Supra-arcuate free fascial MS-TRAM, a modified technique to reduce donor site morbidity in obese population-comparative study.

BACKGROUND: Abdomen-based free flaps represent the gold standard option in the armamentarium of breast reconstruction. The natural evolution to more preservation with less invasive forms of these flaps has been driven by both patient and surgeon satisfaction. Nevertheless, obese patients are challenging due to the increased risk of compromised flap perfusion and donor site morbidity. This challenge is compounded by the prevalence of obesity worldwide, resulting in more free abdominal flaps being performed for breast reconstruction in obese patients. The authors present the outcomes of a modified supra-arcuate fascial muscle-sparing transverse rectus abdominus myocutaneous (FMS-TRAM) technique compared to standard muscle-sparing transverse rectus abdominus myocutaneous (MS-TRAM) technique to reduce the donor site morbidity while providing a well-vascularized large volume of autologous tissue. METHODS: A retrospective comparative data analysis was conducted at two centers: Cairo University Hospitals, Egypt, and University Hospitals Birmingham, United Kingdom. Standard MS-TRAM was performed in 65 patients between 2008 and 2011 (Group 1) versus 275 patients between 2011 and 2020 (Group 2) who underwent FMS-TRAM. The modified technique involved limiting the fascial incision to above or at the level of the arcuate line to preserve the integrity of the anterior rectus sheath caudally. All patients included were of the obese population (BMI≥30 kg/m2 ) and underwent unilateral post-mastectomy reconstruction. Patient demographics, comorbidities, operative details, and outcomes focusing on donor site morbidity and flap complications were recorded and compared between the two groups. RESULTS: The median age and BMI for Group 1 were 43 and 32, respectively. While for Group 2, they were 47 and 33, respectively. Flap weight ranged from 560 to 1470 g (Mean 705) for Group 1, while Group 2 ranged from 510 to 1560 (mean 715). The majority (280/340 [82%]) of the patients in both groups received radiotherapy. 7.7% of Group 1 were smokers, while in Group 2 it was 4.7%. The percentage of delayed versus immediate reconstruction in Group 1 was 60%/40%, while in Group 2, it was 43%/56%. The incidence of fat necrosis, partial necrosis, and total necrosis was 7.6%.1.5%, and 3%, respectively, for Group 1 and 8%, 1.4%, and 2.6%, respectively, for Group 2. The two-tailed p-value demonstrated a significant statistical difference (p < 0.00001) in donor site morbidity between both groups, with more bulge 20% (13/65) and hernia 1.5% (2/65) occurrence in Group 1 versus 1.9% (5/275) and 0.7% (2/275) in Group 2 respectively, over a follow-up period ranging from 24 to 60 months (mean 32). CONCLUSION: FMS-TRAM flaps are safe, robust, and reliable with less donor site morbidity while maintaining optimal flap perfusion for large volume flaps in obese patients with excellent, durable outcomes. It should be considered a valuable tool in the reconstructive armamentarium of breast reconstruction.

Sacroperineal Reconstruction With Inferior Gluteal Artery Perforator Flaps After Resection of Locally Advanced Primary and Recurrent Anorectal Malignancy.

ABSTRACT: Modern interdisciplinary concepts with involvement of various surgical specialties can considerably reduce perioperative morbidity after sacroperineal resection of locally advanced primary or recurrent anorectal malignancies. Resultant defects can represent a major challenge for reconstruction particularly with chemoradiotherapy. The aim is to assess the long-term outcomes of sacroperineal reconstruction using inferior gluteal artery perforator flaps.We performed a retrospective data analysis on 31 patients who were treated with inferior gluteal artery perforator flaps (n = 61) over the period 2009-2021. The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection and dehiscence were recorded.The median age was 42 year (range, 25-82 years) with preponderance of males (n = 21). The follow-up period ranged from 6 to 80 months. Early minor complications included superficial wound dehiscence (3), which was managed conservatively, whereas the major (2) included deep wound collection and infection (1), which required surgical drainage, and perineal hernia, which required repair. All flaps survived completely.Inferior gluteal artery perforator flaps are safe, robust, and reliable with less donor side morbidity and positive impact on quality of life. It should be considered as a valuable tool in the reconstructive armamentarium of sacroperineal defects within a multidisciplinary setting.

