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Introduction: Achilles tendon rupture and soft tissue infections with wound dehiscence and tendon exposure following the tendon repair are not infrequent. Various procedures have been described for the reconstruction of soft tissue defects at the Achilles tendon region, yet there is lack of consensus on the ideal method. In this article we report our experience using the distally based peroneal artery perforator flap in reconstruction of combined defects of the Achilles tendon and overlying soft tissue., Methods: 7 patients with Achilles tendon injury and full-thickness soft tissue defects over the Achilles region underwent tendon repair and soft tissue reconstruction with the distally based peroneal artery perforator flap. Perforator vessels were identified at the septum between the peroneus longus and soleus muscles. After choosing the perforator with the largest diameter, meticulous deep dissection of the perforator was performed and completed 6 cm proximal to the lateral malleolus. The peroneal artery was transected and ligated and transposition of the flap to the defect was performed through a subcutaneous tunnel., Results: The size of the soft tissue defects and flaps ranged between 2×3 cm to 4×10 cm and 4×5 cm to 5×12 cm, respectively. Six out of 7 flaps survived completely without any complications. Post-operative venous congestion was observed in one patient which resulted in partial tip necrosis of the flap. The resulting wound healed with conservative treatment. Donor sites healed uneventfully in all patients. All flaps had excellent contour and provided stable soft tissue coverage., Conclusion: Distally based peroneal artery perforator flap can be considered as a reliable alternative for the reconstruction of soft tissue defects around the Achilles tendon region. Advantages include (1) extended reach of the flap for the defects around the plantar and dorsal aspects of the foot, provided by the perforator dissection, (2) convenience with footwear and walking, provided by the skin texture similarity with the target region, (3) creating a protective surface to allow tendon gliding and prevent tissue adhesions after the tendon repair, provided by the crural fascia included in the flap, (4) obviating the need for microsurgical anastomosis and associated length of the operation., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021. Published by Elsevier Ltd.)

Background: The umbilicus is an indicative aesthetic component of the abdomen. Many umbilicoplasty techniques have been defined and the most commonly used method is the round incision technique. In this paper, we present a new umbilicoplasty technique involving the use of a three-armed star flap and compare it with the round technique. Methods: Forty-eight female patients who underwent umbilicoplasty during abdominoplasty and free deep inferior epigastric perforator flap (DIEP) procedures between February 2011 and December 2016 were included in the study. Twenty patients had round umbilicoplasty, whereas in the remaining 28 patients the three armed star flap technique was used. Aesthetic outcomes of both techniques were evaluated by a questionnaire which was completed by the patients and two independent surgeons. Results: The mean follow-up period was 22 months. Hypertrophic scarring was seen in one patient with the three armed star flap technique and in two patients with the round technique and a cicatricial ring formation occurred in one patient with the round technique. The patient and surgeon questionnaire scores were significantly higher in the 3-armed star flap group. ( p  < .05) Conclusion: In this study, round umbilicoplasty technique has been compared with the three armed star flap technique. Patient satisfaction surveys and evaluation by two independent surgeons revealed better cosmetic results with the new technique. We believe that this new technique could be preferred over the round technique since it prevents stenosis, circular scar contraction and provides a natural contour between the umbilicus and abdomen.

Background: The goals of tracheostomy scar revision are filling of the depressed area, providing easy sliding of skin over the trachea. There are various techniques described to correct this situation. In this article, a modification of split sternocleidomastoid (SCM) muscle flap used in the correction of posttracheostomy defects is described., Methods: Thirteen patients who had depressed scars after tracheostomy are included in this study. The mean patient age was 44 years (range, 27-56 years). All patients who suffered from tracheal tug, dysphagia, and bad appearance are included in the study. The area with the depressed scar is de-epithelialized after incising around the depression. Bilateral SCM muscles are split in the coronal plane toward superior half of the muscle while leaving the posterior part of the muscle attached to the bone. After elevation, both SCM muscle flaps are overlapped in the midline., Results: The mean follow-up period of the patients was 11 months (range, 5-20 months). Tracheal tug and dysphagia complaints were resolved in all patients. The depressed area due to the scar was either reduced or completely recovered in all the patients. Apart from 1 hematoma case, none of the early or late complications such as infection, wound dehiscence, skin necrosis, seroma, recurrence, or neck contracture was seen., Conclusions: We think that this technique, which gives functionally and aesthetically satisfying results, can be used safely in depressed scars formed after tracheostomy and treatment of functional impairment due to this procedure.

