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BACKGROUND Complications following vascular procedures involving the groin can lead to significant morbidity. Achieving stable soft tissue coverage over sites of revascularization can help mitigate complications. Prior evidence supports the use of muscle flaps in reoperative groins and in high risk patient populations to reduce postoperative complications. Data regarding the use of prophylactic muscle flap coverage of the groin is lacking. Therefore, the purpose of this study is to evaluate the effect of immediate prophylactic muscle flap coverage of vascular wounds involving the groin. METHODS A retrospective cohort study was performed on all patients undergoing primary open vascular procedures involving the groin for occlusive, aneurysmal, or oncologic disease between 2014 and 2020 at a single institution where plastic surgery was involved in closure. Patient demographics, comorbidities, surgical details, and postoperative complications were compared between patients who had sartorius muscle flap coverage of the vascular repair versus layered closure alone. RESULTS A total of 133 consecutive groins were included in our analysis. A sartorius flap was used in 115 groins (86.5%) and a layered closure was used in 18 (13.5%). Wound breakdown was similar between groups (25.2% sartorius vs. 38.9% layered closure, P = 0.26). However, the rate of reoperation was significantly higher in the layered closure group (50.0% vs. 12.2%, P < 0.01). Among patients who experienced wound breakdown (N = 36), a larger proportion of layered closure patients required operative intervention (71.4% vs. 20.7%, P = 0.02). Other rates of complications were not statistically different between groups. CONCLUSIONS In patients undergoing primary open vascular procedures involving the groin, patients who underwent prophylactic sartorius muscle flap closure had lower rates of reoperation. Although incisional breakdown was similar between the groups overall, the presence of a vascularized muscle flap overlying the vascular repair was associated with reduced need for reoperation and allowed more wounds to be managed with local wound care alone. Consideration should be given to this low morbidity local muscle flap in patients undergoing vascular procedures involving the groin.

Summary The gastrocnemius muscle flap remains a workhorse for lower extremity reconstruction. It provides ample vascularized tissue, is extremely reliable, and can be dissected with ease. However, conventional flap harvest requires additional incisions which increase morbidity. Endoscopic techniques have been described in the harvest of various muscle flaps but none have yet described an effective, minimally-invasive technique for medial gastrocnemius muscle harvest in a clinical case. We present a minimally invasive technique for the harvest of a medial gastrocnemius muscle flap without additional incision, thereby minimizing donor site morbidity and cosmetic deformity.

Volumetric muscle loss (VML) VML is defined as the loss of a critical mass of skeletal muscle that overwhelms the muscle's natural healing mechanisms, leaving patients with permanent functional deficits and deformity. The treatment of these defects is complex, as skeletal muscle is a composite structure that relies closely on the action of supporting tissues such as tendons, vasculature, nerves, and bone. The gold standard of treatment for VML injuries, an autologous muscle flap transfer, suffers from many shortcomings but nevertheless remains the best clinically available avenue to restore function. This review will consider the use of composite tissue engineered constructs, with multiple components that act together to replicate the function of an intact muscle, as an alternative to autologous muscle flaps. We will discuss recent advances in the field of tissue engineering that enable skeletal muscle constructs to more closely reproduce the functionality of an autologous muscle flap by incorporating vasculature, promoting innervation, and reconstructing the muscle-tendon boundary. Additionally, our understanding of the cellular composition of skeletal muscle has evolved to recognize the importance of a diverse variety of cell types in muscle regeneration, including fibro/adipogenic progenitors and immune cells like macrophages and regulatory T cells. We will address recent advances in our understanding of how these cell types interact with, and can be incorporated into, implanted tissue engineered constructs.

Dual innervation in free muscle flap facial reanimation has been used to create a functional synergy between the powerful commissure excursion that can be achieved with the masseter nerve and the spontaneity that can be derived from a cross-face nerve graft. The gracilis has been the most frequently used muscle flap, and multiple combinations of neurorrhaphies have been described, including the masseter to the obturator (end-to-end) combined with a cross-face nerve graft to the obturator (end-to-side) and vice versa. Single and staged approaches have been reported. Minimally, dual innervation is as effective as using the motor nerve to masseter alone.

Exposure of critical structures such as joints, bones, ligaments, and tendons necessitates expeditious closure. The longer these structures remain open to the environment, the higher the risk is for that patient developing osteomyelitis and an amputation. Muscle flaps remain often first choice when dealing with bone infections associated with osteomyelitis, soft tissue infections, and large cavities. Foot defects are a challenge especially in the absence of microsurgical expertise. Intrinsic local flaps of the foot can be an option to cover defects. This article describes local intrinsic muscle flaps for coverage of foot defects.

Highlights • Surgical intervention is indicated in cases of SCJ osteomyelitis after failure of conservative management. It provide definitive management when the joint shows signs of destruction in CT scan. • SCJ debridement followed by delayed resection of the joint together with the surrounding infected tissue including bone and cartilages, offer better results than merely debridement alone. • Pectoralis muscle flap achieves best result in the management of sternoclavicular joint osteomyelitis after resection of the joint., Introduction Sternoclavicular joint (SCJ) osteomyelitis is a very rare condition. Here, we report an uncommon case of a complicated SCJ osteomyelitis in a patient with an anterior chest wall trauma. Presentation of case A 61-year-old male a known case of dyslipidemia, hypertension (HTN), and type II diabetes mellitus (T2DM). The patient presented with pain and erythema over the right SCJ following trauma to the same location. Two weeks later, the patient presented with erythematous swelling with a sinus discharging pus, although he was discharged on oral antibiotics, analgesics, and had underwent an incisional drainage. Computerized Tomography (CT) of the chest showed fluid collection surrounding the right SCJ together with joint effusion suggestive of SCJ osteomyelitis. The patient underwent initial debridement and a definitive bone resection with pectoralis muscle flap two weeks following. Five months later, the patient was seen in the outpatient clinic, the wound was completely healed, and he has a normal function of the right arm. Discussion The management of SCJ osteomyelitis is not well established, yet it can be approached medically, surgically, or both. Conclusion Surgical intervention is indicated in cases of SCJ osteomyelitis after the failure of antibiotic therapy trial. This is especially the case in the presence of abscess and bone destruction. SCJ debridement followed by delayed resection and pectoralis muscle flap might offer better results than merely debridement alone or with resection of the joint.

