Pedicled Anterolateral Thigh Flap As A Workhourse Flap for Reconstruction of Inguino-Scrotal Defects

Background: Reconstructions around inguinoscrotal region has been a challenging task owing to complex anatomy. There are variety of flap options available for reconstruction of Inguinoscrotal region. Our study was done to evaluate the use of pedicled anterolateral thigh flap for reconstruction of defects around inguinoscrotal regions. Methodology: In this study a total of 18 patients with various types of defects around inguinoscrotal region were evaluated. The etiology of defects included trauma (𝑛=6), infection (𝑛=8), malignancy (𝑛=2) and burn (𝑛=2). Patients were evaluated in terms of viability of the flap, number of perforators included, pedicled length and flap dimensions and donor site morbidity. Results: All flaps were survived well except 1 flap develop venous congestion in immediate post operative period due to tension over vascular pedicle which was managed by increasing pedicle length. 2 patients had developed partial loss of the skin graft at the donor site which got healed secondarily in due course. All patients were followed up for an average period of 6 months, ranging from 1 to 12 months. Donor site morbidity was minimal. Conclusion: Pedicled ALT flap is a versatile, reliable flap, with wide arc of rotation which makes it as an ideal flap for the coverage of defects around inguinoscrotal region.

Lessons Learned from 30 Years of Transverse Myocutaneous Gracilis Flap Breast Reconstruction: Historical Appraisal and Review of the Present Literature and 300 Cases

Background: Happy 30th birthday to the transverse myocutaneous gracilis (TMG) flap. Since 1991 the TMG flap has been used to reconstruct a wide variety of defects and became a workhorse flap and reliable alternative to the deep inferior epigastric perforator (DIEP) flap in many breast reconstruction services worldwide. This manuscript sheds light on the history and success of the TMG flap by critically reviewing the present literature and a series of 300 patients receiving a breast reconstruction. Patients and Methods: The present literature and history of the TMG flap was reviewed and a retrospective double center cohort study of 300 free TMG free flaps for autologous breast reconstruction was conducted. Patient demographics, perioperative data, and post-operative complications were recorded and compared with literature findings. Results: Mean flap weight was 320 g. Mean pedicle length was 70 mm. Complications included 19 (6.3%) flap loss. 10 patients (3.3%) had postoperative cellulitis and 28 (9.3%) wound healing disturbance of the donor site. Conclusion: Recipient and donor site complications were comparable to other free flaps used for breast reconstruction. A low BMI or the lack of an abdominal based donor site do not represent a limitation for breast reconstruction and can be overcome using the TMG flap.

TOMOGRAPHIC ANALYSIS OF C7, T1 AND T2 VERTEBRAE ANATOMY IN CHILDREN

ABSTRACT Objective: To evaluate and compare anatomical measurements of C7, T1 and T2 vertebrae in children from 3 to 12 years of age to provide useful epidemiological data for determining the safe anatomical margin for transpedicular and translaminar fixation with screws in this population. Methods: This observational retrospective cross-sectional study evaluated 76 computed tomography scans obtained over 6 months, analyzing the following parameters: the angle of attack, length, thickness and diameter of the pedicle; and the angle of attack, length and thickness of the lamina. Results: The lamina length and thickness, as well as pedicle length varied in size according to age. Although the angle of attack was similar across different ages, age-dependent variation occurred in the T1 vertebra. Conclusion: Screws with a 3.5 mm diameter are safe to use in the C7 and T2 pedicles, while the T1 pedicle allows the introduction of larger screws ranging from 3.5-4.5 mm in diameter. In the lamina, 3.5 mm screws are safe for use only in children older than 7 years. However, each case should be analyzed individually, with the present study not aiming to replace the preoperative use of CT. Level of Evidence III, Retrospective comparative study.

Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer

Background: Reverse-flow posterior interosseous artery (rPIA) flap is an excellent tool for restoration of defects in the hand and upper extremity, sparing the main arteries to the hand. Its reliability has been well established. Materials and Methods: Fifty-one cases of rPIA flap involving 49 patients were retrospectively reviewed. The inclusion criteria were age, sex, etiology, size and location of the defect, flap size, number of perforators included, pedicle length, flap inset, donor site coverage, complications, and ancillary procedures. Results: This study included 44 men and 5 women, ranging in age between 10 and 73 years. The subjects had soft tissue defects of the hand and upper extremity mainly due to traumatic injuries, including scar contractures of the first web space in 18 cases, thumb amputations in 6 cases, and congenital defects in 1 case. Among the 51 rPIA flap elevations, 3 cases involved flap failure due to the absence of proper pedicle. A fasciocutaneous pattern was observed in 45 cases and a myocutaneous pattern in 3 cases. In 5 cases of unplantable thumb amputations, the rPIA flap was performed for arterial inflow to the secondary toe-to-thumb transfer. Venous congestion of varying degrees was noted in 7 cases involving partial necrosis in 2 cases. During the mean 17 months of follow-up, patients were generally satisfied with the final outcomes. Conclusion: The rPIA flap can be used not only for soft tissue coverage of the hand and upper extremity but also as a recipient arterial pedicle for a secondary toe-to thumb transfer.

What is the difference in pedicle morphology of the fifth lumbar vertebra between isthmic and degenerative L5-S1 spondylolisthesis? An anatomic study of 328 patients via multi-slice spiral computed tomography

Purpose The purpose of this study was to investigate and determine whether there are differences in L5 pedicles morphology between isthmic and degenerative L5-S1 spondylolisthesis. Methods One hundred and nineteen patients with isthmic spondylolisthesis and 45 patients with degenerative spondylolisthesis at L5-S1 were enrolled in the IS group and DS group, respectively, and 164 lumbar disc herniation patients without spondylolysis or spondylolisthesis were classified into the normal (NL) group. A series of pedicle parameters of the fifth lumbar vertebra, including pedicle length (PL), pedicle width (PW), pedicle screw trajectory length (PSTL), pedicle height (PH), and the pedicle camber angle (PCA) were measured using multi-slice spiral computed tomography (MSCT). The slip distance of the L5 vertebra was measured on radiography, and the percentage of slip was also recorded. Results The pedicles of the fifth lumbar vertebra were shorter and wider, and the PCA was larger in the IS group compared to the DS group and NL group. On the contrary, the pedicles in the DS group were elongated and thinner, and the PCA was smaller. The pedicle parameters of PL were significantly positively correlated with the percentage of slip in the DS group, but PW and PCA were negatively correlated with the percentage of slip. There was no correlation between the percentage of slip and L5 pedicle parameters in the IS group. Conclusions The L5 pedicles morphology in L5-S1 isthmic spondylolisthesis shows abduction, shortness, and width, while that in the degenerative spondylolisthesis shows adduction, lengthening, and thinning compared with the normal populations. The morphology changes may be the result of pedicle stress remodeling in the development of spondylolisthesis, which should be taken into consideration when placing at the insertion of pedicle screws.

Outcome of Free Medial Sural Artery Perforator Flap (MSAP) for Head and Neck Reconstruction: A Systematic Review and Met Analysis

Introduction: Since first described by Cadavas, A free medial sural artery perforator flap (MSAP) is getting popularity day by day. Specially, where the micro surgeons are desired to have thin, pliable flap with long pedicle and less donor site morbidities. For its above-mentioned characteristics and good outcome, it is now considered as one of the workhorse flaps for head and neck reconstruction. Aims and Objectives: The aim was to find out the feasibilities and versatilities of this flap as workhorse in head and neck reconstruction. As well as taking into consideration of its low donor site morbidities. Methods: A literature search has been performed in July 2020 in various data base including Pub Med, Trip database, Medline and Google Scholler to find out the outcome of head and neck reconstruction with free MSAP Flap. Data then were tabulated and analysed using Microsoft Excel datasheet. Results: The results were promising. Overall, flap survival rate was 95%. Mean flap dimension was 9.3 cm x5.5 cm. Average pedicle length was 10.5 cm. Mean flap thickness was 6mm. Overall complication rate was 16% including 6% wound related and 2% donor site complication. Most of the cases donor site have closed directly (87%). Conclusion: Free MSAP Flap is an ideal workhorse flap for head and neck reconstruction. However, as most of the literatures were case series or personal experiences of surgeons, a multicentre trial with large sample can give us more information.

