconstruction is becoming more relevant. The determining factor is a temporoparietal fascia flap (TPF) with both branches of the superficial temporal artery (STA). There are not many studies regarding vascular branching in people with microtia. METHODS: We conducted an anatomical study on the TPF flap harvested during single-stage endoscopic-assisted microtia auricular reconstruction from May 2018 to July 2021. We observed the flaps under endoscopic and surgical microscopes to determine several variables (vascular size, number of frontal/parietal branches, distance from the branching location to the estimated external ear canal, distance from the frontal artery to projected course of facial nerve's frontal branch, etc.). RESULTS: The study included 55 flaps from 54 patients. Of the 55 flaps, 50 (90.9%) had a parietal branch, and all 55 (100%) had a frontal branch with a mean diameter of 0.98 and 0.91 mm, respectively. Regarding the frontal artery, 1.8%, 25.5%, 50.9%, 16.35% and 5.45% had 0-4 traverse frontal branch(es), respectively. The mean distance from the frontal artery to the estimated course of the frontal nerve was 10.56 mm. Parietal artery absence is more likely in patients with severe hemifacial microsomia or STA trunk go under the auricular cartilage remnants (p < 0.05). Either frontal or parietal artery absence or small diameter can cause necrosis. Frontal arteries travelling near the frontal nerve may result in post-operative nerve palsy. CONCLUSIONS: Microtia auricular reconstructive surgery is always a big challenge for plastic surgeons. Anatomical variants are common. A detailed anatomical description of the STA, with the help of microsurgery and endoscopy, allows arterial-based flap designing and harvest, which tremendously improves surgical success rate by diminishing flap necrosis and nerve damage. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparison of a coupling system and the suture method in end-to-side microvascular anastomosis in head and neck reconstruction.

BACKGROUND: Use of coupling devices in microvascular anastomosis continues to increase, but it is not yet actively used in end-to-side (ETS) anastomosis because there is no standard method. Therefore, we propose an easy and time-saving ETS micro-anastomosis method using coupling devices in head and neck reconstruction and compare it with the conventional suture method. MATERIALS AND METHODS: We retrospectively reviewed 30 consecutive cases (43 anastomoses) of ETS anastomosis in head and neck reconstruction from 2018 to 2022. Patient characteristics, operative details, and anastomosis time were evaluated. When using the coupling device, a cross incision was created in the recipient vessel to form vascular flaps. By pulling the flaps out of the ring, the intact vessel lining was fixed. Other procedures were the same as for a traditional anastomosis. RESULTS: The mean anastomosis time was 12.81 min (range, 6.7-24.87) for the suture and 4.96 min (range, 2.02-9.4) for the coupling device, a statistically significant difference (p-value <.00005). There was no venous insufficiency or flap failure with either method. CONCLUSIONS: ETS venous anastomosis using the coupling device is an easy-to-use, safe, and timesaving procedure for head and neck reconstruction.

Comparative Study of the Morphological Characteristics of Perforators of the Transverse and Descending Branches of the Lateral Circumflex Femoral Artery in Anterolateral Thigh Flap Surgery.

BACKGROUND: The anterolateral thigh flap (ALTF) is a kind of lateral thigh flap that uses branches of the lateral circumflex femoral artery (LCFA) as the vessel pedicle and is widely used in plastic surgery. During classic ALTF surgery, some perforators from the descending branch of the lateral circumflex femoral artery (LCFA-db) are hard to harvest due to their anatomical variants and individual differences; thus, it is necessary to design an appropriate alternative surgical plan. The transverse branch of the LCFA (LCFA-tb) has unique advantages and can be a potential complement to ALTF vascular pedicle selection. The aim of this study was to compare the difference in morphology between LCFA-db and LCFA-tb, and to verify the feasibility and clinical effect of ALTF with LCFA-tb as the source artery. METHODS: The morphological and clinical data of patients who underwent wound repair of the extremities with the ALTF pedicled with the LCFA-tb and LCFA-db were retrospectively analyzed. This study consisted of the clinical data of 62 patients who accepted an ALTF pedicled with LCFA-tb, and 45 patients accepted an ALTF pedicled with LCFA-db. RESULTS: A total of 68 cutaneous perforators originating from the LCFA-tb were found in the surgical field, of which 35 perforators were direct cutaneous perforators (51.5%), 28 perforators were septocutaneous perforators (41.2%), and 5 perforators were musculocutaneous perforators (7.3%). Seventy-four cutaneous perforators were found in the LCFA-db group. The proportions of septocutaneous perforators and musculocutaneous perforators were 23% and 77%, respectively, and the number of direct cutaneous perforators was 0. The harvest time of flaps pedicled with LCFA-tb was remarkably shortened. Regarding prognosis, there were no significant differences between the curative effects of the 2 types of flaps. CONCLUSIONS: This study verified that most LCFA-tb perforators are direct cutaneous perforators and that the piercing-in positions of LCFA-tb perforators on superficial fascia were higher than those of LCFA-db perforators. Furthermore, the ALTF pedicled with LCFA-tb can provide satisfactory soft tissue reconstruction and can be used as a useful supplement to the traditional flap design.

