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The syndrome of the trephined is a neurologic phenomenon that manifests as sudden decline in cognition, behavior, and sensorimotor function due to loss of intracranial domain. This scenario typically occurs in the setting of large craniectomy defects, resulting from trauma, infection, and/or oncologic extirpation. Cranioplasty has been shown to reverse these symptoms by normalizing cerebral hemodynamics and metabolism. However, successful reconstruction may be difficult in patients with complex and/or hostile calvarial defects. We present the case of a 48-year-old male with a large cranial bone defect, who failed autologous cranioplasty secondary to infection, and developed rapid neurologic deterioration leading to a near-vegetative state. Following debridement and antibiotic therapy, delayed cranioplasty was accomplished using a polyetheretherketone (PEEK) implant with free chimeric latissimus dorsi/serratus anterior myocutaneous flap transfer for vascularized resurfacing. Significant improvements in cognition and motor skill were noted in the early postoperative period. At 6-month follow-up, the patient had regained the ability to speak, ambulate and self-feed—correlating with evidence of cerebral/ventricular re-expansion on computed tomography. Based on our findings, we advocate delayed alloplastic implantation with total vascularized soft tissue coverage as a viable alternative for reconstructing extensive, hostile calvarial defects in patients with the syndrome of the trephined.

Introduction: The resection of invasive tumors of the head and neck can result in extensive and complex defects requiring immediate repair. One repair option is the transfer of a transverse rectus abdominis myocutaneous (TRAM) flap pedicled on deep inferior epigastric vessels using vascular microsurgery. This study aimed to register a procedure used in the microsurgical treatment of giant malignant fibrous histiocytoma of the face using a TRAM flap. Case Report: A male patient sought medical care for a giant tumoral lesion in the right hemiface. Computed tomography of the skull revealed a voluminous expansive process of vegetating aspect with poorly defined borders. The excision of the tumor affected the right masseter and temporalis muscles, parotid gland, and right orbital and malar bones. Subsequently, microsurgical withdrawal of the TRAM flap was performed with the deep inferior epigastric artery through a surgical incision in the hypogastric area. Dissection of the facial artery and vein under microscopy and venous and arterial anastomoses followed. The flap was intact with good perfusion and no signs of infection. Conclusions: Microsurgical facial reconstruction allows head and neck surgeons to resect large tumors.

Introduction: The myocutaneous flap is often used in reconstruction of head and neck defects. However, it is restricted to the middle third of the face. Perforating artery dissection techniques allow further lengthening of the pedicle, thus achieving coverage of the orbitofrontal-parietal region. Case report: A 63-year-old male with a poorly-differentiated invasive squamous cell carcinoma presented with a final defect of 12.0 × 18.0 cm in the right orbitofrontal-parietal region, with dura mater, frontal sinus, and right upper orbit exposure after resection. We designed a pectoralis major flap, with a cutaneous island equaling the defect in dimensions, in the right parasternal region, from the fourth intercostal space to the subcostal region (extended). The pedicle was sectioned after 4 weeks. The coverage was effective, with no major complications, and a satisfactory aesthetic result. Conclusion: This flap can be an excellent option for reconstruction of the upper third of the head when there are limitations to microsurgery.

Background In immediate breast reconstruction using an extended latissimus dorsi musculocutaneous (eLDMC) flap, the volume of the flap decreases, which causes a secondary deformity of the breast shape. Since little research has investigated this decrease in muscle volume, the authors conducted an objective study to characterize the decrease in muscle volume after breast reconstruction using an eLDMC flap.

