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Bovill J, Huffman S, Cach G, Haffner Z, Deldar R, Abu El Hawa AA, Sgromolo N, Giladi AM. Propeller Perforator Flaps Used for Hand and Digit Reconstruction: A Systematic Review. J Hand Microsurg 2024; 16:100035. [PMID: 38855530 PMCID: PMC11144646 DOI: 10.1055/s-0043-1768482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024] Open
Abstract
Background Propeller perforator flaps (PPFs) have increased in popularity due to the freedom in design and ability to cover a variety of defects without sacrificing the major vessels. Present reports of PPFs for upper limb reconstruction have not provided guidance for hand reconstruction, specifically. This study aims to review the current literature and evaluate techniques for use of PPFs in hand reconstruction. Methods A comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for articles published from 1991 to 2021. The database search was queried for records using appropriate Medical Subject Headings (MeSH) terms. Studies reporting PPFs were limited to English language and excluded lower extremity or upper extremity reconstruction not specific to defects in the hand or digits. Study characteristics, patient demographics, indications, preoperative testing, flap characteristics, flap survival, and complication rates were collected. Results Out of the initial 1,348 citations yielded, 71 underwent full-text review. Ultimately, 25 unique citations were included encompassing 12 retrospective reviews (48%), 3 prospective cohort studies (10%), and 10 case series (40%). In review, 525 patients underwent reconstruction with a total of 613 propeller flaps performed to repair defects of the hand, digits, or both with use of 18 unique flap types. Overall flap survival was 97.8%. Acute wounds accounted for 72.9% of performed reconstructions. The mean flap coverage was 14.7 cm2. Complications occurred in 19.8% of cases, with venous congestion and partial flap necrosis occurring in 5.5 and 6.5% of cases, respectively, leading to a flap failure rate of 2.1%. Conclusion PPFs are a reliable option for hand or digital reconstruction, allowing surgeons to cover a variety of defects without sacrificing local vasculature. Despite nearly a 20% reported complication rate, nearly all flaps with venous congestion and partial flap necrosis included in these articles resolved without the need for secondary intervention, retaining an excellent overall flap survival.
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Affiliation(s)
- John Bovill
- Georgetown University School of Medicine, Washington, Dist. of Columbia, United States
| | - Samuel Huffman
- Georgetown University School of Medicine, Washington, Dist. of Columbia, United States
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, Dist. of Columbia, United States
| | - Gina Cach
- Georgetown University School of Medicine, Washington, Dist. of Columbia, United States
| | - Zoe Haffner
- Georgetown University School of Medicine, Washington, Dist. of Columbia, United States
| | - Romina Deldar
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, Dist. of Columbia, United States
| | - Areeg A. Abu El Hawa
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Nicole Sgromolo
- Walter Reed National Military Medical Center, Bethesda, Maryland, United States
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland, United States
| | - Aviram M. Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland, United States
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Diaddigo SE, Lavalley MN, Truong AY, Otterburn DM. Catastrophic complications following microvascular free tissue transfer: A 10-year review of NSQIP data. J Plast Reconstr Aesthet Surg 2024; 93:42-50. [PMID: 38640554 DOI: 10.1016/j.bjps.2024.02.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION There is an absence of literature regarding the risks of catastrophic medical outcomes (CMOs) such as stroke, cardiac arrest, and pulmonary embolism in microvascular free tissue transfer. This study aims to determine the CMO and mortality rates, as well as risk factors, associated with microvascular reconstruction of the head and neck, extremity, and breast. METHODS This study uses data from the American College of Surgeons National Surgical Quality Improvement Program. Cases of microvascular free tissue transfer from 2012 to 2021 were analyzed to assess the 30-day rates of CMOs, including death, as well as associated risk factors. RESULTS Of the 22,839 included patients, 785 (3.44%) experienced 1043 CMOs, including 99 (0.43%) deaths. Pulmonary complications of prolonged respiratory failure and pulmonary embolism were the most common. Independent risk factors included age, male sex, underweight status, longer operation times, American Society of Anesthesiologists (ASA) class of III or above, wound classification other than clean, and underlying conditions such as diabetes, hypertension, chronic obstructive pulmonary disorder, dyspnea, metastatic cancer, and ventilator dependence. CMOs were associated with an average 10-day delay in hospital discharge. Multivariate regression analysis revealed that head and neck reconstructions were associated with increased risk of CMO (OR 4.96; p < 0.0001). CONCLUSION This is the largest study to examine CMOs following microvascular free tissue transfer. Compared to previous literature spanning the period between 2006 and 2011, we observed a decreased rate of CMOs but a slight increase in 30-day mortality. Our data provide updated and comprehensive criteria for risk stratification and patient counseling. The modifiable risk factors reported in our study should be considered in elective, non-urgent cases of microvascular reconstruction.
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Affiliation(s)
- Sarah E Diaddigo
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA
| | - Myles N Lavalley
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA
| | - Albert Y Truong
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA
| | - David M Otterburn
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA.
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Lu Y, Wang B, Wang T, Gu J, Liu H. Posterior perforator tibial artery flaps for soft tissue defects of limbs: a retrospective cohort study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02536-5. [PMID: 38678501 DOI: 10.1007/s00068-024-02536-5] [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: 02/22/2024] [Accepted: 04/20/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE To investigate the clinical effect of posterior perforator tibial artery flaps on repairing soft tissue defects of limbs. METHODS From June 2012 to June 2021, 14 cases of soft tissue defects of limbs were repaired with pedicled or free flaps of posterior perforator tibial artery. Among them, there were 9 cases of pedicled flaps and 5 cases of free flaps. The donor sites were closed directly or covered with skin grafting. The defects area varied from 3 × 5 cm to 7 × 16 cm. All cases were followed up for 1 year to 2 years. RESULTS All flaps survived completely except 3 cases with distal end necrosis and the 3 cases healed after dressing change. There were not any other complications at both donor and recipient sites. Appearance of the recipient sites was close to the surrounding skin. All patients were satisfied with the results. CONCLUSION Posterior perforator tibial artery flaps have the advantages of relatively simple technique, few damage, few complications and satisfying appearance. It is a good choice for soft tissue defects of limbs.
