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Shahzad F, Ray E. Pelvic and Perineal Reconstruction. Plast Reconstr Surg 2024; 154:803e-816e. [PMID: 39314105 PMCID: PMC11424020 DOI: 10.1097/prs.0000000000011137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Classify types of bony pelvic resections. 2. Outline reconstructive options for pelvic and perineal defects. 3. Identify advantages and drawbacks of various reconstructive techniques. 4. Recognize the functional benefits of bony and soft-tissue reconstruction. SUMMARY Defects of the pelvis and perineum arise from tumors, trauma, infection, congenital differences, and gender incongruence. Pelvic resections can result in bony instability and soft-tissue deficiency. The goals of reconstruction are maintenance of spinopelvic continuity, elimination of dead space, resurfacing of cutaneous defects, and prevention of hernias. Perineal reconstruction has important functional considerations. Abdominoperineal resection and pelvic exenteration defects benefit from flap reconstruction to decrease pelvic wound complications. Vulvovaginal reconstruction is performed with flaps from the perineum, thigh, or abdomen. Scrotal and superficial penile defects are most commonly reconstructed with scrotal flaps and skin grafts. Total penile reconstruction most commonly uses a radial forearm free flap.
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Affiliation(s)
- Farooq Shahzad
- From the Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center
| | - Edward Ray
- Division of Plastic and Reconstructive Surgery, Cedars-Sinai Medical Center
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Suda S, Hayashida K. Crafting Contours: A Comprehensive Guide to Scrotal Reconstruction. Life (Basel) 2024; 14:223. [PMID: 38398732 PMCID: PMC10890180 DOI: 10.3390/life14020223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 01/29/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
This review delves into reconstructive methods for scrotal defects arising from conditions like Fournier's gangrene, cancer, trauma, or hidradenitis suppurativa. The unique anatomy of the scrotum, vital for thermoregulation and spermatogenic function, necessitates reconstruction with thin and pliable tissue. When the scrotal defect area is less than half the scrotal surface area, scrotal advancement flap can be performed. However, for larger defects, some type of transplantation surgery is required. Various options are explored, including testicular transposition, tissue expanders, split-thickness skin grafts, local flaps, and free flaps, each with merits and demerits based on factors like tissue availability, defect size, and patient specifics. Also, physicians should consider how testicular transposition, despite its simplicity, often yields unsatisfactory outcomes and impairs spermatogenesis. This review underscores the individuality of aesthetic standards for scrotal reconstruction, urging surgeons to tailor techniques to patient needs, health, and defect size. Detailed preoperative counseling is crucial to inform patients about outcomes and limitations. Ongoing research focuses on advancing techniques, not only anatomically but also in enhancing post-reconstruction quality of life, emphasizing the commitment to continuous improvement in scrotal reconstruction.
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Affiliation(s)
| | - Kenji Hayashida
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan;
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Transretroperitoneal Pedicled Omental Flap for Coverage of Traumatic Sacral Defect: A Case Report. Plast Reconstr Surg Glob Open 2022; 10:e4298. [PMID: 35539294 PMCID: PMC9076443 DOI: 10.1097/gox.0000000000004298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 03/15/2022] [Indexed: 11/25/2022]
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Nasr RW, Karami RA, Atallah GM, Abou Heidar NF, Ibrahim AE. Free omental flap for the treatment of chronic scrotal lymphedema: a case report. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-020-01688-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Somasundaram J, Wallace DL, Cartotto R, Rogers AD. Flap coverage for necrotising soft tissue infections: A systematic review. Burns 2021; 47:1608-1620. [PMID: 34172327 DOI: 10.1016/j.burns.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/05/2020] [Accepted: 01/20/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes undertaken. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas. METHODS A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI's (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program 'Covidence' facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate. RESULTS After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier's gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%. CONCLUSION Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.
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Affiliation(s)
- J Somasundaram
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - D L Wallace
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - R Cartotto
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - A D Rogers
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
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Delgado R, Ciudad P, Espinoza FB, Lopez J. Minimal invasive laparoscopic harvest of the greater omental flap for Fournier's gangrene scrotal reconstruction. J Plast Reconstr Aesthet Surg 2018; 72:335-354. [PMID: 30527712 DOI: 10.1016/j.bjps.2018.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 10/28/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Ricardo Delgado
- Department of Plastic and Reconstructive Surgery National Cancer Institute of Peru (INEN). Lima, Peru.
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery National Cancer Institute of Peru (INEN). Lima, Peru
| | | | - Jesús Lopez
- Department of Plastic and Reconstructive Surgery National Cancer Institute of Peru (INEN). Lima, Peru
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Djedovic G, Del Frari B, Matiasek J, Schiltz D, Engelhardt TO, Pierer G, Rieger UM. The versatility of the medial thigh lift for defect coverage in the genito-perineal region. Int Wound J 2016; 14:496-500. [PMID: 27476473 DOI: 10.1111/iwj.12634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 06/12/2016] [Accepted: 06/17/2016] [Indexed: 12/14/2022] Open
Abstract
Soft tissue defects in the genito-perineal region are predominantly because of trauma, infections, neoplasms or iatrogenic causes. As a result of the region's urological, reproductive and gastrointestinal function, defects in this area may cause devastating physical and psychological consequences as well as diminished sexual functioning. The purpose of this study was to examine the efficacy of implementing a medial thigh lift for defect coverage in the perineal region. A retrospective analysis of all medial thigh lift procedures for defect coverage in the genito-perineal region between November 2010 and March 2015 was conducted at three institutions. Ten consecutive patients underwent a medial thigh lift for defect coverage in the genito-perineal region. Nine patients were male, and one was female. The causative factors were Fournier's gangrene in eight patients, one patient had a straddle injury, and one suffered from extramammary Paget's disease. The mean follow-up time was 19·8 months. The average total defect size was 11·1 × 11 cm (length × width). The medial thigh lift procedure is a safe, technically easy and reliable technique with discrete scars. Outstanding aesthetic and functional outcomes result in a high rate of patient satisfaction. Through immediate wound closure, a reduction of recovery time can be achieved.
