Maxillary and total nasal reconstruction with a scapulo dorsal perforator flap.

Facial gunshots injuries remain challenging and present functional and aesthetic problems. Such defects generally require composite tissue flaps for reconstruction. Rebuilding the palate and the maxilla is especially delicate because it requires reconstitution of the facial buttresses, and replacement of bony hard palate, based on occlusion, as well as the restoration of the thin intraoral and intranasal lining which normally constitute the soft palate. Various methods of reconstruction have been applied to this area in search of an ideal soft tissue and bone flap to restore the bony framework of the maxilla and palate while providing an internal lining. The scapula dorsal perforator flap is used in the case of a patient to successfully reconstruct the palate, the maxilla and the nasal pyramid in one stage. Free tissue transfer using thoracodorsal perforator flaps and scapula bone free flap have been already described in literature but never to perform the nasal pyramid reconstruction at the same time. Good functional and aesthetic results have been obtained in this case. This article also reviews, through the authors experience and literature, anatomical landmarks, indications, technical surgical tricks, advantages and disadvantages of this flap for palatal, maxillary and nose reconstruction.

Cleft Alveolar Bone Graft Materials: Literature Review.

INTRODUCTION: Since the early stages of alveolar bone grafting development, multiple types of materials have been used. Iliac cancellous bone graft (ICBG) remains the gold standard. DESIGN/METHODS: A review of literature is conducted in order to describe the different bone filling possibilities, autologous or not, and to assess their effectiveness compared to ICBG. This review focused on studies reporting volumetric assessment of the alveolar cleft graft result (by computed tomography scan or cone beam computed tomography). RESULTS: Grafting materials fall into 3 types: autologous bone grafts, ICBG supplementary material, and bone substitutes. Among autologous materials, no study showed the superiority of any other bone origin over iliac cancellous bone. Yet ICBG gives inconsistent results and presents donor site morbidity. Concerning supplementary material, only 3 studies could show a benefit of adding platelet-rich fibrin (1 study) or platelet-rich plasma (2 studies) to ICBG, which remains controversial in most studies. There is a lack of 3-dimensional (3D) assessment in most articles concerning the use of scaffolds. Only one study showed graft improvement when adding acellular dermal matrix to ICBG. Looking at bone substitutes highlights failures among bioceramics alone, side-effects with bone morphogenetic protein-2 composite materials, and difficulties in cell therapy setup. Studies assessing cell therapy-based substitutes show comparable efficacy with ICBG but remain too few. CONCLUSION: This review highlights the lack of 3D assessments in the alveolar bone graft materials field. Nothing dethroned ICBG from its position as the gold standard treatment at this time.

Musculocutaneous flap of the medial head of the triceps brachii: pedicled flap to cover the posterior cubital region.

INTRODUCTION: The medial head of the triceps brachii flap is already described as a local muscular or as a free flap. It allows coverage of defects of the posterior cubital region. The aim of this study was to describe the vascular anatomy of the musculocutaneous medial triceps brachii pedicled flap. METHODS: Eleven fresh-frozen upper limbs (6 come from women and 5 from men) were proximally injected with Indian ink agar solution. The medial head of the triceps brachii muscle was dissected and the superior ulnar collateral artery (SUCA) was isolated with its collaterals. The collateral arteries were dissected to determine whether there were septocutaneous or musculocutaneous arteries for vascularization of the skin in front of the medial head. Lengths of those collaterals arteries were measured. RESULTS: The average number of collaterals arteries from the SUCA supplying the medial head of the triceps brachii is 4.5 (from 3 to 6 arteries). Among these collaterals' arteries, there are one average 1.5 (0.6-4.5) septocutaneous arteries and 3 (1-4.8) musculocutaneous arteries. DISCUSSION AND CONCLUSION: A musculocutaneous flap with the medial head of the triceps brachii muscle can be described with the muscle. The SUCA gives perforator arteries musculocutaneous and septocutaneous for the vascularization of the triceps brachii medial head. The use of local pedicled flap with similar tissue maximizes healing with a minimal morbidity of the donor site. This study demonstrated the feasibility of the medial head triceps brachii musculocutaneous flap to cover defect of the posterior aspect of the elbow.

[Pasteurellosis breast implant infection: A case report and literature review]. / Pasteurellose sur un implant mammaire ? : à propos d'un cas et revue de la littérature.

