Versatility of vertical rectus abdominis musculocutaneous flaps

Pedicled flap transfer after chest wall malignant tumor resection and potential risk of postoperative respiratory problems for patients with low FEV1.0

Introduction

Musculoskeletal transfer for chest wall tissue defects is a crucial method, and pedicled flaps around the chest wall are preferred in terms of location and simplicity of transfer. These require special care because of complications such as partial necrosis, fistula, wound dehiscence, infection, hematoma and restricted function of the arm or shoulder. However, studies of respiratory function are rare. In the present study, we investigated the complications including respiratory problems after wide resection for malignant chest wall tumors with musculoskeletal pedicle transfer.

Methods

A total of 13 patients (15 operations) who underwent wide resection of primary, recurrent, or metastatic malignant chest wall tumors and musculoskeletal pedicle transfer for coverage of tissue defects were enrolled in the present study. A retrospective review of all patients was performed using data collected from hospital records and follow-up information. The complications of musculoskeletal transfer after chest wall wide resection, including respiratory problems, are evaluated.

Results

Rib or sternal resection was performed in 12 operations, and only soft tissue resection was performed in 3 operations. Latissimus dorsi (LD) pedicle transfer was performed in 13 operations, and pectoralis major (PM) pedicle transfer was performed in 2 operations; basically, wounds were closed primarily. Surgical complications were observed following 5 of the 15 operations (33.3%). Respiratory complications were seen in 7 of the 15 operations (46.7%). Patients with respiratory complications showed significantly lower preoperative FEV1.0% values than those without respiratory complications (p = 0.0196). Skin resection area tended to be higher in the complication group than in the no complication group (p = 0.104).

Discussion

Pedicled myocutaneous flap transfers such as LD, PM, and rectus abdominus can be used following multiple resections. After harvesting LD or PM, the wound can be closed primarily for an 8-10-cm skin defect in patients with normal respiratory function. However, for patients with low FEV1.0%, after primary closure of LD or PM transfer for wide soft tissue defects, attention should be paid to postoperative respiratory complications.

Vertical Rectus Abdominis Myocutaneous Flap for Reconstruction of Forequarter Amputation Defect after Shoulder Soft Tissue Sarcoma Resection: Technical Consideration

Forequarter amputations in advanced local malignancy or trauma cases often leave a large defect that is challenging to reconstruct. Options for defect closure are varied. A vertical rectus abdominis myocutaneous (VRAM) flap could be an alternative to close a significantly large defect, which is relatively easier than the more technically demanding free flap. This case presents a 64-year-old man with a soft tissue sarcoma in the left shoulder that was treated by forequarter amputation and subsequent defect closure using a VRAM flap. The VRAM flap was initially used to reconstruct the chest and abdominal walls. There have been no reported uses for the shoulder defect. The repair site defect was viable even with a less aesthetic donor site, and all of the defects were closed without any signs of infection. The VRAM flap is a good option for a large defect closure at the shoulder region, particularly after forequarter amputation.

Efficacy and safety of pectoralis muscle flap combined rectus abdominis muscle sheath fasciocutaneous flap for reconstruction of sternal infection

Few studies have assessed the efficacy and safety of reconstruction of sternal infection using a pectoralis muscle flap combined with a rectus abdominis muscle (RAM) sheath fasciocutaneous flap. We report here our experience with this procedure to reconstruct the sternal defect in patients (n = 46) with a deep sternal wound infection (DSWI) after cardiac surgery. After wound reconstruction, the proportion of prolonged mechanical ventilation use and intensive care unit (ICU) stay were 17.4% (n = 8) and 21.7% (n = 10), respectively. The 30‐day all‐cause mortality was 15.2%; recurrence rate was 17.4%; postoperative complications were 15.2%; and median hospital stay was 31 (0‐157) days. Multivariate logistic regression analysis revealed that hypertension (β = 21.32, 95%CI 4.955‐37.68, P = .014), drainage‐tube use (β = 0.944, 95%CI 0.273‐1.614, P = .008), and prolonged intensive care unit stay (β = 53.65, 95%CI 31.353‐75.938, P < .001) were significantly correlated with hospital stay. In conclusion, a procedure including surgical debridement, sternal reconstruction with bilateral PM and RAM sheath flap, long‐term antibiotics, and adequate drainage is a beneficial technique in the reconstruction of deep sternal wound infection after cardiac surgery. Duration of drainage tube use may be as an index for a hospital stay or wound healing.

Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative

Pelvic exenteration is a complex operation performed for locally advanced and recurrent pelvic cancers. The goal of surgery is to achieve clear margins, therefore identifying adjacent or involved organs, bone, muscle, nerves and/or vascular structures that may need resection. While these extensive resections are potentially curative, they can be associated with substantial morbidity. Recently, there has been a move to centralize care to specialized units, as this facilitates better multidisciplinary care input. Advancements in pelvic oncology and surgical innovation have redefined the boundaries of pelvic exenterative surgery. Combined with improved neoadjuvant therapies, advances in diagnostics, and better reconstructive techniques have provided quicker recovery and better quality of life outcomes, with improved survival This article provides highlights of the current management of advanced pelvic cancers in terms of surgical strategy and potential future developments.

Novel Technique with Double Free Flap Design for Advanced Mandibular Osteoradionecrosis: A Case Series

Advanced mandibular osteoradionecrosis is arguably among the most challenging cases for reconstructive head and neck surgeons. Several reconstructive methods for complex mandibular defects have been reported; however, for advanced mandibular osteoradionecrosis, a safe option that minimizes the risk of renewed fistulation and infections is needed. For this purpose, we present a new technique using a fascia-sparing vertical rectus abdominis musculocutaneous flap as protection for a vascularized free fibula graft (FFG). This technique also optimizes recipient site healing and functionality while minimizing donor site morbidity. Our initial experiences from a 4 patient case series are included. Mean operative time was 551 minutes (SD: 81 minutes). All donor sites were closed primarily. Mean time to discharge was 13 days (SD: 7 days), and mean time to full mobilization was 2 days (SD: 1 days). This double free flap technique completely envelops the FFG and plate with nonirradiated muscle. It allows for the transfer of an FFG without a skin island, thus avoiding the need for split skin graft closure. This results in faster healing and minimizes the risk of fibula donor site morbidity. The skin island of the vertical rectus abdominis musculocutaneous flap has the added benefit of providing intraoral lining, which minimizes contractures and trismus. Although prospective long-term studies comparing this approach to other double flap procedures are needed, we argue that this technique is an optimal approach to safeguard the mandibular FFG reconstruction against the inherent risks of renewed complications in irradiated unhealthy tissue.

Versatility of Rectus Abdominis Myocutaneous Flap in Primary Reconstruction of Defects in Surgical Oncology

With the advent of microvascular surgery, the choice of reconstruction following resection of the primary has an important bearing on the final functional and cosmetic outcome in surgical oncology. The vertical rectus abdominis myocutaneous (VRAM) flap is arguably the most widely used and versatile flap in reconstructive surgery. All patients undergoing a VRAM flap reconstruction following resection of their tumor in the Surgical Oncology Department of a tertiary cancer center from 2012 to 2019 were included in the study. Defects ranged from the breast (40), head and neck (10), groin (3), and perineum (5). The primary outcome measure was incidence of complete and partial flap necrosis, while incidence of hematoma, seroma, incisional hernia, wound dehiscence, and infection were secondary outcomes measured. The patients were followed up for a minimum period of 1 year. The incidence of complete flap necrosis was 5.1% (3) and partial loss 12% (7). Incidence of minor complications such as seroma was 13.7% (8), hematoma 6.8% (4), wound dehiscence 10.3% (6), and wound infection 5.1% (3). Incisional hernia and donor site wound-related complications were not seen in any. On binary regression analysis, the presence of diabetes mellitus, smoking, and the use of adjuvant treatment were associated significantly with increased odds of flap loss. This study demonstrates the versatility and reliability of the VRAM flap in primary reconstruction of defects in surgical oncology. Optimization of risk factors such as diabetes, smoking, and weight gain can reduce flap loss and improve outcomes.

Pelvic/Perineal Reconstruction: Time to Consider the Anterolateral Thigh Flap as a First-line Option?

Background:

Abdominoperineal resection (APR) and pelvic exenteration continue to be common procedures for the treatment of colorectal malignancy. The workhorse flap for reconstruction in these instances has been the vertical rectus abdominis myocutaneous flap. The associated donor site morbidity, however, cannot be ignored. Here, we provide a review of the literature and present the senior author’s (A.M.) experience using the pedicled anterolateral thigh (ALT) flap for reconstruction of soft tissue defects following APR and pelvic exenteration.