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Affiliation(s)
- Yiming Lu
- The Yangzhou School of Clinical Medicine of Dalian Medical University, Yangzhou, 225001, Jiangsu Province, China
- Clinical Medical College, Yangzhou University, Yangzhou, 225009, Jiangsu Province, China
- Department of Foot and Hand Surgery, Northern Jiangsu People's Hospital, Yangzhou, 225001, Jiangsu Province, China
| | - Bin Wang
- The Yangzhou School of Clinical Medicine of Dalian Medical University, Yangzhou, 225001, Jiangsu Province, China
- Clinical Medical College, Yangzhou University, Yangzhou, 225009, Jiangsu Province, China
- Department of Foot and Hand Surgery, Northern Jiangsu People's Hospital, Yangzhou, 225001, Jiangsu Province, China
| | - Tianliang Wang
- The Yangzhou School of Clinical Medicine of Dalian Medical University, Yangzhou, 225001, Jiangsu Province, China
- Clinical Medical College, Yangzhou University, Yangzhou, 225009, Jiangsu Province, China
- Department of Foot and Hand Surgery, Northern Jiangsu People's Hospital, Yangzhou, 225001, Jiangsu Province, China
| | - Jiaxiang Gu
- The Yangzhou School of Clinical Medicine of Dalian Medical University, Yangzhou, 225001, Jiangsu Province, China
- Clinical Medical College, Yangzhou University, Yangzhou, 225009, Jiangsu Province, China
- Department of Foot and Hand Surgery, Northern Jiangsu People's Hospital, Yangzhou, 225001, Jiangsu Province, China
| | - Hongjun Liu
- The Yangzhou School of Clinical Medicine of Dalian Medical University, Yangzhou, 225001, Jiangsu Province, China.
- Clinical Medical College, Yangzhou University, Yangzhou, 225009, Jiangsu Province, China.
- Department of Foot and Hand Surgery, Northern Jiangsu People's Hospital, Yangzhou, 225001, Jiangsu Province, China.
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Calotta NA, Shores JT, Tuffaha SH. Adipofascial Perforator Flaps for Peripheral Nerve Resurfacing after External Neurolysis. J Hand Surg Asian Pac Vol 2024; 29:111-117. [PMID: 38494169 DOI: 10.1142/s2424835524500127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Background: External neurolysis is an important approach to treating symptomatic peripheral nerve entrapment. In cases of recurrent neurolysis or particularly extensive neurolysis, a paucity of overlying soft tissue for closure over the freshly liberated nerve presents a challenge to long-term surgical success as primary closure of this tissue may predispose the patient to recalcitrant epineural scarring. We report the intermediate term outcomes of the use of adipofascial perforator flaps as a means of vascularised tissue resurfacing of nerves in these difficult scenarios. Methods: We retrospectively reviewed patients undergoing external neurolysis for painful peripheral nerve lesions who subsequently had soft tissue reconstruction with local adipofascial flaps. Data with regard to age, gender, limb involved, duration of symptoms, number of prior surgeries, operative time, type of flap, vascular basis of flap, duration of follow-up, visual analogue pain score, monofilament sensory testing and complications were collected. Results: We included six patients (four women) with a minimum follow-up period of 17 months (range: 17-25 months). Age ranged from 39 to 60 years of age. Four cases involved the upper extremity and two the lower extremity. Symptoms had been present between 1 and 10 years. All operations utilised a local adipofascial flap perfused by a named perforating vessel emanating from an adjacent axial vessel. Operative time for flap creation and inset was 74 minutes, on average. There was one minor complication owing to superficial wound dehiscence. All patients reported substantial pain relief (≥five-point reduction on visual analogue scale; scores 0-3 at last follow-up) and objective sensory testing demonstrated improvement. Conclusions: Our report pays particular attention to surgical technique that is applicable to both upper and lower extremities in addition to intermediate term safety and pain outcomes. Level of Evidence: Level IV (Therapeutic).
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Affiliation(s)
- Nicholas A Calotta
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jaimie T Shores
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sami H Tuffaha
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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Lombardo GAG, Donia C, Ciancio F, Russo A, Stivala A, Ranno R. Temporal Fascia Free Flap for Thumb Coverage in Electrical Burn Injuries: A Case Series Analysis With DASH Score Outcomes Evaluation. J Burn Care Res 2024; 45:493-498. [PMID: 37982657 DOI: 10.1093/jbcr/irad185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Indexed: 11/21/2023]
Abstract
Electrical burns pose unique challenges in reconstructive surgery due to the extensive tissue damage they cause. The thumb is particularly susceptible to electrical burns, leading to severe functional impairment. This case series introduces the use of the temporal fascia free flap for thumb coverage in patients with electrical burn injuries. The study aims to assess the functional outcomes of this approach using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Six male patients underwent thumb reconstruction using temporal fascia free flaps following electrical burn injuries. The extent of the injury was assessed, and necrotic tissue was debrided. Functional outcomes were evaluated using the DASH questionnaire 6 months postoperation. All procedures were conducted in accordance with ethical guidelines, and informed consent was obtained from all patients. All patients achieved successful transplants using temporal fascia free flaps. The average DASH score at the 6-month follow-up indicated satisfactory functional recovery. Patients reported improvements in thumb mobility and functionality, and the cosmetic appearance of the thumb was acceptable. The appearance of the scar in the donor area was well-received. The temporal fascia free flap proved to be an effective method for thumb reconstruction following electrical burn injuries. Its thin and flexible nature allows for optimal contouring and improved range of motion. Although one case of partial flap loss was observed, overall functional and aesthetic outcomes were satisfactory. Further research with larger sample sizes is warranted to optimize surgical techniques and postoperative care for better outcomes.
