Orthoplastic approach in lower leg and foot reconstruction / 中华显微外科杂志

The reconstruction of lower leg and foot is very challenging due to their anatomical characteristics. In the last half century, we assisted to a dramatical change in thinking and approaching the lower leg and foot complex tissue defects. This became possible due to the new knowledge in vascular anatomy and advances in microsurgical techniques and instrumentation. The main way to well treat this kind of lesions is to ensure a multidisciplinary approach by collaboration between the specialists involved in approaching them. That’s why, in the later part of the last millennium, a new specialty appeared: Orthoplastic Surgery. Orthoplastic extremity reconstructive surgery may be addressed to the treatment of traumatic, oncologic, and septic conditions. This paper will discuss the timing of tissue transfer and the armamentarium of tissue reconstructive techniques for surgery of the lower leg and foot, from traditional flaps to the modern perforator flaps.

Modified cross-leg free skin flap for the construction of soft tissue defects of the lower leg / 中华创伤杂志

Objective:To analyze the therapeutic effect of modified cross-leg free skin flaps in repairing soft tissue defects of the lower leg.Methods:A retrospective case series study was conducted to analyze clinical data of 8 patients with soft tissue defects of the lower leg admitted to Affiliated Hospital of Zunyi Medical University from June 2018 to June 2020. There were 6 males and 2 females with the age range of 23-60 years［（39.6±5.7）years］. Area of defect was from 10.0 cm×4.5 cm to 21.0 cm×9.0 cm，with the size of flap from 12 cm×5 cm to 25 cm×10 cm. The free flaps were harvested to repair the wound of the affected leg and the blood vessels were anastomosed by cross-leg with the contralateral posterior tibial artery and vein at the first stage，including lateral circumflex femoral artery flap for 6 patients，superficial circumflex iliac artery flap for 1 and latissimus dorsi myocutaneous flap for 1. At the same time，the pedicled posterior tibial artery perforator flap or random flap was cut to wrap the vascular pedicle. After operation，both legs were placed in a parallel and straight position. After pedicle cleavage at the second stage，the posterior tibial artery and distal artery were re-anastomosed，and the flap was sutured to its original position. Incidences of pressure sores and deep venous thrombosis of the lower leg and patients' acceptance of the position were documented during leg crossing at the first stage. The survival of the flap was observed after pedicle amputation at the second stage. The appearance，texture，function of the affected limb and influence on the healthy leg were observed at the last follow-up. Simultaneously，the lower extremity functional score（LEFS）was used to evaluate the overall function of the affected leg and the Kofoed score to evaluate ankle function.Results:All patients were followed up for 6-18 months［（8.3±1.8）months］. There reported none of pressure ulcer or deep venous thrombosis of the lower leg，without resistance to body position at stage I. All flaps survived after pedicle amputation at stage II. The shape，texture and function of the injured leg were good，with no impact on function of the healthy leg at the last follow-up. The LEFS score of the affected leg and the Kofoed score of the ankle were increased from（31.5±6.9）points and（51.0±10.5）points preoperatively to（51.7±9.8）points and（84.8±8.1）points at the last follow-up（ P<0.01）. Conclusion:For patients with soft tissue defects of the lower leg，the treatment with modified cross free flap has advantages of relatively comfortable position，no impact on function of the healthy leg，good appearance and texture of the flap and satisfactory recovery of the affected leg.

Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study

@#Introduction:Grade 3B/C open tibial fractures with grossly contaminated degloving injuries have poor outcomes, with or without vascular injuries. Treatment decision oscillates between limb salvage and amputation. The standard protocol of repeated debridement and delayed wound cover is a challenge in developing countries due to overcrowded emergencies and limited operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate wound cover as an aggressive modality of treatment. Material and Methods:Thirty-three patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent debridement, external fixation and immediate wound cover with free distant/local rotational muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures. Intra-articular fractures were excluded. Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes. Results: Wound cover was achieved with 24 distant free muscle flaps, four local rotational muscle flaps and five fasciocutaneous flaps. All fractures united with an average time to union of 40.3 weeks (16-88). Fifteen patients (45.4%) underwent only a single major surgery using primary definitive external fixation. Deep infection was seen in four patients (12.1%). Nineteen patients had excellent to good outcomes, six were fair, and eight were poor. Conclusion: “Fix and Flap” in the same sitting, using immediate wound cover and external fixation, has given good results in our hands despite the delayed presentation, the neurovascular deficit and the degloving injury. This may be a better management strategy in overcrowded tertiary care centres of developing countries, with a single surgical procedure in almost half the cases.