Breast implant infection is a potential complication after surgery. This case reports an unusual infection. A patient undergoes a skin sparing mastectomy for a carcinoma with an immediate breast implant reconstruction. Few days after, she consults for pain, erythema and fluctuating breast collection. The implant is removed and a lavage is done. Bacteriological cultures yield Pasteurella Multocida. She has close contact with cats. Her cat scratches a drain. It looks crucial to educate patients before they go back home. Correct postoperative cares and avoid pets are important to prevent complications.

Decrease of Thrombosis in Microsurgical Anastomoses: The Use of Intraoperative Pure Intraluminal Unfractionated Heparin.

BACKGROUND: Unfractionated heparin has anticoagulant properties by catalyzing antithrombin III, which inactivates coagulation enzymes. Used in microsurgery, it would prevent the occurrence of thrombosis during microsurgical anastomoses. The objective of this study was to evaluate the role of intraoperative irrigation of the vascular lumen with pure sodium heparin to prevent vascular thrombosis after end-to-end microsurgical anastomoses. METHODS: End-to-end anastomoses were performed on rats by 21 operators. Three surgical sites were studied (cervical, femoral, and rat tail). The first vessel was irrigated with physiological salt solution (0.9%) before, during, and before the end of the anastomosis. Whenever possible, the contralateral vessel was irrigated with pure unfractionated heparin 5,000 UI/mL. The primary endpoint was the occurrence of thrombosis 60 minutes after anastomosis. RESULTS: From November 2015 to April 2018, 247 anastomoses were performed on 229 arteries and 18 veins. One hundred twenty-five anastomoses were irrigated with physiological salt solution, 122 with pure unfractionated heparin. A 60-minute thrombosis was found on 31 anastomoses (25%) irrigated with physiological salt solution compared with 16 anastomoses (13%) irrigated with heparin, that is, a decrease in the thrombosis rate of 2.6 (p = 0.01). CONCLUSION: The use of pure unfractionated heparin in intraoperative lumen irrigation during microsurgical end-to-end anastomoses reduces the rate of vascular 60-minute thrombosis compared with physiological salt solution irrigation. It is an effective intraoperative procedure for the prevention of microsurgical thrombosis.

[Assessment of patient satisfaction following nipple-areolar complex tattooing after breast reconstruction.] / Évaluation de la satisfaction des patientes ayant bénéficié d'un tatouage de la plaque aréolomamelonnaire après reconstruction mammaire.

INTRODUCTION: Nipple-areolar complex tattooing often completes the breast mound reconstruction process after cancer surgery. However, there have been few studies evaluating patient satisfaction with this technique. OBJECTIVE: To assess patients' esthetic satisfaction with the results of tattooing performed by nurses. METHOD: Ninety-eight women participated in the study. Overall satisfaction with reconstruction and satisfaction with the tattoo's color, dimension, position, and form were determined using questionnaires completed by patients and a professional jury. RESULTS: 97% of patients reported overall satisfaction with the results of nipple-areolar reconstruction. The satisfaction rate with the tattoo's color was 67%, with dimension 96%, with form 95%, and with position 94%. The satisfaction rates of the jury were as follows: nipple-areolar reconstruction 79%; color 52%; dimension 77%; form 75%; and position 69%. DISCUSSION: On the whole, the patients were satisfied with the results one year after tattooing and their satisfaction rate was higher than that of the jury's. Only 6.1% of women required a second tattoo because of discoloration. CONCLUSION: Nipple-areolar complex tattooing has a high rate of patient esthetic satisfaction and can be performed by a trained nurse without the need for hospital admission.

Complex abdominal wall defect reconstruction using a latissimus dorsi free flap with mesh after malignant tumor resection.

PURPOSE: Extended and full-thickness abdominal wall defects are commonly reconstructed using free flaps. Published surgical outcomes involving the latissimus dorsi (LD) free flap procedure are limited and are less numerous than those with free flaps involving the thigh. The aim of this report was to describe the immediate and long-term evaluation of complex abdominal wall reconstruction using a LD free flap with mesh. PATIENTS AND METHODS: Between 2005 and 2013, nine patients with extended malignant tumors of the abdominal wall underwent surgeries. After the surgical resection, the mean defect size was 385 cm2 (range: 190-650 cm2 ). Full-thickness abdominal wall reconstruction was performed with a combination of LD free flaps and meshes. The immediate and long-term outcomes were assessed regarding the complications, sustainable strength of the abdominal wall and cancer recurrence. RESULTS: The meshes measured 927 cm2 in average (range: 500-1036 cm2 ). Eight Parietex Composite® and 1 Bard Collamend Implant® were used. No donor site complications occurred, and complete LD flap survival was achieved without partial necrosis or thrombosis. One obese patient who received a porcine dermis mesh developed an eventration four days postoperatively and exhibited a limited amount of abdominal skin necrosis around the flap. Two patients died from cancer evolution. After a mean follow-up of 60.4 months (range: 29-94 months), clinical evaluation of the abdomen revealed 2 patients without anomalies, 4 cases of abdominal bulging without functional discomfort and 1 case of major abdominal distension. CONCLUSIONS: Complex abdominal reconstruction with LD free flap and mesh allows extended satisfactory coverage with a low incidence of flap and donor site complications. However, patients should be advised of the significant risk of abdominal bulging. © 2014 Wiley Periodicals, Inc. Microsurgery 37:38-43, 2017.