The study of DIEA three dimensional reconstruction technique based on CTA in preoperative perforator selection.

Preoperative selection of perforator is one of the key steps for successful surgery. The purpose of this study is to simulate the selection process of the perforator of the flap using the 3D models of the deep inferior epigastric artery (DIEA). A retrospective study was performed of women who underwent deep inferior epigastric perforator flap breast reconstruction from January 2011 to July 2021. Construct 3D models of the DIEA using computerized tomography angiography images, and then computational fluid dynamics simulations were performed. Correlation and regression analyses were used to analyze the geometric and hemodynamic parameters. Statistical analysis suggested that the outlet flow was positively correlated with the inlet area (r = 0.338, p = 0.000), outlet area (r = 0.840, p = 0.000), the average radius of the perforator (r = 0.592, p = 0.000), and negatively correlated with the length of perforator(r = -0.210, p = 0.024). The results of linear regression analysis showed that the outlet area (p = 0.000), the average radius (p = 0.000), and the length (p = 0.044) of the perforator were the influencing factors on outlet flow. In multiple perforators analysis, there was a significant difference in the total outlet flow among single perforator, double perforators, and triple perforators (p = 0.002). The successful implementation of this experiment provides a new approach for the selection of dominant perforators in the future.

Robotic harvest of the free gracilis muscle flap.

The conventional approach to harvest of the gracilis muscle flap necessitates a medial thigh incision that is often related to several donor site complications. In this report we describe the robotic harvest of the free gracilis muscle flap in order to reduce the morbidity associated with the open incision. Through three ports, the robotic system (Da Vinci Xi, Intuitive Surgical) enables precise dissection of the gracilis muscle, the vascular pedicle, and the obturator nerve; thus, enhancing surgical control, optimizing visualization through magnification, aiding in detailed vascular pedicle dissection and minimizing human error. We believe that the technique of totally robotic harvest of the free gracilis muscle flap, herein introduced, is a feasible and effective approach, and confers specific advantages over traditional harvest technique.

Musculocutaneous Latissimus Dorsi Phalloplasty: Technique and Tips.

BACKGROUND: Musculocutaneous latissimus dorsi (MLD) phalloplasty is a gender-affirming surgical option for transmen which permits penile prosthesis, glansplasty, and urethral extension at later stages. This surgery allows for a neophallus of adequate length and girth, and minimal donor site morbidity, but is technically complex. OBJECTIVE: This video demonstrates a step-by-step technique and tips to optimize outcomes and simplify the operation for the MLD phalloplasty. MATERIALS AND METHODS: A 33-year-old transmale who previously underwent metoidioplasty presented for an MLD phalloplasty. With the patient in a supine position, the superficial femoral artery and saphenous vein are isolated at the recipient site. The patient is repositioned into a lateral flank position, the flap harvested and tubularized, and inferior aspects of the wound closed prior to harvesting the thoracodorsal artery (TDA) and thoracodorsal vein (TDV) to minimize cold ischemia time. The TDA and TDV are dissected to their root at the subscapular artery and vein. The artery is removed with a patch of the subscapular artery. The patient is initially in a supine position and then returned to a supine position to minimize ischemia time of the flap. The neophallus is attached to the previously created recipient site, and an end-to-side anastomosis is created between the superficial femoral artery and TDA and an end-to-end anastomosis between the saphenous vein and the TDV. If the patient has a thick latissimus dorsi muscle or subcutaneous fat, a split-thickness skin graft can be used to close the ventral phallus to minimize tension on the tubularized neophallus and provide a plate for a future urethral lengthening procedure. Positioning and close post-op monitoring of the neophallus are critical. RESULTS: A neophallus of adequate length and girth is created with the option for future urethral extension and penile prosthesis placement. CONCLUSION: Our video demonstrates the technique for a gender-affirming MLD phalloplasty in a transman and tips to optimize outcomes and simplify the operation.