Background: Many things cause leg asymmetry and sequelae seen after poliomyelitis infections are still a cause of leg deformities. In this study, lipofilling and liposuction combinations are performed on patients with poliomyelitis sequelae. Volume deficiency is not the only leg problem with polio sequelae, leg length is also a problem. For this reason, the length deficiency must be addressed in order to achieve the desired symmetry. The aim of this study is correcting limb asymmetry by a method addressing both limb length deficiency by heel raise and volume deficiency by injection of fat based on corrected limb length., Patients and Methods: From 2011 through 2013, 10 female patients who had unilateral leg atrophy as a result of paediatric polio infections were included in our study. All of the patients were treated with liposuction and lipofilling combinations. During planning, a ridge was placed under the affected leg in order to equalize the lengths of both legs. The fat injection sites on the affected leg were marked to mimic the unaffected leg., Results: All the patients stated that they were satisfied with the results. Transient hypoesthesia was seen in only one patient, but this was spontaneously resolved six months later., Conclusion: The study results indicate that the asymmetric fat injection procedure can be a good technique to use with patients who have polio sequelae, both with short legs and volume deformities., Level of Evidence: 4., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The optimal treatment of the pilonidal sinus has not currently been defined. This study described the use of a modified bilateral transpositional adipofascial flap technique that effectively serves to flatten the deep natal cleft while keeping the scar limited to the intergluteal fold for good cosmesis. Between June 2007 and September 2011, 83 patients (61 men, 22 women) were included in the study. Duration of pilonidal sinus symptoms ranged from 1-15 (median 5) years; 15 patients had recurrent disease. Before the operation, perforating branches of the four pairs of lateral sacral arteries were identified with a Doppler audioscope. After complete excision of the sinus cavity and adequate undermining of the skin, bilateral adipofascial flaps were raised in order to realise a Yin-Yang pattern, with the lateral sacral artery perforators at the base of each flap. Complementary flaps were then transposed into the defect and inset to completely obliterate dead space. Skin was closed primarily in two layers. The median (range) defect size after total excision of the sinus cavity was 38 (19-60) cm2. All flaps survived. There was no wound infection or dehiscense. Median (range) follow-up was 26 (6-52) months. No recurrences were observed. Extensive scarring or asymmetry in the gluteal prominences was not observed. Transient paraesthesia over the flap donor region occurred in 14 cases (16%) and resolved completely within 6 months. The bilateral adipofascial transpositional flap method is an alternative to previously described treatment options in pilonidal sinus surgery. It is a safe, reliable, and easily applicable method, which provides cosmetically acceptable coverage of pilonidal sinus defects of moderate size.

The main focus of this paper is the selection of proper vessels for successful free tissue transfer in lower extremities which have suffered extensive trauma. The selection of proper recipient vessels for traumatized lower extremities still presents difficulties for surgeons. This review will provide a general guideline for the selection of proper recipient vessels in traumatic lower extremity reconstruction and describe the possible reasons why some recipient vessels present more problems than others., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objectives: The location of the fingertip entitles it to have significant cosmetic and functional values, but also places it at high risk for injury. During repair, finger length and function should be maintained, and stiffness and neuroma should be avoided. Various flaps have been described for reconstruction of distal finger defects with bone, tendon, or joint exposures, including reverse flow homodigital island flap. In this study, we present our experience of reverse flow homodigital island flap in terms of sensory recovery., Methods: Sixty-six patients (70 fingers) with fingertip amputations were included in the study. Patients were treated with homodigital island flaps. All patients underwent sensitivity assessment by 2-point discrimination and Semmes-Weinstein monofilament tests at 6, 12, and 18 months during follow-up, and complications were recorded., Results: Monofilament testing results were normal in 64 fingers (91.4%), and diminished light touch was found in six fingers. Two-point discrimination results were normal (<6 mm) in 40 fingers and fair (6-10 mm) in 30 fingers (mean 5.7 mm, range 4-9 mm). Complications included one partial flap necrosis, three flexion contractures, and two neuromas., Conclusion: In repair of injuries to areas in which sensory feedback is critical, such as the index finger, the homodigital flap may be the treatment of choice.