Background Bilateral microsurgical autologous reconstruction is known to increase operating time, costs, and complications compared to unilateral procedures. This study aimed to determine whether a unilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flap and a unilateral deep inferior epigastric artery perforator (DIEP) free flap could be a feasible option for bilateral reconstruction in selected circumstances. Methods A retrospective chart review identified patients who underwent unilateral pedicled TRAM and unilateral DIEP reconstruction for bilateral breast reconstruction between 2011 and 2014. Surgical outcomes, complications, and aesthetic scale questionnaire responses were evaluated. Results Fourteen patients were included in this study. Ten patients received bilateral immediate reconstruction, while four patients with a previous history of mastectomy underwent unilateral immediate reconstruction and contralateral delayed reconstruction. All flaps survived without any major complications. A case of nipple-areolar skin necrosis on the pedicled TRAM side and a case of mild abdominal bulging at the free DIEP donor site were reported. There was no partial flap necrosis or palpable fat necrosis. On the aesthetic outcome scale, the free DIEP flaps scored significantly higher than did the pedicled TRAM flaps for overall shape, the upper medial and lower lateral quadrant, and the lateral chest wall. Conclusions Our findings suggest that a unilateral pedicled TRAM flap together with a unilateral free DIEP flap could be performed as a bridging surgical option as institutions move toward bilateral free-flap reconstructions, as a way to reduce operating time and the risk of microsurgery-related complications with acceptable donor site morbidity and aesthetic outcomes.

The anterolateral thigh flap (ALT) has proven over time to be one of the best reconstructive workhorses due to its versatility and reliability. Without preoperative imaging, vascular anomalies such as having no sizable perforator are sometimes encountered during dissection. We propose a technique, based on a modified version of the traditional myocutaneous ALT to allow harvest of the flap based on non-sizable perforators. This technique can also enable the splitting of a flap when only one sizable perforator is present. A retrospective review of patients who received reconstruction with free ALT flap from 2013 to 2019 by the senior author HSS was performed and included all flaps in which non-sizable perforators were harvested. Data collected for analysis included patient demographics, flap size, defect location, inset type, and flap survival. Despite detachment of the majority of skin paddle from the muscle, the flap is harvested with a sleeve of areolar tissue containing preferably more than one non-sizable perforator attached to a small muscular segment of the vastus lateralis containing the pedicle. A total of 349 ALT flaps were performed during the review period by senior author HSS, and 25 flaps were harvested with non-sizable perforator, 10 of which were to enable a split. There were no total losses and 6 partial losses; 2 were amenable to direct closure after debridement, 1 required skin graft, and 3 required a new flap for wound coverage. Incorporating more than one non-sizable perforator increases the reliability of the flap. This technique should be used with caution in patients with multiple underlying comorbidities and when a flow-through flap is required. We were able to achieve primary closure of all donor sites. It is possible to harvest the anterolateral thigh flap without sizable perforators by conversion to a modified version of the myocutaneous flap. In well-selected patients, using our technique, several non-sizable perforators can reliably perfuse an ALT without the need to use an alternative donor site. This maximizes the number of harvestable ALTs and increases the reconstructive potential by splitting previously "un-splitable" flaps. [ABSTRACT FROM AUTHOR]

Purpose: Myelomeningocele (MMC) is the most prevalent form of spina bifida aperta. Here we present the surgical repair technique of a dorsolumbar myelomeningocele with a large associated soft tissue defect. Methods: Data concerning the anamnesis and complementary studies were obtained from the clinical history. Surgical images were obtained in the operation room during surgery. Result: We describe the case of a newborn with a dorsal myelomeningocele with a placode in the central area and a large associated skin defect of 12 x× 12 cm. Urgent intervention was carried out on the day of birth with placode reconstruction. Dorsal and gluteus maximus muscle rotation and skin rotation flap were performed in order to achieve complete closure of the myocutaneous defect. The patient presented a good recovery with no new neurological deficit. Conclusion: Myelomeningocele may be associated with large myocutaneous defects that can be difficult to correct by primary closure. In these cases, rotation flaps may be necessary to achieve complete closure. [ABSTRACT FROM AUTHOR]

Vaginal cuff dehiscence after total hysterectomy or total cystectomy had been increasing since laparoscopic or robotic surgery became a common surgery among gynecologists and urologists. A 52-yearold woman underwent laparoscopic radical total cystectomy for muscle invasive bladder carcinoma at Rakuwakai Otowa Hospital. She was emergently admitted with a fist-sized lump protruding from her vagina four months after surgery. Physical examination and her past history on admission disclosed vaginal cuff dehiscence after cystectomy. Computed tomographic scan and magnetic resonance imaging showed no bowel evisceration in the lump. We confirmed that the content of lump was peritoneal tissue and removed it by laparoscopic surgery. Simultaneously, we repaired the vaginal cuff dehiscence with a gracilis myocutaneous flap. There was no subsequent recurrence of vaginal dehiscence or bladder carcinoma in one-year follow-up.