Temporoparietal Fasciocutaneous Island Flap for Forehead and Anterior Scalp Reconstruction.

Background: Forehead and anterior scalp large defect reconstruction is challenging and often requires skin grafting. Objective: To measure the advancing distance and the survival of the temporoparietal fascia (TPF) island flap in forehead and anterior scalp reconstruction. Methods: The study design was a retrospective case series. Participants included all patients who had undergone TPF island flap for forehead and anterior scalp defects of 3 cm and greater from 2009 to 2021. Flap advancing distance and vascular compromise were analyzed. Results: Patient's average age at time of surgery was 73 (standard deviation [SD] 14) years with more males (n = 24, 67%) than females (n = 12, 33%). Of 36 patients, 24 had forehead and 12 had anterior scalp defects, 26 cases had a full TPF island flap, and 10 cases underwent the partial island modification. Flap edge ischemia occurred in two cases (6%) and complete ischemia occurred in one case (3%). The median flap advancing distance was 3.7 cm (SD 1.2). Conclusions: In this 12-year review, we found that the TPF island flap is able to advance up to 7.5 cm and thus is an effective reconstruction for medium to large forehead and anterior scalp defects.

Comparison of Decellularized Human Dermal Scaffolds versus Bovine Collagen/Elastin Matrices for Engineering of Soft-Tissue Flaps.

BACKGROUND: Free flap-based soft-tissue reconstruction comes at the price of donor-site morbidity. The arteriovenous loop (AVL) technique can overcome this issue by allowing for the de novo generation of axially vascularized soft-tissue flaps from vein grafts embedded into different matrices. Application of the AVL technique has been limited by insufficient long-term volume retention and poor tissue stability. The authors investigated the suitability of a novel human dermal scaffold to improve volume retention and tissue stability. METHODS: AVLs were created in 28 immunocompetent rats and embedded in either decellularized human dermal scaffolds (experimental group, n = 14) (Epiflex) or bovine collagen/elastin matrices (control group, n = 14) (MatriDerm) in subcutaneous polytetrafluoroethylene chambers. The weight and volume of engineered tissues, the extent of angiogenesis, and the proportion of proliferating cells were compared between groups on postoperative days (PODs) 21 and 28 by means of immunohistochemistry and micro-computed tomography. RESULTS: On POD 28, both groups displayed homogeneous microvascular networks on histopathology and micro-computed tomography. Mean microvessel counts and surface areas and the percentage of proliferating cells did not differ between the groups. However, the experimental human scaffold group displayed significantly smaller volume loss and significantly less tissue degradation compared with bovine matrix controls (volume retention, 102% ± 5% versus 27% ± 7% on POD 21, and 79% ± 12% versus 12% ± 7% on POD 28, respectively; P < 0.0001). CONCLUSION: Compared with bovine matrices, decellularized human scaffolds allow for superior volume retention and tissue stability of de novo engineered soft-tissue AVL flaps in rats. CLINICAL RELEVANCE STATEMENT: AVLs allow for the de novo generation of vascularized soft-tissue flaps. However, insufficient long-term volume retention is still an issue. The authors' study shows that decellularized human matrices guarantee superior volume stability of de novo grown soft-tissue flaps in rats.

Mini-Shaped Kiss Flap Design for Palmar and Digital Soft-Tissue Resurfacing.