Recently several studies have addressed the venous problem and confirmed that venous ischemia is more injurious to tissue viability than arterial ischemia of equivalent duration. There are different methods of managing venous-compromised pedicled flaps. Between June 1996 and November 2003, our center treated two submental, five Becker, nine posterior interosseous, three distally based sural, and three colon pedicled flaps (22 flaps in total), which had venous congestion either at the time of flap elevation or immediately after inset of the flap. These cases of venous congestion were managed with an immediate additional venous anastamosis. After vein anastomosis, venous congestion reduced gradually, then improved, and finally disappeared completely in the postoperative follow-up days with all flaps surviving in their entirety. Reexploration was not required for the microsurgical venous anastomosis. In conclusion, flap necrosis resulting from venous congestion causes prolonged hospitalization, multiple debridements, and additional procedures to cover the exposed structures. Additional vein anastomosis, which is a simple, rapid, and reliable auxiliary procedure, may increase complete flap survival and lead to successful end results, both functional and cosmetic.

Although many large series of free tissue transfers for head and neck reconstruction have been reported in adults, there are few studies in paediatric patients. Seventy-three free tissue transfers for reconstruction of various defects of the head and neck were performed in 72 paediatric patients between January 1990 and September 2002, at our centre. The average age at the time of reconstruction was 11.8 years (range: 2 to 17 years). Thirty-eight patients were girls and 34 were boys. There were 19 tumour resection defects, 18 congenital oro-nasal fistula defects (cleft palate), 11 posttraumatic defects, nine corrosive pharyngo-oesophageal injuries, eight burn contractures, six hemifacial atrophies and microsomia, and one facial paralysis. Thirty-nine fasciocutaneous flaps, 16 osteoseptocutaneous flaps, 10 muscle or myocutaneous flaps, and eight jejunal flaps were transferred. The mean operative time was 8 h 20 min. All flaps survived, except one partial necrosis, with 98.6% success rate. Five patients (6.8%) required re-exploration. There were two venous and three arterial thromboses. All five flaps were successfully salvaged. The average hospital stay was 18 days. This study confirmed free tissue transfer as a safe, reliable, cost- and time-effective method for the reconstruction of various head and neck defects in children.

Background: Reconstruction of facial skin defects requires good-quality skin cover to satisfy aesthetic expectations of patient, especially when the skin defect is on the uncovered area of the face. Limitations in the available local tissue and donor-site morbidity restrict the options., Objective: In an effort to solve these problems, we have begun to use a subcutaneous pedicled retroauricular reverse-flow flap., Methods: Between January 1997 and December 2005, reverse-flow subcutaneous pedicled retroauricular island flap was used to cover facial defects in 12 patients who underwent surgical excision of skin tumor. The patients ranged in age from 44 to 81 years with a mean age of 58 years., Results: Only one case experienced a superficial necrosis in the distal one-quarter part of the flap. The functional and aesthetic results were satisfactory for both patients and surgeons, and no tumor recurrence was observed during the 12 to 28 months (mean, 18.8 months) follow-up period., Conclusions: This flap can be used reliably for the reconstruction of facial skin defects of small and medium size. The preference of frontal branch pedicled flap enables more distal facial area defects to be covered, such as dorsal nasal, nasolabial, and upper lip, than flaps based on parietal branch.