Objective: The long-term effects of the unilateral muscle-sparing pedicled transverse rectus abdominis myocutaneous (TRAMmsp) flap procedure on trunk muscle performances and core stability were investigated in women with breast cancer., Methods: Forty women (mean age = 42.6 years) who had received breast reconstruction with the unilateral TRAMmsp flap procedure no less than 6 months earlier (mean = 10.3 [standard deviation, SD = 4.9] months) (TRAM group) participated, and 30 women who were healthy and matched for age (mean age = 41.2 years) served as controls (control group). Their abdominal and back muscle strength was assessed using the curl-up and prone extension tests, respectively, and their static abdominal muscle endurance and back extensor endurance were assessed using the sit-up endurance test in the crook-lying position and the Biering-Sørensen test, respectively. Core stability strength was assessed using a 4-level limb-lowering test (abdominal muscle test), and core stability endurance was assessed while lying supine with both flexed legs 1 inch off the mat while keeping the pelvis in a neutral position with a pressure biofeedback unit., Results: Compared with the control group, trunk muscles of the TRAM group were weaker, showing less endurance, as were their core stability strength and endurance. Static trunk muscle endurances and trunk flexion strength were associated with core stability in both groups., Conclusions: Women exhibit trunk flexor and extensor weakness along with poor endurance and impaired core stability even after an average of 10 months from receiving the TRAMmsp flap procedure. Immobilization after surgery, with possible systemic inflammatory effects from surgery and chemotherapy, might have further contributed to the generalized weakness subsequent to the partial harvesting of the rectus abdominis., Impact: Women after breast reconstruction with the TRAMmsp flap procedure show long-lasting deficits of strength and endurance in abdominal muscles, back extensors, and core stability. Proactive measures including early detection and evaluation of impairments as well as timely intervention targeting these clients are important to minimize the dysfunction and support their return to community participation., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The large soft-tissue defect after total or high sacrectomy for giant sacral tumor induces high incidence of wound complications. It remains a huge challenge to reconstruct the soft-tissue defect and achieve the preferred clinical outcome., Methods: A total of 27 patients undergoing one-stage total or high sacrectomy for giant sacral tumors between 2016 and 2021 in a tertiary university hospital were retrospectively reviewed. Participants were divided into two groups. Thirteen patients underwent a pedicled vertical rectus abdominis myocutaneous (VRAM) flap reconstruction, whereas 14 patients underwent a conventional wound closure. Patient's clinical characteristics, surgical duration, postoperative complications, and outcomes were compared between the two groups., Results: Patients in VRAM and non-VRAM groups were similar in baseline characteristics. The mean tumor size was 12.85 cm (range: 10-17 cm) in VRAM group and 11.79 cm (range: 10-14.5 cm) in non-VRAM group (P = 0.139). The most common giant sacral tumor is chordoma. Patients in VRAM group had a shorter length of drainage (9.85 vs 17.14 days), postoperative time in bed (5.54 vs 17.14 days), and total length of stay (19.46 vs 33.36 days) compared with patients in non-VRAM group. Patients in the VRAM group had less wound infection and debridement than patients in non-VRAM group (15.4% vs 57.1%, P < 0.001)., Conclusions: This study demonstrates the advantages of pedicled VRAM flap reconstruction of large soft-tissue defects after high or total sacrectomy using the anterior-posterior approach. This choice of reconstruction is better than direct wound closure in terms of wound infection, length of drainage, and total length of stay., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Women commonly experience upper eyelid dermatochalasis and upper eyelid depression with advancing age. Blepharoplasty is a suitable method for treating dermatochalasis, but not sunken eyelid. This study proposed a novel technique for eyelid rejuvenation by simultaneously correcting dermatochalasis and sunken upper eyelids in middle-aged women., Methods: Forty patients underwent subbrow blepharoplasty combined with brow fat pad transfer. Ellipse-shaped skin and subcutaneous tissue underneath the eyebrow were measured, demarcated, and excised. The orbicularis oculi muscle beneath the subcutaneous tissue was exposed and dissected in the upper-third area. The brow fat pad was turned downward using the lower edge as the pedicle and was fixed in the layer of retro-orbicularis oculi fat to fill the depressed area in the upper eyelid. The lower muscle flap was fixed to the supraorbital rim periosteum and upper musculocutaneous flaps, thereby forming a cross flap for interlocking fixation. The surgical outcomes were evaluated using a three-dimensional imaging device and the Global Aesthetic Improvement Scale., Results: The depth and volume of upper eyelid depression decreased significantly 3 months after the surgery and stabilized within 6 months. Global Aesthetic Improvement Scale scores significantly improved after the surgery, and the postoperative outcomes were acceptable., Conclusions: The novel technique is simple and effective for simultaneously correcting dermatochalasis and sunken upper eyelids in middle-aged women. The surgical outcomes are predictable and acceptable to most patients., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Postoperative pain after breast reconstruction surgery with the latissimus dorsi flap is a common occurrence. Botulinum neurotoxin (BoNT) injection during surgery is effective in reducing postoperative pain. This study aimed to determine the most appropriate locations for BoNT injection. A modified Sihler’s method was performed on the latissimus dorsi muscles in 16 specimens. Intramuscular nerve arborization was noted under the landmark of the medial side surgical neck of the humerus to the line crossing the spinous process of T5 and the middle of the iliac crest. The latissimus dorsi muscles were divided into medial, middle, and lateral segments with 10 transverse divisions to give 10 sections (each 10%). Intramuscular nerve arborization of the latissimus dorsi muscle was the largest from the medial and lateral part of the muscle ranging from 40 to 60%, middle part from 30 to 60% and medial, middle and lateral part from 70 to 90%. The nerve entry points were at the medial and lateral part with 20–40% regarding the medial side of surgical neck of the humerus to the line crossing spinous process of T5 to the middle of iliac crest. These outcomes propose that an injection of BoNT into the latissimus dorsi muscles should be administered into specific zones.