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Affiliation(s)
- Giuseppe A G Lombardo
- Burn and Plastic, Reconstructive and Aesthetic Surgery Department, Azienda Ospedaliera Cannizzaro, Catania 95100, Italy
- Università Unikore di Enna, Piazza dell'Università, Enna, EN 94100, Italy
| | - Claudio Donia
- Burn and Plastic, Reconstructive and Aesthetic Surgery Department, Azienda Ospedaliera Cannizzaro, Catania 95100, Italy
| | - Francesco Ciancio
- Burn and Plastic, Reconstructive and Aesthetic Surgery Department, Azienda Ospedaliera Cannizzaro, Catania 95100, Italy
| | - Arcangelo Russo
- Università Unikore di Enna, Piazza dell'Università, Enna, EN 94100, Italy
| | - Alessio Stivala
- Nord Plastic and Reconstructive Surgery Hand Surgery, Polyclinique Lyon Rillieux-la-Pape 69140, France
| | - Rosario Ranno
- Burn and Plastic, Reconstructive and Aesthetic Surgery Department, Azienda Ospedaliera Cannizzaro, Catania 95100, Italy
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Struebing F, Bigdeli A, Weigel J, Gazyakan E, Vollbach F, Panayi AC, Vogelpohl J, Boecker A, Kneser U. Robot-assisted Microsurgery: Lessons Learned from 50 Consecutive Cases. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5685. [PMID: 38948156 PMCID: PMC11213613 DOI: 10.1097/gox.0000000000005685] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/25/2024] [Indexed: 07/02/2024]
Abstract
Background The potential of robot-assisted surgery in plastic and reconstructive surgery remains to be established, especially in free tissue transfer. This prospective study aimed to present our experience and findings from the first 50 consecutive cases of robot-assisted microsurgery using the Symani surgical system. Methods A prospective database was maintained, recording patient demographics and surgical details for all cases of robot-assisted microsurgery in a large academic institution. All surgeons underwent an intensive training program with the Symani surgical system. Results A total of 50 patients who underwent robot-assisted microsurgical reconstruction were identified. Free microsurgical tissue transfer was performed in 45 cases, targeted muscle reinnervation in four cases, and lymphovenous anastomoses in a single case. A total of 94 robot-assisted anastomoses and coaptations were performed, (46 venous and 30 arterial anastomoses, 16 nerve coaptations, two lymphovenous anastomoses). Six cases involved perforator-to-perforator anastomoses. Ninety-eight percent of attempted anastomoses were completed using the robot. Size-mismatch anastomoses, seen in 37.8% of cases, took significantly longer. Minor complications occurred in three cases and major in six cases. There were three cases of microvascular compromise requiring revision. One partial flap loss and no complete flap loss occurred. Conclusions Our study highlights the immense potential of robot-assisted microsurgery, and a feasible and effective modality for various microsurgical procedures, with outcomes comparable to those of conventional microsurgery. Despite challenges, such as increased operating times and higher costs, the technology offers significant advantages, such as enhanced precision and motion scaling. We identify a slow learning curve and a necessity for higher caseloads.
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Affiliation(s)
- Felix Struebing
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Amir Bigdeli
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Jonathan Weigel
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Emre Gazyakan
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Felix Vollbach
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Adriana C. Panayi
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Julian Vogelpohl
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Arne Boecker
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
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Schulz T, Nuwayhid R, Houschyar KS, Langer S, Kohler L. Diagnostical accuracy of hyperspectral imaging after free flap surgery. J Plast Surg Hand Surg 2023; 58:48-55. [PMID: 37614177 DOI: 10.2340/jphs.v58.7140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/25/2023] [Indexed: 08/25/2023]
Abstract
Microsurgical free-tissue transfer has been a safe option for tissue reconstruction. This study aimed to analyze the diagnostic accuracy of hyperspectral imaging (HSI) after free-tissue transfer surgery. From January 2017 to October 2019, 42 consecutive free-flap surgeries were performed, and their outcomes were analyzed via HSI. Clinical examination of free-flap perfusion was initially performed. Clinical examination findings were subsequently compared with those of HSI. Potential venous congestion with subsequent necrosis was defined as a tissue hemoglobin index of ≥53%. Student's t-test was used to compare the results of the analysis. The evaluation of sensitivity and specificity for flap failure detection was time dependent using the Fisher's exact test. A p-value of ≤0.05 was considered statistically significant. Microsurgical tissue transfer success rate was 84%. Seven patients presented with venous congestion that caused total flap necrosis. Overall, 124 assessments were made. HSI accurately identified 12 out of 19 pathological images: four as false positive and seven as false negative. The sensitivity and specificity of HSI were 57 and 94%, respectively, compared to those of clinical examination that were 28 and 100%, respectively, within 24 h following tissue transfer. The sensitivity and specificity of HSI were 63 and 96%, respectively, compared to those of clinical examination that were 63 and 100%, respectively, within the first 72 h. A tissue hemoglobin index of ≥53% could predict venous congestion after free-flap surgery. HSI demonstrated higher sensitivity than clinical examination within the first 24 h; however, it was not superior compared to clinical findings within 72 h.
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Affiliation(s)
- Torsten Schulz
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.
| | - Rima Nuwayhid
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | | | - Stefan Langer
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Lukas Kohler
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany; Division of Hand-, Plastic- and Aesthetic Surgery, University Hospital Munich, Munich, Germany
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8
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Shimbo K, Kawamoto H, Koshima I. Venous end-to-side anastomosis for free-flap reconstruction in the extremities: A case series and meta-analysis. J Plast Reconstr Aesthet Surg 2023; 83:4-11. [PMID: 37263077 DOI: 10.1016/j.bjps.2023.05.004] [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: 01/20/2023] [Revised: 04/10/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023]
Abstract
This case series aimed to investigate the result of venous end-to-side (ETS) anastomosis in the extremities to contribute to a meta-analysis to evaluate the postoperative complications of venous ETS anastomosis in the extremities. This was a single-center case series and meta-analysis of patients who underwent venous ETS anastomosis for free-flap reconstruction of the extremities. We reviewed the records of 41 free flaps in 40 patients and performed a comprehensive search of PubMed, Scopus, and Web of Science for studies published from inception to December 2022. Primary outcomes were venous thrombosis, takebacks, and total and partial flap failures. Complication rates and confidence intervals were calculated using a random-effects model. In our case series, four (12.2%) patients with five flaps were taken back to the operating room, three (7.3%) flaps were due to venous thrombosis, and three (7.3%) flaps ultimately resulted in total flap failure. Our meta-analysis demonstrated the following complication rates: 4.0% (95% confidence interval [CI], 0-18.1%; I2 = 0%) for venous thrombosis, 8.5% (95% CI, 0-21.8%; I2 = 0%) for takebacks, 5.8% (95% CI, 0-18.3%; I2 = 0%) for total flap failure, and 8.8% (95% CI, 0-28.4%; I2 = 0%) for partial flap failure. Our case series and meta-analysis showed that the result of venous ETS anastomosis in the extremities was positive, and this technique was effective for addressing venous size discrepancy; although, its superiority to end-to-end anastomosis could not be established.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.
| | - Haruka Kawamoto
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan; International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan.