Reconstructive Options in Head-and-Neck Cancer Surgeries

Introduction: Surgery is the standard treatment to achieve cancer control, but due to socioeconomic and other factors, most patientspresent with a locally advanced tumor leading to extensive resection of mucosa, muscle, bone, and skin. Reconstruction of thesedefects is essential not only in ensuring function and cosmesis but also in enabling the start and completion of adjuvant therapy on time.Aim: The study aims to analyze the various reconstruction methods used in the head-and-neck cancer surgery.Materials and Methods: Various cancers of the head and neck using various reconstruction options such as primary closure, localflaps, and regional flaps. Pre-operative radiotherapy, extent of defect, the type of reconstruction used, post-operative complications,and the functional outcome in the immediate post-operative period, 1 month after surgery, and at 6 months were recorded.Results: Of the 180 surgeries for head-and-neck cancers, primary closure was done in 79 cases. Other reconstruction optionsused were pedicled regional flaps – 75, local flaps – 11, and split skin grafting – 15. Of the 79 primary closures, 2 cases ofinfection, 2 cases of partial necrosis (neck skin and tongue), 8 cases of minor wound dehiscence, and 2 cases of fistulae of whichone was chylous were noted. Of the 50 pectoralis major myocutaneous (PMMC) flaps, 29 were for lining the oral/oropharyngealcavities, 6 were for cover the skin defects, and 15 were for both lining and cover.Conclusion: PMMC is the choice flap in high-volume centers with resource and time constraints where microsurgical expertiseis not available. They have proved effective in the absence of microvascular free flaps. Further improvement in our results canbe achieved if free flaps could be used in a choice few cases and effective mandibular reconstructions are to be used.

Evolving a System of Classification for Scalp Defects and Methods of Reconstruction

Background: Scalp wound closure requires good understanding of scalp anatomy, knowledge of a algorithm for reconstruction ofscalp defects, good planning, adequate debridement, proper execution and proper post-operative care. Aim and objective: Theaim of the study was to use a simple algorithm to reconstruct scalp defects of various sizes and to study the efficacy of thealgorithm in reconstruction of scalp defects. Materials and Methods: All patients with scalp defect who presented to theDepartment of Burns Plastic and Reconstructive surgery at Kilpauk government medical college were studied. Reconstructionof scalp defect was planned based on the algorithm. All patients were followed up for a period of 1 year post operatively.Results: The scalp defects were reconstructed based on the algorithm. Smaller defects were managed with primary closureand SSG. Larger size defects and defects without periosteum were given local or distant flap. All patients recovered well withlesser rate of complications. Conclusion: Reconstruction of scalp defect is made easy with the use of the algorithm for choiceof treatment based on the defect size.

Application of venous super drainage technique in free flaps transfer / 中华显微外科杂志

To investigate the effect of venous super drainage applying in free flaps. Methods From June, 2017 to December, 2018, 7 cases who had severe soft tissue injuries were treated with free flap. Cause of injury: 1 electric injuries, 2 tumor-related wounds, 1 deep burns, 2 mechanical trauma, and 1 necrotizing fasciitis. All patients were underwent free flap transplantation. There were 5 cases of anterolateral thigh artery perforator flap, 1 case of superficial circumflex iliac artery perforator flap, and 1 case of first dorsal metatarsal artery perforator flap.The application of venous super-drainage technology was carried out according to needs and specific conditions. Two sets of venous passages were prepared in both recipient and donor site to form a double set of venous reflux super-drainage mode. Blood supply, swelling, exudation, secondary exploration and survival rate of the flap were observed after operation, and regularly followed-up. Results All 7 flaps survived. Venous super drainage technique was ap-plied in 7 cases. No arteriovenous crisis occurred after the operation. The flaps had good blood circulation, slight swelling, less exudation, rapid edema regression and no secondary surgical exploration. Followed-up for 2-18 (average 10.5) months, there was no infection recurred. Flaps survived well, and the donor sites healed well without sensory loss.The flexion and extension function of joint was normal. Conclusion The technique of venous super-drainage prepares 2 sets of venous systems for the free flap in the treatment of vascular pedicle in the free flap repair operation, which is conducive to reducing the venous crisis after flap surgery, reducing flap edema, reducing exudation, reducing secondary surgical exploration and improving the survival rate of the flap.

