Vascular pedicle ossification of free fibular flap: is it a rare phenomenon? Is it possible to avoid this risk?

Free fibula flap is the most common free tissue transfer for maxillary and mandibular reconstructions. The distal part of the harvested bone is transferred, while the proximal part is removed by sub-periosteum dissection. The vascularized periosteum attached to the vascular pedicle has osteogenic potential. 61 patients reconstructed with free fibula flaps were divided in 2 groups: 41 flaps performed with a standard technique and 20 flaps performed by dissecting the periosteum from the pedicle. Patients were followed up with orthopantomography and CT scan at 6, 12, 18 and 24 months after surgery. The minimum follow-up time was 18 months. With retrospective analysis of the first group we diagnosed 7 pedicle ossifications on 41 reconstructions (17%). In the second group, no pedicle ossification was observed (p < 0.05). The dissection of periosteum from the vascular pedicle of free fibula flaps avoids the risk of ossification.

Cross-leg as salvage procedure after free flaps transfer failure: a case report.

Posttraumatic wounds of the lower leg with soft tissue defects and exposed fractures are a reconstructive challenge due to the scarce availability of local tissues and recipient vessels. Even when a free tissue transfer can be performed the risk of failure remains considerable. When a free flap is contraindicated or after a free flap failure, the cross-leg flap is still nowadays a possible option. We report a case of a male with a severe posttraumatic wound of the lower leg with exposed tibia fracture firstly treated with two consecutive latissimus dorsi muscular free flaps, failed for vascular thrombosis; the coverage was then achieved with a cross-leg flap with acceptable results.

Abdominal wall transplantation with microsurgical technique.

Many patients undergoing intestinal or multivisceral transplantation have a past history of complete midgut removal with the loss of the domain of the abdominal compartment or have severely damaged abdominal walls from repeated laparotomies, tumours or enterocutaneous fistulae. These patients may encounter severe abdominal wall closure problems at the end of transplantation, resulting in increased morbidity and mortality. It is, therefore, of paramount importance to properly cover transplanted organs in order to reduce postoperative complications. Abdominal wall transplantation was recently proposed for closure of patients undergoing both small-bowel and multivisceral transplantation: the results are encouraging. However, the technical procedure proposed requires the procurement of long segments of iliac vessels as far as the vena cava and the aorta. Since donor multiorgan procurement involves many surgical teams, the removal of these vessels, with the abdominal graft, led to their unavailability for vascular surgeons. Here we present three consecutive cases of abdominal wall transplantation in which, by taking advantage of microsurgical experience, we were able to carry out a transplantation of the abdominal wall by direct anastomosis of the epigastric vessels, obtaining a very good outcome.

Free microvascular flaps in oncological surgery of the limbs.

Surgery plays a role of primary importance in the treatment of sarcomas of the soft tissues. The first objective of surgical treatment is the local control of the disease. Local recurrence is a serious event, that often requires amputation, and favors metastatic progression of the disease. Currently, except in very rare cases, conservative treatment is the treatment of choice, as it has by now been demonstrated that its results are equivalent to those obtained when demolitive surgery is used. In the distal sites of the limbs, superficial localization of the tendons, ligaments, and joints, the absence of anatomical compartments, make it difficult to perform wide conservative surgery. To this must be added that patients are often sent to see a specialist after a previous inadequate operation, and the presence of a contaminated surgical scar often requires exeresis of a wide area of the skin, sufficient to obstruct healing by primary intention. The use of revascularized free flaps allows for oncologically adequate conservative surgery to be performed, even in anatomical sites where amputation alone traditionally provided a safe surgical margin.