The development of microsurgical techniques has facilitated proper management of extensive head and neck defects and deformities. Bone or soft tissue can be selected to permit reconstruction with functional and aesthetic results. However, for free tissue transfer to be successful, proper selection of recipient vessels is as essential as the many other factors that affect the final result. In this article selection strategies for recipient vessels for osteocutaneous free flaps, soft tissue free flaps, previously dissected and irradiated areas, recurrent and subsequent secondary reconstructions, simultaneous double free flap transfers in reconstruction of extensive composite head and neck defects, and the selection of recipient veins are reviewed in order to provide an algorithm for the selection of recipient vessels for head and neck reconstruction.

Background: The advantages of free muscle flaps for reconstruction of lower extremity defects have been largely reported to be superior to those of fasciocutaneous flaps., Methods: One hundred seventy-four patients received 177 microsurgical free tissue transfers for distal third and ankle open tibial fractures. Patients were divided into two groups. In group I, 96 patients received 98 free muscle flaps (55.4 percent). In group II, 78 patients were treated with 79 free fasciocutaneous flaps (44.6 percent)., Results: Complete flap survival was 92.9 percent and 91.1 percent in groups I and II, respectively. Postoperative infection was 11.2 percent in group I and 12.7 percent in group II. Chronic osteomyelitis developed in 9.3 percent and 12.7 percent in groups I and II, respectively. The rate of primary bone union was 84.5 percent in group I and 81 percent in group II and the rate of overall bone union was 96.9 percent in group I and 98.7 percent in group II. Finally, 92 patients in group I and 77 patients in group II could walk without crutches at 2-year follow-up. There were no statistically significant differences between the two flaps., Conclusions: The authors achieved equal functional outcomes in both soft-tissue transfers because of (1) preoperative adequate débridement of wounds and (2) selection of proper free flaps in appropriate defects. Defects with serious tridimensionality needed free muscle flaps because they conform better to such complex defects. However, free fasciocutaneous flaps are reliable and as effective for covering the less three-dimensional distal third and ankle traumatic open tibial fractures as free muscle flaps and can better tolerate the subsequent secondary surgical procedures.

Background: Composite maxillary defects often involve the maxilla, nasal mucosa, palate, and maxillary sinus. We presented the surgical techniques and outcome of the osteomyocutaneous peroneal artery perforator (PAP) flap for reconstruction of composite maxillary defects., Methods: Six patients underwent an osteomyocutaneous PAP flap reconstruction of composite maxillary defects. The average age was 52 years. The defects were Cordeiro type II in three patients and type IV midfacial defects in another three patients., Results: No total or partial flap failures occurred. At a mean 12-month follow-up, five patients had a normal speech and were able to eat a regular diet. One patient tolerated a soft diet and had intelligible speech. One patient had ectropion develop. Excellent cosmesis was found in five patients., Conclusions: The osteomyocutaneous PAP flap represents a further refinement of the fibula flap and increases its versatility, with multiple skin paddles, bone segments, and soleus muscle independently isolated. It is a comparable reconstruction option for composite maxillary defects., (Copyright 2005 Wiley Periodicals, Inc.)

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.

Twenty-two elective free-tissue transfers for reconstruction of various defects were performed in 20 pediatric patients over a 7-year period. Patient ages ranged from 5 to 17 years (mean: 12.5 years). There were six open wounds, six unstable scars, five tumor resection defects, three facial gunshot wounds, one facial paralysis, and one penis agenesis. Ten free flaps were transferred to the head and neck region, seven to the lower extremity, four to the upper extremity, and one to the genital area. Ten fasciocutaneous flaps, seven muscle or myocutaneous flaps, and five vascularized bone grafts were transferred. All flaps survived, except for one in an electrical burn patient. The success rate was 95 percent. No vessel spasm was observed. Children tolerated long operation periods better than adults. The recovery time after surgery was considerably shorter than in adults. The mean operative time was 6 hr, and the average hospital stay was 12 days. The mean follow-up period was 27 months. Results of this study indicate that microvascular free-tissue transfer is a safe and reliable method for the reconstruction of various defects in children.