Flap amputation for long-standing post-LASIK flap dislocation with epithelial ingrowth.

A man aged 26 years presented with complaints of diminution of vision in his right eye for 1 year following a fist injury. He had a history of laser-assisted in situ keratomileusis in both eyes 5 years earlier. On examination, his uncorrected distance visual acuity (UDVA) in the right eye was 1.0 logMAR. Slit-lamp examination of the right eye revealed a superotemporal dislocation of the flap with coexisting epithelial ingrowth encroaching the pupillary area. Due to the presence of long-standing fixed flap folds, a flap amputation was performed along with removal of the epithelial ingrowth using 0.02% mitomycin C as adjunct. Postoperatively, the UDVA was 0.3 logMAR on day 1, which improved to 0.2 logMAR at 1 week. At 1 year, the UDVA was 0.2 logMAR improving to 0.1 logMAR with refraction, with minimal paracentral corneal haze and no signs of corneal ectasia.

A Case of Salvage Maxillectomy for Recurrent Oral Cancer After Boron Neutron Capture Therapy During the COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, pedicle flaps instead of free flap transfer were recommended for head and neck reconstruction to reduce infection risk. Boron neutron-capture therapy in Japan was clinically approved in 2020 as a salvage radiotherapy for recurrent head and neck cancer following chemoradiotherapy. The efficacy and safety of salvage surgery following boron neutron-capture therapy remain unclear. CASE REPORT: We describe a 57-year-old male with crT4aN0M0 oral cancer after three different forms of radiotherapy including boron neutron-capture therapy, treated by salvage partial maxillectomy with both buccal fat pad and nasoseptal flaps. His postsurgical course was successful, without tracheostomy, and he had no Clavien- Dindo grade 3 or 4 complications. The pathological diagnosis was T4a squamous cell carcinoma with a negative surgical margin. No recurrence or metastasis had occurred at 113 days postoperatively. No opioid consumption was needed postoperatively. CONCLUSION: Pathological negative margins were achieved in this case and there were no severe complications. Further accrual of cases salvage surgery following boron neutron-capture therapy is required to clarify treatment strategies for recurrent head and neck cancer.

First known case of successful pressure ulcer treatment in a lung transplant patient with post-COVID-19 pneumonia.

Given the current COVID-19 crisis, multiple clinical manifestations and related complications of COVID-19 disease, especially in lung transplant patients following post-COVID-19 pneumonia, are a major challenge. Herein, we report the therapeutic course of the first reported case of sacrococcyx pressure ulcers (PU) in a 65-year-old male COVID-19 patient who underwent lung transplantation and developed a PU following surgery. We used a combination of regulated negative pressure-assisted wound therapy system (RNPT, six treatment courses, five days per treatment course), a skin tension-relief system (an intraoperative aid in minimising wounds caused by sacrococcygeal PUs) and a gluteus maximus myocutaneous flap to repair sacrococcygeal wounds. This successfully treated case provides a reference point for the treatment of similar cases.

Surgical Correction of a Clivus Cerebrospinal Fluid Fistula: A Technical Report.

BACKGROUND: Cerebrospinal fistulas of the clivus region often result from previous surgical intervention at the skull base. The localization and size of the fistula determine the appropriate treatment strategy. When flap closure is not possible, the microsuture technique with autograft placement provides a favorable outcome. METHODS: We present a technical report on the application of the microsuture technique for clivus region cerebrospinal fluid fistula closure in a patient with previous chordoma treatment and nonspecific coronavirus disease 2019 complications. RESULTS: The application of the microsuture technique resulted in stable remission of the fistula and complete regression of the clinical manifestations. CONCLUSIONS: The microsuture technique for clivus region fistula closure is a potentially valuable alternative to vascularized flap closure.

The Application of Digital Design Combined with 3D Printing Technology in Skin Flap Transplantation for Fingertip Defects during the COVID-19 Epidemic.

