Radiological Evaluation of Postsurgical Course of Perforators in Retrograde Posterior Tibial Fasciocutaneous Flaps for Distal Leg and Foot Defects

Background Mapping of vascular perforators by various methodologies have been described for planning of a variety of flaps in the lower limbs. We attempted to assess the changes in posterior tibial perforators after transfer of fasciocutaneous flaps for leg defects. Methods 20 patients with distal leg and foot defects were studied by computed tomography angiography (CTA) and preoperative audio Doppler to ascertain perforators of posterior tibial artery. Fasciocutaneous flaps were raised, based on these perforators, depending on the site and size of soft-tissue defects. The number of perforators and their distance from the medial malleolus were also studied. Postoperative CTA was performed on the 7th to 10th day, with emphasis on postoperative changes of the perforators on which the flaps were based. Results One to four posterior tibial perforators were found between 5 cm and 8 cm proximal to the medial malleolus. After flap transfer, the perforators could be traced to variable distance through the total length of the flap. The perforators formed small vascular loop in 12 patients, following retrograde posterior tibial flap transfer. The height of the loop, the number of such loops, the dilatation and tortuosity of the perforators, and their longitudinal orientation were studied in detail. Most of the findings can be explained by mechanical realignment of perforators as well as by the delay phenomenon associated with retrograde fasciocutaneous flaps. Conclusion It was concluded that the morphological changes associated with the perforators explained the vascular rationality and success of these flaps.

“Like For Like” Reconstruction of Heel Pad with Medial Plantar Artery Flap—Functional and Aesthetic Outcomes in A Series of 19 Cases

Heel pad loss can cause serious problems in weight-bearing and locomotion. The medial plantar artery (MPA) flap is a suitable “like for like” replacement. Nineteen patients whose heels were reconstructed with MPA flap between July 2015 and February 2020 were studied. All patients were assessed based on flap survival, functionality, and patient satisfaction. Loss of heel pad was due to diabetic ulcer (11), trauma (6), tumor (1), and unstable scar (1). The largest flap measured 9 × 7 cm. Sixteen flaps were done as fasciocutaneous flaps and three in combination with abductor hallucis muscle (AbdH). All the flaps survived. The average functional scores at 6, 12, 18, and 24 months were 86.86, 89.62, 89.38 and 97.33 based on AOSAS-AH score. Average patients' satisfaction was 8.7/10. To conclude, the MPA system is a versatile vascular axis providing “like for like” tissue for heel pad reconstruction which is reliable and durable.

Preference for Fasciocutaneous Flap Over Musculocutaneous Flap as a First-Line Option for Ischial Pressure Wound Reconstruction: A Review of 64 Cases

The ischial pressure wound usually comprises a large, extensive defect and involves the repair of more than a small opening. Most surgeons have used a musculocutaneous flap to fill the large dead space of an ischial pressure wound. However, sacrificing muscle tissue has a potential risk of postoperative bleeding. The transferred muscle ultimately loses function as a cushion to absorb pressure. Conservation of muscle structures may be beneficial for use in future recurrence, which is common with ischial pressure wound. We compared the difference in outcome between musculocutaneous and fasciocutaneous flaps and analyzed factors affecting complications with the flaps in ischial pressure wound reconstruction. This study reviewed the results of 64 flaps in 44 patients with ischial wounds. The wounds were reconstructed with 34 musculocutaneous flaps (53%) and 30 fasciocutaneous flaps (47%). Twenty-three cases (36%) had complete healing, and 41 (64%) had complications. There was no significant difference in outcomes between fasciocutaneous and musculocutaneous flap groups. Crude logistic regression analysis showed no significant risk factors for occurrence of major complications. When fasciocutaneous flaps were used, the neighboring perforators and muscle tissues could be conserved. With a perforator-based fasciocutaneous flap, a de-epithelized distal portion of the flap could be used to fill the dead space. Therefore, the fasciocutaneous flap may have priority over the musculocutaneous flap as a first-line option for ischial pressure wound reconstruction.

Microsurgical reconstruction of maxillary defects after limited resections for malignant tumors

Introduction. Partial maxillectomy involves resection of 1 or 2 walls of the upper jaw, usually medial and anterior ones. The main purposes of reconstruction include the formation of an adequate support for the eyeball; isolation of the orbit from the nasal cavity, nasopharynx, and anterior skull base; normal symmetry; good aesthetic result.Materials and methods. Between 2014 and 2020, we followed up 13 patients. Nine of them (69 %) had combined defects involving the inferior orbital, anterior, and medial walls of the maxilla (class V according to according to the Brown–Shaw classification, 2010), as well as skin on the buccal and zygomatic areas; 1 patient also had lower eyelid affected. Four individuals (31 %) had isolated defects involving the inferior orbital, anterior, and medial walls of the maxilla (class V according to according to the Brown–Shaw classification, 2010). Twelve patients have undergone preoperative 3D-computer simulation. We divided patients into 2 groups according to the size of their defects and resection areas in the anterior wall of the maxillary sinus. Group 1 included 5 patients with partial maxillary defects (involving 25–40 % of the total area), whereas Group 2 comprised 7 patients with limited maxillary defects (involving 25–40 % of the total area).Five patients have undergone reconstructive surgeries with fasciocutaneous flaps, including anterolateral thigh flaps used in 4 individuals (31 %) and thoracodorsal flap used in 1 individual (8 %). Eight patients had their defects repaired using radial fasciocutaneous flaps. The inferior orbital wall was reconstructed using an individual titanium mesh implant.Results. All patients from Group 1 after defect repair with anterolateral thigh flaps and thoracodorsal flaps (4 individuals) had satisfactory aesthetic result. One patient had an unsatisfactory aesthetic result after reconstruction with a radial fasciocutaneous flap due to mesh implant protrusion and formation of an opening in the nasal cavity. The assessment of the eyeball position demonstrated that symmetry was achieved in 4 patients (80 %) after reconstruction using anterolateral thigh flaps (3 patients) and thoracodorsal flap (1 patient). Five patients from Group 2 (72 %) had excellent results, while 2 patients (28 %) had satisfactory results. The assessment of the eyeball position demonstrated that symmetry was achieved in 5 patients (70 %); two participants (28 %) had lower eyelid ectropion.Conclusion. Patients with large maxillary defects (involving 41–60 % of the total area of the anterior wall of the maxillary sinus and the alveolar process of the maxilla) should undergo reconstructive surgeries with fasciocutaneous anterolateral thigh flaps. In case of relatively small defects (involving 25–40 % of the total area of the anterior wall of the maxillary sinus and the alveolar process of the maxilla) the best option is defect repair with radial fasciocutaneous flaps. Such strategy ensures excellent aesthetic and functional results in 75 % of patients.