The rectus femoris pedicled muscle flap is a widely used option for coverage of infected vascular grafts in groin reconstruction as well as in reconstruction of abdominal wall defects. Here we present the case of primary placement of a pedicled rectus femoris flap to provide well-vascularized tissue interposed between an aortic Dacron interposition graft and bowel. This previously undescribed use of the rectus femoris proves to be an indispensable method when the more common alternatives, such as omental and rectus abdominis flaps, are not available. Keywords: Rectus femoris flap, Aortic graft, Pedicled muscle flap

Objective Cryopreserved human arterial allografts are a recognized acceptable alternative for vascular reconstruction when other traditional conduits are either unavailable or contraindicated. We reviewed our experience using cryopreserved arterial allografts for peripheral artery reconstructions in contaminated and infected surgical fields. Methods A single-center, retrospective review was conducted of 57 patients who underwent a peripheral vascular reconstruction using a cryopreserved arterial allograft from January 2002 through July 2017. Indications for repair included removal of infected prosthetic bypass (n = 29), revascularizations in contaminated fields (n = 11), primary arterial repair in the setting of infection (n = 10), and infected vascular closure devices (n = 7). Aorta-based repairs were excluded. Demographics, index procedural details, postoperative complications, and conduit patency were analyzed. Primary end points included conduit-related mortality and graft failure as measured by reinfection, hemorrhage, or aneurysmal degeneration. Mean follow-up for the study is 27.8 months (range, 2-125 months). Results A total of 57 peripheral vascular reconstructions using cryopreserved arterial allografts were performed during the 15-year period. Among the 22 women and 35 men treated, the mean age was 61 years. The vascular beds involved included iliofemoral (n = 39), femoropopliteal or femoral-distal (n = 10), axillosubclavian or brachial (n = 2), mesenteric (n = 3), and carotid (n = 3) arteries. Adjunctive muscle flap coverage of the allograft conduit was performed in the majority of cases (61%; n = 35). The 30-day mortality was 9%; one death was directly related to conduit insertion. The 30-day conduit-related complication rate was 14% and included hemorrhage from the graft requiring return to the operating room (n = 4) and graft infection (n = 4). The late conduit-related complication rate was 15.8% and included graft infection (n = 1), graft thrombosis (n = 3), major amputation resulting from conduit failure (n = 1), pseudoaneurysm degeneration requiring repair (n = 2), graft hemorrhage (n = 1), and symptomatic graft stenosis (n = 1). Conclusions A cryopreserved arterial allograft is a useful alternative conduit for peripheral vascular reconstruction in infected or contaminated surgical fields when other autologous or prosthetic conduits are either unavailable or contraindicated. In the immediate postoperative period, these repairs demonstrate acceptable resistance to graft failure and reinfection, particularly in conjunction with adjunctive rotational muscle flap coverage. Late conduit-related complications appear to be infrequent.

Summary PURPOSE Pelvic reconstruction following abdominoperineal resection or pelvic exenteration is associated with signification surgical site morbidity. Immediate pelvic reconstruction with a muscle flap is now the gold standard, associated with reduced perineal morbidity compared to primary closure alone. 2 , 3 The purpose of the present study was to directly compare outcomes of VRAM and gracilis flap pelvic reconstruction following oncologic resection. METHODS A multicenter retrospective review was performed of 88 patients who underwent abdominoperineal resection or pelvic exenteration and immediate pelvic reconstruction, either with a VRAM (N = 61) or Gracilis flap (N = 27). Electronic medical records were analyzed for patient demographics, intraoperative data, and postoperative outcomes. Mortality, minor complication rate, major complication rate and time to complete wound healing was compared between groups. RESULTS Overall, there was no significant difference in the minor complication rate (44% gracilis vs 48% VRAM, p = 0.8), major complication rate (19% gracilis vs 13% of VRAM, p = 0.53), 30-day mortality (0% VRAM vs 0% gracilis, p = 1.0) and median time to complete wound healing (68 days vs 67 days, p = 0.19) between the gracilis and VRAM groups. Muscle-only gracilis flaps had a significantly reduced healing time compared to musculocutaneous gracilis flaps (48 days vs 85 days, p = 0.007). CONCLUSIONS The workhorse flap in pelvic reconstruction remains the VRAM. While previous studies have alluded to the inferiority of thigh based flaps compared to the VRAM, we demonstrate here that pelvic reconstruction with the gracilis flap can be performed with comparable donor and recipient complication rates and similar time to complete wound healing as the VRAM.

Zenker's traction diverticulum is a potentially fatal complication of anterior cervical spinal surgery which is likely under-reported. It is managed by medical stabilization, surgical abscess drainage, hardware removal, cricopharyngeal myotomy, and diverticulectomy with or without muscle flap interposition. We present two cases of Zenker's traction diverticulum perforation with spinal hardware erosion and infection, both of which opted for the muscle flap interposition. Given the inevitable scarring of the esophagus from the hardware and the low risk and significant benefit associated with a flap, a preemptive sternocleidomastoid flap at the time of the anterior spinal hardware may help reduce the growing burden of complication.

INTRODUCTION: Autologous breast reconstruction has evolved from more morbid procedures that sacrificed the abdominal muscle (the TRAM or transverse rectus abdominus muscle flap) to “perforator” flaps. Commercial insurers recognized the higher technical demand of perforator flaps by creating procedural codes with higher professional fees. This study examined whether procedure code discrepancies between insurance payers disproportionally incentivize perforator flaps among the commercially insured. METHODS: Autologous breast reconstructions identified from the National Inpatient Sample (NIS) were subdivided into microvascular perforator (85.74, 85.75, 85.76), microvascular TRAM (85.73), and pedicled TRAM flaps (85.72). Demographics, comorbidities and access to care were compared. A logistic regression comparing microvascular reconstructions only was used to identify predictors for perforator flap reconstruction. RESULTS: A total of 66,968 cases of autologous breast reconstruction were identified. Perforator flaps were more likely among the commercially insured (p < 0.001) and higher insurance quartiles (p < 0.001). When comparing microvascular reconstruction, perforator flaps were 1.72 (p < 0.001) times more likely among the commercially insured. As compared to the lowest income quartile, the fourth quartile had an odds ratio of 1.36 (p < 0.001) for perforator flap reconstruction. CONCLUSION: The presence of a separate perforator flap billing code among the commercially insured may be exacerbating existing socioeconomic disparities in breast cancer reconstruction.