Methods:

Patients who underwent pelvic/perineal reconstruction with pedicled ALT flaps between 2017 and 2019 were included in the study. Parameters of interest included age, gender, body mass index, comorbidities, history of radiation, extent of ablative surgery, and postoperative complication rate.

Results:

A total of 23 patients (16 men and 7 women) with a median age and body mass index of 66 years (inter-quartile range [IQR]: 49–71 years) and 24.9 kg/m² (IQR: 24.2–26.7 kg/m²) were included in the study, respectively. Thirteen (56.5%) patients presented with rectal cancer, 5 (21.7%) with anal squamous cell carcinoma (SCC), 4 (17.4%) with Crohn’s disease, and 1 (4.3%) with Paget’s disease. Nineteen patients (82.6%) received neoadjuvant radiation. Nine (39.1%) patients experienced 11 complications (2 major and 9 minor). The most common complication was partial perineal wound dehiscence (N = 6 [26.1%]). Stable soft tissue coverage was achieved in all but one patient.

Conclusions:

The ALT flap allows for stable soft tissue coverage following APR and pelvic exenteration without being associated with abdominal donor site morbidity. Consideration to its use as a first-line reconstructive option should be given in pelvic/perineal reconstruction.

[Soft tissue defects following tumor resection in the limbs and trunk : Plastic reconstructive soft tissue and revision concepts]

BACKGROUND

Tissue defects of the trunk and limbs after oncologic surgery and radiation require plastic reconstructive tissue coverage. Depending on the location and size of the wound as well as the interdisciplinary treatment concept, different reconstructive procedures are performed. These range from skin transplantation to local and pedicle flaps, to perforator flaps and free microsurgical tissue transfer.

METHODS

The modern "reconstructive ladder" can be regarded as an orientation for the sequence of the reconstructive options. Considering the patient's wishes and risk profile, an individual reconstructive concept must be devised. The best functional and simultaneously safest procedure with the smallest secondary defect is to be chosen. Wound preconditioning via vacuum-assisted closure can precede definitive tissue coverage in order to optimize local conditions.

CONCLUSION

Safe tissue coverage can be achieved even in advanced stages of oncologic disease and after extensive surgery by performing wound preconditioning and arteriovenous loop grafting to induce safe de novo recipient vessels for two-stage free tissue transfer. The choice between maximum plastic reconstructive options for a curative approach or limited palliative surgery is to be harmonized and balanced with therapeutic goals and the patient's biologic resources. Preservation and restoration of quality of life and functionality is the plastic surgeon's dictum.

An Algorithmic Approach to Perineal Reconstruction

Perineal wounds are one of the more challenging plastic surgical defects to reconstruct. Resections in the perineum vary in size and are frequently complicated by radiation, chemotherapy, and contamination. Furthermore, the awkward location and potential need to maintain function of the anus, urethra, and vagina and to allow comfortable sitting all contribute to the complexity of these reconstructions. In light of this complex nature, many options are available for flap coverage. In this paper, we discuss the properties of perineal defects that make each option appropriate.

Reconstructive Surgery of Inguinal Defects: A Systematic Literature Review of Surgical Etiology and Reconstructive Technique

BACKGROUND/AIM

This study aimed to evaluate the literature regarding surgical etiology demanding inguinal reconstructive surgery, associated reconstructive techniques and outcomes.

MATERIALS AND METHODS

A systematic literature search was performed according to the PRISMA statement between 1996-2016.

RESULTS

A total of 64 articles were included, comprising 816 patients. Two main subgroups of patients were identified: Oncological resections (n=255, 31%), and vascular surgery (n=538, 66%). Oncological resection inguinal defects were treated with pedicled myocutaneous flaps (n=166, 65%), fasciocutaneous flaps (77, 31%), muscle flaps (7, 3%) and direct closure (3, 1%). Vascular surgery complications were treated with muscle flaps (n=513, 95%). Complications for the respective subgroup (oncological resections, vascular surgery) were: infection (24%, 14%), seroma (34%, 7.5%), flap dehiscence/delayed healing (20.6%, 40.8%,). The total reintervention rate was 20%.

CONCLUSION

Reconstruction of inguinal defects should be addressed on a case-by-case basis. Myocutaneous flaps were favoured after oncological resections, while muscle flaps were preferred after vascular surgery.

