A review of the Turned-down Onto Pericapsular-tissue Hemisectioned Amputated Toe (TOPHAT) flap for wound coverage during ray amputations

Abstract Obesity and the related medical, social, and economic impacts are relevant multifactorial and chronic conditions that also have a meaningful impact on outcomes following a severe injury, including burns. In addition to burn-specific difficulties, such as adequate hypermetabolic response, fluid resuscitation, and early wound coverage, obese patients also present with common comorbidities, such as arterial hypertension, diabetes mellitus, or nonalcoholic fatty liver disease. In addition, the pathophysiologic response to severe burns can be enhanced. Besides the increased morbidity and mortality compared to burn patients with normal weight, obese patients present a challenge in fluid resuscitation, perioperative management, and difficulties in wound healing. The present work is an in-depth review of the current understanding of the influence of obesity on the management and outcome of severe burns.

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Limited Bilateral Advancement of the Sternocostal Head of Pectoralis Major for Sternal Reconstruction: Preserving the Axillary Fold

International Surgery ◽

10.9738/intsurg-d-15-00029.1 ◽

2017 ◽

Vol 102 (3-4) ◽

pp. 189-195

Author(s):

Warren M. Rozen ◽

Ken G. W. Teo ◽

Gausihi Sivarajah ◽

Rafael Acosta

Keyword(s):

Pectoralis Major ◽

High Rate ◽

Pectoralis Major Flap ◽

Limited Sample ◽

Wound Coverage ◽

Caudal Portion ◽

Sternal Reconstruction ◽

The Right ◽

Good Cosmesis ◽

Rate Of Success

The introduction of well-vascularized flaps for infected sternotomy wound reconstruction has improved mortality rates dramatically. Multiple variations of the pectoralis major flap have been described in this context. However, unresolved limitations of this flap include poor cosmesis and problematic coverage of the inferior third of the sternotomy wound. We describe an approach to address these issues. The humeral attachments are preserved and bilateral muscles are advanced in a limited fashion. The left sternocostal head is advanced medially and rotated anticlockwise, using this portion to fill the upper half of the sternum while the caudal portion of the right pectoralis muscle is used as a turnover flap at the lower half of the wound. In all 25 patients, the anterior axillary fold was preserved bilaterally and the infection completely resolved. Complications included 3 cases of hematoma, 2 cases of coagulopathy, and 1 late bone sequestrum (aseptic). Although the study had a limited sample size, we had a high rate of success and few complications. With the preservation of bilateral axillary folds, good cosmesis, and adequate wound coverage, we recommend this modification of the pectoralis major flap in even complicated cases of mediastinitis.

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