Introduction: Breast cancer is the most common cancer among women worldwide. Locally advanced breast cancer is characterized by clinical stage IIIb or IV and accounts for 20- 25% of all cases. Defects are reconstructed using myocutaneous and fasciocutaneous flaps, primarily from the latissimus dorsi and rectus abdominis muscles. The objective is to evaluate the results of thoracic wall reconstructions in cases of locally advanced breast cancer using fasciocutaneous and myocutaneous flaps. Methods: This was a retrospective, observational, and descriptive single-center study. Variables studied included defect size and flap dimensions, myocutaneous flap type, presence of cutaneous and visceral metastasis, postoperative evolution, and complications. Results: We selected 11 patients with a mean age of 49 years; the left side was the most commonly affected. The most common tumor type was invasive ductal carcinoma. The flaps were made of latissimus dorsi VY (LDVY) in two patients, latissimus dorsi associated with thoracoabdominal flaps (LDVYTA) in two, vertical rectus abdominus myocutaneous flap (VRAM) in four, and thoracoabdominal flaps (TA) in three. The mean defect area was 421.72 cm2, while the mean flap area was 451 cm2. The most frequent complication was partial dehiscence (seven patients). Six patients achieved lethal exit. VRAM flaps presented more complications. The mean survival for VRAM was 25.5 months, LDVY was 17 months, TA was 17 months, LDVYTA was 20.5 months. Conclusion: Myocutaneous and fasciocutaneous flaps are effective for chest wall reconstruction after locally advanced breast cancer resection.

Introduction: The paper describes a 14-year experience with breast reconstruction using a latissimus dorsi myocutaneous flap (LDMF) and breast implants. The objective was to delineate the experience with LDMF and breast implants, skin island schedules and dissection details, flap transposition and placement of the implant under a double layer, strategies to minimize damage in the donor area, and strategies of breast symmetry and reconstruction of the nipple-areola complex, in association with evaluation using the Breast-Q questionnaire. Methods: A review of medical records was performed between April 2003 and June 2017. Results: In the period, 76 patients with a mean age of 50.09 years underwent reconstruction with a LDMF, which was bilateral in 11, for the right breast in 34, for the left breast in 31, immediate in 41, late in 22, and for rescue in 13. Conclusion: We conclude and verified with the Breast-Q questionnaire that with a precise indication, the proposed reconstruction technique with a double subpectoral plane and coverage with a LDMF is safer with a lower complication rate.