Inguinal Reconstruction Using Pedicled Rectus Abdominis Flap: A Useful Option for the Application of Radiotherapy

Given their high rate of complications, radical surgical procedures of anorectal and gynecological tumors require a reliable and individualized reconstruction. The latter is influenced by the frequent indication of adjuvant chemo/radiotherapy that they present. We describe the case of a patient with medical history of vulvar carcinoma that required radical surgery and bilateral inguinal lymphadenectomy. Because of the stage of the tumor, the application of postoperative radiotherapy was clinically indicated; however, after surgery, the patient developed bilateral inguinal ulcers that made postoperative radiotherapy application impossible. Using a radical surgical approach in combination with postoperative radiotherapy increases survival in patients with these types of tumors. Therefore, delaying its use because of wound complications or inadequate reconstruction cannot be justified. The pedicled abdominal rectus flap is an excellent option for this purpose in patients with moderate- to large-sized defects.

Outcomes after Phalloplasty: Do Transgender Patients and Multiple Urethral Procedures Carry a Higher Rate of Complication?

BACKGROUND

Phalloplasty is associated with improved quality-of-life in those with penile defects, and in female-to-male transgender (transmale) patients seeking gender-confirming surgery. However, aggregate complication and outcome data are sparse. This study compares phalloplasty outcomes between transmale and cismale patients and between those with primary versus staged urethroplasty.

METHODS

A comprehensive literature search of PubMed, MEDLINE, and Google Scholar databases was conducted for studies relating to phalloplasty. Data on techniques, complications, outcomes, and patient demographics were collected. Analysis using the random-effects model with subgroup analyses was performed.

RESULTS

A total of 50 studies (1351 patients) were included: 19 studies (869 patients) for transmale patients and 31 studies (482 patients) for cismale patients. The urethral complication rate in the transmale group was 39.4 percent (95 percent CI, 30.6 to 48.9 percent; p = 0.028) compared to 24.8 percent (95 percent CI, 16.5 to 35.4 percent; p < 0.001) in the cismale group. The overall flap complication rates for transmale and cismale patients were 10.8 percent (95 percent CI, 7.0 to 16.2 percent; p < 0.001) and 8.1 percent (95 percent CI, 5.5 to 11.7 percent; p < 0.001), respectively. Twenty-three studies (723 patients) used primary urethroplasty and 13 studies (210 patients) performed staged urethroplasty procedures. Flap complication rates of primary and staged urethroplasty were 8.6 percent (95 percent CI, 5.3 to 13.8 percent; p < 0.001) and 16.7 percent (95 percent CI, 10.7 to 24.9 percent; p < 0.001), respectively. Primary urethroplasty had superior outcomes of voiding while standing, sexual function, and patient satisfaction compared with staged urethroplasty.

CONCLUSIONS

Cismale patients undergoing phalloplasty had lower urethral and flap complication rates compared with transmale patients. Staged urethroplasty had more flap complications, and worse outcomes and patient satisfaction compared with primary urethroplasty.

How to deal with penile carcinoma inguinal metastases invading femoral vessels

Penile cancer accounts for 1–10% of men neoplastic diseases and 30–60% of patients have inguinal metastases at the time of diagnosis. Inguinal metastases of penile cancer with femoral vessel involvement could lead to vascular fistula and hemorrhagic shock. We present 3 consecutive patients with inguinal metastases of penile cancer complicated by infection and hemorrhage from femoral vessels invaded by the tumor. Simultaneous extra-anatomical axillo-femoral bypass graft, wide excision of tumor and groin defect reconstruction was used to achieve “tumor-free” oncologic aim and to save the lower limb. We consider the extra-anatomic axillo-femoral bypass associated with wide inguinal tumor excision and defect covering a feasible surgical solution for improving the life quality and extend life expectancy in patients with lymph node metastasis of penile cancer complicated by necrosis, infection and femoral vessel involvement.

Sternal reconstruction after post-sternotomy mediastinitis

Background

Deep sternal wound complications are uncommon after cardiac surgery. They comprise sternal dehiscence, deep sternal wound infections and mediastinitis, which will be treated as varying expressions of a singular pathology for reasons explained in the text.

Methodology and review

This article reviews the definition, prevalence, risk factors, prevention, diagnosis, microbiology and management of deep sternal wound infections and mediastinitis after cardiac surgery. The role of negative pressure wound therapy and initial and delayed surgical management is discussed with special emphasis on plastic techniques with muscle and omental flaps. Recent advances in reconstructive surgery are presented.