Single-arm external stent combined with free flap used in forearm fractures of Gustilo type Ⅲ / 中华创伤骨科杂志

Objective@#To evaluate the clinical application of single-arm external stent combined with free flap in the treatment of forearm fractures of Gustilo type Ⅲ.@*Methods@#A retrospective study was conducted of the 16 patients who had been treated at Repair and Reconstruction Center, Traditional Chinese Medicine Hospital Affiliated to Southwest Medical University from September 2015 to January 2018 for open forearm fractures combined with soft tissue defects with single-arm external stent combined with free flap. They were 11 men and 5 women, aged from 18 to 64 years (average, 41.6 years). By the Gustilo classification, 9 cases were type ⅢB and 7 type ⅢC. The area of soft tissue defects at the upper arm and hand ranged from 7.5 cm×5.5 cm to 16.5 cm × 11.0 cm. Emergency debridement was performed at the primary stage. After repair of major blood vessels, nerves and tendons, the reduced fractures were fixated with a single-arm external stent. The soft tissue defects were repaired with free flaps at the secondary stage. Nine cases were repaired with a free anterolateral perforating branch flap and 7 with a free ilioinguinal flap. The single-arm external stent became the ultimate fixation mode in 5 cases but was changed into plate fixation after survival of the flaps in the other 11 cases. Complications were recorded postoperatively. At the last follow-up, the upper limb function was evaluated according to the tentative criteria for evaluation of the upper limb function proposed by the Hand Surgery Society of Chinese Medical Association.@*Results@#Of all the free flaps, 14 survived smoothly but 2 anterolateral ones survived only after the venous crisis appearing at 24 h after operation was relieved by exploration. The 16 patients were followed up for 9 to 18 months (average, 13.5 months). The fractures united well with fine alignment of the fracture ends and recovered force line. According to the Anderson criteria for forearm fractures, 10 cases were excellent, 4 good and 2 fair after operation. According to the tentative criteria for evaluation of the upper limb function proposed by the Hand Surgery Society of Chinese Medical Association, 11 cases were excellent and 5 good. No nail infection or nonunion occurred.@*Conclusion@#In the treatment of forearm fractures of Gustilo type Ⅲ, single-arm external stent plus free flap can effectively restore the force line of upper extremity, promote bone healing, allow reasonable timing for wound repair, reduce postoperative complications like infection and osteomyelitis and facilitate functional recovery of the affected extremity.

Single-arm external stent combined with free flap used in forearm fractures of Gustilo type Ⅲ / 中华创伤骨科杂志

