Introducing an innovative surgical technique: gluteal turnover flap for posterior vaginal wall reconstruction: a case series.

Four patients with rectal cancer required reconstruction of a defect of the posterior vaginal wall. All patients received neoadjuvant (chemo)radiotherapy, followed by an en bloc (abdomino)perineal resection of the rectum and posterior vaginal wall. The extent of the vaginal defect necessitated closure using a tissue flap with skin island. The gluteal turnover flap was used for this purpose as an alternative to conventional more invasive myocutaneous flaps (gracilis, gluteus, or rectus abdominis). The gluteal turnover flap was created through a curved incision at a maximum width of 2.5 cm from the edge of the perineal wound, thereby creating a half-moon shape skin island. The subcutaneous fat was dissected toward the gluteal muscle, and the gluteal fascia was incised. Thereafter, the flap was rotated into the defect and the skin island was sutured into the vaginal wall defect. The contralateral subcutaneous fat was mobilized for perineal closure in the midline, after which no donor site was visible.The duration of surgery varied from 77 to 392 min, and the hospital stay ranged between 3 and 16 days. A perineal wound dehiscence occurred in two patients, requiring an additional VY gluteal plasty in one patient. Complete vaginal and perineal wound healing was achieved in all patients. The gluteal turnover flap is a promising least invasive technique to reconstruct posterior vaginal wall defects after abdominoperineal resection for rectal cancer.

Pectoralis major muscle turnover flap reconstruction for treatment of deep sternal wound infection in infants and children.

OBJECTIVE: The aim of the study is to assess the therapeutic effect and applicability of pectoralis major muscle turnover flap (PMMTF) reconstruction for treatment of deep sternal wound infection (DSWI) after cardiac surgery in infants and children. METHODS: From March 2013 to October 2021, 23 patients with DSWI after cardiac surgery underwent PMMTF reconstruction. The data and outcomes of the patients were retrospectively analyzed. RESULTS: Twenty patients were treated with unilateral PMMTF reconstruction, and three patients were treated by bilateral PMMTF. All of the sternal wounds healed successfully. All patients survived and were discharged without evidence of infection. In a follow-up period, ranging from 15 to 83 months (mean 32.6 months), all patients demonstrated normal development with no limitations to limb movements. There were no signs of chronic sternal infection in all of them. CONCLUSION: PMMTF reconstruction is a simple, feasible, and effective treatment of DSWI after cardiac surgery in infants and children, with minimal developmental problems.

Reverse Dermis Flap for Coverage of Distal Leg and Ankle Defects.

Soft tissue defects of the distal third of the leg and ankle, which frequently expose tendon, bone or osteosynthesis material, are difficult to cover and pose a major challenge to the plastic surgeon. Traditional reconstructive options for this region usually require complex flaps which made them unsuitable for elderly patients or those with multiple comorbidities. We hereby present the reverse dermis flap as an easy and reliable choice to cover this type of wounds and refer our experience in 9 cases in which clinical, operative, and follow-up data were recorded. Of the 9 flaps performed, 8 survived completely and 1 presented a partial flap necrosis, requiring additional surgery. No other operative procedure was required. In conclusion, the reversed dermis flap is a simple, quick, noninvasive, and safe technique for coverage of noble structures such as tendon or bone in the distal third of the leg that every plastic surgeon should incorporate in his surgical armamentary.

Perineal wound closure using gluteal turnover flap or primary closure after abdominoperineal resection for rectal cancer: study protocol of a randomised controlled multicentre trial (BIOPEX-2 study).