The transverse musculo-cutaneous gracilis flap for breast reconstruction: How to avoid complications.

BACKGROUND: The transverse musculocutaneous gracilis (TMG) flap has become a common solution for breast reconstruction. However, the safe skin paddle limits are not yet understood. In this study, we attempted to address this issue based on our experiences with inferior and posterior skin paddle extension. METHODS: Forty-four breast reconstructions with TMG flaps performed between November 2010 and January 2014 were analyzed retrospectively. For the first 20 cases, the flap skin paddle was extended 3 cm posteriorly to the middle thigh (group 1). For the next 20 flaps (group 2), the posterior tip was limited to this line, whereas more fat was recruited inferiorly. In the four cases of group 3, the skin flap was extended posteriorly with a second vascular pedicle from the profunda artery perforator (PAP) flap. The weights and the dimensions of the flaps, operating durations, and postoperative complications of the entire series were analyzed. Groups 1 and 2 were statistically compared. RESULTS: Flap complications were statistically more frequent in group 1 compared with group 2 (45 vs. 0%, P = 0.0012); 40% posterior flap tip necrosis was observed in group 1. Conversely, donor site complications were statistically more frequent in group 2 than in group 1 (40 vs. 5%, P = 0.019) with 35% inner thigh dehiscence. In the TMG with extended PAP flap group, the operating duration was 77 min longer compared with the rest of the series with no donor site complications. In one case, limited necrosis occurred at the anterior skin tip. CONCLUSIONS: Harvesting the posterior portion of the TMG up to the middle of the posterior thigh may lead to partial flap necrosis. Extending subcutaneous fat removal under the inferior skin incision may increase the risk of donor site complications. Adding a second vascular pedicle from the PAP flap may improve posterior TMG tip perfusion at the expense of a longer operation.

Venous coupler use for free-flap breast reconstructions: specific analyses of TMG and DIEP flaps.

PURPOSE: The purpose of this report was to present the results of comparisons of anastomotic data and flap complications in the use of venous coupler in breast reconstruction with the transverse musculocutaneous gracilis (TMG) flap and the deep inferior epigastric perforator (DIEP) flap. METHODS: Over a three-year period, 95 patients suffering from breast cancer were treated with mastectomy and breast reconstruction using free flaps. We performed 121 mechanical venous anastomoses for 105 flap procedures (80 DIEP and 25 TMG). The coupler size, anastomotic duration, number of anastomoses and postoperative complications were assessed for the entire series. RESULTS: The coupling device was perfectly suitable for all end-to-end anastomoses between the vein(s) of the flap and the internal mammary vein(s). No venous thrombosis occurred. The mean anastomotic time did not significantly differ between the DIEP (330 seconds) and TMG flap procedures (352 seconds) (P = 0.069). Additionally, there were no differences in coupling time observed following a comparison of seven coupler sizes (P = 0.066). The mean coupler size used during the TMG flap procedure was smaller than that used with the DIEP (2.4 mm versus 2.8 mm) (P < 0.001). The mean size was also smaller when double venous anastomoses were required compared to single anastomosis (2.4 mm versus 2.9 mm) (P < 0.001). The double branching was more frequent with the TMG flap (28%) than with the DIEP flap (11%). CONCLUSIONS: The coupler size used was smaller for the TMG procedure and when double venous anastomosis was performed. Additionally, anastomotic time was not affected by the flap type or coupler size used or by anastomosis number.

Hyperparathyroidism-related extensor tenosynovitis at the wrist: a general review of the literature.