OBJECTIVE: We aimed to evaluate the advantages of preoperative digital design of skin flaps to repair fingertip defects during the COVID-19 pandemic. We combined digital design with a 3D-printed model of the affected finger for preoperative communication with fingertip defect patients under observation in a buffer ward. METHODS: From December 2019 to January 2021, we obtained data from 25 cases of 30 fingertip defects in 15 males and 10 females, aged 20-65 years old (mean 35 ± 5 years). All cases were treated by digitally designing preoperative fingertip defect flaps combined with a 3D-printed model. Preoperative 3D Systems Sense scanning was routinely performed, 3-matic 12.0 was used to measure the fingertip defect area ranging from 1.5 cm × 3.5 cm to 2.0 cm × 5.0 cm, and the skin flap was designed. The flap area was 1.6 cm × 3.6 cm to 2.1 cm × 5.1 cm. CURA 15.02.1 was used to set parameters, and the 3D model of the affected finger was printed prior to the operation. Full-thickness skin grafts were taken from donor areas for repair. RESULTS: No vascular crises occurred in any of the 25 cases, and all flaps survived. The postoperative follow-up occurred over 3-12 months. All patients were evaluated 3 months after operation according to the trial standard of hand function evaluation of the Chinese Hand Surgery Society. The results showed that 20 cases had excellent outcomes (80%), four cases had good outcomes (16%), and one case had a fair outcome (4%). The excellent and good rate was 96%. CONCLUSIONS: During the COVID-19 epidemic, fingertip defects were treated with preoperative digital design of fingertip defect flaps combined with 3D printing. Precision design saves surgery time and improves the success rate of surgery and the survival rates of skin flaps. In addition, 3D model simulations improve preoperative communication efficiency, and the personalized design improves patient satisfaction.

Resurgence of regional flaps for head and neck reconstruction.

PURPOSE OF REVIEW: The strain on healthcare resources in light of the COVID-19 pandemic has forced many head and neck surgeons to explore reconstructive options that may decrease length of stay. Here, we review three common and versatile regional flaps used in head and neck reconstruction that are comparable alternatives to free tissue transfer. RECENT FINDINGS: Initial anatomic descriptions of the facial artery musculocutaneous (FAMM) flap, the supraclavicular artery island flap and the submental artery island flap were published decades ago. Since then, many have proposed modifications to these descriptions to improve technical ease and patient outcomes. Benefits of regional flaps include ease of harvest, comparable outcomes to free tissue microvascular flaps, shorter operative time and hospital length of stay. Drawbacks to regional flaps include limitations to size and reach, partial necrosis, wound dehiscence and surgeon experience. The integrity of the vascular pedicle is also contingent upon vessel preservation during the cancer ablation. SUMMARY: Although a resurgence of regional flaps began well before the COVID-19 pandemic, many institutions began looking for alternatives to free flap reconstruction to conserve healthcare resources and minimize patient hospitalization time in the past year. There has been a revival of regional flaps such as the FAMM, supraclavicular and submental flaps that are valuable reconstructive options for many defects of the head and neck.

Taking a step down on the reconstruction ladder for head and neck reconstruction during the COVID-19 pandemic.

BACKGROUND: Most of the head and neck cancers are time-critical and need urgent surgical treatment. Our unit is one of the departments in the region, at the forefront in treating head and neck cancers in Pakistan. We have continued treating these patients in the COVID-19 pandemic with certain modified protocols. The objective of this study is to share our experience and approach towards head and neck reconstruction during the COVID-19 pandemic. RESULTS: There were a total of 31 patients, 20 (64.5%) were males and 11 (35.4%) patients were females. The mean age of patients was 52 years. Patients presented with different pathologies, i.e. Squamous cell carcinoma n = 26 (83.8%), mucoepidermoid carcinoma n = 2 (6.4%), adenoid cystic carcinoma n = 2 (6.4%) and mucormycosis n = 1 (3%). The reconstruction was done with loco-regional flaps like temporalis muscle flap n = 12 (38.7%), Pectoralis major myocutaneous flap n = 8 (25.8%), supraclavicular artery flap n = 10 (32.2%) and combination of fore-head, temporalis major and cheek rotation flaps n = 1 (3%). Defects involved different regions like maxilla n = 11 (35.4%), buccal mucosa n = 6 (19.3%), tongue with floor of mouth n = 6 (19.3%), mandible n = 4 (12.9%), parotid gland, mastoid n = 3 (9.6%) and combination of defects n = 1 (3%). Metal reconstruction plate was used in 3 (9.6%) patients with mandibular defects. All flaps survived, with the maximum follow-up of 8 months and minimum follow-up of 6 months. CONCLUSION: Pedicled flaps are proving as the workhorse for head and neck reconstruction in unique global health crisis. Vigilant use of proper PPE and adherence to the ethical principles proves to be the only shield that will benefit patients, HCW and health system.