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Nagel SS, Rauh A, Siegwart LC, Hundeshagen G, Kotsougiani-Fischer D, Kuepper S, Kneser U, Hirche C. From Esthetic Medicine to Optimizing Reconstructive Outcome: A Feasibility Trial on Secondary Refinement of Fasciocutaneous Anterolateral Thigh Flaps with Cryolipolysis. J Reconstr Microsurg 2023; 39:156-164. [PMID: 36150694 DOI: 10.1055/s-0042-1755259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Free adipocutaneous anterolateral thigh (ALT) flaps have evolved as workhorse flaps to reconstruct complex, multicompound defects. While coverage is safely achieved, flaps may remain bulky. As a standard of care, flaps are refined with liposuction, partial excision, or combination of both. Cryolipolysis is widely used for fat reduction in esthetic medicine. This pilot comparative study analyses whether cryolipolysis may serve as a safe alternative method to effectively reduce volume in fasciocutaneous flaps. Moreover, patients' satisfaction with the procedure is evaluated. METHODS In this single-center, retrospective, interventional comparative cohort study, 10 patients with free subfascial ALT flaps for distal extremity reconstruction underwent cryolipolysis (60 minutes, -9°C). Circumference of the extremities and subcutaneous fat thickness were determined before (T1) and 12 weeks (T2) after cryolipolysis. Patient satisfaction was evaluated with a questionnaire of Likert's scale questions. Duration of hospital stay, intervention time, costs, and possible complications were analyzed and compared with surgical flap contouring (n = 12). RESULTS All patients undergoing cryolipolysis were male, with a median age of 52 years without arterial disease-like state or deep vein thrombosis (DVT). At T2, a significant reduction of circumference of 1.8 ± 0.9 cm (p < 0.001) and subcutaneous fat layer of 7.7 ± 3.0 mm (p < 0.0001) was recorded. Overall, 90% of the patients were satisfied with the result. Cryolipolysis was well tolerated. One patient developed a second-degree frostbite which healed without further intervention. Cryolipolysis proofed to be as safe as surgical flap contouring. Hospital stay was significantly shorter (p < 0.01) and personal resources were spared when flap contouring was performed with cryolipolysis. CONCLUSION This is a novel application of evolving body-contouring cryolipolysis from esthetic medicine into optimizing outcomes in reconstructive surgery. Cryolipolysis has been shown to be relatively safe and effective to reduce ALT's volume with high patients' satisfaction. This successful pilot study encourages further investigation with a prospective randomized control trial.
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Affiliation(s)
- Sarah S Nagel
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany
| | - Annika Rauh
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany
| | - Laura C Siegwart
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany
| | - Dimitra Kotsougiani-Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany
| | - Simon Kuepper
- Department of Plastic Surgery and Burn Center, BG Hospital Berlin, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main GmbH, Goethe University of Frankfurt, Germany
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10
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Klietz ML, Mewe C, Wiebringhaus P, Hirsch T, Aitzetmüller MM, Kückelhaus M. Seasonal Impact on Free Flap Surgery in Terms of Flap Loss and Wound Healing Disorders: A Retrospective Cohort Study of 158 Free Flaps. Healthcare (Basel) 2023; 11:healthcare11030403. [PMID: 36766977 PMCID: PMC9914697 DOI: 10.3390/healthcare11030403] [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: 12/11/2022] [Revised: 01/18/2023] [Accepted: 01/28/2023] [Indexed: 02/01/2023] Open
Abstract
(1) Background: Postoperative flap loss and wound healing disorders are severe complications after microsurgical free flap surgery. Despite multiple clinical observations, a possible influence of season and external temperature on outcome are largely missing. (2) Methods: Retrospectively, data were collected from 151 patients receiving microsurgical free flaps from March 2018 to August 2019. Patients were divided into two cohorts. The winter group includes all patients who underwent surgery from October 2018 to March 2019 and the summer group al those who underwent surgery from April 2018 to September 2018. Data included demographic information, pre-existing conditions, flap characteristics, and postoperative complications like flap losses and wound healing problems. External temperatures during the first 14 postoperative days were documented and the predictor of flap loss and wound healing disorders was detected. (3) Results: In the winter group (October-March; Ø 7.24 °C) 72 patients (46 female, 24 males; Ø 57.0 years) and in the summer group (April-September; Ø 18.79 °C) 81 patients (48 female, 33 males; Ø 56.0 years) received free flap surgery. There were no significant differences in demography (age: p = 0.593; gender: p = 0.419; BMI: p = 0.141). We found a significant increase in flap loss during summer (χ2(1) = 6.626; p = 0.010; V = 0.209) strengthened by logistic regression analysis (p = 0.037; Exp(B) = 9.655). Additionally higher average temperatures 14 days postoperatively represents another main driver (p = 0.023, Exp(B) = 1.161) for postoperative flap loss. (4) Conclusions: The data confirm a significantly higher postoperative flap loss in the summer group. This information may potentially contribute to optimization of perioperative management and planning of elective and semi-elective surgeries.