Extensor tenosynovitis often occurs accompanying with rheumatoid arthritis, gout, trauma, mycobacterium and dialysis-related amyloidosis. However, there is no recognition of extensor tenosynovitis accompanying with hyperparathyroidism. The purpose of this general review was to describe the clinical condition and to report the results of surgical intervention in the extensor tenosynovitis at the wrist related to hyperparathyroidism. Hyperparathyroidism is thought to be a rare disease in adult. Although renal symptoms are the commonest symptom, musculoskeletal complaints also occur in hyperparathyroidism. From our general review, hyperparathyroidism deserves consideration in the differential diagnosis of extensor tenosynovitis at the wrist.

Fifth carpometacarpal fracture dislocations fixed with Meta-HUS®: a series of 31 cases.

Fracture dislocations of the fifth carpometacarpal are usually treated by percutaneous K-wires despite occasional complications: displacement, stiffness, malunions, and arthritis. Our aims were to evaluate the use of locked K-wire fixation for these fracture dislocations. Our series includes 31 fracture dislocations, five extra-articular and 26 articular, 21 of which were at the base of the metacarpal, four at the hamate, and one involving both the hamate and the metacarpal. Mean tourniquet time was 22 min and irradiation 2 mGy. After reduction, an M4 M5 K-wire and a carpometacarpal wire were connected using an MetaHUS® connector. Immediate immobilization was allowed. Return to normal activity was resumed at 6.5 weeks. At around 15 months follow-up, mean pain score was 8.5, Quick DASH was 6.36, and overall grip strength was 92%, TAM of the fifth ray was 96% of the contralateral side. There were two displacements that were re-operated with good result, three superficial infections, and one case of stiffness. All fractures healed without arthritis. Overall, percutaneous K-wire and splinting of fracture dislocations of the fifth carpometacarpal joint is unstable, and internal fixation can cause adhesions and stiffness. Our results show that the percutaneous locked K-wire technique is a good alternative as it associates closed reduction with K-wire fixation and a solid fixation using an external connector. This technique allows immediate mobilization of the hand and removal of hardware in clinic.

Two formulations of epoprostenol sodium in the treatment of pulmonary arterial hypertension: EPITOME-1 (epoprostenol for injection in pulmonary arterial hypertension), a phase IV, open-label, randomized study.

BACKGROUND: Epoprostenol sodium with arginine-mannitol excipients (epoprostenol AM; Veletri [Actelion Pharmaceuticals Ltd, Allschwil, Switzerland]) and epoprostenol sodium with glycine-mannitol excipients (epoprostenol GM; Flolan [GlaxoSmithKline, Triangle Park, NC]) are intravenous treatments for pulmonary arterial hypertension (PAH). Epoprostenol AM contains different inactive excipients, resulting in greater stability at room temperature compared with epoprostenol GM. METHODS: In this prospective, multicenter, open-label, randomized, phase IV exploratory study, epoprostenol-naïve patients in need of injectable prostanoid therapy were randomized 2:1 to open-label epoprostenol AM or epoprostenol GM. The study period was 28 days, followed by a 30-day safety follow-up. Study aims were to descriptively compare the safety, tolerability, drug metabolite levels, and treatment effects of epoprostenol AM and epoprostenol GM in PAH. Statistical analysis was descriptive only because of the exploratory nature of the study. RESULTS: Thirty patients with PAH (18-70 years, 24 women, 20 idiopathic PAH) were randomized to epoprostenol AM (n = 20) or epoprostenol GM (n = 10). Most frequently reported adverse events included jaw pain, headache, nausea, and flushing. Two deaths occurred during the study period, and 1 death occurred during the 30-day safety follow-up period, all in patients receiving epoprostenol AM. All deaths were classified by the treating physician as unrelated to epoprostenol AM. The median (range) change from baseline to day 28 in 6-minute walk distance was 36 m (-127 to 210 m) and 49 m (-44 to 110 m) for the epoprostenol AM and epoprostenol GM groups, respectively. CONCLUSIONS: In this randomized clinical study of epoprostenol AM in PAH, use of this novel preparation with greater room temperature stability was well tolerated.

Ultrasonic elastography for the prevention of breast implant rupture: Detection of an increase with stiffness over implantation time.