Conclusions

Deep sternal wound complications no longer spell debilitating morbidity and high mortality. Better understanding of risk factors that predispose to deep sternal wound complications and general improvement in theatre protocols for asepsis have dramatically reduced the incidence of deep sternal wound complications. Negative pressure wound therapy and appropriately timed and staged muscle or omental flap reconstruction have transformed the outcomes once these complications occur.

Vascularised and modified lower-leg rotationplasty for the treatment of severe infection and bone loss of the proximal femur: a case report

CASE DESCRIPTION

We report a reconstructive case in a paraplegic patient, who suffers from a severe proximal femur infection. Aiming at the preservation of the capacity to remain in a seated position to operate a wheelchair, lower leg rotationplasty was considered suitable for reconstruction. Due to severe infection and subclinical femoral artery stenosis, rotationplasty was supercharged by the inferior epigastric artery. Furthermore, extensor tendons of the foot were attached to the acetabulum to facilitate stability of the neo-hip joint.

RESULTS

Follow-up examination 1 year after surgery revealed no complications and a satisfied patient.

CONCLUSIONS

Especially in paraplegic patients, lower leg rotationplasty is a possible treatment option for severe femoral infection. Supercharging provides well-vascularised tissue to the former infection site and improves wound healing.

Phalloplasty: A Review of Techniques and Outcomes

BACKGROUND

Acquired or congenital absence of the penis can lead to severe physical limitations and psychological outcomes. Phallic reconstruction can restore various functional aspects of the penis and reduce psychosocial sequelae. Moreover, some female-to-male transsexuals desire creation of a phallus as part of their gender transition. Because of the complexity of phalloplasty, there is not an ideal technique for every patient. This review sets out to identify and critically appraise the current literature on phalloplasty techniques and outcomes.

METHODS

A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through July of 2015 with multiple search terms related to phalloplasty. Data on techniques, outcomes, complications, and patient satisfaction were collected.

RESULTS

A total of 248 articles were selected and reviewed from the 790 identified. Articles covered a variety of techniques on phalloplasty. Three thousand two hundred thirty-eight patients underwent phalloplasty, with a total of 1753 complications reported, although many articles did not explicitly comment on complications. One hundred four patients underwent penile replantation and two underwent penile transplantation. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction.

CONCLUSIONS

Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. Penile replantation and transplantation are also options for amputation or loss of phallus. Further studies are required to better compare different techniques to more robustly establish best practices. However, based on these studies, it appears that phalloplasty is highly efficacious and beneficial to patients.

[Locoregional solutions for groin defects : Coverage after vascular surgery]

INTRODUCTION

Vascular surgery through a groin incision may be associated with severe wound healing disorders in this sensitive area. There are many options to reconstruct the defect surgically. The choice of surgical reconstruction depends mainly on the individual status of vasculature, which is most often compromised in these patients. There are random pattern flaps, as well as perforator, pedicled flaps or microvascular flaps to choose from.

AIM

We give an overview of plastic surgical solutions for groin defects, with a special focus on complex wounds after vascular surgical complications. We discuss advantages and disadvantages of different flaps with two case reports and also show alternatives.

PATIENTS AND METHODS

We demonstrate in two cases how the reconstruction of the groin defect was planned, taking into account the vascular status, and why we chose an innovative and seldom-used option in each case.

RESULTS

The selected flaps, a pedicled fasciocutaneous ALT propeller flap and a perforator-based, pedicled abdominal advancement flap reconstructed the defects successfully.

DISCUSSION

The surgical therapy for the reconstruction of groin defects should be chosen according to the individual vascular status to ensure safe and reliable blood supply. To guarantee the best possible reconstruction and avoid postoperative healing disorders and infections, less common flaps should also be considered.

Hydrogen peroxide priming of the venous architecture: a new technique that reveals the underlying anatomical basis for venous complications of DIEP, TRAM, and other abdominal flaps

BACKGROUND

Previous studies of venous anatomy lack the detail of their arterial counterparts because of (1) the technical challenge of retrograde perfusion against competent valves and (2) anterograde venous perfusion failing to adequately delineate the area of interest. We introduced a novel technique: retrograde hydrogen peroxide priming that dilates veins and renders valves incompetent, thereby facilitating complete cadaveric venous perfusion.