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Affiliation(s)
- Marie-Luise Klietz
- Department for Plastic and Reconstructive Surgery, Institut for Muskuloskeletal Medicine, Westfälische Wilhelms-University, 48149 Münster, Germany
- Department for Plastic and Reconstructive Surgery, Fachklinik Hornheide, 48157 Münster, Germany
- Division for Plastic Surgery, Department for Traumatology and Hand Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Chiara Mewe
- Department for Plastic and Reconstructive Surgery, Institut for Muskuloskeletal Medicine, Westfälische Wilhelms-University, 48149 Münster, Germany
- Department for Plastic and Reconstructive Surgery, Fachklinik Hornheide, 48157 Münster, Germany
| | - Philipp Wiebringhaus
- Department for Plastic and Reconstructive Surgery, Institut for Muskuloskeletal Medicine, Westfälische Wilhelms-University, 48149 Münster, Germany
- Department for Plastic and Reconstructive Surgery, Fachklinik Hornheide, 48157 Münster, Germany
- Division for Plastic Surgery, Department for Traumatology and Hand Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Tobias Hirsch
- Department for Plastic and Reconstructive Surgery, Institut for Muskuloskeletal Medicine, Westfälische Wilhelms-University, 48149 Münster, Germany
- Department for Plastic and Reconstructive Surgery, Fachklinik Hornheide, 48157 Münster, Germany
- Division for Plastic Surgery, Department for Traumatology and Hand Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Matthias Michael Aitzetmüller
- Department for Plastic and Reconstructive Surgery, Institut for Muskuloskeletal Medicine, Westfälische Wilhelms-University, 48149 Münster, Germany
- Department for Plastic and Reconstructive Surgery, Fachklinik Hornheide, 48157 Münster, Germany
- Division for Plastic Surgery, Department for Traumatology and Hand Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Maximilian Kückelhaus
- Department for Plastic and Reconstructive Surgery, Institut for Muskuloskeletal Medicine, Westfälische Wilhelms-University, 48149 Münster, Germany
- Department for Plastic and Reconstructive Surgery, Fachklinik Hornheide, 48157 Münster, Germany
- Division for Plastic Surgery, Department for Traumatology and Hand Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
- Correspondence:
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11
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Behr B, Schlüchtermann J, Radtke JP, Rhomberg I, Hellmich S, Sogorski A, Wagner JM, Auhuber T, Lehnhardt M, Wallner C. [Analysis of Efficency, Cost Structure and Revenues of ALT Free Flaps in Extremity Reconstruction]. HANDCHIR MIKROCHIR P 2022; 54:475-483. [PMID: 36252606 DOI: 10.1055/a-1951-1508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Microvascular reconstructions can be lengthy procedures lasting the entire day. As a result of unforeseeable events, the standardization of these procedures can be challenging. Moreover, the length of these procedures varies strongly, which impedes adequate scheduling and, therefore, optimal capacity utilization. Within the years 2018-2020, the duration of ALT free flap extremity reconstructions was correlated with the experience of the microsurgeon (category 1:<50 free flaps life-time experience, category 2: 50-200, category 3:>200) and comorbidities. The resulting costs were compared with the matrix of the German DRG Institute InEK. The surgical experience of the microsurgeon had a significant impact on the duration of surgery in extremity reconstruction. In due consideration of potential complications, category 2 microsurgeons were 45 minutes faster and category 3 microsurgeons were 167 minutes faster than category 1 microsurgeons. Comorbidities, by contrast, did not have a significant impact on procedure duration. Cost analysis revealed deficits for these procedures in relation to the InEK matrix. However, an additional analysis showed that the duration of surgery was within the German average while costs for personnel/OR minute were slightly below the average. According to this calculation, costs for microsurgical training were approximately 1000€/case. The reimbursement for flaps in extremity reconstruction is not entirely mapped in the German DRG system. Given the longer procedure times, microsurgical training is associated with higher costs. Defining the duration of microsurgery based on the level of expertise should result in improved adherence to schedule and more efficient utilization of the valuable operating room time.
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Affiliation(s)
- Björn Behr
- Klinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, BG-Universitätsklinikum Bergmannsheil Bochum, Bochum, Germany
| | | | - Jan Philipp Radtke
- Klinik für Urologie, Heinrich-Heine-Universität Düsseldorf, Dusseldorf, Germany
| | - Iwo Rhomberg
- Klinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, BG-Universitätsklinikum Bergmannsheil Bochum, Bochum, Germany
| | | | - Alexander Sogorski
- Klinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, BG-Universitätsklinikum Bergmannsheil Bochum, Bochum, Germany
| | - Johannes Maximilian Wagner
- Klinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, BG-Universitätsklinikum Bergmannsheil Bochum, Bochum, Germany
| | - Thomas Auhuber
- Klinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, BG-Universitätsklinikum Bergmannsheil Bochum, Bochum, Germany
| | - Marcus Lehnhardt
- Klinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, BG-Universitätsklinikum Bergmannsheil Bochum, Bochum, Germany
| | - Christoph Wallner
- Klinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, BG-Universitätsklinikum Bergmannsheil Bochum, Bochum, Germany
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12
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Ikeguchi R, Noguchi T, Ando M, Yoshimoto K, Sakamoto D, Matsuda S. Anterolateral thigh flap for upper extremity reconstruction in older patients. Microsurgery 2022; 42:793-799. [PMID: 36196891 DOI: 10.1002/micr.30965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/23/2022] [Accepted: 09/02/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The anterolateral thigh (ALT) flap has been used in upper extremity reconstruction. However, there is no consensus about the age at which the flap can be used safely, which is a concern when applying ALT flaps for upper extremity reconstruction in older patients. We present the results of the use of ALT flap for upper extremity reconstruction in a series of older patients. PATIENTS AND METHODS Seventeen patients who underwent ALT flaps for soft tissue defects in the upper extremities from 2010 to 2020 were included. The patients' mean age was 63.5 (range, 26-83) years. Ten of seventeen patients were smokers. Defect locations were the dorsum of the hand in seven patients, palm in two patients, dorsum and palm in two patients, and forearm in six patients. Etiologies of the defect were traumatic in 14 patients and malignant tumor in three patients. The defect size was 8 to 25 × 5 to 11 cm. When dissecting the perforators, we preserved the surrounding small muscular and fatty tissue with the perforators and to harvest them together to prevent intima damage. Flap thinning was performed for 16 flaps to adjust the flap thickness to match defect site requirements. We used an end-to-side or interposition arterial anastomosis to regulate the blood flow. RESULTS The flap size was 9 to 28 × 5 to 13 cm. One patient had venous congestion and vein re-anastomosis was needed. All flaps survived. One patient had a methicillin-resistant Staphylococcus aureus infection and debridement and irrigation was needed. The mean follow-up period was 20 (range, 13-37) months. Fifteen patients returned their previous activities. The mean DASH score was 30.6 (range, 3-70). CONCLUSIONS Regardless of patient age or smoking status, the ALT flap was a safe and reliable surgical option for soft tissue defect reconstruction of the upper extremity.
