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Background: Reconstruction of complex back defects, especially after corrective spine surgery, is a challenging problem. In these patients hardware issues predominate and flap failure has serious consequences. Certain subunits of the back pose even greater problems, specifically the central region between T9 and T12. The purpose of this article is to present a novel technique for reconstruction of such spinal defects using a newly described trapezius muscle propeller flap based on the dorsal scapular vessels., Methods: Four cadaveric trapezius muscle propeller flaps were raised to ensure appropriate rotation into central region of the posterior trunk between T9 and T12. Three patients all had similar presentations with a history of scoliosis, previous failed spinal instrumentation, prominent hardware, impending exposure, worsening kyphosis, and back pain. The patients underwent planned extension fusions from the upper thoracic to lumbar vertebrae by orthopedic surgery. All three patients lacked local reconstructive options and propeller trapezius muscle flaps were dissected., Results: All cadaveric dissections demonstrated adequate rotation of the muscle flap without tension or kinking of the vascular pedicle. For the case studies, two patients had right sided trapezius flaps utilized, one patient had injury to the right dorsal scapular vessels during dissection, thus a left sided trapezius was rotated. One patient had complications including a seroma requiring aspiration and superficial wound breakdown. All had complete healing with no postoperative shoulder dysfunction noted., Conclusion: As a result, the trapezius muscle propeller flap is found to be a novel flap that provides a simple, yet robust solution to an otherwise difficult reconstructive problem., (© 2018 Wiley Periodicals, Inc.)

Background and Objective: The clinical application of laser-assisted vascular anastomosis is afflicted by unreliable and low bonding strengths as well as tedious handling during microvascular surgery. The challenge to be met arises from the flow-off of the chromophore during soldering that changes the absorption and stains the surrounding tissue, leading to an uncontrollable thermal damage zone. In this study, we investigated the feasibility to produce an indocyanine green (ICG)-loaded patch by electrospinning and tested its applicability to both in vitro and in vivo microvascular laser soldering., Materials and Methods: A blend of polycaprolactone and ICG was electrospun to produce a pliable patch. Prior to soldering, the patch was soaked in 40% wt. bovine serum albumin solution. The solder patch was wrapped in vitro around blood vessel stumps of rabbit aortas. An intraluminal balloon catheter enabled an easy alignment and held the setup in place. The soldering energy was delivered via a diffusor fiber from the vessel lumen using a diode laser at 810 nm. During the procedure, the surface temperature was observed with an infrared camera. Afterward, samples were embedded in methylmethacrylate and epon to study thermal damage. The quality of the fusion was assessed by measuring the tensile strength. After in vitro tests with rabbit aortas, eight large white pigs were subjected to an acute in vivo experiment, and the artery of the latissimus dorsi flap was anastomosed to the distal femoral artery., Results: The ICG-loaded patch, produced by electrospinning, has a thickness of 279 ± 62 μm, a fiber diameter of 1.20 ± 0.19 μm, and an attenuation coefficient of 1,119 ± 183 cm -1 at a wavelength of 790 nm. The patch was pliable and easy to handle during surgery. No leakage of the chromophore was observed. Thermal damage was restricted to the Tunica adventitia and Tunica media and the area of the vessel wall that was covered with the patch. Six pigs were successfully treated, without any bleeding and with a continuous blood flow. The in vivo flap model yielded a similar tensile strength compared to in vitro laser-assisted vascular anastomoses (138 ± 52 vs. 117 ± 30 mN/mm 2 )., Conclusion: Our study demonstrated the applicability of the ICG-loaded patch for laser-assisted vascular anastomosis. By using electrospinning, ICG could be bound to polymer fibers, avoiding its flow-off and the staining of the surrounding tissue. This patch demonstrated several advantages over liquid solder as it was easier to apply, ensured a high and reliable bonding strength while maintaining a constant concentration of ICG concentration during the surgery. Lasers Surg. Med. 49:928-939, 2017. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Background: In free flap reconstruction and replantation surgery, prolonged ischemia time may lead to flap or replantation failure. The aim of the study was to investigate the effects of hypothermic flap ischemia or remote ischemic perconditioning (RIPER) during normothermic ischemia on acute inflammation of musculocutaneous flaps subjected to ischemia-reperfusion injury., Materials and Methods: In 24 pigs, a musculocutaneous latissimus dorsi flap was dissected and subjected to 4 hours of arterial ischemia and 7 hours of reperfusion. The animals were allocated into two experimental groups: hypothermic flap ischemia at 4°C (n = 8) or normothermic flap ischemia with RIPER (n = 8), and one control group with normothermic flap ischemia (n = 8). The hypothermic ischemic flaps were cooled in a basin with fresh water and ice. RIPER was initiated 1 hour before reperfusion, by inducing three 10 min cycles of hind limb ischemia with a tourniquet, each separated by 10 min of reperfusion. Acute inflammation was described by inflammatory cytokine secretion (IL-1β, IL-6, IL-10, IL-12p40, and TNF-α) from the flap during reperfusion, and by quantitative determination of macrophages in flap biopsies of dermis, subcutaneous tissue, and skeletal muscle following reperfusion., Results: No significant differences were found between normothermic and hypothermic flap ischemia in inflammatory cytokine secretion. However, the IL-6 secretion was significantly reduced in the RIPER group compared with the control group at 5 hours of reperfusion (P = 0.036), and in the RIPER group compared with the hypothermic ischemia group at 3 (P = 0 0.0063), 5 (P = 0.0026), and 7 hours of reperfusion (P = 0.028). The IL-12p40 secretion was significantly reduced in the RIPER group compared with the control group (P = 0.0054) as well as the hypothermic ischemia group (P = 0.028) at 5 hours of reperfusion. No significant difference was found among groups in macrophage infiltration., Conclusion: RIPER reduced IL-6 and IL-12p40 secretion during reperfusion of porcine musculocutaneous flaps, when compared with hypothermic ischemic flaps and normothermic ischemic flaps without RIPER. © 2016 Wiley Periodicals, Inc. Microsurgery 37:148-155, 2017., (© 2016 Wiley Periodicals, Inc.)

Background and Objectives: One of the surgical treatment options for lymphedema is vascularized lymph node transfer (VLNT). We present our experience with latissimus dorsi (LD) flap based VLNT for lymphedema treatment., Methods: We reviewed 14 consecutive patients treated with pedicled or free LD VLNT between 2014 and 2016 for recalcitrant upper or lower extremity lymphedema. Seven patients underwent lymphovenous bypass in addition to LD VLNT. Limb volume and quality of life scores using the Lymphedema Life Impact Scale (LLIS) were analyzed for quantitative and qualitative assessment., Results: Mean duration of lymphedema was 69 months (range 24-124 months). Follow-up ranged from 3 to 12 months (mean 6.7 month). Major complications included one free flap loss and one reoperation for thrombosis. Mean preoperative volume differential between normal and affected limb was 35% (range 3-87%). Volume differential reduction was 48%, 28%, and 46% at 3, 6, and 12 months, respectively. The LLIS score improved from mean of 46.8 before surgery to a mean of 38.6 at 12 month, demonstrating improvement in quality of life., Conclusions: The LD VLNT provides a viable option for treatment of UE and LE lymphedema in selected patients. J. Surg. Oncol. 2017;115:72-77. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)