Comparison of Lymphatic Drainage of the Lower Limbs After Soft Tissue Reconstruction by Microvascular Muscle Flap Versus Fasciocutaneous Flaps.

INTRODUCTION: Complex traumatic injuries of the lower limb are increasingly being salvaged. The common long-term morbidity includes secondary lymphedema. The role of microvascular flaps is often discussed for lymph flow restoration. However, the differential effect of using muscle flap versus fasciocutaneous flap in the lower-limb trauma to avoid secondary lymphedema is not studied. METHODS: Forty patients who underwent microvascular flap reconstruction were reviewed retrospectively to obtain data regarding clinical demographics and surgical procedure. Assessment for presence of clinical lymphedema was done. The lymphatic drainage in all these patients was assessed by 99mTc lymphoscintigraphy. RESULTS: Of the 40 patients included in the study, group A (n = 23) underwent muscle-based free flap reconstruction, and group B (n = 17) had fasciocutaneous flaps. Clinical lymphedema was present in 21 patients, of which 18 were of group A and 3 of group B. On lymphoscintigraphy, 14 patients had either partial or complete obstruction in the reconstructed lower limb, 11 in group A and 3 in group B. All of them (n = 14) were found to have associated clinical lymphedema. The association of clinical lymphedema (P < 0.001) and obstructive pattern on lymphoscintigraphy (P < 0.05) with muscle flaps was found to be statistically significant. CONCLUSIONS: With the advancement in surgery and techniques, not only salvageability but also stable and morbidity free outcomes are the goals. Fasciocutaneous flaps may have better lymphatic outcomes than the muscle-based flaps, and the criteria for lower-limb reconstruction can be reformed to include simultaneous soft tissue and lymphatic reconstruction.

Abdominal Wall Reconstruction in Adults With Exstrophy of the Bladder.

INTRODUCTION: Abdominal wall reconstruction in an adult patient with exstrophy bladder is challenging. A variety of local and regional flaps are described. We describe our experience with a 3-layer technique with the differential reconstruction of the fascial and cutaneous layer. PATIENT AND METHODS: Three adult patients with untreated bladder exstrophy were included in the study period from 2017 and 2019. The surgical technique involved 3-layer abdominal reconstruction involving closure with unilateral anterior rectus sheath turnover and a pedicled anterolateral thigh flap for skin cover reinforced with a mesh between the two. RESULTS: All three were male patients with an average age of 22.3 years. The average size of the defect was 10 × 9 cm. The mean period of follow-up was 6 months (range, 2-18 months). In all 3 patients, the flaps settled well with no complications. CONCLUSIONS: Although rare as they may be, the management of untreated bladder exstrophy presenting in adulthood has evolved over the years. The goals of the management have changed from simple defect closure to the dynamic reconstruction of the abdominal wall covering a continent neobladder. Our technique of a 3-layer closure can provide good functional integrity to the abdominal wall even in large defects.

Simultaneous Bilateral Reconstruction of the Axilla with Posterior Arm Flap in Recurrent Hidradenitis Suppurativa.

Introduction Hidradenitis suppurativa (HS) is a chronic inflammatory disease, with the axilla being the most commonly affected site. Radical excision of the involved tissue is a definitive treatment. There are numerous techniques described for the reconstruction of the axilla. Patients and methods Patients with axillary HS who underwent wide excision and posterior arm flap cover between August 2017 and December 2020 were reviewed. Results A total of 15 flaps were done in eight patients in the study period. Bilateral radical excision of the disease was done simultaneously in all eight patients with the help of a two-team approach. Reconstruction of the axilla was done with a posterior arm flap bilaterally, except one side in a single patient, wherein the split-thickness skin graft was performed. All flaps settled well without significant complications. On follow-up ranging from 12 to 42 months, one patient complained of disease recurrence on one side. The flap and the donor site had settled well in all patients, causing no significant morbidity. Conclusion Radical excision of axillary hidradenitis must be considered early on presentation. After wide excision, simultaneous bilateral reconstruction with posterior arm flap is a simple and reliable technique with an excellent patient-reported outcome.

Pedicled thoracodorsal artery perforator flap in the soft-tissue reconstruction of an acute traumatic cubital fossa defect.

INTRODUCTION: Complex cubital fossa injuries with bony and vascular injuries are not an uncommon clinical presentation after trauma to the elbow. The revascularization of the upper limb by brachial artery repair with the venous graft is paramount, followed by immediate cover with a sturdy flap to salvage the limb. The use of local muscle and fasciocutaneous flaps is limited in the setting of vascular injury. The pedicled latissimus dorsi muscle flap and abdominal flaps are routinely used with few advantages. This article describes the use of a pedicled thoracodorsal artery perforator flap in the management of acute traumatic cubital fossa defect. MATERIAL AND METHODS: A retrospective observational study was performed from September 2015 to December 2020 with patients who underwent the pedicled TDAP flap as a soft-tissue cover of cubital fossa injuries primarily. Patient variables, including the size of defect and flap, the number of perforators, the complications, and the outcome, were recorded. RESULTS: Eleven patients were included in the study. The majority of the patients were males (n = 10) and presented with a history of trauma in a road traffic accident (n = 6) or because of a fall from height (n = 4). All of them (n = 11) had some form of bony injury. Seven patients in this group required brachial artery repair with an interposition vein graft successfully covered with a TDAP flap. There was a constant dominant musculocutaneous perforator about 10-13 cm from the apex of the axilla. At discharge, all flaps had settled well. On follow-up ranging from 2 months to 2 years, the patients reported satisfactory outcomes.