METHODS

The superficial and deep venous systems of 41 hemiabdomens and 20 hemichests of unembalmed human cadavers were primed by retrograde injection with 6% hydrogen peroxide. Specimens were then injected with lead oxide contrast, radiographed, and dissected. In five hemiabdomens, the valves were mapped by dissection. Results were compared with archival venous studies of six total body injections, six abdominal lipectomy specimens, and two intraoperative venograms of delayed transverse rectus abdominis musculocutaneous flaps.

RESULTS

Unprecedented venous filling of the anterior torso was demonstrated. Two types of superficial-to-deep venous connections were defined: large venae communicantes and small venae comitantes. Venae communicantes (>2 mm) formed major connections between large superficial and deep veins, mostly within 5 cm of the umbilicus in the abdomen, the axilla and fifth or sixth intercostal space parasternally. Seventy-four percent of venae communicantes coursed with arteries greater than 1.0 mm. Four major longitudinal valved subcutaneous pathways of the superficial inferior epigastric vein and superficial circumflex iliac vein were defined bilaterally with large avalvular transverse connections in the midline and small-caliber connections laterally that explain venous complications seen sometimes in transverse abdominal flaps.

CONCLUSION

Retrograde hydrogen peroxide priming of veins in cadavers renders valves incompetent and facilitates detailed venous studies that help refine flap design and explain venous complications.

Surgical outcomes and patients' satisfaction with suprapubic phalloplasty

INTRODUCTION

Many techniques, specifically forearm free flap phalloplasty, are used in penile reconstructive surgery. Although satisfying, a major disadvantage is the large, stigmatizing scar on the donor site, which leads many patients to explore alternatives.

AIM

The aim of this study is to assess the outcomes and satisfaction of patients offered the choice between metaidioplasty, forearm free flap, and suprapubic phalloplasty.

METHODS

Medical outcomes from the three-stage surgery were collected from the hospital files of 24 patients, who were also interviewed to assess their satisfaction, sexual function, and psychosexual well-being.

MAIN OUTCOME MEASURES

Medical complications, anthropometric measures, and interviewing questionnaire on satisfaction with appearance, sexual function, and psychological variables.

RESULTS

Duration of surgery and of hospital stay was relatively short in the first (1 hour 30 minutes; 3 days) and last (1 hour 40 minutes; 3 days) stage of surgery involving tissue expansion and neophallus release. These two stages were associated with few complications (17% and 4% minor complications respectively, 12% additional complications with hospitalization for the first stage). The second stage involving tubing was associated with longer surgery and hospital stay (2 hour 15 minutes; 5 days) and had more complications (54% minor complications and 29% requiring hospitalization) although fewer than one-step surgery. No loss of neophallus was reported. Overall, 95% of patients were satisfied with their choice of phalloplasty, 95% with the appearance, 81% with the length (Mean = 12.83 cm), and 71% with the circumference (Mean = 10.83 cm) of their neophallus. Satisfactory appearance was significantly correlated (P < 0.01) with penile length (r = 0.69) and diameter (r = 0.77). Sexual satisfaction was significantly correlated with penile diameter (r = 0.758), frequency of orgasm (r = 0.71), perceived importance of voiding while standing (r = 0.56), presurgery satisfaction with sexuality (r = 0.58), current masculine-feminine scale (r = 0.58), attractive-unattractive scale (r = 0.69), and happy-depressed scale (r = 0.63).

CONCLUSION

Suprapubic phalloplasty, despite the lack of urethroplasty, offers an interesting alternative for patients concerned with the stigmatizing scar on the donor site.

Reconstruction of groin defects following radical inguinal lymphadenectomy: an evidence based review

Inguinal lymph node involvement is an important prognostic and predictive factor in various neoplasms of the genitalia and lower limb. As part of the multimodality approach, these patients undergo surgery and adjuvant radiotherapy. Morbidity of inguinal lymphadenectomy includes lymphedema, lymphorrhea and infection; however the most common distressing complication is skin necrosis. Myocutaneous flaps have been the most popular form of primary or delayed groin reconstruction. This paper aims to critically review the different myocutaneous flaps used in groin reconstruction, discuss evidence based data on the versatility and utility of these flaps and discuss ways in which modifications maybe incorporated in treatment and radiation planning following groin reconstruction. A comprehensive search of the scientific literature was carried out using PubMed to access all publications related to groin reconstruction. The search focused specifically on current management, technique, safety and complications of these procedures. Keywords searched included "inguinal lymphadenectomy", "primary reconstruction", "musculocutaneus flap", "myocutaneous flap", "tensor fascia lata flap", "anterolateral thigh flap", "rectus abdominis flap". Low to middle income countries witness a huge burden of locally advanced genital malignancies and melanoma of the lower extremity. Higher tumor burden both at the primary site as well as the inguinal basin requires surgery as the primary modality of treatment. Groin reconstruction is required not only to prevent femoral blowouts but also for early administration of adjuvant radiation. The versatility of tensor fascia lata, anterolateral thigh, and rectus abdominis flaps is useful to cover the defect, provide radiation, eradicate pain and achieve good palliation. Assessment of aesthetic and functional outcomes of one flap over the other and the "ideal" form of reconstruction for groin defects needs additional investigation.

