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.

"Proximal to distal" sequence of the release of the upper extremity post-burn contracture: Rule or case-based approach?

Post-burn contractures are common entities seen in developing countries. There are multiple reasons for the development of contractures, most are preventable. In extensive contractures, a strategic plan is necessary to release all contractures and yet not antagonize post-operative positions. It is also necessary to be cost-effective and minimize the number of surgeries needed. Conventionally the release sequence in extensive burn contractures is proximal to distal. In this case report, we discuss an unusual sequence where we released distal contractures before the proximal to achieve optimum results. A 3-year-old child with post-burn contracture of hand, wrist, elbow, and axilla was treated in 2 stages, with the release of wrist contracture and cover with pedicled abdominal flap in the first stage and division of pedicled flap with the release of axilla and elbow contracture in the second stage. Thus, the release of all contractures was achieved without antagonizing post-operative positions and minimized the number of surgeries. A case-based approach may be crucial in making a strategic surgical plan to minimize the rehabilitation phase, rather than following known dictums.

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.

Effectiveness of Parkland formula in the estimation of resuscitation fluid volume in adult thermal burns.

PURPOSE: Acute burn resuscitation in initial 24 h remains a challenge to plastic surgeons. Though various formulae for fluid infusion are available but consensus is still lacking, resulting in under resuscitation or over resuscitation. Parkland formula is widely used but recently its adequacy is questioned in studies. This study was conducted to see how closely the actual volume of fluid given in our center matches with that of calculated volume by Parkland formula. METHODS: All patients admitted with more than 20% flame burn injury and within 8 h of incident were included in this study. Crystalloid solution for infusion was calculated as per Parkland formula; however, it was titrated according to the urine output. Data on fluid infusion were collected from patient's inpatient records and analyzed. RESULTS: The study included a total of 90 patients, about 86.7% (n = 78) of the patients received fluid less than the calculated Parkland formula. Rate of fluid administered over 24 h in our study was 3.149 mL/kg/h. Mean hourly urine output was found to be 0.993 mL/kg/h. The mean difference between fluid administered and fluid calculated by Parkland formula was 3431.825 mL which was significant (p < 0.001). CONCLUSION: The study showed a significant difference in the fluid infused based on urine output and the fluid calculated by Parkland formula. This probably is because fluid infused based on end point of resuscitation was more physiological than fluid calculated based on formulae.