Purpose Volumetric or multiplane defects of the upper and midface remain a challenge for reconstruction because of limited regional flap options. In this study, the authors harvested the reverse temporalis muscle flap and pericranial flap (RTMP flap) based on the same vascular pedicle, the superficial temporal artery, in a chimeric manner to obtain double-layer closure of deep facial defects. Materials and Methods This study was a prospective case series performed in the Department of Plastic Surgery of Ataturk University (Erzurum, Turkey). The outcomes, including flap survival, postoperative complications, reconstructive success, esthetic appearance, and donor site morbidity, were clinically evaluated. Results Fourteen patients (10 male and 4 female) with deep defects of the middle third of the face underwent reconstruction using the chimeric RTMP flap. All chimeric RTMP flaps survived without postoperative complications. All defects were successfully repaired and covered with chimeric RTMP flaps. Patients were satisfied with the esthetic results. Conclusion The chimeric RTMP flap is a good reconstruction option and can be used safely for moderate to large 3-dimensional defects of the middle and upper face. Smooth and durable coverage over the bulky muscle flap used to fill the volume defect and a larger flap for larger volume defects can be obtained by including the pericranial segment of the chimeric RTMP flap.

Summary Background Intraoperative resident education is an integral mission of academic medical centers and serves as the basis for training the next generation of surgeons. The actual effort associated with teaching residents is unknown as it pertains to additional operative time. Using a large validated multi-institutional dataset, this study aims to quantify the effect of having a resident present in common plastic surgery procedures on operative time. Future directions for developing standardized methods to record and report teaching time are proposed, which can help inform prospective studies. Study design The 2006–2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify seven isolated plastic surgical procedures that were categorized based on resident involvement and supervision. Linear regression models were used to calculate the difference in operative time with respect to resident participation while controlling for patient and operative factors. Results Resident involvement was associated with longer operative times for muscle flap trunk procedures (53 min, 95% CI = [25, 80], p-value = 0.0002) and breast reconstruction procedures with a latissimus dorsi flap (55 min, 95% CI = [22, 88], p-value = 0.001). For six of the seven surgeries evaluated, resident involvement was associated with longer operative times, as compared to no resident involvement. Conclusion Resident involvement is associated with an increase in operative time for certain plastic surgery procedures. This finding underscores the need for a mechanism to quantify the time and effort that the attending surgeons allocate toward intraoperative resident education. Further study is also necessary to determine the causal impact on patient care.

Free muscle flaps are being used more commonly for complex lower limb reconstruction. Up to 33% of flaps used to reconstruct lower limb trauma will require an orthopaedic procedure after reconstruction. To date there have been only case reports detailing the variable survival of muscle flaps after actual or simulated pedicle injury and the process and timeframe of neovascularisation remains undefined. We aim to show that perfusion of a muscle flap is possible after injury to its anatomical vascular pedicle.Pedicled muscle flaps were raised and transposed to a cutaneous inset on the chest wall in a rodent model. Each flap was subjected to simulated pedicle injury at a variable time. Allocation was by computer randomisation. Flap perfusion was assessed before and after pedicle injury followed 48 h later by sacrifice of the animal and static angiography of the flaps.By the 21st day after inset, all flaps survived simulated pedicle injury. Prior to this, flap survival was significantly lower (p = 0.017, Fisher's Exact Test). Clinical signs at the time of pedicle injury did not predict flap survival. Most new vessels form at the distal part of the inset (p 0.01, ANOVA). The total number does not change with time (p = 0.82, ANOVA). New vessels anastomose preferentially with skin. The fall in perfusion after pedicle ligation was significant for all groups except the day 35 group (p = 0.53).Muscle flaps can perfuse after an injury to the anatomical vascular pedicle through neovascularisation at the inset. These new vessels are evident early but may not function adequately to perfuse the flap. Regional variations in neovascularisation suggest that a gradient of ischaemia drives this process. Inset at the cutaneous level is important, which has implications for buried muscle flaps. The correlation between change in flap perfusion after pedicle injury and flap necrosis suggests a role for the former in determining the capacity of a muscle flap to tolerate a pedicle injury and thereby the approach to re-raising it.

Summary Background In the experience of our centre, 33% of reconstructed compound lower limb injuries will need an orthopaedic revision. 1 A flap may be re-raised through numerous methods, and historically, the approach of choice has been based on the principle of protecting the vascular pedicle rather than the inset. Our aim was to determine whether a marginal versus a split approach to re-raising inferred a higher risk of flap necrosis and whether more attention should be paid to protecting the inset of the flap, particularly at the distal portion. Method A pedicled pectoralis profundus muscle flap was raised in 32 Sprague–Dawley rats and transposed to the lateral chest wall. After 21 days, the flaps were randomised into one of four treatment groups according to the surgical approach and whether or not the anatomical vascular pedicle was ligated. Necrosis was assessed 48 h later, both clinically and through the analysis of digital photographs. Results The rate of necrosis in the marginal group was higher than that in the split group (63% vs 0%, p Conclusions Splitting a muscle flap produces significantly less necrosis than incising the inset, regardless of whether the pedicle is in flow. It also offers wider exposure of structures deep to the flap. These findings provide a detailed model for human trials, which is presented as a proposed management algorithm. It also highlights conditions that must be met for translation to a human population.

Novel and combined tissue transfers from the lower extremity provide new tools to combat soft tissue defects of the hand, foot, and ankle, or fracture nonunion. Flaps can be designed for special purposes, such as providing a gliding bed for a grafted or repaired tendon or for thumb or finger reconstruction. Propeller flaps can cover soft tissue defects of the leg and foot. In repairing severe bone and soft tissue defects of the lower extremity, combined approaches, including external fixators, one-stage vascularized bone grafting, and skin or muscle flap coverage of the traumatized leg and foot, have become popular.