Infections in surgery of primary tumors of the sacrum

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To evaluate the risk of infection, related treatment, and outcome after surgery of the 2 most common primary sacral tumors.

SUMMARY OF BACKGROUND DATA

Rarity of sacral tumors has limited the number of population-based studies. Treatment depends on malignancy or local aggressiveness: wide resection is indicated for malignant lesions, intralesional surgery for benign.

METHODS

We studied 82 patients with sacral chordomas (55 cases) or giant cell tumor (GCT) (27 cases) treated between 1976 and 2005. All patients had IV antibiotic therapy with amikacin and teicoplanin. Surgery of chordoma was resection; surgery of GCT was intralesional excision. Infections were classified as immediate postoperative, early (within 6 months), and late (more than 6 months from surgery). Mean follow-up was 9.5 years (range: 3-27 years). Some factors possibly influencing the risk of infection were statistically analyzed by Kaplan Meier curves and log-rank test.

RESULTS

No deep infections were observed in the GCT series. Three patients with sacral chordoma died for postoperative complications and were excluded from this analysis. Of the remaining 52 patients with chordoma, 23/52 had deep wound infection (44%) that required 1 or more surgical debridements combined with antibiotics, according to cultures. In 16 patients (70%), infection occurred within 4 weeks postoperatively, and in 7 within 6 months. Most frequent bacteria were Enterococcus (23%), Escherichia coli (20%), and Pseudomonas aeruginosa (18%). In 74% of cases, infection was multimicrobial. Level of resection, previous intralesional treatment elsewhere, tumor volume, and age did not statistically influence risk of infection.

CONCLUSION

Type of surgery was the prominent factor related to a major risk of infection. Operating procedure time correlated as well. Resections of sacral chordoma imply a high risk of deep infection, while intralesional excision of GCT does not. All infections healed with surgical debridements and antibiotic therapy.

Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects

BACKGROUND

Reconstruction of irradiated pelvic defects following oncologic resection requires dead-space obliteration to reduce wound healing complications. Although the vertical rectus abdominis myocutaneous (VRAM) flap is often the best option for pelvic reconstruction following abdominoperineal resection or pelvic exenteration, donor- and recipient-site complications are common. The authors hypothesized that certain adjuvant techniques would improve pelvic VRAM flap outcomes.

METHODS

Six technical modifications to improve VRAM flap outcomes were evaluated: fascia-sparing VRAM flap, component separation donor-site closure, inlay mesh abdominal reinforcement, deepithelialized VRAM flap skin paddle, extended VRAM flap, and omental flap plus VRAM flap. Prospectively collected data from consecutive patients with immediate pelvic VRAM flap reconstruction from 2001 to 2009 were analyzed retrospectively. Donor- and recipient-site complications were compared between patients treated with each technical modification and all other study patients.

RESULTS

One hundred eighty-five patients were included (mean follow-up, 25.1 months). Fascia-sparing VRAM flaps resulted in significantly fewer hernias (1.5 percent versus 11.5 percent, p < 0.01), with less dehiscence, abdominal bulge, and evisceration. Patients receiving donor-site mesh inlay had fewer postoperative hernias (2.6 percent versus 5.5 percent) but more abdominal laxity/bulge (7.7 percent versus 0 percent, p = 0.01). Minor recipient-site dehiscence was significantly lower with omental plus VRAM flaps (11.1 percent versus 32.5 percent, p < 0.05) and extended VRAM flaps (7.7 percent versus 30.8 percent, p < 0.05). Multivariate logistic regression identified omental plus VRAM flaps as protective against (p < 0.05), and increasing body mass index as predictive for (p = 0.009), perineal skin dehiscence.

CONCLUSIONS

Several technical modifications of VRAM flap reconstruction improve pelvic reconstruction outcomes and should be considered. Further prospective studies will be important to elucidate specific indications for each technique.