BACKGROUND: Although palmar and digital soft-tissue resurfacing with intrinsic flaps may provide functional and aesthetic reconstruction, the donor site may result in a tight closure or need for a skin graft once the flap is raised. In this series, the "mini-shaped kiss flap" was used to increase the resurfacing efficiency and preserve hand function. METHODS: The mini-shaped kiss flaps, based on common palmar digital arteries (eg, princeps pollicis artery and ulnar palmar digital artery), were developed for the resurfacing of distal or proximal finger areas. The tiny skin paddles were "kissed" together and transferred as pedicled in proposed dimensions and shape. The flap size, donor/recipient site, perforator source, whether free or pedicled, surgical outcome, and donor-site morbidity were evaluated. RESULTS: Twenty mini-shaped kiss flaps were harvested for the purpose of palmar and digital resurfacing. The flap sizes varied from 3 × 1.2 cm to 5 × 2 cm. All 19 patients, aged 6 to 52 years (mean, 35 years), achieved successful reconstruction without major complications after 6- to 12-month follow-up. CONCLUSIONS: The mini-shaped kiss flap technique exhibited favorable surgical outcomes with excellent color and texture match to the recipient sites. The reverse midpalm, thenar, and hypothenar island flap can be raised at the cost of an unnoticeable linear scar with minimized functional compromise in the donor area. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Difficulties of nasocutaneous fistula repair, following lacrimal outflow system malignancy resection.

PURPOSE: To evaluate the incidence of nasocutaneous fistula (NCF) development, following en bloc resection of lacrimal outflow system malignancies (LOSM), and describe the methods of surgical repair. METHODS: Retrospective review of all patients who underwent resection of LOSM with reconstruction and post-treatment protocol at the University of Miami between 1997 and 2021. RESULTS: Of the 23 included patients, 10 (43%) developed postoperative NCF. All NCFs developed within one year of surgical resection or completion of radiation therapy. NCF was seen more frequently in patients who underwent adjuvant radiation therapy and those who had reconstruction of the orbital wall with titanium implants. All patients underwent at least one revisional surgery to close the NCF, including local flap transposition (9/10), paramedian forehead flap (5/10), pericranial flap (1/10), nasoseptal flap (2/10), and microvascular free flap (1/10). Local tissue transfer, pericranial, paramedian, and nasoseptal forehead flaps failed in most cases. Two patients had long-term closure; one patient who underwent a paramedian flap and a second who underwent a radial forearm free flap, suggesting that well-vascularized flaps may be the most viable option for repair. CONCLUSIONS: NCF is a known complication, following en bloc resection of lacrimal outflow system malignancies. Risk factors for formation may include adjuvant radiation therapy and use of titanium implants for reconstruction. Surgeons should consider utilizing robust vascular-pedicled flaps or microvascular free flaps for repair of NCF in this clinical scenario.

Digit ratio and the femoral circumflex artery perforator: A sex-dependent association between the vascular system of the thigh and prenatal sex hormones?

BACKGROUND: The anterolateral thigh flap (ALTF) is a type of free flap which is commonly used in reconstructive surgery procedures and is based on the perforator from femoral circumflex artery. Some authors found that the location of the perforator differs between sexes. OBJECTIVE: To verify the influence of prenatal sex hormones (as measured by 2D:4D) on the morphology of the perforator of the descending branch of the femoral circumflex artery. METHODS: 88 participants (43 women) of a mean age of 28.5 years (SD 8.1 years) had the following measurements performed: height and weight; right and left-hand 2nd and 4th fingers' lengths; and distance from anterior superior iliac spine to the perforator from descending branch of lateral femoral circumflex artery related to the thigh length (right and left) (AP ratio). RESULTS: Right 2D:4D and Dr-l (right minus left 2D:4D) were dimorphic, similarly to AP ratio (right and left), which in women was significantly higher than in men. A significant correlation was found between right and left 2D:4D and location of the perforator of the left thigh in men. The higher right and left 2D:4D (more feminine) the higher the left AP ratio (more feminine). CONCLUSION: Our findings suggest that the location of perforator of femoral circumflex artery may be influenced by prenatal sex steroids such that low prenatal testosterone and high prenatal oestrogen are correlated to high AP (lower branching of the artery).