A 37-year-old incarcerated male ingested a complex “X-shaped” foreign body that resulted in a penetrating aorto-esophageal injury. A primary esophagotomy with retrieval of the foreign body and muscle flap closure was performed simultaneously with thoracic endovascular aortic repair. This multidisciplinary surgical approach controls for both immediate exsanguination and postoperative complications to improve patient outcome.

Facial palsy (FP) in children is congenital or acquired. When present at birth (congenital), etiologies are mostly traumatic and rarely developmental. Acquired FP needs investigation. Research on the etiology helps to determine prognostic and treatment. At most times, no specific cause is found. Treatment of idiopathic FP consists of early oral corticosteroid therapy and ocular protection. Treating the sequelae is essential and the physician has to consider the dynamic balance of both sides of the face. Dynamic rehabilitation should mainly concern the inferior facial third. We recommend the lengthening temporalis myoplasty (LTM). This relevant technique ensures replicable and reliable results with a harmonious smile. Facial dynamic rehabilitation after surgical procedure (muscle tranfer or free muscle flap) must be directed toward control of voluntary movement, to move from a mandibular smile to a spontaneous and voluntary smile, thanks to brain plasticity. Furthermore, botulinum toxin is well tolerated and remains a great tool to treat a child who can support injections.

Objective To evaluate outcome of modalities for management of deep sternal wound infection (DSWI) defined as peri-procedural mortality and to determine the predictors for this outcome. Patients & Methods Management plan was controlled by the findings after sternal wound debridement till the patient was bacteriologically negative. This plan ranged between simple rewiring of sternal remnants, if appropriate, rewiring and bilateral pectoralis major advancement flap (PMF) coverage, vascularized omental flap (VOF) or PMF coverage without rewiring if sternal remnants were inappropriate and combined VOF and PMF coverage in case of wide sternal defect and/or absence of any trustable sternal remnants. Results Throughout the study duration 121 out of 7850 patients underwent sternotomy for open cardiac surgery developed DSWI for a frequency of 1.54%. Nineteen patients died for a total mortality rate of 15.7%, 9 patients developed complications for a morbidity rate of 7.4% and 93 patients passed their postoperative (PO) course uneventfully for a total success rate of 76.9%. PMF and VOF showed success rates of 94.7% and 81.8%, respectively. Wiring only and wiring followed by PMF showed success rates of 78.6% and 75%, respectively. Combined VOF and PMF showed a success rate of 72.2% for selected cases with wide sternal wound. Number of risk factors/patient was significantly higher in non-survivors than in survivors. Obesity and multiplicity of risk factors were the most significant predictors for mortality. Individually obesity and diabetes mellitus were the significant predictors for mortality. Conclusion Management of DSWI is tedious, has prolonged hospital stay and is associated with high morbidity and mortality rates. Management of DSWI must be personalized according to findings on exploration of the sternal wound and flap coverage must be initiated only when the patient is bacteriologically free. Both PMF and/or VOF provided high acceptable success rate defined as survival free of DSWI recurrence.

Objective In any immediate reconstruction of the maxillofacial defect after total maxillectomy, the defect is often covered with a flap, however, dentures cannot be maintained stably by the flap, because of the high mobility and large amount of displacement of the flap under pressure. Therefore, we developed a method in which a muscle flap is transplanted without creating a skin island in the oral cavity and a denture is immediately fixed with titanium screws, and obtained favorable results. Patients and methods The subjects were 9 patients who underwent resection for maxillary sinus cancer. In all patients, a free rectus abdominis muscle flap was used for the reconstruction and the raw surface of the muscle tissue was left in the oral cavity without creating a skin island. Dentures that had been made preoperatively were fixed on the remaining palate and alveolus with titanium screws for one month, so that they covered the muscle tissue. Results Good palatal morphology was formed without hanging down after epithelialization of the surface of the muscle tissue. In comparison with the preoperative levels, the masticatory and conversational functions recovered to 77% and 90%, on average. Conclusions Our method is considered to be one of the useful reconstruction methods for maxillofacial defects.

Objective Lesions involving both the trachea and the esophagus are often considered inoperable because of the lack of reliable reconstruction. The purpose of this study was to review our experience of combined supercharged jejunal and other flaps for tracheal and esophageal reconstruction. Methods A retrospective review of 5 consecutive cases with combined tracheal and total esophageal defects was performed. The esophageal defect was reconstructed with a supercharged jejunal flap, and the trachea was reconstructed with a free anterolateral thigh flap or a pedicled muscle flap. Results Primary diagnosis included tracheostoma recurrence after a total laryngectomy for laryngeal cancer in 2 patients and tracheoesophageal fistula due to esophageal stenting for complications from prior treatment for non-Hodgkin's lymphoma, parathyroid cancer, and esophageal cancer in 3 patients, respectively. Tracheal and esophageal reconstructions were staged in 4 patients, and 1 patient received simultaneous reconstruction. Tracheal necrosis developed in 1 patient with a mediastinal tracheostoma, and the patient eventually died of infection 2 months later. The other 4 patients recovered well and resumed an oral diet. Conclusions Complex and often life-threatening lesions involving both the trachea and the esophagus are not necessarily inoperable. With careful planning, these combined defects can be safely reconstructed with multiple flaps with good functional outcomes and reasonable survival.

The development of a fistula between the tracheobronchial tree and oesophagus due to nonmalignant causes is uncommon. Division of the fistula with muscle flap interposition eliminates contact between the tracheobronchial segment and the oesophagus, theoretically decreasing the chance of recurrence as well as providing a robust blood supply to aid in healing. The split latissimus dorsi muscle flap is a well-suited flap for such repairs because of the ability to simultaneously cover two separate apertures (tracheobronchial and oesophageal). The authors describe the split latissimus dorsi muscle flap with step-by-step technique for repair of intrathoracic aerodigestive fistulas.