Breast implants are widely used after breast cancer resection and must be changed regularly to avoid a rupture. To date, there are no quantitative criteria to help this decision. The mechanical evolution of the gels and membranes of the implants is still underinvestigated, although it can lead to early rupture. In this study, 35 breast explants having been implanted in patients for up to 17 years were characterized by ex vivo measurements of their mechanical properties. Using Acoustic Radiation Force Impulse (ARFI) ultrasound elastography, an imaging method for non-destructive mechanical characterization, an increase in the stiffness of the explants has been observed. This increase was correlated with the implantation duration, primarily after 8 years of implantation. With an increase of the shear modulus of up to a factor of nearly 3, the loss of flexibility of the implants is likely to lead to a significant increase of their risk of rupture. A complementary analysis of the gel from the explants by mass spectrometry imaging (MSI) and liquid chromatography coupled to high resolution mass spectrometry (LC-HRMS) confirms the presence of metabolites of cholesterol originating from the breast tissues, which most likely crossed the membrane of the implants and most likely degrades the gel. By observing the consequences of the physical-chemical mechanisms at work within patients, this study shows that ultrasound elastography could be used in vivoas a quantitative indicator of the risk of breast implant rupture and help diagnose their replacement.

Aging of non-implanted Natrelle™ gel breast implants.

This study questions the aging of non-implanted breast prostheses for a period of 9-60 months. Every 6 months, two non-implanted Natrelle™ prostheses were tested to measure the strength at break, the elongation at break, and the thickness of the shell. Then, the breaking stress was calculated from the preceding quantities. All these quantities were observed by separating the samples taken from the anterior and posterior sides of the prostheses. One-way ANOVA analyses (analysis of variance) were performed to define the influence of aging duration, lot membership, and side. In addition, the elongation at break and the thickness of the shell showed significant variations as a function of aging regardless of the side but without any trend emerging. For other quantities, there were significant disparities between the anterior and posterior sides of the prostheses, differences between prostheses from different lots, and similarities between prostheses from the same lot. Finally, the thickness is an important parameter. Since manufacturing is a manual process, it is necessary to check the thickness, which must be homogeneous on both sides. Always weaker on the anterior side than on the posterior side, it influences the mechanical properties. We recommend, like other studies, that its control be part of the quality controls during manufacturing.

Hyperkinetic seizures in patients with temporal lobe epilepsy: clinical features and outcome after temporal lobe resection.

PURPOSE: Temporal lobe epilepsy (TLE) is usually associated with automatisms. Hyperkinetic seizures are supposed to be unusual. Because we witnessed several patients with TLE and ictal hyperkinetic symptoms, we retrospectively assessed the number, clinical findings, and seizure outcome in such patients who had undergone temporal lobe resection. METHODS: We reviewed medical history, video-electroencephalography (EEG) recording and neuroimaging of adult patients who underwent epilepsy surgery for TLE at the Kork Epilepsy Center over the last 20 years with a minimum postoperative follow-up of 12 months. KEY FINDINGS: Among 294 patients who were resected exclusively in the temporal region, we identified 17 (6%) who presented with hyperkinetic semiology such as violent vocalization, complex movements of the proximal segments of the limbs, rotation of the trunk, pelvic thrusting, or early tonic or dystonic posturing. Most of the patients had a preceding aura. Ictal EEG activity was located in the corresponding temporal region, usually with a wide distribution over temporal electrodes with fast spread to unilateral frontal electrodes and to the contralateral side. Neuroimaging revealed extended lesions in the temporal lobe involving mesial and neocortical structures. Most of the patients underwent classical anterior temporal lobe resection including amygdalo-hippocampectomy. Fourteen patients (82%) became completely seizure-free (Engel class Ia). Histopathology showed mainly focal cortical dysplasia plus hippocampal sclerosis. SIGNIFICANCE: Hyperkinetic seizure semiology may occasionally occur in patients with TLE and is, therefore, no contradiction to the hypothesis of TLE if scalp EEG patterns and neuroimaging findings correspond. The postoperative seizure outcome is favorable in such patients and not different from outcome data in classical TLE.

Complications following autologous latissimus flap breast reconstruction.

Use of an autologous latissimus flap in breast reconstruction accounts for a supple and natural look of reconstructed breast. Most common postoperative complication, seroma, became more of a rule then an exception when it comes to postoperative evaluation of the patients who underwent this reconstructive procedure. A retrospective study analysing and evaluating different complication rates in 20 patients who underwent breast reconstruction by autologous latissimus flap, was conducted. All patients included in the study were operated at the Department of plastic surgery of Hôpital Civil in Strasbourg, France, between 1996 and 2008. The complication rates were noted as follows: seroma in 19 of our 20 patients (95%), late hypertrophic scarring in 3 patients (15%), postoperative surgical site hematoma in 3 patients (15%), and 2 patients (10%) presented postoperative chronic back pain. Different options used in seroma treatment and prevention (subcutaneous-fascia anchor sutures of donor site, application of corticosteroids by injection into donor site postoperatively, passive drainage) can reduce seroma formation and thus overall complication rates, leading to much faster patient's recovery time and return to normal daily activities.