Background The umbilicus makes an important contribution to the natural appearance of the abdomen. To date, studies on its position in Korean women are lacking, and no standards have been established. The purpose of this study was to investigate the position of umbilicus in Korean women and to review changes in its position after ipsilateral pedicled rectus abdominis musculocutaneous (IP-RAM) flap.

INTRODUCTION: We report a case of reconstruction of the proximal third of the right humerus and rehabilitation of the elbow in a 20-year-old male patient who was injured in an automobile accident and developed bone necrosis of 5 cm at the proximal third of the humerus and avulsion of the brachial biceps. METHODS: A scapular bone flap was used, together with a latissimus dorsi myocutaneous flap, using subscapular vessels for the pedicle. RESULTS: The patient had excellent postoperative course, presenting in the 2-month postoperative period with bone consolidation and initiation of elbow flexion. CONCLUSIONS: This flap modality is a safe and useful option for bone reconstruction.

Although uncommon, shark attacks can lead to devastating outcomes for victims. Surgeons also face unique challenges during operative management such as exsanguination, shock, specific injury patterns and infections. This case report presents the management of a 39-year-old previously healthy female attacked by a shark while on vacation in Mexico. The patient sustained severe injuries to her left arm and her left thigh. She was transferred to a Canadian institution after ambiguous operative management in Mexico and presented with no clear antibiotic coverage and a Volkman’s contracture of the left upper extremity. In total, the patient underwent four washouts of wounds, two split-thickness skin grafts, one free anterolateral thigh flap, and one free transverse rectus abdominus myocutaneous flap for the reconstruction and salvage of the left lower extremity. This article highlights the specifics of this case and describes important points in managing these devastating injuries.

• Objective: Several pressure ulcer (PU) risk factors including paralysis and age greater than 70 have been identified, while others such as nutrition are debated. The object of this study is to identify perioperative risk factors that may predict improved outcomes and reduced complications in primary and recurrent PU reconstructions. • Method: A retrospective chart review of patients treated surgically for PUs from 2004 to 2013 at the University of Toledo Medical Center, Toledo, Ohio, US, was completed. Data collected included ulcer and medical history, as well as risk factors, complications and postoperative outcome. Data were statistically analysed for perioperative variances between primary and recurrent ulcers and closure status. • Results: A total of 49 patients with 102 reconstructions were reviewed. Spinal cord injured patients accounted for 90% receiving flap coverage of ulcers. Numerous differences between primary and recurrent ulcers were identified, including ulcer location, patient nutritional status, wound infection, postoperative course and recurrence. Multivariate analysis revealed a flap reconstruction prediction model using creatinine, haematocrit, haemoglobin, and prealbumin that is able to successfully predict closure outcome in 83.6% of cases. • Conclusion: Many factors play a role in the development, course and treatment of PUs. It is vital to understand the role of patient risk factors in the development of PUs, to direct subsequent management and reconstruction, and to prevent future recurrences. [ABSTRACT FROM AUTHOR]

Background: Ischial sores have higher risks of recurrence and considered the most difficult to treat. There are mainly 2 groups of techniques used in ischial pressure sore reconstruction which are as follows: (1) fasciocutaneous and/or myocutaneous flaps (Fc/Mc) and (2) perforator flaps. The aim of this study is to determine the advantages of perforator flaps over Fc and/or Mc flaps in reconstruction of ischial pressure ulcers. Methods: All articles published before April 2018 were investigated and searched for eligibility using the databases PubMed and Google Scholar. Eligible studies were determined according to inclusion and exclusion criteria. Recurrence rates, complication rates, and time of recurrences were assessed. Results: A total of 15 studies with 279 patients and 305 flaps were identified and included in the final analysis. The overall recurrence rate of flaps was 6.31 (95% CI, 5.86 to 6.78; p < 0.001); complication rate of flaps was 3.06 (95% CI, 2.91 to 3.23; p < 0.001); and recurrence time of flaps was 0.77 (95% CI, 0.66 to 0.90; p < 0.001). The mixed-effects analysis results have revealed that there was no statistically significant difference between the perforator and the Fc/Mc groups (between-level) in terms of recurrence rates (p > 0.05), complication rates (p > 0.05), and time of recurrences (p > 0.05). Conclusions: Perforator flaps mandate thorough pre-operative preparations, meticulous dissections, and long surgery times. There seem no advantage in applying perforator flaps in ischial pressure sore reconstructions in terms of complications and recurrences. Surgeons may prefer to perform straightforward procedures, such as myocutaneous flaps. Level of evidence: Level IV, risk/prognostic, therapeutic study. [ABSTRACT FROM AUTHOR]