BACKGROUND: Abdominoperineal resection (APR) for rectal cancer is associated with high morbidity of the perineal wound, and controversy exists about the optimal closure technique. Primary perineal wound closure is still the standard of care in the Netherlands. Biological mesh closure did not improve wound healing in our previous randomised controlled trial (BIOPEX-study). It is suggested, based on meta-analysis of cohort studies, that filling of the perineal defect with well-vascularised tissue improves perineal wound healing. A gluteal turnover flap seems to be a promising method for this purpose, and with the advantage of not having a donor site scar. The aim of this study is to investigate whether a gluteal turnover flap improves the uncomplicated perineal wound healing after APR for rectal cancer. METHODS: Patients with primary or recurrent rectal cancer who are planned for APR will be considered eligible in this multicentre randomised controlled trial. Exclusion criteria are total exenteration, sacral resection above S4/S5, intersphincteric APR, biological mesh closure of the pelvic floor, collagen disorders, and severe systemic diseases. A total of 160 patients will be randomised between gluteal turnover flap (experimental arm) and primary closure (control arm). The total follow-up duration is 12 months, and outcome assessors and patients will be blinded for type of perineal wound closure. The primary outcome is the percentage of uncomplicated perineal wound healing on day 30, defined as a Southampton wound score of less than two. Secondary outcomes include time to perineal wound closure, incidence of perineal hernia, the number, duration and nature of the complications, re-interventions, quality of life and urogenital function. DISCUSSION: The uncomplicated perineal wound healing rate is expected to increase from 65 to 85% by using the gluteal turnover flap. With proven effectiveness, a quick implementation of this relatively simple surgical technique is expected to take place. TRIAL REGISTRATION: The trial was retrospectively registered at Clinicaltrials.gov NCT04004650 on July 2, 2019.

Feasibility of a subcutaneous gluteal turnover flap without donor site scar for perineal closure after abdominoperineal resection for rectal cancer.

BACKGROUND: Abdominoperineal resection (APR) carries a high risk of perineal wound morbidity. Perineal wound closure using autologous tissue flaps has been shown to be advantageous, but there is no consensus as to the optimal method. The aim of this study was to evaluate the feasibility of a novel gluteal turnover flap (GT-flap) without donor site scar for perineal closure after APR. METHODS: Consecutive patients who underwent APR for primary or recurrent rectal cancer were included in a prospective non-randomised pilot study in two academic centres. Perineal reconstruction consisted of a unilateral subcutaneous GT-flap, followed by midline closure. Feasibility was defined as uncomplicated perineal wound healing at 30 days in at least five patients, and a maximum of two flap failures. RESULTS: Out of 17 potentially eligible patients, 10 patients underwent APR with GT-flap-assisted perineal wound closure. Seven patients had pre-operative radiotherapy. Median-added theatre time was 38 min (range 35-44 min). Two patients developed a superficial perineal wound dehiscence, most likely because of the excessive width of the skin island. Two other patients developed purulent discharge and excessive serosanguinous discharge, respectively, resulting in four complicated wounds at 30 days. No flap failure occurred, and no radiological or surgical reinterventions were performed. Median length of hospital stay was 10 days (IQR 8-12 days). CONCLUSIONS: The GT-flap for routine perineal wound closure after APR seems feasible with limited additional theatre time, but success seems to depend on correct planning of the width of the flap. The potential for reducing perineal morbidity should be evaluated in a randomised controlled trial.

Adipofascial perforator flaps: Its role in reconstruction of soft-tissue defects of lower leg and ankle.

BACKGROUND: Despite advances in surgical skills, adipofascial flaps are still less preferred option for coverage of leg defect. We evaluate the use of perforator-based adipofascial flap in small-to-medium-sized soft-tissue defects in the lower limb. PATIENTS AND METHODS: After localisation of perforators along the major axial vessels in the lower limb using handheld Doppler, adipofascial flap based on the nearest best perforator of anterior tibial artery, posterior tibial artery and peroneal artery was raised to cover soft-tissue defect in 21 patients. The flap was transposed over the defect and covered by split-skin graft. Donor site was primarily closed. Flap complications, functional and aesthetic outcomes are noted in follow-up. RESULTS: There was partial loss of flap in five patients. After debridement and dressings, split-skin grafting was done for four patients and one patient was managed with local flap. Scar over the flap was stable with no reports of recurrent ulceration or breakdown of wound in 6-month follow-up. Four of five patients reported adequate healing of the fractured bone. Average visual analogue score was 8.24/10 for appearance of donor site as evaluated by the patient. CONCLUSIONS: Perforator-based adipofascial flap is a good alternative for coverage of small-to-medium-sized soft-tissue defect of the leg, particularly over the malleolus and lower part of the leg. Use of adipofascial tissue and primary closure of the donor site causes minimal donor-site morbidity. Adipofascial perforator flap provides aesthetically superior recipient-site scar with satisfactory functional outcome.