Use of the Propeller Lumbar Perforator Flap: A Series of 32 Cases.

Lumbosacral substance defect is a challenge in reconstructive surgery because few coverage solutions are available in this anatomical region. Lumbar artery perforator flaps (LAPs) have been progressively developed and make it possible to solve very complex situations. We report a multicenter study on LAP performed to treat medium and low lumbar defects of various etiologies, to highlight the versatility of this flap as well as its robustness and reproducibility. METHODS: Between 2012 and 2019, 32 LAPs were performed in the Toulouse and Strasbourg University hospitals. Etiologies of the defects encountered were diverse: chronic wounds following neurosurgery, oncodermatology, burn sequelae, and ballistic injury. All LAPs were used in their pedicled form, turned as propeller, and combined or not with other flaps. RESULTS: We treated 31 patients with 32 LAPs. Average flap size was 14.3 cm (range 8-26) × 6.5 cm (range 5-10), and average arc of rotation was 131.3 degrees (range 70-180 degrees). Only 4 patients (12.9%) presented partial necrosis, but required no other covering procedure because secondary healing was sufficient. No coverage failure was reported. Average follow-up duration was 9.7 months (range 1-18). CONCLUSIONS: In the case of lumbosacral defects of various etiologies, propeller LAP is a reliable and efficient surgical procedure, offering the advantage of low donor site morbidity. The reconstructive surgeon should propose this technique to patients as a first-line option where surgery is indicated.

Incidence of breast implant rupture in a 12-year retrospective cohort: Evidence of quality discrepancy depending on the range.

BACKGROUND & OBJECTIVE: The majority of studies assessing the rupture rate of breast implants were performed by the breast implant manufacturing industry with questionable independence. After repetitive removals of ruptured implants from the same model, our team decided to assess the rupture rate and the estimated risk thereof for most of the silicone gel-filled implants we have used since they regained market approval in France in 2001. METHODS: Our study is a retrospective cohort of 809 patients operated in our University Hospital from 2001 to 2013 for cosmetic or reconstructive goals. We could track 1561 implants, 90% of them from the same manufacturer, Allergan (Irvine, CA, USA). For each of those, we gathered their exact reference, date of implantation, surgical approach, status, last follow-up visit or the eventual date, and cause of removal. RESULTS: Of 225 explanted devices, only 27 were ruptured, all from the Allergan brand. Risks of removal for rupture were estimated: 0.5% at 1000 days, 6% at 2000 days, and 14% at 3000 days. Risks were significantly different between the models from this same manufacturer. One of the range of macro-textured round implants showed risks of removal for rupture of 33% at 3000 days compared to 6% for the anatomically shaped range. CONCLUSIONS: These results suggest a qualitative discrepancy among the different ranges of breast implants of a single manufacturer within the same timeframe of implantation. To determine the in vivo lifespan of the implants that we use more precisely and sooner, we suggest that each removed implant should be analyzed for wear and tear, independently from the industry.

Complex posterior thoracic wall reconstruction using a crossover combined latissimus dorsi and serratus anterior free flap.

Radical resection of an extended malignant sarcoma of the chest wall requires full-thickness thoracic chest wall reconstruction. Reconstruction is tedious in the case of posteriorly located tumours, because the ipsilateral pedicled myocutaneous latissimus dorsi flap is involved and hence not usable for soft tissue coverage. We report an original case of a left giant dorsal chondrosarcoma originating from the 11th costovertebral joint. After extended resection and skeletal reconstruction, soft tissue coverage was achieved with an original contralateral free flap encompassing both latissimus dorsi and serratus anterior muscles. The flap pedicle was anastomosed to the ipsilateral thoracodorsal vessels.

The Transverse Musculocutaneous Gracilis Free Flap: Virtual Animation-Assisted Dissection and Application in Breast Reconstruction.

The transverse musculocutaneous gracilis free flap is a valuable choice for autologous tissue, unilateral or bilateral breast reconstruction. This procedure is an excellent and customized option for immediate or delayed breast reconstruction in patients with small to moderate size breasts. Few descriptions of flap dissection and breast mound shaping are available. In this first educational video, the authors report the original dissection of the transverse musculocutaneous gracilis free flap used for breast reconstruction. Virtual animations insist on surgical key points and relevant details of the harvesting of the flap.