Addressing the Pandemic Training Deficiency: Filling the Void with Simulation in Facial Reconstruction.

OBJECTIVE/HYPOTHESIS: To assess the use of a three-dimensional (3D) printed, multilayer facial flap model for use in trainee education as an alternative method of teaching surgical techniques of facial reconstruction. STUDY DESIGN: Cohort study. METHODS: A 3D printed facial flap simulator was designed from a computed tomography scan and manufactured out of silicone for low-cost, high-fidelity simulation. This simulator was tested by a group of Otolaryngology-Head and Neck Surgery trainees at a single institution. The simulator group was compared to a control group who completed an exercise on a traditional paper facial flap exercise. Both groups underwent didactic lectures prior to completing their respective exercises. Pre- and post-exercise Likert scale surveys measuring experience, understanding, effectiveness, and realism were completed by both groups. Central tendency, variability, and confidence intervals were measured to evaluate the outcomes. RESULTS: Trainees completing the facial flap simulator reported a statistically significant (p < 0.05) improvement in overall expertise in facial flap procedures, design of facial flaps, and excision of standing cutaneous deformities. No statistically significant improvement was seen in the control group. CONCLUSIONS: Trainees found the facial flap simulator to be an effective and useful training tool with a high level of realism in surgical education of facial reconstruction. Surgical simulators can serve as an adjunct to trainee education, especially during extraordinary times such as the novel coronavirus disease 2019 pandemic, which significantly impacted surgical training. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E2444-E2448, 2021.

Outcomes of major head and neck reconstruction during the COVID-19 pandemic: The St. Andrew's centre experience.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic has generated enormous pressure on healthcare establishments, prompting the restructuring of services to rationalise resources. Complex head and neck reconstructive surgery in this setting may carry substantial risk to patients and staff. This paper outlines the management strategy and outcomes of major head and neck oncological cases at a single regional tertiary referral centre. METHODS: A database review was undertaken of consecutive patients undergoing major head and neck surgery and reconstruction during the COVID-19 pandemic at St Andrew's Centre for Plastic Surgery & Burns, Chelmsford UK. Patient demographics, tumour and reconstruction characteristics as well as peri­operative information were determined. Patients were prospectively contacted with regard to COVID-related symptoms and investigations. RESULTS: Twenty-two patients (15 males and 7 females) with a mean age of 67 years (range: 36-92 years) were included between March 1 and June 13, 2020. Patients underwent pre-operative throat swabs at 72 h and 24 h as well as chest CT scanning as part of a robust protocol. Twelve free flaps, four loco-regional flaps, four parotidectomies and 23 cervical lymphadenectomies were performed. Two patients required a return to theatre. No post-operative deaths occurred and flap survival rate was 100%. A single patient tested positive for COVID-19 pre-operatively and no post-operative COVID-19 infections occurred. CONCLUSION: Although head and neck surgery represents a high-risk procedure to patients and healthcare professionals, our institutional experience suggests that in the presence of a robust peri­operative protocol and judicious patient selection, major head and neck surgery, including free tissue transfer reconstruction, may be performed safely.

The COVID-19 Pandemic: The effect on open lower limb fractures in a London major trauma centre - a plastic surgery perspective.

