Microvascular skin coverage in wounds that expose the Achilles tendon

Achilles tendon rupture is one of the most frequent tendon ruptures. Surgical intervention is the best option, but it has a high rate of complications leading to skin infections and necrosis. Extensive and aggressive debridement is necessary, producing tendon exposure and large skin defects. There are many alternatives for the skin coverage of the Achilles tendon, like sequential closures, vacuum assisted closure, local flaps, regional flaps, and more recently and efficiently microsurgery flaps. Skin defects in the Achilles tendon region have many peculiarities in comparison with other parts of the body: it is a zone that is always under mechanical stress due to footwear, this is why it must be highly resistant but thin. Its coverage must have sensitive properties, endure tendon gliding and allow early rehabilitation. Sometimes tendon reinforcement or creation or a neo tendon will be needed. For fulfilling these requirements free flaps by microsurgery are the only option in 90% of the cases. In this review article, we analyze three of the most frequently used free flaps in reconstructive medicine for complex Achilles tendon defects; free radial forearm flap, free radial forearm flap with vascularized flexor carpi radialis tendon and free anterolateral thigh (ALT) flap with vascularized fascia lata. This choice will be determined by the number of tissues involved, size of the defect, etiology of the defect, overall condition of the affected extremity and quality of neighboring tissues.

Skin Oncoplasties: Is Z-Plasty A Technique of Choice In Situation of Limited Resources? Case of Burkina Faso.

Background: In developing countries, the long delays in consultation lead to a delay in diagnosis and management of the skin tumours. The lesions are often large and brings the problem of skin coverage after their resections. Several reconstruction techniques allow skin coverage. The objective of this study is to describe the place of Z-plasty in the surgical treatment of skin cancers in Ouagadougou.Patients and methods: It was a two-centre, retrospective, descriptive study on Z-plasty in skin cancers. It included patients who underwent surgery between January 1st, 2013 and March 30th, 2021 in Ouagadougou. Scar quality and healing time in Z-plasty were compared with those of secondary healing. Results: In 8 years and 3 months, 171 skin cancers were identified. The mean time to consultation was 13.6 months. The average size of the tumours was 9 cm. A Z-plasty was performed in 42 cases, being 58.3% of the patients operated on. The average healing time was 15 days. It was four and a half times shorter in Z-plasty than in secondary healing. Ischaemic necrosis of the Z-corner was noted in 7 cases. The recurrence rate in Z-plasty and secondary healing was 7.1% and 9.1% respectively. Hypertrophic or keloidal scars were noticed in 7 cases and hypochromia in 2 cases.Conclusion: Z-plasty is a technique of choice for skin coverage after large resections in surgical oncology. It reduces the healing time and the cost of postoperative care without increasing the risk of tumour recurrence.

Anterior Lung Evisceration Following an Assault with Knife: A Case Report

Introduction: Evisceration of the lung is a rare consequence of open chest trauma that can be fatal. Evisceration of the lung refers to the protrusion of lung parenchyma through a defect of the thoracic wall, without parietal pleural or skin coverage. Case report: A 20-year-old man was brought to the emergency department (ED) with left lung evisceration from stab wounds. The eviscerated lung was left in place, and the patient was not intubated in the ED. He was immediately taken to the operating room (OR) for intubation and surgical repair. Other significant injuries were ruled out, the eviscerated lung was retrieved, the chest wall defect was closed, and the patient recovered well. He was discharged after seven days in good condition. Conclusion: The initial management of patients with lung evisceration is critical to prevent rapid decompensation and death. Appropriate ED airway management, lung retrieval in the OR, and thoracic wall repair is recommended for patients with lung evisceration.

549 Lessons Learned from Two Survivors of Greater Than 90% Total Body Surface Area Full Thickness Burn Injuries Using a Dermal Biodegradable Substitute and Autologous Skin Cell Suspension: A Case Series

Introduction Advances in burn injury knowledge, critical care, and pharmacological developments have increased survival rates among extensive burn patients. Survival now dependents not just on skin coverage, but effective control of SIRS response, metabolic derangement, fluid loss and sepsis. Novel synthetic dermal substitutes create robustness, thickness, and pliability of the skin in addition to an improved aesthetic appearance while; point-of-care autologous skin cell harvesting enhances treatment by amplifying small split-thickness skin samples to produce an autologous skin cell suspension (ASCS) to cover a larger burn area. This study reports on two survivors with greater than 90% total body surface area full-thickness burns utilizing a combined treatment of a dermal substitute along with ASCS and traditional burn management strategies. Methods Chart review of two patients with >90% burns and inhalation injury after being trapped in a burning vehicle following a traffic collision occurred. Most of the burns in both patients were “leathery” and consistent with full thickness, sparing only the plantar and dorsal aspect of the feet and bilateral small areas of the hip in Patient 1. Patient 2 had fourth-degree burns in some areas of the chest and flank with only the bilateral groin regions and feet spared. The patients were treated with a multi-step process which included using allograft, dermal substitute, and ASCS with split-thickness skin grafts (STSG) in place of cultured epidermal autograft to achieve coverage of >90% burns with high meshed ratio. Results The dermal substitute was limited to deep burns that penetrated down to fat, muscle, and/or joints. Fluid loss was well controlled by the dermal substitute during initial resuscitation. Post reconstruction, areas covered with the dermal substitute and grafted with autogenous STSG with ASCS exhibited less hypertrophy and contracture bands. The elbow and knee joints showed minimal restriction with passive motion and good skin compliance, but contractures persisted in areas where 4th degree tendon and fascia thermal injury occurred. Areas that showed signs of infection were trimmed or unroofed and allowed to drain while maintaining the remainder of the dermal substitute. Conclusions The use of dermal substitutes and ASCS allowed the care team to achieve SIRS control, improved fluid management, enhanced skin coverage, and reduced hospitalization stay. The process experienced in these cases shows promise for future patients with extensive burns. Both patients were able to survive and show improvement during rehabilitation.