A novel technique for managing open abdomen with the combined use of mesh-mediated traction and the bilateral anterior rectus abdominis sheath turnover flap method: how to do it.

Proper management of abdominal compartment syndrome and open abdomen is important for improving the survival of critically ill patients. However, in cases requiring a prolonged period of open abdomen, it is frequently difficult to perform definitive fascial closure due to lateralization of the abdominal musculature. We herein present a novel combined technique for managing open abdomen. A 74-year-old male with diffuse peritonitis was transferred to our department, after which a long period of open abdomen made it difficult to achieve fascial closure. Polypropylene mesh was sutured to the fascial edges to reduce the gap, which was then serially tightened under negative pressure wound therapy. However, since it was not possible to accomplish definitive fascial closure, abdominal closure was performed using the bilateral anterior rectus abdominis sheath turnover flap method after removing the mesh, without any complications. This combined technique may be an effective alternative in patients requiring open abdomen with subsequent difficulty in achieving definitive fascial closure.

Reconstruction of Lower Eyelid with Nasolabial Flap for Anterior Lamella and Turnover Flap for Posterior Lamella.

Reconstruction of full-thickness eyelid defects is done to provide a mobile lid with corneal protection, having good aesthetic quality, and acceptable donor site morbidity. Various flap procedures have been described and used for the lower eyelid reconstruction; however, the nasolabial flap is rarely employed. It is a random pattern cutaneous flap with redundant blood supply from the perforating branches of the facial and angular arteries and can be used as an inferiorly or superiorly based flap. Here, we aim to present the clinical results of using the superiorly based nasolabial island flap for reconstruction of anterior lamella and turnover/hinge flap of infraorbital skin and palpebral conjunctiva with support of conchal cartilage for reconstruction of posterior lamella for lower eyelid defect. To our best knowledge, this reconstructive combination of flaps has not been described previously for total and full-thickness posttraumatic defect of lower eyelid.

Better nerve regeneration with distally based fascicular turnover flap than with conventional autologous nerve graft in a rat sciatic nerve defect model.

The authors hypothesize that a fascicular turnover flap will achieve better nerve regeneration in nerve gap repair than a conventional nerve graft in a rat sciatic nerve defect model. Seven-millimeter-long sciatic nerve defects were repaired with an autologous nerve graft, a proximal fascicular turnover flap, or a distal fascicular turnover flap. Following walking footprint analysis 8 weeks after the surgery, the gastrocnemius-soleus muscles of the hind limbs, nerve graft, and flaps were harvested for wet muscle weight assessment, immunohistochemistry, and transmission electron microscopy. The distal fascicular turnover flap exhibited improvement in the sciatic function index similar as that observed for the autologous nerve graft. Histologically, cross sections showed a higher staining intensity for S-100 in the distal fascicular turnover flap group than for S-100 in the nerve graft group (p = 0.01). In the longitudinal sections, the staining intensity for NF-200 was higher in the distal fascicular turnover flap group than in the nerve graft (p = 0.009) and proximal fascicular turnover flap (p = 0.004) groups. More mature capillaries were observed in the proximal (p < 0.001) and distal (p = 0.029) fascicular turnover flap groups than in the nerve graft group. Transmission electron microscopy results showed a compact, regular myelin sheath around the myelinated nerve fibers in the distal fascicular turnover flap group, unlike observations in the nerve graft and proximal fascicular turnover flap groups. This study demonstrates better nerve regeneration in nerve gap repair with the distal fascicular turnover flap than with the conventional nerve graft.

Reconstruction of medial epicanthal fold using v-y advancement and turnover flap.

BACKGROUND: Since the 1900s, many methods have been developed to correct the epicanthal fold. Increased use of epicanthoplasty has yielded unsatisfactory results. OBJECTIVES: To describe a method of epicanthal fold reconstruction using V-Y advancement and turnover flap for clinical application. This method is simpler than conventional surgery. It is easy to perform with excellent esthetic results. METHODS: The authors performed medial epicanthal fold reconstruction in 82 patients (16 males and 66 females) between April 2014 and September 2017. All patients enrolled in this retrospective study underwent surgical procedures at the authors' institution. Interepicanthal distance was the distance between medial epicanthal folds. It was measured with a surgical ruler. RESULTS: Before surgery, mean interepicanthal distance was 35.4 mm. Using our surgical technique, successful outcome was achieved in 79 (96.3%) patients with satisfactory results. The mean distance between the medial epicanthi post-surgery was 38.6 mm, increasing the total length by 3.2 mm without showing any major postsurgical complications. DISCUSSION: Epicanthal fold reconstruction using V-Y advancement and turnover flap is a simple and effective technique that can readily improve the frontal view. It improves periorbital contouring, makes eyes look natural without fully showing the caruncle, and yields excellent esthetic results. In particular, there were no major visible scars following eversion suture.