Staging computerized tomography before delayed breast reconstruction could alter the management plan.

BACKGROUND: Delayed breast reconstruction (DBR) comprises a significant proportion of breast reconstruction practice post completion of breast cancer treatment. The tumour's biology, staging, time constraints, ongoing treatment, and patient and surgeon's preference influence the decision to pursue DBR. There are no guidelines for assessing the oncological status before DBR in otherwise asymptomatic patients, particularly in those with a higher risk of recurrence. The purpose of this study was to identify the cohort of patients who could potentially benefit from staging CT scan before DBR regardless of the reconstructive modality and its impact on the overall management. MATERIAL AND METHODS: A retrospective review on 207 consecutive patients, who underwent staging CT scan before DBR in the period between 2009 and 2019 was performed. The CT scan findings were correlated with the breast prognostication scoring model (Nottingham Prognostic Index [NPI]) as an indicator factor for staging reasons. RESULTS: Incidental findings were reported in 34% (71/207) of the reviewed CT scans (incidentaloma group). There was no statistical significance in the NPI scores between non incidentaloma and incidentaloma groups. However, 5.7% (12/207) had their DBR procedure cancelled or the surgical plan altered. CONCLUSION: The patients with moderate to poor prognosis (NPI score 3.4 and above) could benefit from CT staging scan before DBR. This scan could detect adverse prognostic features precluding major surgery, which saves patients from unnecessary surgical risks and discomfort, and direct them towards the relevant management pathway.

Preoperative Long-term Therapeutic Subcutaneous Heparin Administration into Abdomen: Possible Cause for Nonobstructive Microvascular Flap Failure.

The anterioabdominal wall is the most common site for low molecular weight heparin administration for anticoagulation, either for prophylactic or for therapeutic indications. Occasionally, this could be associated with damage of the abdominal pannus microvasculature, which could possibly jeopardize the reliability of free abdominal flaps as deep inferior epigastric perforator and muscle sparing transverse rectus abdominis muscle, especially with therapeutic anticoagulation therapy. These flaps are reliant on a highly intricate complex vascular anatomy and perforasomes for their adequate perfusion and survival. The authors report a case of nonobstructive microvascular failure of a free muscle sparing transverse rectus abdominis muscle utilized for soft tissue coverage following resection of a chest wall breast cancer recurrence on a background of portacath-induced deep venous thrombosis of the axillary and subclavian vein whilst on chemotherapy. History of long-term therapeutic low molecular weight heparin administration in the abdomen resulted in microangiopathic densities evident on computerized tomography scan with subsequent flap failure due to possible jeopardization of the flap microvasculature and perfusion. Following exclusion of common local and systemic factors that can cause vascular compromise, a debridement and salvage re-reconstruction procedure utilizing a contralateral free latissimus dorsi flap was performed. Reconstructive surgeons should be cautious when planning to utilize free abdominal-based flaps on the background of long-term therapeutic low molecular weight heparin administration in the abdomen and may possibly explore other alternative options of using non-abdominal free flaps from the reconstructive armamentarium within this unique context.

Therapeutic Mammoplasty and Dermal Flap: A Novel Hybrid Approach for Chest Wall Reconstruction.

Breast reduction techniques in management of breast cancer have been described since 1980 mainly to resect a large tumor in large breasts. Driven by the demand for more aesthetically acceptable results without compromising oncological safety, these oncoplastic approaches have become more popular. In addition, the utilization of redundant lower pole dermal flap has been a widely practiced tool in the armamentarium of implant-based breast reconstruction in patients with large ptotic breasts. The authors advocate a novel hybrid technique utilizing both therapeutic mammoplasty and lower breast pole dermal flap to provide coverage for anterior chest wall defect posttumor resection in patients with large or ptotic breasts. METHODS: A retrospective review was conducted on patients who underwent chest wall resection and reconstruction using therapeutic mammoplasty and dermal flap to provide soft tissue coverage in the period between 2012 and 2018. Patient's demographics, clinicopathological, radiological, operative details, postoperative morbidity, and follow-up data were recorded. RESULTS: Nine patients with chondrosarcoma (7/9) and giant cell tumor (2/9) were managed with a mean age 44.1 years (range 28-73). Complete oncological resection was achieved in all patients followed by rigid/nonrigid skeletal reconstructions. All procedures were completed successfully with no nipple areolar complex (NAC) necrosis or prosthesis failure experienced during the follow-up period (range 12-72 months). Excellent functional and aesthetic outcomes were reported in all patients. CONCLUSION: The authors' results demonstrate that this technique could be safely planned for soft tissue coverage postchest wall resection with superior aesthetic and durable outcomes.