Objective To evaluate the clinical application of single-arm external stent combined with free flap in the treatment of forearm fractures of Gnstilo type Ⅲ.Methods A retrospective study was conducted of the 16 patients who had been treated at Repair and Reconstruction Center,Traditional Chinese Medicine Hospital Affiliated to Southwest Medical University from September 2015 to January 2018 for open forearm fractures combined with soft tissue defects with single-arm external stent combined with free flap.They were 11 men and 5 women,aged from 18 to 64 years (average,41.6 years).By the Gustilo classification,9 cases were type ⅢB and 7 type Ⅲ C.The area of soft tissue defects at the upper arm and hand ranged from 7.5 cm ×5.5 cm to 16.5 cm × 11.0 cm.Emergency debridement was performed at the primary stage.After repair of major blood vessels,nerves and tendons,the reduced fractures were fixated with a single-arm external stent.The soft tissue defects were repaired with free flaps at the secondary stage.Nine cases were repaired with a free anterolateral perforating branch flap and 7 with a free ilioinguinal flap.The single-arm external stent became the ultimate fixation mode in 5 cases but was changed into plate fixation after survival of the flaps in the other 11 cases.Complications were recorded postoperatively.At the last follow-up,the upper limb function was evaluated according to the tentative criteria for evaluation of the upper limb function proposed by the Hand Surgery Society of Chinese Medical Association.Results Of all the free flaps,14 survived smoothly but 2 anterolateral ones survived only after the venous crisis appearing at 24 h after operation was relieved by exploration.The 16 patients were followed up for 9 to 18 months (average,13.5 months).The fractures united well with fine alignment of the fracture ends and recovered force line.According to the Anderson criteria for forearm fractures,10 cases were excellent,4 good and 2 fair after operation.According to the tentative criteria for evaluation of the upper limb function proposed by the Hand Surgery Society of Chinese Medical Association,11 cases were excellent and 5 good.No nail infection or nonunion occurred.Conclusion In the treatment of forearm fractures of Gustilo type Ⅲ,single-arm external stent plus free flap can effectively restore the force line of upper extremity,promote bone healing,allow reasonable timing for wound repair,reduce postoperative complications like infection and osteomyelitis and facilitate functional recovery of the affected extremity.

Unplanned change from double free flap to a chimeric anterolateral thigh flap in recurrent laryngeal cancer

Reconstruction method choice in recurrent head and neck cancer depends on surgical history, radiation therapy dosage, conditions of recipient vessels, and general patient condition. Furthermore, when defects are multiple or three dimensional in nature, reconstruction and flap choice aimed at rebuilding the functional structure of the head and neck are difficult. We experienced successful reconstruction of recurrent laryngeal cancer requiring reconstruction of esophageal and tracheostomy stroma defects using a chimeric two-skin anterolateral thigh flap with a single pedicle.

Free tissue flaps in head and neck reconstruction: clinical application and analysis of 93 patients of a single institution / Retalhos livres de tecido para reconstrução em cirurgias de cabeça e pescoço: aplicação clínica e análise de 93 pacientes de uma única instituição

Abstract Introduction Reconstruction with a free flap is routine in head and neck surgery because of better functional outcomes, improved esthetics, and generally higher success rates. Objective To evaluate the clinical outcomes in patients undergoing different microvascular free flap reconstructions. Methods This was a retrospective study of 93 patients undergoing reconstructions with free flaps from 2007 to 2015. Four types of free flap were performed: anterolateral thigh (76.3%), radial forearm (16.1%), fibula (4.3%) and jejunum (3.3%). Patients' demographic data were collected, and the outcomes measured included flap survival and complications. Postoperative functional and oncological outcome were also analyzed. Results The patients included 73 men and 20 women, with a mean age of 56.1 years. The most common tumor location was the tongue. Squamous cell carcinoma represented the vast majority of the diagnosed tumors (89.2%). The most common recipient vessels were the superior thyroid artery (77.4%) and the internal jugular vein (91.4%). Nine patients required emergency surgical re-exploration and the overall flap success rate was 90.3%. Venous thrombosis was the most common cause for re-exploration. Other complications included wound infection (5.4%), wound dehiscence (1.1%), partial flap necrosis (9.7%), fistula formation (10.8%), and 1 bleeding (1.1%). The majority of patients had satisfactory cosmetic and functional results of both donor site and recipient site after 46.7 months of mean follow-up. Conclusion Microsurgical free flap is shown to be a valuable and reliable method in head and neck surgery. It can be used safely and effectively with minimal morbidity in selected patients. The reconstruction can be performed by appropriately skilled surgeons with acceptable outcomes. Success rate appears to increase as clinical experience is gained.