Distally Based Sural Fasciocutaneous Flaps for Reconstructing Soft Tissue Defects Proximal and Distal to the Tarsometatarsal Joints: A Comparative Analysis

Distally based sural fasciocutaneous (DBSF) flaps are widely used for reconstructing soft tissue defects of the foot. The purpose of this paper was to compare the clinical efficacy of the use of flaps to repair defects in areas proximal and distal to the level of the tarsometatarsal joints in a relatively large number of patients and to analyze the effects of factors on the risk of developing partial necrosis of the flaps. Between April 2001 and December 2019, a total of 355 DBSF flaps were utilized to cover soft tissue defects in the foot. According to the furthest location of the defects reconstructed with the flaps, the flaps were divided into the proximal foot group (n = 260) and the distal foot group (n = 95). The partial necrosis rates, their influencing factors, and the clinical outcomes of the procedure were compared between the two groups. In the proximal foot group, the partial necrosis rate (6.2%, 16 of 260) was significantly lower than that in the distal foot group (14.7%, 14 of 95) ( P < .05). The proportion of successful coverage of the defects using the flaps alone or in combination with a simple salvage treatment was comparable between the groups ( P > .05). The ratio of unfavorable conditions in the distal foot group was higher than that in the proximal foot group ( P < .05). DBSF flaps can be effectively utilized to repair defects in the proximal and distal areas of the foot. The use of a DBSF flap to repair defects in the proximal areas of the foot is superior to the use of DBSF flaps for repairing defects in the distal areas of the foot in terms of reliable survival of the flap.

Free Flap Reconstruction of Traumatic Pediatric Foot and Ankle Defects: An Analysis of Clinical and Functional Outcomes

Background Traumatic lower extremity injuries involving the foot and ankle can have devastating consequences and represent a complex reconstructive challenge. To date, there are limited reports on microsurgical reconstruction for foot and ankle defects in children. This study aims to evaluate clinical and functional outcomes of free flaps for pediatric foot and ankle injuries. Methods This is a retrospective review of patients undergoing free flaps for traumatic foot and ankle defects at a pediatric trauma center between 2000 and 2015. Patients with less than 5-year follow-up were excluded. Demographics, clinical characteristics, and postoperative outcomes were evaluated. Results Thirty patients undergoing 30 flaps were analyzed. The mean age was 11.9 years (range: 2 to 17 years). Muscle flaps (n = 21, 70%) were more common than fasciocutaneous flaps (n = 9, 30%). Limb salvage with functional ambulation was achieved in 96.7% of patients (n = 29). The complication rate was 33.3% (n = 10), with wound breakdown (n = 6, 20.0%) as most common feature. There were no significant differences in limb salvage, total or partial flap loss, fracture union, and donor-site complications based on flap type. Fasciocutaneous flaps were more likely to require revision procedures for contour compared with muscle flaps (55.6 vs. 9.5%, p = 0.013). Mean follow-up was 8.5 years. Conclusion Microsurgical reconstruction of pediatric foot and ankle defects results in high rates of limb salvage. A defect- and patient-centered approach to reconstruction, emphasizing durable coverage and contour, is critical to facilitating ambulation and ensuring favorable long-term functional outcomes.

RECONSTRUCTION OF UPPER LIMB SOFT TISSUE INJURIES, EXCEPT FOR FINGERTIPS LESIONS

ABSTRACT Objective: The main purpose of this work was to evaluate the advantages and disadvantages of reconstructive procedures applied in upper limb soft tissue injuries according to their location. Methods: The study involved 94 male and 22 female patients (116 total) operated between April 2001 and November 2017 due to traumatic injuries in a upper limb. Individuals were evaluated considering their age, sex, etiology, reconstruction area , applied methodology and complications. The finger injuries were excluded. Results: The performed reconstruction procedures include 29 skin grafts; six advancement flaps; seven rotation flaps; 33 pedicled fasciocutaneous flaps, 9 free fasciocutaneous flaps; 5 pedicled muscle flaps; 12 free muscle flaps, three pedicled musculocutaneous flaps; one free musculocutaneous flap; 11 neurovascular free flaps. Conclusion: Reconstructive procedures in the upper limbs are diverse, varying from skin grafting to free flaps. The indication of the best option depends on the type of injurie and the surgeon. The final goal is to reach the best functional result combined with the lowest possible morbidity. Level of Evidence IV, Case series.