Nipple-Sparing Mastectomy and Prepectoral Implant/Acellular Dermal Matrix Wrap Reconstruction in Large Ptotic Breasts.

Nipple-sparing mastectomy (NSM) with simultaneous prepectoral direct to implant reconstruction and acellular dermal matrix (ADM) is increasingly offered to patients opting for prophylactic or therapeutic mastectomies. The recent introduction of prepectoral implant/ADM in the armamentarium of breast reconstruction has proven to reduce pain and animation deformity. Despite this promising method, patients with macromastia and ptotic breasts remain a challenging group to treat. More often they would require secondary corrective procedures and can experience high failure rate and unsatisfactory outcomes. The authors present their experience in utilizing a bipedicled nipple-areola complex dermal flap through Wise pattern to achieve a successful NSM with prepectoral implant/ADM (Braxon) wrap (IBW) as a single stage in patients with large ptotic breasts. Patients seeking NSM with large ptotic breasts were included in the study in the period between 2016 and 2018. They were offered a single-stage Wise pattern NSM and immediate prepectoral IBW breast reconstruction. The technique and outcomes were recorded. Sixteen reconstructions were performed in 8 women with a median age of 32 years (range, 27-50 years) and a median body mass index of 32 kg/m2 (range, 29-39 kg/m2). The resected breasts weight ranged from 750 to 1,600 g (median, 890 g). All procedures were completed successfully with no nipple-areola complex necrosis or failure experienced during the follow-up period (range, 3-24 months) with all patients reported excellent satisfaction. The authors' results demonstrate that this technique could be safely planned for NSM in large ptotic breasts with excellent durable outcomes.

Chest Wall Reconstruction with Porcine Acellular Dermal Matrix (Strattice) and Autologous Tissue Transfer for High Risk Patients with Chest Wall Tumors.

BACKGROUND: Tenets of chest wall reconstruction for malignancy are well known; however, the insertion of synthetic prosthetic material to achieve rigid and nonrigid skeletal reconstruction could be associated with more complications including infection and extrusion especially in high risk patients. This includes fungating, infected tumors, previous radiotherapy, scars, smoking, diabetes, and morbid obesity. Bioprosthesis Acelluar Dermal Matrix Strattice would be a substitute to resist infection and provide stable coverage. METHODS: A retrospective data analysis study on 8 high-risk patients who underwent chest wall resection and reconstruction with bioprosthesis (Strattice) with/without titanium plates in the period between 2012 and 2017 was performed. Patient's demographics, risk factors, clinico-pathological, radiological, operative details, adjuvant therapy, postoperative morbidity, and follow-up data were recorded. RESULTS: Sarcoma was the pathology in 7 and recurrent breast cancer in 1 with age range from 21 to 71 years (mean, 50) and preponderance of female patients (n = 5). Defects were located anterior/anterolateral with size ranging from 270 to 1,050 cm2 (mean, 511). Reconstruction was performed using Strattice only in 4 patients, whereas in 4 it was combined with titanium plates. All patients required flap reconstruction (3 pedicled and 5 free). The follow-up ranged from 9 to 52 months (mean, 24.8). Minor complications occurred in 2 patients; however, good functional outcome was achieved in all. CONCLUSION: Strattice would act as a safe alternative modality for chest wall reconstruction to resist infection in high-risk patients with extensive defects. It should be considered as a valuable tool in the armamentarium of chest wall reconstruction.