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Affiliation(s)
- Ryosuke Ikeguchi
- Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
| | - Takashi Noguchi
- Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
| | - Maki Ando
- Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
| | - Koichi Yoshimoto
- Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
| | - Daichi Sakamoto
- Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
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13
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Kallenberger AK, Xiong L, Gazyakan E, Ziegler B, Will P, Kneser U, Hirche C. Intraoperative Heparin Bolus and Postoperative Anticoagulation with Low Molecular Weight Heparin Increase Reliability of Microsurgical Free Flaps for Upper Extremity Reconstruction. J Reconstr Microsurg 2022; 39:334-342. [PMID: 35952676 DOI: 10.1055/s-0042-1755264] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
BACKGROUND Microsurgery is an indispensable tool of upper extremity reconstruction addressing defect coverage and the restoration of function. Perioperative anticoagulation and antiplatelet therapy are controversially discussed with impact on microsurgical outcome, but without clear evidence. This study aims to evaluate the impact of perioperative anticoagulation and antiplatelet therapy in microsurgical upper extremity reconstruction. METHODS All eligible patients treated with microsurgical upper extremity reconstruction between January 2000 and July 2014 were included in a comparative analysis to define a superior anticoagulation and antiplatelet regime in a retrospective study. Endpoints were all major complications (e.g., total flap loss, arterial and venous thrombosis) as well as minor complication. RESULTS A total of 183 eligible free flaps to the upper extremity were transferred in 169 patients. Altogether, 11 arterial (6.0%) and 9 venous (4.9%) thromboses, 11 total flap losses (6.0%), and 16 cases with hematoma (8.7%) were detected. In the subgroup analysis, patients who did not receive any heparin intraoperatively (n = 21; 11.5%) had a higher rate of major complications (p = 0.001), with total flap loss being the most frequent event (p = 0.004). A trend was shown for intraoperative bolus administration of 501 to 1,000 units unfractionated heparin (UFH) intravenously to have the lowest rate of major complications (p = 0.058). Intraoperative administration of acetylsalicylic acid (n = 13; 8.1%) did not have any influence on the rate of major complications. Postoperative anticoagulation with continuous UFH intravenously (n = 68; 37.2%) resulted in more frequent complications (p = 0.012), for example, an increased rate of total flap loss (p = 0.02) and arterial thrombosis (p = 0.02). CONCLUSION The results of the present study favor administration of 501 to 1,000 units UFH intravenously as an intraoperative bolus (e.g., 750 units UFH intravenously). Postoperative low molecular weight heparin subcutaneous application in a prophylactic dose given once or twice a day was associated with less complications compared with continuous infusion of UFH, although continuously applied UFH may reflect an increased risk profile.
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Affiliation(s)
- Ann-Katrin Kallenberger
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic and Hand Surgery, Burn Center, St. Georg Hospital gGmbH Leipzig, Leipzig, Germany
| | - Lingyun Xiong
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Emre Gazyakan
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Benjamin Ziegler
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, University of Frankfurt, Frankfurt, Germany
| | - Patrick Will
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, University of Frankfurt, Frankfurt, Germany
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14
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Functional and Aesthetic Outcomes of the Anterolateral Thigh Flap in Reconstruction of Upper Limb Defects: A Systematic Review. World J Plast Surg 2022; 11:13-22. [PMID: 36694679 PMCID: PMC9840761 DOI: 10.52547/wjps.11.3.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/27/2022] [Indexed: 12/23/2022] Open
Abstract
Background Soft tissue coverage in the upper limb after trauma, burn injury, or tumour removal is a commonly addressed problem by the plastic surgeon. The anterolateral thigh flap (ALT) is recognized as a popular free flap option for covering various types of soft tissue defects due to its versatility. We aimed to assess the functional and aesthetic outcomes of the ALT flap for reconstruction of upper limb defects. Methods Four electronic databases were searched (MEDLINE (PubMed), Scopus, Web of Science, and Cochrane) from inception to Feb 2021. Two reviewers independently extracted the data and performed risk assessment using the modified Downs and Black (MDB) quality assessment tool and the modified Newcastle Ottawa Scale for case series. Results This review included seven studies for quantitative assessment. The eligible studies had 67 patients. Included studies had used a varied number of validated upper extremity functional scoring systems; the most commonly used score was QuickDASH with mean of 21.24, DASH score was 15.5. In regard to aesthetic outcome, an overall satisfactory result was reported. A secondary debulking procedure was performed in 7 patients. Conclusion Further studies are recommended to ascertain the functional and aesthetic outcomes of the ALT free flap for upper limb defects, especially using standardized outcome scoring systems. This may be supplemented with a questionnaire that addresses common patient concerns (such as colour, contour, textile and hair growth) for the aesthetic outcome. Nevertheless, based on our review, the ALT flap may be a good reliable reconstructive option for upper limb defects with good functional outcome and satisfactory aesthetic results.
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15
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Thomas B, Cordts T, Lange W, Falkner F, Haug V, Aman M, Böcker A, Vollbach F, Gazyakan E, Harhaus L, Kneser U, Bigdeli AK. Development of a mathematical formula and online tool to calculate the potential maximum flap width to allow for primary anterolateral thigh donor-site closure in Caucasians. Microsurgery 2022; 42:641-648. [PMID: 35818858 DOI: 10.1002/micr.30934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 05/22/2022] [Accepted: 06/23/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Primary anterolateral thigh (ALT) flap donor-site closure is crucial to achieve patient satisfaction, avoid burdensome secondary surgeries, and avert poor outcomes. Only vague maximum flap width recommendations have been suggested, which fall short of acknowledging individual patient habitus and thigh morphology. Therefore, we aimed at identifying a user-friendly preoperative calculation of maximum flap width for primary closure. METHODS A total of 429 ALT free flaps performed between 2009 and 2020 were analyzed. A total of 350 donor-sites were closed primarily (82%) and 79 (18%) were split-thickness skin-grafted (STSG). Patient demographics including sex, age, and BMI, operative details, and flap characteristics were compared to assess their impact on the outcome variable. Receiver operating characteristic (ROC) curves were plotted for all significant predictors discriminating between closure and STSG. Areas under the curve (AUCs) were calculated for each parameter combination and optimal cutoffs were determined using Youden's Index. RESULTS Sex, age, BMI, and flap width alone were poor discriminators. Dividing flap width by BMI and logarithmized BMI yielded AUCs of 0.91 and 0.94, respectively. Including patient sex yielded the best fitting regression model (χ2 = 251.939, p < .0001) increasing the AUC to 0.96 (95% CI: 0.93-0.98, p < .0001). The optimal cutoff value discriminated between primary closure and STSG with 90% sensitivity and 89% specificity. An online calculator of patient-individual maximum ALT width was then programmed. CONCLUSIONS Sex and BMI are reliable predictors of successful primary ALT donor-site closure in Caucasians. We devised a novel formula for calculating patient-individual maximum ALT widths preoperatively, predicting failure of primary closure with 90% sensitivity in our cohort, available at: https://kitteltaschenbuch.com/altwidth/calculate.htm.