Objective To review our experience with nonmuscle flap repairs of enterourinary fistulae (EUF) and urinary cutaneous fistulae (UCF). EUF and UCF can be treated either with temporary urinary diversion allowing for healing by secondary intention or primary closure of the defect using an interposing omental, sliding, or muscle flap. Even after successful fistula repair, permanent urinary diversion can be required because of persistent urinary incontinence. Materials and Methods We reviewed 86 patients who underwent treatment of EUF or UCF at Washington University between the years 1998 and 2013. Of these, 39 patients underwent fistula repair, whereas 47 patients underwent either surgical or nonsurgical urinary diversion. Outcomes measured included postoperative fistula closure, need for permanent urinary diversion, and urinary incontinence. Results The mean age in our series was 59 years (21-87 years) at the time of surgery, with median follow-up of 20 months (1-137 months). Among patients who underwent surgical repair, radiation was associated with higher rates of repair failure ( P = .0002), postsurgical incontinence ( P P = .0076). At the time of final follow-up, 32 of the 44 radiated patients had required permanent diversion (72%) compared with 3 of the 42 nonradiated patients (7%; P Conclusion Patients who undergo pelvic radiation before EUF and UCF repairs are at higher risk for developing repair failure and postsurgical incontinence. Many patients eventually require permanent urinary diversion. Therefore, EUF and UCF repairs in radiated patients should be undertaken with caution, and patients should be counseled about the possibility of urinary diversion as primary therapy.

Congenital diaphragmatic hernia is a birth defect that affects about one in 2500 live births. Although the overall survival has improved over the last several decades thanks to advancements in postnatal resuscitation and intensive care treatment, morbidity and mortality remain high. The surgical management of these infants is far from being standardized, and many aspects are still disputed among experts. The timing of surgical repair remains controversial and the indications for the ideal time for surgery have not been validated. The main novelty in the surgical treatment is related to the use of minimally invasive techniques, although these have been associated with intraoperative blood gas disturbances and higher recurrence rates. Herein, we report and comment on the main controversies of postnatal CDH repair in this rapidly evolving field.

Summary Introduction The purpose of this study is to analyse the 2-stage Muller's muscle flap technique for the treatment of orbital implant exposure and its results. Materials and methods This retrospective study reviewed all patients undergoing surgery using this technique in our university hospital over a 14-year period (1999–2012) in terms of success (no re-exposure of the implant) or failure. Results Nineteen patients were managed using this 2-stage procedure. Orbital implant exposure occurred 94.4 months (2–240) after implantation. The success rate was 68.4% (13/19) and failure rate 31.6% (6/19). Risk factors for exposure were enucleation for melanoma followed by radiation therapy, acrylic implant, and early exposure probably due to excessive suture tension. Discussion Implant exposure is the most common complication after evisceration, enucleation or socket surgery. Several techniques to repair exposures have been described. Two-stage Muller's muscle flap is an interesting option, especially for patients presenting defects larger than 4 mm 2 and without previous radiation therapy treatment. Conclusion The two-stage Muller's muscle flap procedure allows for an autologous vascularized pedicle flap from the ipsilateral upper eyelid. It is a reliable technique with a success rate of 68% in our study.

Restoration of structure, function, and sensation are critical after trauma or tumor resection of the hand. Thorough debridement, reconstruction of functional structures, and immediate soft tissue coverage are most effectively performed in a single stage within approximately 24 hours of the injury. Skin flaps provide robust, pliable, and cosmetically appropriate tissue that is not prone to contracture and that facilitates secondary reconstructive work. Muscle flaps retain indications for complex defects with substantial initial contamination or dead space, or for reanimation. In this article, the indications, options, and surgical techniques for free muscle flap reconstruction of upper limb defects are reviewed.

Summary Introduction Muscle flaps are often used in the prevention and treatment of pharyngocutaneous fistula following total salvage laryngectomy in the setting of chemo-radiated neck for laryngeal carcinomas. We report our experience with the gracilis free muscle flap compared to the pedicled pectoralis major for the prophylaxis of fistula formation. Methods Forty-nine patients with radio-recurrent laryngeal carcinoma over ten years who underwent salvage laryngectomy and either immediate free gracilis (22 patients) or pedicled pectoralis major muscle flap (27 patients) reconstruction were reviewed. Results There were 12 complications in pectoralis major flap group and eight in gracilis flap group. Most of these occurred early in the post-operative period. These were related to poor wound healing with the pectoralis major flap reconstructions. Fistulation rates were similar in the two groups (Pectoralis major: 6/27, gracilis: 5/22). Conclusions In our experience, the gracilis free muscle flap is a good reconstructive option in the prevention of pharyngocutaneous fistula formation following salvage laryngectomies. It is at least equivalent to a pectoralis muscle flap in the prevention of fistulae, but we prefer the gracilis for many reasons, including ease of harvest and preservation of the pectoralis major flap for future reconstructions.

Background Limb function after excision of deltoid muscle sarcomas has not been thoroughly investigated, although a large defect of soft tissue often causes some degree of dysfunction after wide excision. We formulated a hypothesis that the limb functional results depend on the volume of the excised deltoid muscle and examined the clinical outcomes in patients with a sarcoma in the deltoid muscle treated by surgical resection. Methods The clinical outcomes of 8 patients with a malignant soft tissue tumor in the deltoid muscle were retrospectively reviewed. The following items were evaluated: type of excision of the deltoid muscle, including total excision, subtotal excision, and partial excision; surgical margins; reconstruction procedure used; postoperative complications; local recurrence; metastasis; survival; and functional results (determined by the Musculoskeletal Tumor Society scoring system). Results After surgical resection, reconstruction in 6 of 8 patients was performed by pedicled latissimus dorsi musculocutaneous or muscle flap or pedicled trapezius musculocutaneous flap. Two patients did not undergo reconstruction because skin closure was possible. The partial excision group had a Musculoskeletal Tumor Society score of 100.0%, and the subtotal excision case and the total excision group had scores of 76.6% and 82.2%, respectively. None of the patients has demonstrated any evidence of local recurrence. Conclusion We conclude that the functional results may depend on the volume of the excised deltoid muscle. Latissimus dorsi and trapezius musculocutaneous flaps were found to be useful for covering a defect of the deltoid muscle, although these flaps did not contribute to function of the shoulder.