Fascicular turnover flap in the reconstruction of facial nerve defects: an experimental study in rats.

The purpose of this study was to assess the utility of a fascicular turnover flap for facial nerve repair and to investigate its possible application in the field of facial nerve repair using a rat model of facial paralysis. Twenty-four Wistar rats were used in this study. A left vibrissal muscle palsy model was established via excision of the buccal and marginal branches through a periauricular incision. In Group 1, the nerve gap was not reconstructed. In Group 2, the nerve gap of the marginal mandibular branch was reconstructed using an autograft, and in Group 3, the gap was reconstructed using a fascicular turnover flap. At 12 weeks after the operation, the nerve regeneration was assessed based on clinical, histopathological and electrophysiological evaluations. The functional recovery of the vibrissal muscle was observed with a fascicular turnover flap. The functional recovery of whisker movement was almost same between Groups 2 and 3 (p = .57). The histopathological examinations almost same result between Groups 2 and 3 (p = .17). The compound muscle action potential after reconstruction was also almost same between Groups 2 and 3 (p = .99). We found that the fascicular turnover flap could be applied to facial nerve gap reconstruction. However, further evaluations will be necessary to clarify its indication and mechanism in human.

Twenty years' follow-up of a de-epithelialised turnover flap.

The authors have used the de-epithelialised turnover flap (Thatte's Flap) for covering compound defects over the tendo-achilles in 31 patients in the period covering 1980-2000. Two of these patients have come up for follow-up after 20 years. In this late follow-up, the results are good and the tendon which was bridged by the dermis of the flap is functioning to allow the patients to stand on their toes. The de-epithelialised turnover flap is a simple and easy technique giving good long-term results. In spite of all the new advances in flap coverage, the de-epithelialised turnover flap is a good alternative for the tendo-achilles area in the armamentarium of a plastic surgeon.

A Devasting Course of an Iliopsoas Muscle Abscess Subsequently Leading to Septic Shock, Septic Hip Arthritis, and Extended Gluteal Soft Tissue Necroses in an Elderly Immunocompromised Patient with Multiple Carcinomas: A Case Report and Brief Review of Literature.

BACKGROUND: A devasting course of Iliopsoas Muscle (IPM) abscess remains a challenging therapeutic problem. METHODS: A 69-year-old polymorbid male had a history of multiple carcinomas and presented with advanced stage of septic shock due to a right IPM abscess which communicated with the right hip joint and subsequently led to septic hip arthritis accompanied with post-infectious right gluteal deep soft tissue necroses. Management of surgical treatment included abscess revision, coverage with the use of Long Head Biceps Femoris Muscle (LHBFM) 180° turnover flap, and creating a Girdlestone resection-arthroplasty. RESULTS: After a duration of patient's hospitalization of six months that included the necessity of artificial respiration over two months accompanied with in summary 18 required surgical procedures, the patient could be recovered successfully regarding his polymorbidity and his low-demand claims in activities of daily living with his Girdlestone resection-arthroplasty. CONCLUSION: Recovery of immunocompromised patients with those life-threatening situations can only be achieved by an interdisciplinary management. The LHBFM 180° turnover flap can be useful for filling off post-infectious deep soft tissue cavities communicating with the hip joint. The definitive Girdlestone resection-arthroplasty for treatment of septic hip arthritis is the method of choice for mobilization of elderly polymorbid patients with low demand claims in their activities of daily living.

Urethroplasty Using A Turnover Flap for Correction of Problematic Urethrocutaneous Fistula: A Case Report.

