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Background There is a steep learning curve to attain a consistently good result in microvascular surgery. The venous anastomosis is a critical step in free-tissue transfer. The margin of error is less and the outcome depends on the surgeon’s skill and technique. Mechanical anastomotic coupling device (MACD) has been proven to be an effective alternative to hand-sewn (HS) technique for venous anastomosis, as it requires lesser skill. However, its feasibility of application in emerging economy countries is yet to be established. Material and Method We retrospectively analyzed the data of patients who underwent free-tissue transfer for head and neck reconstruction between July 2015 and October 2020. Based on the technique used for the venous anastomosis, the patients were divided into an HS technique and MACD group. Patient characteristics and outcomes were measured. Result A total of 1694 venous anastomoses were performed during the study period. There were 966 patients in the HS technique group and 719 in the MACD group. There was no statistically significant difference between the two groups in terms of age, sex, prior radiotherapy, prior surgery, and comorbidities. Venous thrombosis was noted in 62 (6.4%) patients in the HS technique group and 7 (0.97%) in the MACD group (p = 0.000). The mean time taken for venous anastomosis in the HS group was 17 ± 4 minutes, and in the MACD group, it was 5 ± 2 minutes (p = 0.0001). Twenty-five (2.56%) patients in the HS group and 4 (0.55%) patients in MACD group had flap loss (p = 0.001). Conclusion MACD is an effective alternative for HS technique for venous anastomosis. There is a significant reduction in anastomosis time, flap loss, and return to operation theater due to venous thrombosis. MACD reduces the surgeon’s strain, especially in a high-volume center. Prospective randomized studies including economic analysis are required to prove the cost-effectiveness of coupler devices.

Purpose The purpose of the study was to share our indications, technique, outcome, and complications associated with the pedicled latissimus dorsi myocutaneous flap (LDMF) for reconstructing various upper limb and trunk soft tissue defects. Patients and Methods We reviewed the prospectively collected data of the patients who underwent reconstruction of upper limb/trunk soft tissue defects with pedicled LDMF between January 2016 and March 2019. By analyzing the clinical scenarios, the location of flap inset, the arc of rotation, reach of the flap, and associated complications, we put forward few significant findings from our experience. Results Thirty-four patients were included in the study: 13 of them underwent LDMF for coverage of upper limb defects, 12 of them for postradical mastectomy soft tissue defects, 8 for posterior trunk reconstruction, and 1 for sternal wound infection. LDMF was successfully used to cover the scapula, anterior and posterior arms, axilla, cubital fossa, mid-forearm, breast, sternum, and midline dorsal wounds. When used reversely, the flap could cover the exposed spine in the midline dorsum. Three patients (9%) had major complications (two patients had partial flap necrosis which required additional debridement and skin grafting, and one patient required an additional transpositional flap). Three patients had minor complications (managed nonoperatively). Conclusion Pedicled LDMF is a straightforward and versatile option for reconstruction of the varied upper limb and trunk soft tissue defects with minimal complications. Level of Evidence This is a level IV, therapeutic, retrospective study.

Background Persistent dead space following flap cover is a frequently encountered challenge following the reconstruction of complex wounds. It may lead to a hematoma, seroma, wound infection, and wound dehiscence. Wound dehiscence could be a devastating complication. Closed incisional negative pressure wound therapy (ciNPWT) over the surgical incisions was found to reduce surgical site infection (SSI) and wound dehiscence. We applied this principle at the closed flap suture line and through this article, we share the indications, technique, and outcomes. Methods A retrospective analysis (January 2018–June 2019), in which selected high-risk patients who underwent ciNPWT at the flap suture following complex reconstruction (pedicled or free flap) were included in the study. The indications include deep incisional/organ SSI after debridement and flap coverage, persistent dead space following flap coverage, chronic osteomyelitis. Patients were analyzed in the follow-up period in terms of complications, wound healing. Results Nine patients underwent ciNPWT over the flap suture line. The mean age was 32.2 years (range: 10–48 years). The mean duration of the NPWT application was 7.3 days (range: 3–21 days). Three of the nine patients had flap-related minor complications. One patient had marginal flap necrosis and required skin grafting, one patient had minor wound dehiscence (1 cm) which required secondary skin suturing and one patient had chronic discharging sinus related to osteomyelitis of ischium, which subsequently healed with antibiotics and local wound care. None of the patients had NPWT-related complications. Conclusion Closed incisional NPWT decreases the untoward effects of dead space following the reconstruction of complex wounds. The incidence of SSI and wound gaping can be reduced.