Free functional muscle transfer (FFMT) replaces destroyed, denervated, or resected skeletal muscle units in the upper extremity with functioning skeletal muscle from other locations in the body. Common indications for FFMT include brachial plexus injuries, ischemic contracture, tumor resection, and extensive direct muscle trauma. Recent studies have focused on improving patient outcomes through refinements in muscle flap harvest and inset, donor nerve selection, and postoperative management. In this review, we assess and summarize the current literature on FFMT, with emphasis on etiopathogenesis, diagnosis, treatment, postoperative management, and clinical outcomes.

Summary Background and aim Experimental studies have shown that musculocutaneous flaps are not dependent on a major pedicle for survival after 7–8 days, as revascularisation occurs from surrounding well-nourished tissue. However, muscle component loss in myocutaneous flaps after pedicle division has been reported. No study that examines the nature of the vascular ingrowth from underlying beds by blocking the peripheral cutaneous beds has been conducted in musculocutaneous and skin-covered muscle flaps. This study was designed to investigate the origin of the dominant source of neo-vascularisation after interruption of the major vascular supply in island musculocutaneous and island skin-covered muscle flaps by blocking neo-vascularisation from wound edges and the recipient bed. Method Twenty-eight rats were divided into four experimental groups. In group I, a cutaneous maximus musculocutaneous island flap (MCIF) was raised, and the wound edges of the flap were blocked with a silastic sheet. In group II, an MCIF was raised, and the recipient bed was blocked with silastic. In group III, an island cutaneous maximus muscle flap (IMF) was raised as an island flap covered by a full-thickness skin graft (FTSG), and the wound margins were blocked with silastic. In group IV, an IMF was raised as an island flap covered by an FTSG, and the recipient bed was blocked with a silastic sheet. On the seventh postoperative day, vessel ligation was performed in each animal. Microangiographic studies and histopathological evaluations were performed 14 days after the first operation. Results In microangiographic studies, neo-vascularisation was more prominent in groups II and IV (the groups in which the recipient beds were blocked) than in groups I and III (the groups in which the wound edges were blocked). Upon histopathological examination, the number of vessels was significantly lower in group I and group III than in group II and group IV ( p Conclusions Our findings revealed that neo-vascularisation from either the recipient bed or the wound edges was sufficient to ensure full flap survival in musculocutaneous flaps, and skin-grafted muscle flaps do not need major axial vessels 7 days after flap elevation in rats if the recipient bed or wound edges are well-vascularised. The results also indicated that revascularisation mainly comes from the peripheral wound edges and is independent of flap type.

INTRODUCTIONTracheocutaneous fistula is a complication of tracheostomy. Tracheocutaneous fistulectomy followed by primary closure carries a high possibility of complications.PRESENTATION OF CASEAn 11-year-old boy underwent surgery to repair a tracheocutaneous fistula, using skin and muscle flaps. A vertical incision was made around the fistula and 3 skin flaps were prepared: 2 hinge flaps, and 1 to cover the skin defect (advanced flap). The 2 hinged turnover flaps were invaginated by multiple layered sutures, and a strap muscle flap was placed over the resulting tracheal closure. An advanced skin flap was used to cover the area of the previous defect. The patient was extubated immediately after surgery. He was discharged on the sixth postoperative day without tracheal leakage or subcutaneous emphysema. The patient is currently doing well, with no respiratory symptoms and no recurrence at the postoperative 5 months.DISCUSSIONOur technique is minimally invasive and has a low risk of lumen stenosis, other complications, or recurrence.CONCLUSIONThis technique demonstrates the multiple-layered closure of a tracheocutaneous fistula, using skin flaps and a muscle flap.

Introduction Chest wall skeletal defects are usually closed using muscle flaps or prosthetic materials. Postoperative prosthetic infections are critical complications and often require plastic surgery support. We report a new surgical technique, involving a subscapular muscle flap, for covering posterior chest wall defect., Presentation of case A 75-year-old man was admitted to our hospital. We performed a right upper lobectomy with posterior chest wall resection between the third and sixth ribs. The resulting chest wall defect was covered with a polytetrafluoroethylene mesh that became infected postoperatively. We removed the infected mesh and used the subscapularis muscle, the nearest muscle to the defect, to cover the chest wall defect. The scapular tip was lifted and the lower half of the muscle was dissected. The free end of the flap was sutured to the stumps of the anterior serratus and rhomboid major muscles. Computed tomography, 1 month later, revealed that the flap was engrafted to the chest wall., Discussion No previous study has reported the use of a subscapularis muscle flap for chest wall reconstruction. The lower third of the scapula was excised since blood supply to the scapula tip may be reduced after dissection of the subscapularis muscle, and to prevent the scapula tip from falling into the thoracic cavity., Conclusion The use of a subscapularis muscle flap to repair chest wall defect is a simple and safe technique that can be conducted in the same surgical field as the initial reconstruction surgery and does not require plastic surgery support.

Lower extremity blast injuries represent a unique challenge to surgeons and often involve complex, limb-threatening wounds with extensive soft tissue and bone loss. Surgical treatment of these injuries can be difficult because of limited autogenous resources for reconstruction of the defect. In this article, we describe a technique for medial column reconstruction using iliac crest bone graft and soft tissue coverage with an abductor hallucis rotational flap combined with a split-thickness skin graft. This method addresses the extensive bone and soft tissue defects that frequently characterize blast injuries to the foot, and may be applicable in other situations where trauma or infection has caused extensive destruction of the medial column.

SummaryRepeated soft tissue injuries around the knee represent challenging clinical situations where functional prognosis of the joint is often poor, especially in the presence of total knee arthroplasty (TKA). When gastrocnemius muscle flap techniques have already been used and failed, therapeutic solutions become rare. The authors suggest a regional solution to salvage these cases by the transfer of distally-based vastus lateralis muscle flaps. Four clinical operations of this muscle flap transfer are described, with three around TKA revision and one case of a post-traumatic knee amputation resulting from a compound open knee injury. Technical details of the intervention are presented. In all cases, skin closure was achieved, even if distal marginal necrosis was seen in two cases related to the type of muscle flap vascularisation. Final joint mobility was always poor (45° on average). Distally-based vastus lateralis muscle flaps represent a salvage procedure to correct iterative soft tissue defects around the knee that threaten short-term joint function. These muscle flaps do not require microsurgical anastomosis.