Internal Pudendal Artery Perforator Island Flap for Management of Recurrent Benign Rectovaginal Fistula.

The management of recurrent rectovaginal fistula after obstetric injury and cryptoglandular sepsis is considered a major surgical challenge. The fistula poses a significant negative psychosocial and sexual morbidity. In addition, the poor quality of local tissues due to previous attempts at surgical repair adds to this challenge. There are few data regarding the management of persistent or recurrent fistula in the literature; however, several studies reported high failure rates after 2 or more procedures. We present 4 cases managed successfully in a multidisciplinary approach involving fistulectomy and immediate reconstruction with an internal pudendal artery perforator island flap.

Multidisciplinary Oncoplastic Approach Reduces Infection in Chest Wall Resection and Reconstruction for Malignant Chest Wall Tumors.

BACKGROUND: Management of complex thoracic defects post tumor extipiration is challenging because of the nature of pathology, the radical approach, and the insertion of prosthetic material required for biomechanical stability. Wound complications pose a significant problem that can have detrimental effect on patient outcome. The authors outline an institutional experience of a multidisciplinary thoracic oncoplastic approach to improve outcomes. METHODS: Prospectively collected data from 71 consecutive patients treated with chest wall resection and reconstruction were analyzed (2009-2015). The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection were recorded. All patients were managed in a multidisciplinary approach to optimize perioperative surgical planning. RESULTS: Pathology included sarcoma (78%), locally advanced breast cancer (15%), and desmoids (6%), with age ranging from 17 to 82 years (median, 42 years) and preponderance of female patients (n = 44). Chest wall defects were located anterior and anterolateral (77.5%), posterior (8.4%), and apical axillary (10%) with skeletal defect size ranging from 56 to 600 cm(2) (mean, 154 cm(2)). Bony reconstruction was performed using polyprolene mesh, methyl methacrylate prosthesis, and titanium plates. Soft tissue reconstructions depended on size, location, and flap availability and were achieved using regional, distant, and free tissue flaps. The postoperative follow-up ranged from 5 to 70 months (median, 32 months). All flaps survived with good functional and aesthetic outcome, whereas 2 patients experienced surgical site infection (2.8%). CONCLUSIONS: Multidisciplinary thoracic oncoplastic maximizes outcome for patients with large resection of chest wall tumors with reduction in surgical site infection and wound complications particularly in association with rigid skeletal chest wall reconstruction.

Active range of motion outcomes after reconstruction of burned wrist and hand deformities.

This works aim is to evaluate the efficacy of skin grafts and flaps in reconstruction of post-burn hand and wrist deformities. A prospective study of 57 burn contractures of the wrist and dorsum of the hand was performed. Flaps were used only if there was a non-vascularized structure after contracture release, otherwise a skin graft was used. Active range of motion (ROM) was used to assess hand function. The extension deformity cohort uniformly underwent skin graft following contracture release with a mean improvement of 71 degrees (p<0.0001). The flexion deformity cohort was treated with either skin grafts (8 patients) or flaps (9 patients) with a mean improvement of 44 degrees (p<0.0001). Skin grafts suffice for dorsal hand contractures to restore functional wrist ROM. For flexion contractures, flaps were more likely for contractures >6 months. Early release of burn contracture is advisable to avoid deep structure contracture.

Triangular lipodermal flaps in Wise pattern reduction mammoplasty (superomedial pedicle): A novel technique to reduce T-junction necrosis.

BACKGROUND: Although Wise pattern reduction mammoplasty is one of the most prevalent procedures providing satisfactory cutaneous reduction, it is at the expense of inevitable lengthier scars and wound complications, especially at the inverted T junction. OBJECTIVE: To describe a novel technique providing tension-free closure at the T junction through performing triangular lipodermal flaps. The aim is to alleviate skin tension, thus reducing skin necrosis, dehiscence and excessive scarring at the T junction. METHODS: One hundred seventy-three consecutive procedures were performed on 137 patients between 2009 and 2013. Data collected included demographics, perioperative morbidity and resected breast tissue weight. The follow-up period ranged from three to 30 months; early and late postoperative complications and patient satisfaction were recorded. RESULTS: Superficial epidermolysis without T-junction dehiscence was experienced in eight (4.6%) procedures while five (2.9%) procedures developed full-thickness wound dehiscence. Ninety-four percent of patients were highly satisfied with the outcome. CONCLUSIONS: The technique is safe, versatile and easy to execute, providing a tension-free zone and acting as internal dermal sling, thus providing better wound healing with more favourable aesthetic outcome and maintaining breast projection.