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Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Tomke Cordts
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Willy Lange
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany.,Medical University of Vienna, Vienna, Austria
| | - Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Martin Aman
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Arne Böcker
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Felix Vollbach
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
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16
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Ballestín A, Malzone G, Menichini G, Lucattelli E, Innocenti M. New Robotic System with Wristed Microinstruments Allows Precise Reconstructive Microsurgery: Preclinical Study. Ann Surg Oncol 2022; 29:7859-7867. [PMID: 35727461 DOI: 10.1245/s10434-022-12033-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Microsurgery allows complex reconstruction of tissue defects after oncological resections or severe trauma. Performing these procedures may be limited by human tremor, precision, and manual dexterity. A new robot designed specifically for microsurgery with wristed microinstruments and motion scaling may reduce human tremor and thus enhance precision. This randomized controlled preclinical trial investigated whether this new robotic system can successfully perform microsurgical needle driving, suturing, and anastomosis. METHODS Expert microsurgeons and novices completed six needle passage exercises and performed six anastomoses by hand and six with the new robot. Experienced microsurgeons blindly assessed the quality of the procedures. Precision in microneedle driving and stitch placement was assessed by calculating suturing distances and angulation. Performance of microsurgical anastomoses was assessed by time, learning curves, and the Anastomosis Lapse Index score for objective performance assessment. RESULTS Refined precision in suturing was achieved with the robot when compared with the manual technique regarding suture distances (p = 0.02) and angulation (p < 0.01). The time required to perform microsurgical anastomoses was longer with the robot, however, both expert and novice microsurgeons reduced times with practice. The objective evaluation of the anastomoses performed by novices showed better results with the robot. CONCLUSIONS This study demonstrated the feasibility of performing precise microsutures and anastomoses using a new robotic system. Compared to standard manual techniques, robotic procedures were longer in time, but showed greater precision.
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Affiliation(s)
- Alberto Ballestín
- Tumor Microenvironment Laboratory, UMR3347 CNRS / U1021 INSERM, Institut Curie, Orsay Paris, France. .,Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain.
| | - Gerardo Malzone
- Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
| | - Giulio Menichini
- Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
| | - Elena Lucattelli
- Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
| | - Marco Innocenti
- Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
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17
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Arakelyan S, Aydogan E, Spindler N, Langer S, Bota O. A retrospective evaluation of 182 free flaps in extremity reconstruction and review of the literature. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2022; 11:Doc01. [PMID: 35111561 PMCID: PMC8779818 DOI: 10.3205/iprs000162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Introduction: During the past decades, free flaps have been given a central role in the reconstructive surgery. Especially in the extremities, where there is a scarcity of available tissues for local flaps, free flaps play a central part. The aim of this study was to evaluate the risk factors contributing to partial and total flap failure. Patients and methods: In a retrospective cohort study, all data concerning patients who underwent free flap reconstruction of the extremities during the first five years since the founding of the department of plastic surgery were gathered. Patient- and surgery-related risk factors were analyzed in correlation to the postoperative complications. Results: In total, 182 free flaps were included in this study. Partial and total flap failure were noted in 21.42% and 17.03%, respectively. A correlation was seen between the time lapsed from debridement until flap coverage, with flaps performed between day 4 and 14 having the least quote of flap failure (p=0.022). Gender, age, arterial hypertension, nicotine abuse, diabetes mellitus, peripheral arterial disease and the number of anastomosed veins were not significantly associated with free flap failure. Conclusion: Our study showed that free flaps can be safely performed in healthy patients as well as in patients with risk factors, with an acceptable flap loss rate. Randomized controlled studies are needed to clarify the exact role of each risk factor in free flap surgery.
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Affiliation(s)
- Sergey Arakelyan
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Germany,*To whom correspondence should be addressed: Sergey Arakelyan, Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany, E-mail:
| | - Emrah Aydogan
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Germany
| | - Nick Spindler
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Germany
| | - Olimpiu Bota
- University Center of Orthopaedic, Trauma and Plastic Surgery University Hospital Carl Gustav Carus, TU Dresden, Germany
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18
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Mohammed A, Lee KT, Mun GH. Evaluating effects of primary defatting for flap thinning on the development of perfusion-related complications in free perforator flap reconstruction. Microsurgery 2021; 41:716-725. [PMID: 34609025 DOI: 10.1002/micr.30819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 07/23/2021] [Accepted: 09/10/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Primary defatting is suggested as an effective and appealing technique for achieving flap thinning. There has been a long-standing concern regarding its potential adverse effects on flap perfusion, for which limited clinical evidence exists. This study aimed to investigate whether primary defatting negatively influences the outcomes of free perforator flap reconstruction. METHODS Patients who underwent upper or lower extremity reconstruction using free perforator flaps between 2002 and 2020 were investigated. They were categorized into two groups according to whether they underwent primary defatting. The association of primary defatting with the development of perfusion-related complications was evaluated. RESULTS A total of 421 patients were included in the analysis. Perfusion-related complications developed in 61 (14.5%) cases, including 12 cases (2.9%) of total flap loss. In total, 302 patients underwent primary defatting and 119 did not. The patients who underwent primary defatting had a higher body mass index (BMI), lower rate of comorbidities, and smaller harvested flaps than the controls. Both groups had similar rates of perfusion-related complications (13.9% vs. 16.0%, p = .589), including total flap loss (3.0% vs. 2.5%, p = .799). In the multivariate analyses, primary defatting was not associated with the development of perfusion-related complications (p = .957). In the subgroup analyses, the rate of perfusion-related complications did not differ between the two groups regardless of the BMI (≥25 or <25 kg/m2 ), comorbidities, and flap size (≥200, 100-200, or <100 cm2 ). CONCLUSIONS Primary defatting does not appear to be associated with the development of perfusion-related complications in free perforator flap extremity reconstruction.