Urethral fistula formation after urethroplasty for hypospadias is a frequent complication. Repeated failures can occur even after multiple attempts at repair. A surgical procedure is described for a problematic resistant urethrocutaneous fistula (UF) with the transverse turnover flap using the Buck's fascia of the corpus cavernosum. A 23-year-old male was admitted to our hospital with recurrent coronal UF. We placed a suprapubic catheter in the bladder and operated the patient with the flap technique combined with glanuloplasty. In 3rd month follow up, the patient had no fistula with normal voiding.

Therapeutic Outcomes of Pectoralis Major Muscle Turnover Flap in Mediastinitis.

BACKGROUND: This study aimed to evaluate the therapeutic results and safety of pectoralis major muscle turnover flaps in the treatment of mediastinitis after coronary artery bypass grafting (CABG) procedures. METHODS: Data regarding 33 patients with post-CABG deep sternal wound infections (DSWIs) who underwent pectoralis major muscle turnover flap procedures in the Emam Reza and Ghaem Hospitals of Mashhad, Iran were reviewed in this study. For each patient, age, sex, hospital stay duration, remission, recurrence, and associated morbidity and mortality were evaluated. RESULTS: Of the 2,447 CABG procedures that were carried out during the time period encompassed by our study, DSWIs occurred in 61 patients (2.5%). Of these 61 patients, 33 patients (nine females [27.3%] and 24 males [72.7%]) with an average age of 63±4.54 years underwent pectoralis major muscle turnover flap placement. Symptoms of infection mainly occurred within the first 10 days after surgery (mean, 10.24±13.62 days). The most common risk factor for DSWIs was obesity (n=16, 48.4%) followed by diabetes mellitus (n=13, 39.4%). Bilateral and unilateral pectoralis major muscle turnover flaps were performed in 20 patients (60.6%) and 13 patients (39.4%), respectively. Complete remission was achieved in 25 patients (75.7%), with no recurrence in the follow-up period. Four patients (12.1%) needed reoperation. The mean hospitalization time was 11.69±6.516 days. Four patients (12.1%) died during the course of the study: three due to the postoperative complication of respiratory failure and one due to pulmonary thromboembolism. CONCLUSION: Pectoralis major muscle turnover flaps are an optimal technique in the treatment of post-CABG mediastinitis. In addition to leading to favorable therapeutic results, this flap is associated with minimal morbidity and mortality, as well as a short hospitalization time.

Application of split gluteus maximus muscle--adipofascial turnover flap and subcutaneous tension-reducing suture technique in repair of decubitus ulcers.

The purpose of this study was to study the clinical effect of split gluteus maximus muscle-adipofascial turnover flap and tension-reducing suture in the treatment of decubitus ulcers. Thirty-one cases of sacrococcygeal decubitus ulcers were repaired by split gluteus maximus muscle-adipofascial turnover flap. The surface of flaps ranged from 5×6 cm to 7×8 cm. The skin was then closed, primarily using subcutaneous tension-reducing suture. Eighty-eight percent of the flaps (27 of 31) healed primarily. The split gluteus maximus muscle-adipofascial turnover flap and tension-reducing suture technique was found to be a highly efficient method of repairing decubitus ulcers with a relatively low ratio of recurrence.

Therapeutic Outcomes of Pectoralis Major Muscle Turnover Flap in Mediastinitis

BACKGROUND: This study aimed to evaluate the therapeutic results and safety of pectoralis major muscle turnover flaps in the treatment of mediastinitis after coronary artery bypass grafting (CABG) procedures. METHODS: Data regarding 33 patients with post-CABG deep sternal wound infections (DSWIs) who underwent pectoralis major muscle turnover flap procedures in the Emam Reza and Ghaem Hospitals of Mashhad, Iran were reviewed in this study. For each patient, age, sex, hospital stay duration, remission, recurrence, and associated morbidity and mortality were evaluated. RESULTS: Of the 2,447 CABG procedures that were carried out during the time period encompassed by our study, DSWIs occurred in 61 patients (2.5%). Of these 61 patients, 33 patients (nine females [27.3%] and 24 males [72.7%]) with an average age of 63+/-4.54 years underwent pectoralis major muscle turnover flap placement. Symptoms of infection mainly occurred within the first 10 days after surgery (mean, 10.24+/-13.62 days). The most common risk factor for DSWIs was obesity (n=16, 48.4%) followed by diabetes mellitus (n=13, 39.4%). Bilateral and unilateral pectoralis major muscle turnover flaps were performed in 20 patients (60.6%) and 13 patients (39.4%), respectively. Complete remission was achieved in 25 patients (75.7%), with no recurrence in the follow-up period. Four patients (12.1%) needed reoperation. The mean hospitalization time was 11.69+/-6.516 days. Four patients (12.1%) died during the course of the study: three due to the postoperative complication of respiratory failure and one due to pulmonary thromboembolism. CONCLUSION: Pectoralis major muscle turnover flaps are an optimal technique in the treatment of post-CABG mediastinitis. In addition to leading to favorable therapeutic results, this flap is associated with minimal morbidity and mortality, as well as a short hospitalization time.