BACKGROUND: COVID-19 has created huge pressures on healthcare systems. The ongoing provision of major trauma services during this time has proved challenging. We report our experience of managing open lower limb fractures (oLLFs) during the pandemic in a London major trauma centre (MTC). METHODS: This was a prospective study of all open lower limb fractures presenting to our unit over the initial 48 days of UK government lockdown - 24th March till 10th May 2020. Results were compared to the same time period in 2019 retrospectively. Epidemiological data, mechanism, Gustilo-Anderson (G-A) severity grading, time to initial debridement and definitive coverage were analysed. RESULTS: There was a 64% reduction in emergency department (ED) attendances (25,264 vs 9042). There was an 18% reduction in oLLFs (22 vs 18). Approximately three-quarters of injuries were in males across both cohorts (77% vs 78%) and tended to occur in younger patients (median age, 37 vs 35). Road-traffic-accidents (RTAs) were the most common injury mechanism in both 2019 and lockdown, but a rise in jumpers from height was seen in the latter. A similar pattern of G-A severities were seen, however only 3 injuries during lockdown required major soft tissue reconstruction. There was no significant difference in times taken for initial debridement (p = 0.72786) or definitive wound coverage (p = 0.16152). A greater proportion of independent operating was seen during lockdown between orthopaedics and plastic surgery. CONCLUSIONS: Despite government lockdown measures, oLLFs still placed significant burden on our MTC. Notwithstanding significant staffing alterations and theatre pressures, we have been able to ensure these lower limb emergencies remain a surgical priority and have managed to utilise resources appropriately.

Use of domestic tools to downstage the reconstructive ladder in a patient with severe crush and degloving injury: a case report.

In the COVID-19's crisis, elective surgery and non-emergent cases were postponed; all other procedures have to be minimized. A 17-year male patient with severe crush and degloving injury over the thigh, gluteal, sacral, and perineum areas was admitted to our Department on the 16th of March 2020. The patient presented soft tissue skin and muscle loss. A double Latissimus Dorsi and Anterolateral Thigh free flaps were indicated. However, due to the particular circumstance of the COVID-19 crisis, we applied domestic negative wound therapy (NPWT) using gauzes and wall suction. We obtained suitable granulation tissue after 17 consecutive days with this treatment. The raw area was then covered with an expanded split-thickness skin graft. The wound healed at 95%, and the patient was discharged on 25th of April 2020. He was followed up in an outpatient setting with wound care and physiotherapy. This case showed that in a limited-resource setting, with available wall suction, the domestic NPWT is a versatile tool to promote granulation tissue.

Quantitative shadowgraphy of aerosol and droplet creation during oscillatory motion of the microkeratome amid COVID-19 and other infectious diseases.

PURPOSE: To quantify the atomization of liquid over the cornea during flap creation using microkeratome using high-speed shadowgraphy. SETTING: Laboratory study. DESIGN: Laboratory investigational study. METHOD: In an experimental setup, flap creation was performed on enucleated goat's eyes (n = 8) mounted on a stand using One Use-Plus SBK Moria microkeratome (Moria SA) to assess the spread of aerosols and droplets using high-speed shadowgraphy. Two conditions were computed. A constant airflow assumed uniform air velocity throughout the room. A decaying jet assumed that local air velocity at the site of measurements was smaller than the exit velocity from the air duct. RESULTS: With the advancement of the microkeratome across the wet corneal surface, the atomization of a balanced salt solution was recorded on shadowgraphy. The minimum droplet size was ∼90 µm. The maximum distance traversed was ∼1.8 m and ∼1.3 m assuming a constant airflow (setting of refractive surgery theater) and decaying jet condition (setting of an operating theater with air-handling unit), respectively. CONCLUSIONS: The microkeratome-assisted LASIK flap creation seemed to cause spread of droplets. The droplet diameters and velocities did not permit the formation of aerosols. Therefore, the risk of transmission of the virus to the surgeon and surgical personnel due to the microkeratome procedure seemed to be low.