Resumo Introdução Reconstrução com retalhos livres é um procedimento de rotina nas cirurgias de cabeça e pescoço devido aos melhores resultados funcionais e estéticos e às taxas de sucesso geralmente maiores. Objetivo Avaliar os desfechos clínicos de pacientes submetidos a diferentes reconstruções microvasculares com retalhos livres. Método Estudo retrospectivo de 93 pacientes submetidos à reconstruções com retalhos livres, de 2007 a 2015. Foram utilizados quatro tipos de retalho livre: coxa anterolateral (76,3%), antebraço radial (16,1%), fíbula (4,3%) e jejuno (3,3%). Os dados demográficos dos pacientes foram coletados e os parâmetros avaliados incluíram sobrevida e complicações. Os resultados funcionais e oncológicos pós-operatórios também foram analisados. Resultados Os pacientes incluíram 73 homens e 20 mulheres, com idade média de 56,1 anos. O local mais comum para o tumor foi a língua. O carcinoma de células escamosas representou a maioria dos tumores diagnosticados (89,2%). As artérias receptoras mais comuns foram a artéria tireóidea superior (77,4%) e a veia jugular interna (91,4%). Nove pacientes necessitaram de reexploração cirúrgica de emergência e a taxa de sucesso global do retalho foi de 90,3%. A trombose venosa foi a causa mais comum da reexploração. Outras complicações incluíram infecção da ferida cirúrgica (5,4%), deiscência da ferida (1,1%), necrose parcial do retalho (9,7%), formação de fístula (10,8%) e sangramento (1,1%). A maioria dos pacientes apresentou resultados estéticos e funcionais satisfatórios, tanto no local doador quanto no receptor, após 46,7 meses de seguimento médio. Conclusão O retalho livre microcirúrgico mostrou ser um método valioso e confiável na cirurgia de cabeça e pescoço. Pode ser usado de forma segura e eficaz, com morbidade mínima em pacientes selecionados. A reconstrução pode ser feita por cirurgiões adequadamente qualificados com resultados aceitáveis. A taxa de sucesso parece aumentar à medida que a experiência clínica é adquirida.

Reconstrucción de extensa úlcera por presión lumbar -glútea grado IV con colgajo lumbar bipediculado / Reconstruction of extensive ulcer by lumbar pressure - gluteal grade IV with bipedicled lumbar flap

INTRODUCCIÓN: La literatura cita numerosas técnicas quirúrgicas para la cobertura de defectos en región lumbar- glútea, complejos secundario a complicaciones neurológicas, como: colgajo de rotación, colgajos de transposición, colgajos musculocutáneos (dorsal ancho, glúteo mayor, vasto lateral, entre otros). Un severo compromiso en la extensión del defecto lumbar-glúteo hace difícil su reconstrucción total con resolución inmediata. OBJETIVO: Buscar alternativas de cobertura en extensas pérdidas de sustancia en base a los tejidos circundantes y demostrar la utilidad de los colgajos para cobertura de pérdida de sustancia, en reconstrucción de úlceras por presión extensas en la zona lumbar. PRESENTACIÓN DEL CASO: Presentamos el caso de una paciente cuadripléjica con pérdida de tejido en la zona lumbar y glútea de gran extensión que fue reconstruida con un colgajo lumbar transverso bi-pedunculado con vascularización tipo aleatorio. RESULTADOS: Se realizó una cirugía reconstructiva que la que se utilizó un colgajo lumbar transverso bi-pedunculado con vascularización tipo aleatoria, empleando un colgajo dermograso capaz de cerrar defectos lumbosacros severos, amplios y complejos, con satisfactorios resultados estéticos. CONCLUSIONES: El colgajo lumbar transverso es una opción quirúrgica confiable y recomendable con destacadas ventajas en virtud de notable amplitud de extensión para cobertura de defectos en la región lumbosacra como en la úlcera por presión de la presente paciente. Este tipo de colgajo tiene una adecuada vascularización que se integra apropiadamente a los tejidos adyacentes. El riesgo quirúrgico por la extensión del colgajo hace un reto y desafío para el cirujano.