A single incision is generally used to dissect the extensor digitorum brevis (EDB) muscle flap. However, in addition to exposure difficulties, this single incision may cause problems at donor sites, since both the dorsalis pedis vascular bundle and the sinus tarsi branch of the lateral tarsal artery require careful dissection. Thus, we modified the approach by using two parallel longitudinal incisions to expose the dorsalis pedis vascular bundle and the sinus tarsi branch of the lateral tarsal artery separately. Using this modified parallel-incision EDB muscle flap, we were able to reduce the operation times and donor site skin complications.

Objectives To report our experience with vaginal reconstruction with the deep inferior epigastric perforator (DIEP) flap. Vaginal reconstruction can be accomplished with a variety of flaps, depending on the defect. The use of perforator flaps, however, is still uncommon. Methods From June 2007 to April 2008, 5 patients with congenital vaginal absence and 1 patient with a total vaginectomy defect after ablative surgery underwent total vaginal reconstruction with pedicled DIEP flaps. Preoperative mapping of the perforators was performed using enhanced computed tomography (CT) scanning with three-dimensional reconstruction. The desired perforators were selected according to their diameters and intramuscular courses. The vertically oriented DIEP flaps were then raised and tubed to form the neovagina, which was brought to the prerectal pocket through a retropubic tunnel. Results All flaps survived in their entirety. Wound infection occurred in 1 patient, and secondary healing was achieved with local wound care. The mean follow-up was 5 months. The vaginal depth remained stable, without evidence of orifice constriction. Conclusions The vertical DIEP flap is a reliable option for total vaginal reconstruction with consistent results. It spares the rectus abdominus muscle when a muscle flap is not required.

Summary Acquired tracheo-esophageal fistula (TEF) is very infrequent in the pediatric age group and is usually caused by esophageal foreign body impaction. Bronchoscopy plays an essential role in the diagnostic work-up of this rare complication. Delayed surgical closure with muscle flap interposition is the treatment of choice if spontaneous healing does not occur. The authors present the case of a 5-year-old boy with an acquired TEF caused by a very unusual esophageal foreign body, treated surgically. Management of this rare entity is discussed.

Partial or total resection of a previously irradiated clavicle and surrounding soft tissues is a difficult clinical problem. Attempts to close the defect with local tissue often result in wound breakdown and exposure of any remaining clavicle. Furthermore, the most appealing local muscle flap, the pectoralis major, is often unsuitable for reconstruction because of previous resection or radiation damage. Over a 3-year period, 8 patients had resection of a previously irradiated clavicle and surrounding soft tissues. Four underwent excision for sarcoma and four for osteoradionecrosis complicated by chronic wounds. All defects were reconstructed with a pedicled latissimus dorsi muscle flap. No patient had a flap failure, and all had closed wounds at a minimum 18-month follow-up. Our series demonstrates the success of latissimus dorsi flap coverage for post-claviculectomy defects in an irradiated field. To our knowledge, this is the first described series of such patients. The latissimus dorsi muscle flap should be considered for all difficult wounds involving the clavicle and surrounding soft tissues.

Zusammenfassung Gestielte Muskel – und Fernlappenplastiken sind allesamt durch eine axiale Gefasversorgung charakterisiert. Aufgrund der zuverlassigen Durchblutung des transferierten Muskelanteils oder fasziokutanen Gewebeblocks zahlen diese Lappenplastiken zu den haufig durchgefuhrten Defektdeckungsverfahren am Fus, Sprunggelenk und Unterschenkel. Selbst bei Vorhandensein von angio- und/oder neuropathischen Veranderungen der unteren Extremitat greift man gerne auf diese zuverlassigen Lappenplastiken zuruck. Zu den Standard-Muskellappenplastiken zur Defektdeckung am Unterschenkel zahlen die M. gastrocnemius- und die M. soleus- bzw. hemisoleus-Lappenplastik. Die Praparation dieser zumeist von der A. poplitea und/oder A. tibialis posterior ernahrten Lappenplastiken ist einfach und wird nach dem Transfer in den Defekt mit der Transplantation von gemeshter Spalthaut auf den Muskellappen abgeschlossen. Zu den gestielten Fernlappenplastiken zahlt die fasziokutane A. suralis-Lappenplastik, welche ihre Anwendung bei Defekten am Unterschenkel, Sprunggelenk und Fus findet. Bei distaler Stielung der Lappenplastik erfolgt die axiale Durchblutung mit stets retrograder Perfusion uber die A. suralis, eine Begleitarterie des N. suralis. Die Praparation dieser Lappenplastik kann sich aufwendig und bei venoser Insuffizienz des transferierten, fasziokutanen Gewebblocks auch in zwei voneinander zeitlich getrennten operativen Schritten darstellen.

Background The standard approach for correction of pectus carinatum deformity includes elevation of the pectoralis major and rectus abdominis muscle from the sternum and adjacent ribs. A postoperative restriction of shoulder activity for several weeks is necessary to allow stable healing of the elevated muscles. To reduce postoperative immobilization, we present a modified approach to the parasternal ribs using a pectoralis muscle split technique. Methods At each level of rib cartilage resection, the pectoralis muscle is split along the direction of its fibers instead of elevating the entire muscle as performed with the standard technique. From July 2000 to May 2007, we successfully used this technique in 33 patients with pectus carinatum deformity. Results After the muscle split approach, patients returned to full unrestricted shoulder activity as early as 3 weeks postoperatively, compared to 6 weeks in patients treated with muscle flap elevation. Postoperative pain was reduced and the patients were discharged earlier from the hospital than following the conventional approach. Conclusions The muscle split technique is a modified surgical approach to the parasternal ribs in patients with pectus carinatum deformity. It helps to maintain pectoralis muscle vascularization and function and can reduce postoperative pain, hospitalization, and rehabilitation period.

