Mandibular reconstruction: meta-analysis of iliac- versus fibula-free flaps.

BACKGROUND: Free vascularized bone flaps are widely recognized as the optimal reconstruction for patients who undergo mandibular resection. The fibula-free flap is currently considered the gold standard, workhorse flap for mandibular reconstruction. Although previous studies have analysed individual success of each flap type, few have compared iliac- and fibula-free flaps. METHODS: A systematic review of the literature was conducted in line with the PRISMA protocol searching the PubMed and EBSCO databases. Twenty-four studies were included as per predetermined inclusion criteria. Double-arm random effect meta-analysis was conducted with STATA 12, and single-arm meta-analysis was conducted utilizing Meta-XL. RESULTS: The results of this meta-analysis confirm that there is no significant difference in total flap loss between fibula- and iliac-free flap reconstruction of mandibular defects. In terms of recipient site complication, there was a significantly higher risk of delayed healing and suture line breakdown in the iliac flap group (P = 0.05). Donor site complications showed a trend towards being higher in the fibula flap group. Osseointegrated dental implant loss in fibula flaps was higher than in iliac flaps (5.3% compared with 1.7%). CONCLUSION: Both iliac- and fibula-free flaps should be considered for use in mandibular reconstruction. We suggest the iliac crest as the first choice for mandibular angle or body defects (better contour match) or also defects requiring greater soft-tissue bulk for intra-oral lining. The fibula flap is best when bony length is required such as in subtotal or total mandibulectomy.

Quadriceps keystone island flap for radical inguinal lymphadenectomy: a reliable locoregional island flap for large groin defects.

BACKGROUND: Radical inguinal lymphadenectomy (RIL) for bulky metastatic melanoma and non-melanoma skin cancers of the inguinal region, while shown to improve morbidity and survival oncologically, can result in substantial morbidity from wound complications. Skin defects cannot be closed primarily and the substantial dead space predisposes to seroma, wound dehiscence and infection. Despite the clear need for reconstructive options, extended series describing reconstruction of large inguinal defects in this setting have not been reported. METHODS: A prospectively entered, retrospectively reviewed study of 20 consecutive patients undergoing quadriceps keystone island flaps (QKIF) for the closure of complicated inguinal defects is described. RESULTS: There was 100% flap survival, with no partial or complete flap losses. A reduction in wound breakdown/dehiscence from reported rates was seen, with four patients (20%) having wound breakdown, compared to double that rate in reported series. Other wound complications comprised six patients (30%) with mild wound infections, seven patients (35%) with seromas and two patients (10%) with haematomas. CONCLUSION: The QKIF is an effective means of reconstructing inguinal defects after RIL, particularly in high-risk patients, and is technically simpler than other reconstructive techniques advocated for this purpose. Furthermore, the QKIF offers patients with advanced disease (where management is primarily palliative) a potentially improved quality of life with reduced operative morbidity.

Guiding local perforator flaps with preoperative imaging: revealing perforator anatomy to improve flap design.

BACKGROUND: Perforator flap nomenclature continues to evolve, with many classification schemes reported. Each of them focuses on the fascial penetration pattern of perforators, which has no impact on flap perfusion. With the advent of advanced imaging technologies, the subcutaneous course of perforators can be highlighted for the first time, offering new insight into flap design. METHODS: The current study presents the authors' technique for imaging local perforator flaps with computed tomographic angiography, utilizing a standard technique for perforator imaging with computed tomographic angiogram, regardless of whether the flap is a local or free flap, and regardless of body region. This technique has been used in more than 1000 image-guided perforator flaps, with the current study highlighting three such cases in different body regions. RESULTS: With the use of preoperative imaging, flap design can be based on the subcutaneous ramification of individual perforators. Several ramification patterns are presented and potential improvements to nomenclature schemes suggested. CONCLUSION: : With the use of preoperative imaging, "image-guided" perforator flaps that are truly axial-pattern in terms of their arterial supply can be designed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic: V.

Seat belt injury to the female breast: review and discussion of its surgical management.

With the use of the three-point lap-diagonal seat belt restraint, there has been a reduction in the number of deaths caused by automobile trauma. However, a new pattern of injury has emerged, the 'seat-belt syndrome', which comprises a constellation of injuries including soft tissue injury to the breast. Given that seat belt legislation is becoming more widespread, it is likely that the incidence and reporting of these injuries will become more common. In this paper, we provide an overview of the varied clinical and radiological presentations, and suggested management of seat belt injury to the female breast. The consequences of such injury can be severe in their functional, psychosocial and aesthetic impact, and thus, using an index case as an example, the previously unreported area of breast reconstruction in a breast deformed as a result of blunt trauma is discussed, highlighting some of its challenges.

Retained foreign body following pleural drainage with a small-bore catheter.

Small-bore radiopaque drains can be used to drain pleural effusions. They offer reliable drainage of simple pleural effusions and provide a safe, less-invasive, more comfortable alternative to the standard tube thoracostomy. Importantly, removal of such drains does not require purse-string sutures and hence can be removed without assistance. We report here the cautionary tale of a retained foreign body related to drainage of a pleural effusion with a Pleurocath in a patient following cardiac surgery to raise awareness of this potential complication. Emphasized is the need for all staff to be familiar with the normal appearance of equipment being utilized in the ward and to report when incomplete removal of drain equipment is suspected. In addition, amendments to insertion techniques for such small-bore drains are proposed to avoid similar undue complications.