INTRODUCTION: The literature cites numerous surgical techniques for the coverage of defects in the lumbar-gluteal region, complexes secondary to neurological complications, such as: rotation flap, transposition flaps, musculocutaneous flaps (latissimus dorsi, gluteus maximus, vastus lateralis, among others). A severe compromise in the extension of the lumbar-gluteal defect makes it difficult to fully reconstruct it with immediate resolution. There are several surgical techniques to repair gluteus-lumbar skin defects caused by pressure ulcers related to chronic neurologic disorders including rotation flap, transposition flap, muscle cutaneous flap (latissimus dorsa flap, gluteus maximus flap, vastus lateralis flap). OBJECTIVE: Search for alternative coverage in extensive losses of substance based on the surrounding tissues and demonstrate the usefulness of the flaps for coverage of loss of substance, in reconstruction of extensive pressure ulcers in the lumbar area. CASE PRESENTATION: We present the case of a quadriplegic patient with loss of tissue in the lumbar and gluteal area of ​​great extension that was reconstructed with a transverse lumbar bi-pedunculated flap with random type vascularization. RESULTS: Reconstructive surgery was performed using a transverse lumbar bi-pedunculated flap with random-type vascularization, using a dermofat flap capable of closing severe, wide and complex lumbosacral defects, with satisfactory aesthetic results. CONCLUSIONS: The transverse lumbar flap is a reliable and recommendable surgical option with outstanding advantages by virtue of a remarkable amplitude of extension for coverage of defects in the lumbosacral region as in the pressure ulcer of the present patient. This type of flap has an adequate vascularity that is properly integrated into adjacent tissues. The surgical risk due to the extension of the flap makes it a challenge and challenge for the surgeon.

Clinical application of complete transposition of arteriovenous in free flap artery crisis / 中华显微外科杂志

Objective To explore the clinical effect of complete transposition of arteriovenous in free flap artery crisis. Methods From October, 2009 to April, 2017, 13 cases of extremities tissue defect were repaired with free flaps.The intractable arterial crisis appeared after transplantation.Repeated anastomosis vessels were adapted but it was not relieved. Then the complete transposition of arteriovenous was adapted in the flaps. Namely the vein of the flap was anastomosed with the arterial in the recipient site to reconstruct the blood supply, and the arterial of the flap was anastomosed with the vein in the recipient site to reconstruct recirculation.Ten cases of hand defect and 3 cases of crus defect were repaired by 5 low abdominal flaps and 8 anterolateral thigh flaps. The tissue defect area was 16 cm× 7 cm-6 cm×4 cm and the flap area was 18 cm×8 cm-7 cm×4 cm. Results Ten flaps survived completely, the other 3 flaps almost survived that scab healed in 1 case and skin grafted in 2 cases. The flap for skin color was from purple red to dark red, and finally close to normal, and skin flap edge would have different degrees of ecchymosis; the bleed-ing from the incision of the skin flap was from dark red to bright red; the swelling of the flap was obvious in the early stage and the later swelling subsided. All cases were followed-up from 6 months to 32 months with an average of 16 months.The wounds healed well.The flaps had a clear boundary and soft texture. Conclusion Complete transposi-tion of the arteriovenous system can be used as an alternative in the presence of intractable arterial crisis after free flap transplantation, to save the flap and to reduce the trauma to the patient.

The Pros and Cons of Computer-Aided Surgery for Segmental Mandibular Reconstruction after Oncological Surgery

Computer-aided surgery (CAS) started being used for head and neck reconstruction in the late 2000s. Its use represented a paradigm shift, changing the concept of head and neck reconstruction as well as mandible reconstruction. Reconstruction using CAS proceeds through 4 phases: planning, modeling, surgery, and evaluation. Thus, it can overcome a number of trial-and-error issues which may occur in the operative field and reduce surgical time. However, if it is used for oncologic surgery, it is difficult to evaluate tumor margins during tumor surgery, thereby restricting pre-surgical planning. Therefore, it is dangerous to predetermine the resection margins during the pre-surgical phase and the variability of the resection margins must be taken into consideration. However, it allows for the preparation of a prebending plate and planning of an osteotomy site before an operation, which are of great help. If the current problems are resolved, its applications can be greatly extended.