Anatomical study of first palmar intermetacarpal flap in cadavers and application for congenital first web contracture in a child with Apert's syndrome.

INTRODUCTION: Reconstructing severe first web contractures often involves using either pedicled forearm flaps, which can cause extensive scarring, or free flaps, which can be highly complex. In this study, we present a local palmar hand flap that overcomes both of these challenges. METHODS: Ten fresh upper limbs were examined after arterial injection with colored latex. The study focused on identifying the most distal palmar vascular cutaneous branches suitable for designing an elliptical cutaneous flap over the volar intermetacarpal area. This flap's width was approximately 50% of the width of the thenar eminence. Additionally, we present the case of an 8-year-old child with a type 1 Upton's Apert's hand, which exhibited a severe first web contracture. RESULTS: In seven cadaver hands, one distal cutaneous perforator was found, while in three hands, two perforators were identified. These perforators originated from the thumb radial collateral artery six times, pollex princeps three times, index radial collateral vessels twice, and thumb ulnar collateral vessels twice. The mean perforator diameter was 0.5 mm (ranging from 0.4 to 0.6 mm), and the mean perforator length was 10 mm (ranging from 0.8 to 12 mm). Using this flap bilaterally in our patient resulted in a straightforward procedure that created a broad and functional first web. A total-thickness skin graft was necessary to cover the proximal thenar area, and fortunately, no complications arose. A wide first web with an intermetacarpal angle of 40° ultimately was obtained scoring 8 on the kapandji. CONCLUSIONS: The first palmar intermetacarpal flap presents itself as a reasonable and uncomplicated option for addressing significant moderate-to-severe first web contractures.

Superficial lateral arm flap for post-burn antecubital contractures.

This paper presents a new variant of the distally based lateral arm fasciocutaneous flap that involves a straightforward and easy dissection as no specific vessel identification or inclusion is needed. Ten fresh cadavers were dissected to study the vascular supply. All three recurrent arteries-radial, ulnar, and interosseus-nourish the flap. The study also identified muscular perforators from the radial recurrent artery, piercing brachioradialis, and, in addition, septocutaneous perforators from the ulnar and interosseous recurrent arteries entering the base of the flap. Clinical application in 12 patients with upper limb burns including antecubital fossa contracture is also reported. This is a reliable and reproducible flap. The clinical dissection is straightforward and easy, with no need to identify or include a specific vessel at the base of the flap. Harvest requires neither the microscope nor loupes and can be done without a tourniquet, so it can be used in even the most modest surgical settings.

Skin Perfusion After Hemostatic Net: An Anatomic and Radiologic Study in a Cadaver Model.

BACKGROUND: The hemostatic net is a recent technique initially developed to reduce the occurrence of postoperative hematomas following facelift procedures. Its applications have expanded to include skin redraping, deep plane fixation, and other areas beyond the face. However, no experimental study has investigated its effect on skin blood supply. OBJECTIVES: The aim of this study was to analyze facial skin vascularization after applying a hemostatic net to fresh cadavers. METHODS: Fourteen hemifaces from fresh adult cadavers were examined. The study model involved a deep plane facelift procedure with the use of a hemostatic net. The first step, involving 4 hemifaces, included dissections and two-/three-dimensional angiographies by digital microangiography and computed tomography scan, respectively. The purpose was to evaluate the influence of the hemostatic net on vascular perfusion. The second step involved a sequential dye perfusion study performed on 10 other hemifaces that underwent facelift procedures with the hemostatic net to determine its impact on skin perfusion. RESULTS: The anatomic and radiologic techniques enabled visualization of skin, and showed the arterial system reaching the subdermal vascular plexus and branching between the vascular territories, without interference from the net. The sequential dye perfusion study showed staining after injection in each facelift flap, with comparable coloration distributions before and after the application of the net. CONCLUSIONS: The hemostatic net did not affect the skin blood supply, correlating with no clinical increases in ischemia and necrosis rates in the facelift flap. This study provides additional evidence supporting the safety of the hemostatic net in clinical practice.