The versatility of the pedicled vertical rectus abdominis myocutaneous flap in oncologic patients

PURPOSE

The vertical rectus abdominis muscle (VRAM) flap is considered a safe and simple option to cover defects of the trunk and proximal thigh. Detailed long-time follow-up studies in oncologic patients including complications and donor site morbidity are rare. In this study, complications and donor site morbidity were analysed.

METHODS

Data of 78 consecutive patients with oncologic disease, having received VRAM flaps, were analysed retrospectively. Patients with soft tissue sarcomas (n = 38), radiation ulcers (n = 18), carcinoma (n = 10), wound-healing difficulties after tumour resection (n = 8), breast reconstruction after ablation (n = 3) and malignant melanoma (n = 1) were included. Statistics concerning patients' satisfaction, the occurrence of wound-healing difficulties, incisional herniation, loss of abdominal wall strength in correlation to operative and (neo)adjuvant treatment and patients' history were performed. The mean follow-up time was 5.5 years.

RESULTS

No complete flap loss was observed. A body mass index over 30 was positively correlated with wound-healing difficulties; radiation had no negative effect. A contralateral cutaneous pedicle could reduce the risk of lymphoedema in groin defect patients. Incisional hernia was present in 13%. Strength endurance of the abdominal wall was reduced compared to an age-matched control. Most patients were satisfied with the postoperative result.

CONCLUSIONS

VRAM flaps are reliable tools for defect coverage in the oncologic patient to prevent chronic ulceration, lymphangitis or more severe complications like septic rupture of femoral vessels and hip disarticulation. Donor site morbidity is tolerable, and patients' satisfaction is high.

Modified vertical rectus abdominis musculocutaneous flap for limb salvage procedures in proximal lower limb musculoskeletal sarcomas

Introduction and aim. Management of complicated wounds after tumor extipiration of pelvic and proximal lower limb musculoskeletal sarcoma represents an essential component in the outcome of these patients. The authors present modified vertical rectus abdominis musculocutaneous (VRAM) flap techniques to reconstruct extensive defects after debridment of these complicated wounds. Material and Methods. Over a period of 4 years (2002–2005), 5 men and 2 women were managed. Median age was 21 years (range 15–49). The patients were managed for complicated lower trunk, groin, and upper thigh wounds after resection of three pelvic chondrosarcomas as well as two pelvic and two proximal femur osteosarcomas. The modifications included a VRAM flap with lateral and tongue-like extension design of the skin paddle (5 cases) or a delayed extended VRAM flap (2 cases). Results. All flaps showed complete survival and healing with no ischemic events providing stable coverage. All patients were ambulant with good limb functions in terms of walking and gait after adequate rehabilitation, 2 needed support with crutches. Conclusion. The modified VRAM flaps offer reliable reconstructive tools for coverage of complex groin and thigh defects by providing larger well-vascularized soft tissue with acceptable donor site.

Reconstruction of large sacral defects following tumour resection: a report of two cases

Sacral tumours often present surgical resection and reconstruction challenges. Wide resections result in large sacral defects and neoadjuvant radiotherapy impairs wound healing. The wounds need to be covered with bulky, well-vascularised, healthy tissues. We present 2 cases where large sacral defects were reconstructed following tumour resection. Both defects were reconstructed with inferiorly based, transpelvic, pedicled vertical rectus abdominis myocutaneous flaps. This is a robust flap and carries a well-vascularised muscle bulk and skin paddle. The donor site is distant from the lesion site and is thus unaffected by both the resection and radiotherapy. This is a useful flap for reconstructing large sacral defects.

Repairs of complex groin wounds with contralateral rectus abdominis myocutaneous flaps

Management of complex groin wounds posterior to complications of vascular prosthetic surgery, malignant tumor excision, and irradiation therapy for recurrent cancers continued to pose a difficult task in reconstructive surgery. Pedicled and microsurgical myocutaneous flaps are valuable tools for wound repairs, but applications of these flaps are limited when the healthy vascular vessels are not available around the wound. In this report, we present our experience on the use of the contralateral rectus abdominis myocutaneous flaps for the coverage of the groin complex wounds in 13 patients. All the flaps were completely survived and the wounds healed uneventfully. The results suggest that the contralateral myocutaneous flap can be used for the repair of the groin wound with presence of significant comorbidities in the area, in which the ipsilateral local flaps and microsurgical flaps are not available.