Two-Blade Guillotine Technique for Nipple Graft Harvest

The nipple-sharing technique for nipple reconstruction offers excellent tissue matching. The method used for nipple graft harvesting determines the quality of the graft and hence, the success of nipple sharing. Here, we described a guillotine technique wherein the nipple is first transfixed with 2 straight needles to stabilise it. Two No. 11 blades are then inserted in the center and simultaneously swept outwards to amputate the distal portion of the nipple. This technique provides good control, resulting in a very evenly cut base. The recipient bed is deepithelialized thinly, and the nipple graft is inset with interrupted 8-0 nylon sutures under magnification. Being a composite graft, it is protected with splint dressings for 6 weeks, and the dressing is regularly changed by the surgeon. The height of the nipple grafts ranges from 4 to 8 mm. This technique was performed in 9 patients with an average follow-up of 2.9 years (range, 1–4.5 years). Apposition between the nipple graft and its bed is crucial for the success of this technique. When correctly applied, we observed rapid revascularization of the graft.

Two-Blade Guillotine Technique for Nipple Graft Harvest

The nipple-sharing technique for nipple reconstruction offers excellent tissue matching. The method used for nipple graft harvesting determines the quality of the graft and hence, the success of nipple sharing. Here, we described a guillotine technique wherein the nipple is first transfixed with 2 straight needles to stabilise it. Two No. 11 blades are then inserted in the center and simultaneously swept outwards to amputate the distal portion of the nipple. This technique provides good control, resulting in a very evenly cut base. The recipient bed is deepithelialized thinly, and the nipple graft is inset with interrupted 8-0 nylon sutures under magnification. Being a composite graft, it is protected with splint dressings for 6 weeks, and the dressing is regularly changed by the surgeon. The height of the nipple grafts ranges from 4 to 8 mm. This technique was performed in 9 patients with an average follow-up of 2.9 years (range, 1–4.5 years). Apposition between the nipple graft and its bed is crucial for the success of this technique. When correctly applied, we observed rapid revascularization of the graft.

Reconstrucción microquirúrgica de lengua / Microsurgical tongue reconstruction

Malignant tumors of tongue are a common pathology with high morbidity and mortality. Treatment requires surgical oncology and systemic management, with the respective reconstruction in order to achieve an adequate quality of life, due to the primary function of the tongue during feeding, communication, social and labor interaction. That is why the choice of donor tissue for reconstruction depends heavily on its characteris-tics and the type of defect, essential to obtain favorable results in the patients. A review of the classification of resulting defects after tongue's tumors resection is performed, and management algorithm and microvascular free flaps more frequently used in this type of reconstruction.

Los tumores malignos de lengua son una patología frecuente con alto grado de morbilidad y mortalidad. Su tratamiento requiere manejo quirúrgico y sistémico oncológico, con la respectiva reconstrucción, para lograr así una adecuada calidad de vida, debido a la función primordial de la lengua durante la alimentación, la comunicación, la interacción social y laboral. Es por esto que la elección de los tejidos donantes para ello depende en gran medida de sus características y del tipo de defecto, aspecto fundamental para obtener resultados favorables en los pacientes. Se realiza una revisión de la clasificación de los defectos resultantes después de la resección de tumores de lengua, un algoritmo de manejo y los colgajos libres microvasculares más utilizados en este tipo de reconstrucción.

Reconstruction of Postburn Contracture of the Forefoot Using the Anterolateral Thigh Flap

BACKGROUND: Severe forefoot deformities, particularly those involving the dorsum of the foot, cause inconvenience in daily activities of living including moderate pain on the dorsal aspect of the contracted foot while walking and difficulty in wearing nonsupportive shoes due to toe contractures. This paper presents clinical results of reconstruction of severe forefoot deformity using the anterolateral thigh (ALT) free flap. METHODS: Severe forefoot deformities were reconstructed using ALT flaps in 7 patients (8 cases) between March 2012 and December 2015. The mean contracture duration was 28.6 years. RESULTS: All the flaps survived completely. The size of the flaps ranged from 8 cm × 5 cm to 19 cm × 8 cm. The mean follow-up period was 10 months (range, 7 to 15 months). There was no specific complication at both the recipient and donor sites. There was one case where the toe contracture could not be completely treated after surgery. All of the patients were able to wear shoes and walk without pain. Also, the patients were highly satisfied with cosmetic results. CONCLUSIONS: The ALT flap may be considered ideal for the treatment of severe forefoot deformity.