SURAL FLAP EFFECTIVENESS IN EXPOSED FRACTURES IN LOWER EXTREMITIES

Objectives: To determine the effectiveness of the sural flaps when utilizing this technique as a treatment for exposed fractures in the lower limb in adult patients. Materials and Methods: A prospective observational descriptive study, the evaluated patients and patient files as primary and secondary sources, respectively, and a control with observational variables. The sample consisted of 24 patients who got 4 follow-up appointments at 5 days, 2 weeks 1 month and a year. Results: The results manifested an effectiveness of 95.8%. The area most affected was the lateral malleolus. Additionally, comorbidities, schooling and gender showed no influence on the effectiveness of the flap. Conclusion: The effectiveness of the sural flap technique in exposed fractures was 95.8%. Recommendations: Physicians ought to consider using the sural flap as the treatment of choice for skin coverage defects localized in the distal and middle third regardless of the leg and cause of the defect.

Microsurgical Reconstruction of the Nose: The Aesthetic Approach to Total Defects

Background Reconstruction of complex defects involving nose and close facial units represents an aesthetic and functional challenge. Restoring satisfactory nasal shape, combining aesthetic, nasal function and patent airways is mandatory. In this paper, we describe our approach to total nose defects and we report our 20-year experience in microvascular nose reconstruction.Clinical cases are shown to illustrate different surgical techniques and the evolution of our approach. Methods Nasal reconstruction procedures were performed on 21 patients between 2000 and 2020 using the radial forearm flap (RFF) or anterolateral thigh (ALT) flap. Reported reconstructions included total/subtotal nasal defects, caused by cancer resections. The key point of our approach is the expanded forehead flap for skin coverage. Reconstruction is completed by cartilage grafts to restore nasal framework and to shape nasal tip. Ancillary procedures were needed in some cases to optimize aesthetic outcomes. Results Twenty-one patients completed the multistage nasal reconstruction. The RFF flap was used in 56% of the cases (n = 11), while the ALT flap was used in 44% (n = 10) of our case series. No difference has been detected in the number of reconstructive stages required to achieve the final result comparing RFF and ALT reconstruction (3.3 vs. 3.1 reconstructive steps). Ancillary procedures were performed in 7 patients. Conclusion Microvascular tissue transfer plays a key role in full-thickness nasal defects restoration. Comparing the two groups, both the RFF and ALT are effective and reliable options in lining reconstruction, although with different indications. Expanded forehead flap, combined to free cartilage graft, is our gold standard to provide external skin coverage to rebuild the nasal framework. According to our current approach, accurate preoperative planning, supported by modern technologic tools, multistage reconstruction, and ancillary procedures are useful to accomplish satisfactory functional and aesthetic outcomes.

Lessons Learned From Two Survivors of Greater Than 90% TBSA Full-Thickness Burn Injuries Using NovoSorb Biodegradable Temporizing Matrix™ and Autologous Skin Cell Suspension, RECELL™: A Case Series

Since autologous split-thickness skin grafts are scarce and lab skin growth requires a significant amount of time, there are limited available treatment approaches for patients with full-thickness burns greater than 90% TBSA. Additionally, to achieve the primary goal of skin coverage and resuscitation, there must exist a balance between fluid loss and metabolic derangement. Allografts and xenografts have traditionally been used early in the process to achieve these goals. Currently, novel approaches to treatment consider the additional use of synthetic dermal substitutes and autologous skin cell suspension to improve outcomes. This case series describes the treatment course of patients with greater than 90% TBSA full-thickness burn injuries using a staged, multifaceted approach of using NovoSorb Biodegradable Temporizing Matrix™ as the primary dermal substitute in conjunction with a RECELL™ Autologous Cell Suspensions Device applied with autograft and allograft to achieve improved resuscitation, limiting fluid loss, and finally skin coverage. Allograft and NovoSorb Biodegradable Temporizing Matrix™ were used early to cover excised burns, resulting in improved metabolic control by limiting the systemic inflammatory response syndrome and fluid loss. Both patients survived using this approach.

Use of Lateral Calcaneal Flap for the Reconstruction of Posterior Heel Defect

Soft tissue defect of the lateral malleolus and achilles tendon is very challenging for reconstruction due to the bony prominence and limited local tissue availability. The purpose of this study to describe our early experience of 30 patients treated with this flap for reconstruction of posterior heel defects with or without exposure of tendo-achilles. The study was conducted at department of plastic surgery, National Institute of Traumatology and Orthopedic Rehabilitation between 2015 to 2018. Twenty five patients (20 male and 5 females) with soft tissue defects over the posterior heel underwent reconstruction using a lateral calcaneal flap. The etiology is trauma in twelve patients, chronic ulcer in four and surgical wound dehiscence for repair of Tendo-Achilles in nine patients. Patients age range from 15 to 60 years (mean 35yrs) and follow up period ranged from 6 months to 2 years(mean 1 yr). All flaps had good perfusion and survived completely. In 3 cases there was partial loss of skin graft managed conservatively. The lateral calcaneal flap can be used safely to provide sensory skin coverage of posterior heel in single stage J Bangladesh Coll Phys Surg 2020; 38(3): 116-120