Anatomic Considerations of Microvascular Free Tissue Transfer in Endoscopic Endonasal Skull Base Surgery

Objective Though microvascular free tissue transfer is well established for open skull base reconstruction, normative data regarding flap design and inset after endoscopic endonasal skull base surgery (ESBS) is lacking. We aim to describe anatomical considerations of endoscopic endonasal inset of free tissue transfer of transclival (TC) and anterior cranial base resection (ACBR) defects. Design and Setting Radial forearm free tissue transfer (RFFTT) model. Participants Six cadaveric specimens. Main Outcome Measures Pedicle orientation, pedicle length, and recipient vessel intraluminal diameter. Results TC and ACBR defects averaged 17.2 and 11.7 cm2, respectively. Anterior and lateral maxillotomies and endoscopic medial maxillectomies were prepared as corridors for flap and pedicle passage. Premasseteric space tunnels were created for pedicle tunneling to recipient facial vessels. For TC defects, the RFFTT pedicle was oriented cranially with the flap placed against the clival defect (mean pedicle length 13.1 ± 0.6 cm). For ACBR defects, the RFFTT pedicle was examined in three orientations with respect to anterior–posterior axis of the RFFTT: anteriorly, posteriorly, and laterally. Lateral orientation offered the shortest average pedicle length required for anastomosis in the neck (11.6 ± 1.29 cm), followed by posterior (13.4 ± 0.7cm) and anterior orientations (14.4 ± 1.1cm) (p < 0.00001, analysis of variance). Conclusions In ACBR reconstruction using RFFTT, our data suggests lateral pedicle orientation shortens the length required to safely anastomose facial vessels and protects the frontal sinus outflow anteriorly while limiting pedicle exposure through a maxillary corridor within the nasal cavity. With greater understanding of anatomical factors related to successful preoperative flap planning, free tissue transfer may be added to the ESBS reconstruction ladder. Level of Evidence NA

Review of the superficial circumflex iliac artery perforator flap: recommendations to the approach of a groin perforator flap

Introduction: The superficial circumflex iliac artery perforator (SCIP) flap has gained in popularity due to its thinness and superior donor site scar. However, there exist inconsistencies in the description of the surgical anatomy of the SCIP flap. The aim of this quantitative review was to provide a summary of published evidence to the surgical approach to such flaps. Methodology: A literature review of the MEDLINE® and Cochrane databases was conducted. Articles were assessed by two reviewers using predefined data fields and selected using specific inclusion criteria. The two authors independently reviewed the literature and discrepancies were resolved by consensus. Results: Included for evaluation were 39 articles. Of these, 30 fulfilled the criteria for surgical dissection, 16 for surgical anatomy and nine for preoperative imaging. The arterial anatomy of the groin perforator flap is variable and in 0.9 per cent of cases the pedicle originates from the superficial inferior epigastric artery rather than the superficial circumflex iliac artery (SCIA). The flap pedicle length is probably dependent on patient build and the course of the source vessel, rather than which groin perforator it is based on. CT is the gold standard preoperative imaging and should be used given the anatomical unpredictability. Lymphatics under the inguinal ligament and medial to the femoral artery should be preserved. Conclusion: This quantitative study provides a guide to safe groin perforator flap harvest and surgical pearls to consider for surgical planning. The usage of this flap remains novel and further long-term outcomes have yet to be established.