Reconstruction of a Mangled Foot with an Anterolateral Thigh Free Flap

PURPOSE: In recent decades, amputation is still recommended for patients with extensive lower extremity wounds requiring coverage. Although the feet contribute relatively little to total body surface area, they are essential organ for ambulation, and a high mortality rate after amputation has been reported. We report on 10 challenging cases of a mangled foot which was reconstructed using an anterolateral thigh (ALT) free flap, and analyze the advantages and disadvantages of this technique. MATERIALS AND METHODS: This retrospective study was conducted on 10 patients who underwent reconstructive surgery on a foot. Patients' charts were reviewed for age, sex, causes, defect size and site, flap size and type, flap type, and complications. Cases with a defect size of >100 cm2 were included. RESULTS: Seven of the 10 patients were male, and overall mean age was 38.5 years (range, 22 to 61 years). Mean defect size was 179.6 cm2 (range, 104 to 330 cm2), and mean flap size was 193 cm2 (range, 120 to 408 cm2). Three cases were reconstructed with a musculocutaneous free flap and seven cases were reconstructed with a fasciocutaneous free flap. There were two occurrences of local wound complication. All ten flaps survived well, however five patients underwent a debulking procedure to reduce flap volume. CONCLUSION: Reconstruction of a near completely degloved soft tissue defect or a wide defect containing two or more surfaces of extremity with an ALT free flap was performed. The purpose of this case study is to report on free tissue transfer using the ALT flap for salvage of the lower extremity.

Anterolateral Thigh Thickness Measurement in Positron Emission Tomography-Computed Tomography for the Prediction of Free Flap Reconstruction Outcomes in Head and Neck Cancer / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Anterolateral thigh (ALT) flaps are commonly used for head and neck surgery reconstruction. However, a thick ALT often leads to long operation times. Therefore, ALT thickness on a preoperative non contrast image of positron emission tomography-computed tomography (PET-CT) scan was measured to predict surgical outcome. SUBJECTS AND METHOD: The correlation between ALT thickness and total reconstruction time was analyzed in 106 patients. The differences in ALT thickness between the successful and compromised-flap groups were analyzed retrospectively. RESULTS: Median ALT thickness was 4.49 mm, and total reconstruction time was 190 min. Total reconstruction time was significantly correlated with ALT thickness (p=0.019). ALT thickness, body mass index (BMI), total reconstruction time and ischemia time were significantly greater in the compromised-flap group than in the successful group. In the multivariate analysis, only BMI and ischemia time were predictors for the compromised flap. CONCLUSION: ALT thickness measured on a non-contrast image of PET-CT scan is useful as a surgical outcome predictor with respect to total reconstruction time. A further study may suggest the risk of a thick ALT in a compromised flap in head and neck reconstruction using an ALT free flap.

Perforator Reconstruction to Salvage the Jeopardized Flaps

During flap elevation, most perforators are cut except one or more perforators that are essential to flap survival. However these cutout perforators can cause deterioration of the blood circulation of the flap. To salvage the jeopardized flaps, rebuilding the perforator system is essential for flap survival. In the first case, after flap elevation, the upper abdominal flap margin was severely ischemic. To supply blood to the upper abdominal flaps, we found and used a major perforator underneath the upper abdominal flap which was cut earlier during the elevation, and we performed reanastomosis with ipsilateral deep inferior epigastric artery. Upper abdominal flap ischemic area was limited to a narrow suture area. In the second case, we performed free superficial inferior epigastric artery (SIEA) flap reconstruction. After successful anastomosis of the SIEA and superficial inferior epigastric vein (SIEV) with internal mammary artery and vein, serious venous congestion occurred immediately because of SIEV malfunction. We found the largest perforator vein under the flap, as an alternate way to drain, then connected it with the thoracoacromial vein with a vein graft harvested in the contralateral SIEV. Circulation has improved. In conclusion, perforator system reconstruction is essential in a jeopardized flap salvage.