The aim of this study was to investigate the feasibility of reconstructing critical size continuity osteoperiosteal defects of the mandible using a composite of recombinant BMP-7 contained in a bovine type-1 collagen carrier wrapped in a pedicled sterno-occipitalis muscle flap. At 3 months following surgery, bridging of the surgical defect was noted in three subjects (60%). Histologically, the induced bone regenerate showed maturation from woven to lamellar bone. Islands of cartilage were distributed throughout the defect. Replacement ossification of the degenerated muscle was a common feature in all specimens. Microradiography showed a gradual increase in the calcification of mineralized tissue from the margin to the centre of the newly generated bone. This research represents a proof of the concept that bone can be satisfactorily formed within a muscular scaffolding at the site of the created defect in a one-stage procedure.

The most widely used techniques for graft preservation after localized graft infections are muscle flap closure or antibacterial dressings and irrigations after débridement. Vacuum assisted closure (VAC) has been increasingly used for complex wounds in vascular surgery, including groin infections, but not directly on exposed bypass grafts as a stand-alone technique. We used the VAC system after wound débridement in four patients with fully exposed synthetic bypass grafts who were too unstable or risky for further operative interventions. Mean duration of VAC use was 22.8 days (range, 6 to 53 days), with time to total wound closure of 30 to 63 days (mean, 41 days). There were no reinfections with 11 to 25 months' follow-up (mean, 18.3 months). For high-risk surgical patients with a fully exposed infected prosthetic vascular graft, VAC therapy along with aggressive débridement and antibiotic therapy may be an effective alternative to current management strategies.

Summary Introduction Tumours of the posterior part of the mouth and/or the oropharynx are often diagnosed at advanced stages. Reconstruction in this region has advanced considerably during the last three decades. Although microsurgery has offered major progress and has obviously improved the patients’ outcome, the use of local and regional flaps generally remains an ideal solution for reconstruction. Material and methods Between January 1994 and December 2001, the defects resulting from resection in 22 out of 38 patients with retromolar and/or anterior faucial pillar squamous cell carcinomas treated at this institution, were repaired by one of two types of masseter muscle flaps. The first type is the superiorly based or cross-over masseter muscle flap, and the second type the island muscle flap (being a modification of the first type). Results The superiorly based masseter muscle flap was used in 12 patients and the island masseter muscle flap in 10. Both techniques offer a quick and reliable method for repairing oropharyngeal defects in oncologically “safe” cases. Neither require elaborate technique or aftercare. Conclusion The island masseter muscle flap has an advantage over the superiorly based masseteric flap, as it is more flexible, pliable for larger defects, and causes no postoperative trismus.

Objectives. To evaluate the feasibility and long-term outcome of distal arterial reconstruction combined with free muscle flap transfer for patients who would otherwise have undergone major amputation. Methods. Between 1996 and 2001, 27 reconstructions using autologous vein were performed in 25 patients. Seventeen of these patients had diabetes mellitus. Gracilis, rectus abdominis and latissimus dorsi muscles were used as free flaps, covered with split-thickness skin grafts. Results. Eighty-five percent of patients had a patent graft and viable muscle flap after 1-month. Mean follow-up was 51 months (4–72 months). At the time of follow-up 77% of reconstructions were patent and 70% of patients regained full functional capacity of their lower extremities. Conclusion. Limb-salvage by distal arterial reconstruction and free muscle flap transfer, is feasible with low mortality and morbidity and provides excellent long-term results with regard to graft patency and functional status.

International audience; Large defect congenital diaphragmatic hernias comprise a defect too large to be closed primarily and diaphragm agenesis. This condition remains a surgical and intensive care challenge. Many different approaches have been described. Prosthetic patches are often used, but they face the major issue of high recurrence rate ranging from 27 to 50%. Some reports in the literature describe muscle flap repair and though they are scarce and concern small series, they indicate that muscle flaps recur only in 0 to 4.3%3,4 . For the last 20 years, our routine clinical practice has been to avoid patches by using a muscle flap to repair the defects that are too large for primary closure. We therefore present a simple novel technique using a single layer muscle flap based on the transversus abdominis muscle

For the reconstruction of defects localised near the midline region of the back, there have been occasional reports of reconstruction using a paraspinous muscle flap; however, to the best of our knowledge, there have been no reports of empyema space reconstruction using a paraspinous muscle flap. A patient who developed empyema after a pulmonary lobectomy and in whom a paraspinous muscle flap was used to reconstruct a dead space in the medial region of the upper back created by fenestration is presented. The dead space was filled sufficiently, and the patient had a favourable course without complications. Although the rotation arc of the paraspinous muscle flap is limited, the flap's blood flow is stable, and flap elevation is easy and less invasive. The paraspinous muscle flap is useful for filling and closing a defect near the midline region of the back.

It is estimated that worldwide, 16 million people, aged 15-64 years inject illicit drugs regularly. When peripheral venous access becomes obliterated, drug users start injecting into the subdermal area of the skin - "skin popping". When this area ulcerates, the well vascularised granulation tissue called a "shooter's patch" is maintained as a portal for continuing injection. These "shooter's patches" are usually on the limbs, but have been reported on the breast and the penis. We present a case of a reconstructive muscle flap being used in an unforeseen manner as a shooters patch. Surgeons rely on muscle flaps to provide a robust reconstructive option, but we have learnt that drug users value them for their rich vascularity and high absorption.

The most effective way to treat the chest wall tuberculosis is to fill the residual space with a muscle flap after complete resection of the lesion. However, in some situations a muscle flap cannot be used. The greater omentum has been widely used for reconstruction and the treatment of infections. We describe our technique of using a pedicled omental transposition flap in the management of chest wall tuberculosis for closing the dead space created by excision of the lesion.

It is difficult to resurface skin defects of the sole because of its unique anatomy, which is resistant to mechanical stimuli. Though various methods have been reported, few are functionally satisfactory, and it is especially difficult to repair the distal plantar area. We report a reconstruction of the distal plantar area using a flexor digitorum brevis muscle flap based on a reverse-flow lateral plantar artery pedicle in a patient with a malignant melanoma on the right lateral metatarsal head of the fifth toe. The muscle flap was sufficient to cover the exposed fifth metatarsal and was covered with a full-thickness skin graft. The result was favourable and the patient has a normal gait and no pressure sores.