BACKGROUND: Wound complications probably result in severe soft tissue defects after total knee arthroplasty, which brings orthopedic surgeon a big challenge. Some treatment options, such as frequent sterile dressings changes, persistent drainage, minor or thorough debridement, negative pressure wound therapy and split-thickness skin grafts, fail to help those quite large and deep wounds around the knee, with exposed fascia or prosthesis, bone, joint, tendon, large vessels and nerve, heal by secondary intention. Under these situations, orthopedic surgeon should consult plastic surgery and propose flap re-construction. OBJECTIVE: To introduce some types of flaps for orthopedic surgeon, so as to help orthopedic surgeon understand and chose flaps logically, and reduce severe consequences caused by soft tissue defect wounds. METHODS: The first author retrieved databases of PubMed, Medline, Wanfang and CNKI for the articles concerning wounds repaired by flap transfer after total knee arthroplasty published before 2019. The key words were "flap, knee, wound" in Chinese and English, respectively. Initially 668 articles were retrieved and 45 eligible articles were included in accordance with the inclusion and exclusion criteria for analysis. RESULTS AND CONCLUSION: (1) Flap reconstruction is widely applied in plastic surgery. It is significant for orthopedic surgeon to recognize the characteristics of each flap. (2) Selecting and designing suitable type of flap according to the three-dimensional structure and position of wounds is helpful for repairing soft tissue defect, reducing the risks of prosthesis exposure, periprosthetic infection, prosthesis removal and even amputation after total knee replacement after total knee arthroplasty. [ABSTRACT FROM AUTHOR]

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Background: Ischial pressure sores are mostly seen in wheelchair-bound patients and they have a high risk of recurrence due to a multitude of reasons compared with sacral and trochanteric ulcers. Various treatment modalities have been presented but high recurrence rates maintain its importance. Methods: Between 2009 and 2016, a total of 14 patients with spinal cord injuries were operated on for a total of 17 Shea stage IV ischial ulcers with the described technique. Demographic variables were recorded. Postoperative outcomes were categorized as early and late complications. A partial distal portion of gluteus maximus muscle (not the whole) was dissected and freed from the femoral insertion. The muscle was used as a carrier for the triangular flap lying above. The muscle was transposed medially and the triangular flap was advanced in a V-Y fashion to cover the defect. Results: The follow-up periods ranged between 15 and 61 months. Among all the 14 patients, only one (7.1%) had a recurrence after 1 year postoperatively which needed an additional debridement and advancement of the previous flap. This patient had a non-recurrent period of 16 months after the second operative procedure. Wound dehiscence, as an early complication, was seen in one patient which healed secondarily. Conclusions: The distal partial gluteus maximus musculocutaneous V-Y flap is a simple and new approach with low complication rates for reconstruction of ischial pressure sores. Although there is still not an ideal flap for this challenge, the present technique could be a reliable option for the reconstructive armamentarium.Level of evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Purpose: To compare the efficacy of quadratus femoris muscle pedicle bone flap transplantation combined with hollow compression screw fixation versus AO hollow compression screw fixation in the treatment of femoral neck fracture for Chinese young and middle-aged patients. Methods: Case-controlled studies (CCTs) were used to compare the two operative methods in the treatment of femoral neck fractures. Data were retrieved from the Cochrane Library, Pubmed Database, CNKI, Chinese Biomedical Database. Wanfang Data published during the period of January 2005 to December 2014. Methodological quality of the trials was critically assessed, and relevant data were extracted. Statistical Software Revman 5.0 was used for data-analysis. Results: Eight articles were included in the meta-analysis. The results showed that there was statistical significance in the rate of fracture healing [OR = 5.43, 95% CI (2.89, 10.20), p