HISTORIQUE: Même si la réduction mammaire par patron de Wise est l'une des interventions les plus prévalentes pour assurer une réduction cutanée satisfaisante, elle se fait aux dépens de complications plus longues et inévitables des cicatrices et des plaies, particulièrement à la jonction en T inversée. OBJECTIF: Décrire une technique novatrice sans fermeture de tension à la jonction en T par lambeaux lipodermiques triangulaires. L'objectif consiste à soulager la tension cutanée, réduisant ainsi la nécrose cutanée, la déhiscence et la cicatrisation excessive à la jonction en T. MÉTHODOLOGIE: Entre 2009 et 2013, 173 interventions consécutives ont été exécutées auprès de 137 patients. Les données colligées incluent la démographie, la morbidité périopératoire et le poids des tissus mammaires réséqués. La période de suivi durait de trois à 30 mois. Les complications postopératoires précoces et tardives et la satisfaction des patients ont été enregistrées. RÉSULTATS: Huit interventions (4,6 %) se sont associées à une épidermolyse superficielle sans déhiscence de la jonction en T, tandis que cinq (2,9 %) ont donné lieu à une déhiscence pleine épaisseur de la plaie. Ainsi, 94 % des patients étaient pleinement satisfaits des résultats. CONCLUSIONS: La technique est sécuritaire, polyvalente et facile à exécuter, assure une zone sans tension et agit comme une attelle dermique interne, ce qui entraîne une meilleure cicatrisation de la plaie, aux résultats esthétiques plus favorables, qui maintient la projection mammaire.

The reverse sural flap: modifications to improve efficacy in foot and ankle reconstruction.

The aim of this work is to evaluate the efficacy of the reverse sural flap in covering defects in the foot and ankle region when certain technical modifications are employed. We provide a retrospective review of 32 consecutive reverse sural flaps for foot and ankle defects, and compare the technique and results with other reports. There were 23 fasciocutaneous flaps, 7 fascial flaps, and 2 tissue-expanded flaps. Four flaps (12.5%) suffered significant flap loss, and 4 patients had delayed healing.Several modifications are suggested to increase the versatility of the sural flap in covering foot and ankle defects, including preserving the mesentery connecting the sural nerve to the deep fascia, inclusion of skin of the upper third of the leg, limiting pedicle width to 2 cm with preservation of a tongue-like skin process all along its length, and generous release of the fascia over the peroneal compartment. In addition, we describe the use of tissue expanded sural flaps.

Modified vertical rectus abdominis musculocutaneous flap for limb salvage procedures in proximal lower limb musculoskeletal sarcomas.

Introduction and aim. Management of complicated wounds after tumor extipiration of pelvic and proximal lower limb musculoskeletal sarcoma represents an essential component in the outcome of these patients. The authors present modified vertical rectus abdominis musculocutaneous (VRAM) flap techniques to reconstruct extensive defects after debridment of these complicated wounds. Material and Methods. Over a period of 4 years (2002-2005), 5 men and 2 women were managed. Median age was 21 years (range 15-49). The patients were managed for complicated lower trunk, groin, and upper thigh wounds after resection of three pelvic chondrosarcomas as well as two pelvic and two proximal femur osteosarcomas. The modifications included a VRAM flap with lateral and tongue-like extension design of the skin paddle (5 cases) or a delayed extended VRAM flap (2 cases). Results. All flaps showed complete survival and healing with no ischemic events providing stable coverage. All patients were ambulant with good limb functions in terms of walking and gait after adequate rehabilitation, 2 needed support with crutches. Conclusion. The modified VRAM flaps offer reliable reconstructive tools for coverage of complex groin and thigh defects by providing larger well-vascularized soft tissue with acceptable donor site.