A Dermal Turnover Flap for Treating the Accessory Tragus

PURPOSE: Accessory tragus is a fairly common congenital malformation and usually located at pretragal area. Surgical removal is a common treatment of accessory tragus irrespective of location and morphology. Most accessory tragi do not have depression site around them, but some do. So in those cases, simple surgical excision was not enough to promote the aesthetic facial appearance. For depression site remodeling, the excess amount of skin and cartilage need to be remained partially instead of total excision. This method can achieve the symmetric contour of pretragal area. The authors excised the epidermis and cartilaginous tissue totally and remained the dermis for reconstruction of the depression site around accessory tragus. The depression site is filled with dermal turnover flap. The purpose of this report is to present new idea to promote cosmetic result in treatment of accessory tragus containing the depression site. METHODS: Two patients had a pair of accessory tragi at pretragal area. One was a common featured accessory tragus, but the other was different. Depression site was found around accessory tragus. After epidermis and cartilaginous tissue were removed from it, dermis component was used as turnover flap for reconstruction of depression site. RESULTS: After accessory tragus was removed and depression site was reconstructed, facial contour and cosmetic result was achieved. Complication such as flap necrosis and wound dehiscence was not observed. CONCLUSION: The accessory tragus has variant morphology and degree of invasive depth. And some has a depression site around them. In those cases, simple surgical removal results in morphological distorsion and do not promote facial symmetry. The authors suggest dermal turnover flap as reconstruction method of the depression site. This method improves both surgical outcome and cosmetic result.

Experiencia con el uso del colgajo en voltereta en pacientes del Hospital del Trabajador de Santiago: una alternativa válida / Experience using turn over flap in patients at the Hospital del Trabajador de Santiago: a valid alternative

Background: The plastic surgeon is frequently faced with need of choosing from a variety of local and distant flaps for the coverage of difficult wounds. In 1981, Thatte described a local flap consisting in a random pattern de epithelialized flap adjacent to the lesion rotated in 180° with a dermoepidermal graft to cover the flap and donating zone. Objective: To present the experience of the Plastic Surgery and Burns Unit of the Hospital del Trabajador de Santiago with the use of this flap. Material: Retrospective study of 16 Turn Over flaps in 15 patients. Results: The complications recorded were 1 case of graft loss and 2 partial lost of the flap. We didn't observe complications directly related to the flap. Conclusions: This type of flap is another therapeutic alternative in certain cases. Rate Base: Length = 1:2 is appropriate to ensure irrigation.

Frecuentemente el cirujano plástico se enfrenta a la necesidad de utilizar colgajos para lograr cubrir una serie de defectos de cobertura cutánea. En 1981, Thatte describió una nueva técnica de colgajo, la que consistía en el levantamiento de un colgajo random desepitelizado, anexo a la lesión, y posteriormente doblarlo sobre su base, para finalmente ser injertado junto con la zona dadora. Nuestro objetivo es presentar la experiencia del Servicio de Cirugía Plástica y Quemados del Hospital del Trabajador de Santiago con el uso de este colgajo. Se revisó en forma retrospectiva el resultado de 16 colgajos en 15 pacientes realizados con esta técnica. Se observó en 1 caso pérdida del injerto y en 2 casos pérdida parcial del colgajo en voltereta. Durante el seguimiento no se observaron complicaciones directamente relacionadas con el colgajo. Nos parece que este tipo de colgajo es una alternativa válida en determinados casos. La proporción base: longitud = 1: 2 es adecuada para asegurar su irrigación.