Composite Flap - Serratus Anterior with Rib Component – a Foot Salvage Solution after a Severe Crush Injury

Severe work accidents are one of the most frequent causes for physical disability in adults, alongside car accidents and war/gunshot injuries. In this article we present the case of a severe crush injury of the left foot that occurred in a 31 year-old patient who was involved in a work accident. After an unsuccessful tissue coverage using local flaps, the salvage solution was that of a composite free flap, aiming not only to cover, but also to restore stability to the foot. The treatment of choice was the serratus anterior muscle harvested together with osseous component (8th rib). The healing was difficult, due to wound dehiscence with bone exposure over a small area, but the problem was addressed using FGF (fibroblast growth factor) sponges, which enabled granulation and complete wound closure. The outcome of the case was favourable, gait being possible without any deficiency. For the cosmetic and functional reasons, the patient suffered one last surgical procedure to debulk the dorsal aspect of the foot. The final result was more than satisfactory, the patient being totally rehabilitated and socially and professionally reintegrated.

Facelift Surgery: History, Anatomy, and Recent Innovations

Facelift surgery has become a beautifully predictable, safe, and extremely effective operation. Our patients can expect natural and long-lasting results as a direct outcome of our improved understanding and applications of surgical facial anatomy. Rhytidectomy, once an operation of simple well-placed elliptical skin excisions, evolved to include longer skin flaps, skin and platysma flaps with various superficial muscular aponeurotic system (SMAS) manipulations, and various deep plane techniques involving the skin and SMAS as a single unit composite flap. Extended deep plane rhytidectomy and vertical vector neck and SMAS lifting have emerged in recent years as techniques that extend the traditional deep plane dissection into the neck in a subplatysmal plane to allow for release of the platysma from the cervical retaining ligaments. This, ultimately, allows for the creation of a dramatically more youthful appearing face, neck, and jawline.

Composite sural neurocutaneous flap with gastrocnemius tendon for repairing defects of Achilles tendon and overlying soft tissue

Purpose: Defect of Achilles tendon and overlying soft tissue remains a surgical challenge due to its insufficient blood supply and high requirement of function. This study aims to report the clinical efficacy of the composite sural neurocutaneous composite flap with gastrocnemius tendon on the complicated defect of Achilles region. Methods: Seven cases of defects of Achilles tendon and overlying soft tissue were reconstructed by the composite sural neurocutaneous composite flaps with gastrocnemius tendons. It is important to keep the connection between gastrocnemius tendon and deep fascia of the composite flap during operation. The smallest and the largest areas of transferred skin flaps were 7.5 cm × 4.5 cm and 11 cm × 10 cm respectively. The size of gastrocnemius tendon ranged from 5 cm × 3 cm to 9 cm × 4 cm. Patients was evaluated by using the Arner-Lindholm scale at the last follow-up. Results: Six flaps survived completely with no complication. One flap developed wound dehiscence and went on to heal by daily dressing. With 12–60 months follow-up, all patients gained satisfactory appearance and function of ankle, without tendon re-rupture or recurrent infection. Based on Arner-Lindholm scale, six cases were noted to be excellent and one was good. Conclusion: The composite sural neurocutaneous flap with gastrocnemius tendon is a viable and practical method to salvage Achilles tendon defect and overlying soft tissue coverage, with minimal adhesion and satisfactory function.

How to Harvest The Free Fibula Flap

Summary: Free fibular flap (FFF) is a composite flap consisting of fibular bone and skin paddle. Muscle may be added to the flap. It has several advantages and disadvantages. The fibular free flap is well suited for any reconstruction of the head and neck. It is suitable for defects of the anterior mandibular arch or lateral defects in patients who wish to undergo osseointegrated dental reconstruction. Meanwhile, its contraindications are related to significant atherosclerotic diseases the patient has or congenital variants of the arteries. Preparations for FFF procedure consist of history taking, physical examinations and supporting examinations, like other free flaps procedure in general. Several intraoperative preparations should also be done.

The composite extensor retinaculum cutaneous flap: an anatomical cadaveric study

Background: Complex digital extensor tendon injuries are difficult to manage when adhesion formation and stiffness prevail. Vascularised tissue to reconstruct the skin and extensor defect would be the ideal reconstruction in both the acute and delayed settings. This anatomical study evaluates vascular supply to a suitable composite flap comprising skin, subcutaneous tissue and extensor retinaculum.Methods: An anatomical study of 18 cadaveric upper limbs was conducted to investigate the technical feasibility of a composite flap prior to its clinical application. The anterior (n = 9) or posterior (n = 9) interosseous artery was exposed and selectively injected with a coloured dye. Specimens were then dissected to raise the proposed composite flap of extensor retinaculum and the overlying integument. Specimens were subsequently assessed by digital subtraction angiography to evaluate the corresponding microvascular supply to the composite flap. Results: The anterior and posterior interosseous arteries supplied the extensor retinaculum through a dense network of vessels with choke anastomoses. The skin overlying the extensor retinaculum was predictably supplied by either artery through the perforator vessels between the fourth and fifth extensor tendon compartments.Conclusion: A composite unit of skin and extensor retinaculum can be harvested on either the anterior or posterior interosseous arteries. It can be employed for simultaneous vascularised tendon and skin reconstruction.