Purpose: Pedicled flaps are still the workhorse flaps for reconstruction of upper limb soft tissue defects in many centers across the world. They are lifeboat options for coverage in vessel deplete wounds. In spite of their popularity existing algorithms are limited to a particular region of upper limb; a general algorithm involving entire upper limb which helps in clinical decision making is lacking. We attempt to propose one for the day to day clinical practice. Methods: A retrospective analysis of patients who underwent pedicled flaps for coverage of post-traumatic upper extremity (arm, elbow, forearm, wrist & hand) soft tissue defects within the period of January 2016 to October 2017 was performed. Patients were divided into groups according to the anatomical location of the defects. The flaps performed for different anatomical regions were enlisted. Demographic data and complications were recorded. An algorithm was proposed based on our experience, with a particular emphasis made to approach to clinical decision making. Results: Two hundred and twelve patients were included in the study. Mean age was 27.3 years (range: 1–80 years), 180 were male, and 32 were female. Overall flap success rate was 98%, the following complications were noted marginal flap necrosis requiring no additional procedure other than local wound care in 32 patients (15%), partial flap necrosis requiring flap advancement or extra flap in 15 patients (7%), surgical site infection in 11 patients (5%), flap dehiscence requiring re-suturing in 5 patients (2.4%), total flap necrosis 4 patients (2%). Conclusion: The proposed algorithm allows a reliable and consistent method for addressing diverse soft tissue defects in the upper limb with high success rate. Keywords: Algorithm, Upper limb, Soft tissue defect, Reconstruction, Pedicled flaps, Decision making

Purpose Microvascular reconstruction is the standard of care for salvage of soft tissue defects in complex upper extremity due to their distinct advantages over the pedicled flaps. However, in the era of microsurgery, pedicled flaps have an acceptable significant role for reconstruction of complex soft tissue defects. The authors aim to demonstrate the versatility of pedicled thoracoumbilical flap (TUF) in selected clinical scenarios. Patients and Methods Retrospective analysis of patients who underwent TUF for upper limb posttraumatic reconstruction was performed between January 2016 and October 2017. The demographic details, etiology, wound parameters, clinical circumstances, and complications were recorded. Results Ten patients were included in the retrospective case series. Out of them, nine of the patients had critical issues, which justified a pedicled TUF over free flap. The critical issues were severe comorbid illnesses (n = 3), the paucity of recipient vessels (n = 1), salvage of hand replant and revascularization (n = 2), circumferential degloving injury to the multiple fingers and palm (n = 1), coverage for metacarpal hand (n = 1), and extensive scarring at the surgical site (n = 1). Mean age was 34.4 years (range: 11–70 years), six of them were males, and four were females. Two patients had infections resulting in wound gaping. One of the patients had flap tip necrosis. Conclusion Pedicled flaps have a significant acceptable role in this era of microsurgery, and a pedicled TUF is a versatile option for coverage of complex soft tissue defects of the forearm, wrist, hand, and fingers. Level of Evidence This is a level IV, therapeutic, and retrospective study.

The authors present a retrospective review of 7 patients who underwent wide excision of the malignant tumors around the clavicle. Patient demographics, clinical details, the arc of rotation, outcome, and complications were analyzed.

A 20-year-old woman presented to us with a crush avulsion amputation of the right upper limb at the level of forearm following a sideswipe injury. She was a right-handed person. The warm ischaemia time was 6 hours. She had a comminuted fracture of both bones of the forearm and severely crushed upper

A 45-year-old man was referred to us for the management of an infected groin wound following femoral artery repair. One week earlier he sustained fall from a rooftop and was diagnosed with pelvic diastasis, right acetabular fracture, femoral artery and vein injury. He underwent femoral artery repair

Introduction Reconstruction of complex soft tissue defects around the cervico-occipital and thoracic spine regions is a challenging task. We want to share our experience with trapezius flap for the reconstruction of these complex cases. Materials and Methods A retrospective analysis of patients who underwent reconstruction using trapezius flaps from January 2016 to June 2019 was performed. The indications, technique, complications, and outcomes were analyzed and presented. Results Six patients (three males and three females, >10 years of age) underwent seven reconstructions using trapezius flaps (one of the patients underwent reconstruction using a bilateral trapezius flap). Trapezius flap was used to resurface the parieto-occipital (n = 2), cervico-occipital (n = 2), cervicothoracic (n = 1), and thoracic (n = 1) regions. All flaps showed successful outcomes; one patient had wound dehiscence, and one patient had partial skin graft loss. Conclusion Trapezius flap is a reliable and good alternative to free flaps for the coverage of complex cervical-occipital and upper thoracic soft tissue defects.

A 18-year-old man presented to us following a sideswipe injury leading to crush avulsion amputation of the right upper limb at the level of the upper 1/3 of the humerus shaft. The injury occurred 7 hours earlier, and he was haemodynamically stable at the time of presentation. On examination of the

Skin avulsion injuries are one of the most common soft tissue injuries encountered by the trauma surgeons and reconstructive surgeons. Harvesting skin graft from the avulsed skin either avoids or reduces the requirement of subsequent skin grafting. A 12-year-old child presented to us with an avulsion injury left lower limb 6 hours following road traffic accident. On examination, the patient had avulsion of skin from the anterolateral surface of the thigh and circumferential skin avulsion extending from knee joint to the foot (figure 1). The non-viable avulsed skin was debrided till the fresh bleeding edges were obtained. The avulsed skin was cleaned, and gross defatting was performed with a surgical blade and curved Metzenbaum scissors in a turnover fashion (dermal side facing above and epidermis side facing below). Once …