Background A pharyngocutaneous fistula is a common and difficult-to-manage complication after head and neck reconstruction. It can lead to serious complications such as flap failure, carotid artery rupture, and pharyngeal stricture, and may require additional surgery. Previous radiotherapy, a low serum albumin level, and a higher T stage have been proposed as contributing factors. We aimed to clarify the risk factors for pharyngocutaneous fistula in patients who underwent flap reconstruction and to describe our experiences in treating pharyngocutaneous fistula. Methods Squamous cell carcinoma cases that underwent flap reconstruction after cancer resection from 1995 to 2013 were analyzed retrospectively. We investigated several significant clinical risk factors. The treatment modality was selected according to the size of the fistula and the state of the surrounding tissue, with options including conservative management, direct closure, flap surgery, and pharyngostoma formation. Results A total of 127 cases (18 with fistulae) were analyzed. A higher T stage (P=0.048) and tube-type reconstruction (P=0.007) increased fistula incidence; other factors did not show statistical significance (P>0.05). Two cases were treated with conservative management, 1 case with direct closure, 4 cases with immediate reconstruction using a pectoralis major musculocutaneous flap, and 11 cases with direct closure (4 cases) or additional flap surgery (7 cases) after pharyngostoma formation. Conclusions Pharyngocutaneous fistula requires global management from prevention to treatment. In cases of advanced-stage cancer and tube-type reconstruction, a more cautious approach should be employed. Once it occurs, an accurate diagnosis of the fistula and a thorough assessment of the surrounding tissue are necessary, and aggressive treatment should be implemented in order to ensure satisfactory long-term results.

Abstract Background and purpose To explore the methods of clinical classification in chronic radiation-induced ulcers in the chest wall (CRUCWs). Materials and methods A total of 64 patients with CRUCWs were treated. We divided the cases into 3 types (mild, moderate, or severe) according to their clinical manifestations. Conservative treatments, axial-pattern myocutaneous or local flaps, or filleted flaps were applied correspondingly. Results The cases were divided as follows: mild (n = 11), moderate (n = 45), and severe (n = 8). Eight cases were cured by conservative surgical therapy. One case had a recurrence 6 months after conservative therapy and was cured by a latissimus dorsi myocutaneous flap. The transferred flaps all survived, including 26 transverse rectus abdominis myocutaneous flaps, 8 longitudinal rectus abdominis myocutaneous flaps, 6 latissimus dorsi myocutaneous flaps, 3 contralateral breast flaps, 5 lateral thoracic rotation flaps, and 7 filleted flaps. In 2 transverse rectus abdominis myocutaneous flaps and 2 latissimus dorsi myocutaneous flaps, distal necrosis appeared in small areas. The resulting wounds were salvaged with skin graft and full healing was achieved. Conclusion CRUCWs can be divided into three types. Surgical methods should vary with distinguished classifications. The effective classification of CRUCWs has definite instructive significance on the selection of surgical approaches.

Objective:To assess the efficacy of a modified pedicled latissimus dorsi myocutaneous flap (LDMF) in the reconstruction of defects of the head and neck region.Methods:The retrospective analysis of 17 consecutive patients operated between 2010 and 2014 in the Plastic and Reconstructive Surgery Department of a tertiary care center was performed. Among them, four (23.5%) were initially diagnosed with trauma, while 13 (76.5%) had squamous cell carcinoma originating from the head and neck region. Tumor recurrence, necrosis of the free flap, advanced age, presence of a comorbidity, and previous history of radiotherapy were indicators for a pedicled LDMF. The pedicled LDMF technique was performed via the modified subcutaneous tunnel method in all patients. Demographic, clinical, and peroperative data as well as complications in and a survey of our patients were documented.Results:Our series comprised 11 males (64.7%) and six females (35.3%); the average age was 64.29±5.43 (range, 51 to 72) years. Seroma (5/17, 29.4%) and partial flap necrosis (3/17, 17.6%) were the most common complications, while the rate of mortality during the follow-up period was 17.6% (3/17). One patient died during the early postoperative period, while two died during their oncological treatment and followup. No remarkable functional disabilities or restrictions were postoperatively observed.Conclusion:Our results showed that a pedicled LDMF can constitute a safe and effective alternative for the reconstruction of head and neck defects in selected patients. However, further controlled clinical trials on larger series are warranted to precisely unveil the indications, contraindications, and outcomes of a pedicled LDMF.