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Affiliation(s)
- Gabriel Djedovic
- Department of Plastic, Reconstructive and Aesthetic Surgery, Innsbruck Medical University, Innsbruck, Austria.,Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Johann Wolfgang von Goethe University, Frankfurt, Germany
| | - Barbara Del Frari
- Department of Plastic, Reconstructive and Aesthetic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Johannes Matiasek
- Department of Plastic, Aesthetic and Reconstructive Surgery, Wilhelminenspital, Vienna, Austria
| | - David Schiltz
- Department of Plastic, Reconstructive and Aesthetic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Timm O Engelhardt
- Departmant of Handsurgery, Plastic and Aesthetic Surgery, Munich University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Gerhard Pierer
- Department of Plastic, Reconstructive and Aesthetic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Ulrich M Rieger
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Johann Wolfgang von Goethe University, Frankfurt, Germany
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Mopuri N, Fitzgerald O'Connor E, Iwuagwu FC. Scrotal reconstruction with modified pudendal thigh flaps. J Plast Reconstr Aesthet Surg 2016; 69:278-83. [DOI: 10.1016/j.bjps.2015.10.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/13/2015] [Indexed: 10/22/2022]
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New Refinements in Greater Omentum Free Flap Transfer for Severe Secondary Lymphedema Surgical Treatment. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e387. [PMID: 26090277 PMCID: PMC4457250 DOI: 10.1097/gox.0000000000000358] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 03/20/2015] [Indexed: 11/25/2022]
Abstract
Lymphedema is a chronic debilitating disease, affecting a considerable part of the population; it results from impairment of the lymphatic system. It is highly prevalent among patients subjected to axillary and groin nodal dissection after surgery for breast cancer, abdominopelvic surgery, and lymphadenectomy after melanoma surgery. Interestingly, among the surgical treatment options for lymphedema, groin lymph node transfer is gaining popularity; however, in some cases, dissection at this site can cause significant morbidity, including possible development of iatrogenic lymphedema. To avoid these complications, new donor nodal groups are being proposed (eg, submental or supraclavicular). We have used the greater omentum as a lymph node and lymph vessel donor site. Dissection of the omentum is easy to perform and can even be done in patients who have undergone previous abdominal surgeries. We present refinements in the surgical technique for free omentum transfer in the management of secondary lymphedema: the first free omental flap dissection performed laparoscopically and the use of a primary flap as the recipient pedicle of a free greater omentum flap for anatomical repair after chest osteoradionecrosis and simultaneous functional repair of chronic lymphedema.
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Khan Q, Knight RJW, Goodwin-Walters A. Scrotal reconstruction: a review and a proposed algorithm. EUROPEAN JOURNAL OF PLASTIC SURGERY 2013. [DOI: 10.1007/s00238-013-0833-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Porzionato A, Sfriso MM, Macchi V, Rambaldo A, Lago G, Lancerotto L, Vindigni V, De Caro R. Decellularized omentum as novel biologic scaffold for reconstructive surgery and regenerative medicine. Eur J Histochem 2013; 57:e4. [PMID: 23549463 PMCID: PMC3683611 DOI: 10.4081/ejh.2013.e4] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 09/17/2012] [Accepted: 09/19/2012] [Indexed: 12/17/2022] Open
Abstract
Homologous tissues, such as adipose tissue, may be an interesting source of acellular scaffolds, maintaining a complex physiological three-dimensional (3D) structure, to be recellularized with autologous cells. The aim of the present work is to evaluate the possibility of obtaining homologous acellular scaffolds from decellularization of the omentum, which is known to have a complex vascular network. Adult rat and human omenta were treated with an adapted decellularization protocol involving mechanical rupture (freeze-thaw cycles), enzymatic digestion (trypsin, lipase, deoxyribonuclease, ribonuclease) and lipid extraction (2-propanol). Histological staining confirmed the effectiveness of decellularization, resulting in cell-free scaffolds with no residual cells in the matrix. The complex 3D networks of collagen (azan-Mallory), elastic fibers (Van Gieson), reticular fibers and glycosaminoglycans (PAS) were maintained, whereas Oil Red and Sudan stains showed the loss of lipids in the decellularized tissue. The vascular structures in the tissue were still visible, with preservation of collagen and elastic wall components and loss of endothelial (anti-CD31 and -CD34 immunohistochemistry) and smooth muscle (anti-alpha smooth muscle actin) cells. Fat-rich and well vascularized omental tissue may be decellularized to obtain complex 3D scaffolds preserving tissue architecture potentially suitable for recellularization. Further analyses are necessary to verify the possibility of recolonization of the scaffold by adipose-derived stem cells in vitro and then in vivo after re implantation, as already known for homologus implants in regenerative processes.
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Affiliation(s)
- A Porzionato
- Section of Human Anatomy, Department of Molecular Medicine, University of Padua, Padova,
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