Background: Sternotomy wound complications are more frequent after orthotopic heart transplantation (OHT) compared to other cardiac surgeries, primarily due to additional risk factors, including immunosuppression. Flap closure often becomes necessary for definitive treatment, although there is a scarcity of data on the outcomes of sternal wound reconstruction in this specific population., Methods: A retrospective analysis was conducted on 604 sternal wound reconstructions performed by a single surgeon between 1996 and 2023. Inclusion criteria comprised patients who underwent OHT as their primary cardiac procedure. Surgical interventions involved sternal hardware removal, debridement, and muscle flap closure., Results: The study included 66 patients, with culture-positive wound infection being the most common indication for reconstruction (51.5%). The median duration between transplantation and sternal wound reconstruction was 25 days. Bilateral pectoralis major myocutaneous advancement flaps (n = 63), rectus abdominis flaps (n = 2), or pectoralis major turnover flaps (n = 1) were used. Intraoperative wound cultures revealed positivity in 48 patients (72.7%), with Staphylococcus epidermidis being the most frequently cultured organism (25.0%). The overall complication rate was 31.8%, and two patient deaths were related to sternal wounds, resulting from multiorgan failure following septic shock. The majority of the patients reported excellent long-term functional and esthetic outcomes., Conclusions: Sternal wounds following OHT pose a significant morbidity risk. Our strategy focuses on immediate and aggressive antibiotic therapy, thorough debridement, and definitive closure with bilateral pectoralis myocutaneous advancement flaps. This approach has demonstrated complication and mortality rates comparable to the general cardiac surgery population, as well as excellent functional and esthetic results., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Subtotal or total glossectomy for advanced tongue cancer has an adverse impact on swallowing. The purpose of this retrospective study was to analyse postoperative swallowing outcomes and to determine the ideal reconstruction method in these patients. The clinical and swallowing data of patients with tongue cancer who underwent subtotal glossectomy at the study institution between 2005 and 2019 were reviewed retrospectively. Data were available for 101 patients. The most common reconstruction method was a free rectus abdominis musculocutaneous flap (69 cases). The postoperative feeding tube dependency rate was 11.1% at discharge and 9.4% at 1 year. During the study period, laryngeal suspension and/or a cricopharyngeal myotomy was performed in 39 patients (38.6%), with 25 of these operations performed after 2017. Patients treated in 2017-2019 were significantly more able to take thin liquid (P < 0.001) and lost less weight (P = 0.015) compared to those treated in 2005-2016. Multivariate analysis of 61 patients who did not undergo laryngeal suspension and/or cricopharyngeal myotomy showed significant feeding tube dependency in those aged 65 years and older (P = 0.004). Thin liquid intake was significantly improved after subtotal glossectomy with laryngeal suspension, which led to better postoperative swallowing and improved quality of life., Competing Interests: Competing interests None., (Copyright © 2023 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Few studies have reported the outcomes of LDF and immediate fat transfer (LIFT) during breast reconstruction. The aim of this study was to compare the perioperative outcomes and complications of LIFT and standard LDF (without immediate fat transfer) for breast reconstruction., Methods: We retrospectively reviewed charts from patients undergoing autologous breast reconstruction after total mastectomy between 2011 and 2021. We compared intraoperative and postoperative outcomes between groups., Results: One hundred nineteen reconstructions (61.02%) were performed with LIFT, while seventy-six (38.98%) were performed with standard LDF. The median volume of total fat transferred during LIFT was 125-cc [110-170 ​cc]. The rates of donor site wound disruption (23.7% versus 12.6%, p ​= ​0.044) were higher using the standard LDF compared to LIFT. Reconstructions performed with LIFT (HR 4.01, p ​< ​0.001) were found to be associated with secondary fat grafting procedures., Conclusion: LIFT is a safe procedure to enhance the volume of LDF in patients desiring autologous reconstruction without increasing recipient-site morbidity. On a time-to-event analysis, LIFT was associated with the requirement of further revision procedures using secondary fat grafting., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)