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Affiliation(s)
- Alfawzan Mohammed
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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19
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Zhang Y, Gazyakan E, Hundeshagen G, Fischer S, Bigdeli AK, Marks PW, Kneser U, Hirche C. A meta-analysis evaluating risk factors for compound free flaps for upper extremity defect reconstruction comparing complications and functional outcomes of compound free flaps with and without bone components. Microsurgery 2021; 41:688-696. [PMID: 34357657 DOI: 10.1002/micr.30791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 07/06/2021] [Accepted: 07/22/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Compound flaps offer the advantage of one stage defect reconstruction respecting all relevant tissues and early functional recovery by optimal vascularity of all components. Due to its specific vascular anatomy and the three-dimensional donor site, compound flaps with bone components may result in higher complication rates compared to soft tissue compound flaps. The meta-analysis summarizes the available evidence and evaluates whether bone components are a risk factor for periprocedural complications in upper extremity multidimensional defect reconstruction. METHOD PubMed and Embase were searched for all publications addressing compound free flaps for upper extremity defect reconstruction with bone or soft tissue components published between January 1988 and May 2018. The methodological quality was assessed with the American Society of Plastic Surgeons Evidence Rating Scale for Therapeutic Studies. Flap loss, thrombosis rate, early infection, hematoma, seroma, as well as donor site complications were extracted and analyzed. RESULTS Twelve out of 1157 potentially eligible studies (evidence-III) comprising 159 patients were finally included with publication bias for all summarized complication rates. Complication rates for flaps with/ without bone components were: total flap loss 5%, 95% CI = 3%-10% (6%/5%); partial flap loss 8%, 95% CI = 5%-15%, (9%/8%); arterial/venous thrombosis 7%, 95% CI = 4%-12%, (8%/5%)/14%, 95% CI = 9%-21% (16%/6%, P < .05) with higher risk for flaps with bone components; infection 6%, 95% CI = 3%-12% (6%/6%); hematoma 6%, 95% CI = 3%-11% (6%/5%); seroma 5%, 95% CI = 3%-10% (5%/5%); dehiscence 10%, 95% CI = 6%-17% (11%/9%). CONCLUSION Compound flaps for upper extremity defect reconstruction including bone components have a higher venous thrombosis rate compared to compound soft-tissue flaps.
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Affiliation(s)
- Ying Zhang
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.,Department of Burn, Plastic and Reconstructive Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Emre Gazyakan
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany
| | - Sebastian Fischer
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, Affiliated Hospital to the Goethe-University Frankfurt am Main, Germany
| | - Patrick Will Marks
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany
| | - Christoph Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, Affiliated Hospital to the Goethe-University Frankfurt am Main, Germany
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Negative Pressure Wound Therapy as a Salvage Procedure in Venous Congestion of Microsurgical Procedures. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3725. [PMID: 34367853 PMCID: PMC8337063 DOI: 10.1097/gox.0000000000003725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 06/08/2021] [Indexed: 12/02/2022]
Abstract
Negative pressure wound therapy (NPWT) is widely used in skin defects, active infection, and surgical reconstruction; lately, it is being used after skin graft to improve the adhesion on the receptor area. During the last decade, another indication has been identified: the use of NPTW to avoid complications after free flaps such as venous congestion and the risk of necrosis. NPWT can be used in the initial complication of a free flap, and the venous congestions can be treated with this technique, with very good outcomes. NPWT can be established as a part of a postoperative protocol in microsurgical procedures to avoid major complications.
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21
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The Effect of Medial Sural Artery Perforator Flap on Reconstruction of Soft Tissue Defects: A Meta-Analysis With Multiple Free Soft Flaps. J Craniofac Surg 2021; 32:1689-1695. [PMID: 33273197 DOI: 10.1097/scs.0000000000007294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND With the gradual popularity of relatively novel medial sural artery perforator flap (MSAPF), robust studies are needed to compare the surgical outcomes of MSAPF versus multiple free soft flaps (MFSFs) to verify the advantages and disadvantages of MSAPF. METHODS The authors searched PubMed, Web of Science, EMBASE, Cochrane Library, Chinese BioMedical Literature Database (CBM), and China National Knowledge Infrastructure (CNKI) until September, 2020, to identify studies that compared surgical outcomes of MSAPF and MFSFs. Two authors followed the PRISMA guidelines, individually extracted the data and performed the quality assessments. Survival rate of flaps, satisfaction degree of patients in recipient and donor site, skin grafting, and morbidity of recipient and donor site were evaluated. RESULTS A total of 441 cases from 7 studies were included in our analysis. No significant differences were found regarding survival rate of flaps, recipient morbidity, and recipient satisfaction degree between the 2 groups. However, MSAPF group was significantly superior to MFSFs group in terms of skin grafting, morbidity, and satisfaction degree of donor site. CONCLUSION Our meta-analysis showed that the MSPAF and MFSFs groups were similar in terms of survival rate of flaps, recipient morbidity, and recipient satisfaction degree. Medial sural artery perforator flap group was superior to MFSFs group in terms of morbidity and satisfaction degree of donor site. The results may prove that MSAPF is gaining popularity for a reason and is a good choice for repairing soft tissue defects.
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22
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Implementation and Validation of Free Flaps in Acute and Reconstructive Burn Care. ACTA ACUST UNITED AC 2021; 57:medicina57070718. [PMID: 34356999 PMCID: PMC8306341 DOI: 10.3390/medicina57070718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/24/2022]
Abstract
Microsurgical free flap reconstruction in acute burn care offers the option of reconstructing even challenging defects in a single stage procedure. Due to altered rheological and hemodynamic conditions in severely burned patients, it bears the risk of a higher complication rate compared to microsurgical reconstruction in other patients. To avoid failure, appropriate indications for free flap reconstruction should be reviewed thoroughly. Several aspects concerning timing of the procedure, individual flap choice, selection and preparation of the recipient vessels, and perioperative measures must be considered. Respecting these specific conditions, a low complication rate, comparable to those seen in microsurgical reconstruction of other traumatic limb defects, can be observed. Hence, the free flap procedure in acute burn care is a relatively safe and reliable tool in the armamentarium of acute burn surgery. In reconstructive burn care, microsurgical tissue transfer is routinely used to treat scar contractures. Due to the more robust perioperative condition of patients, even lower rates of complication are seen in microsurgical reconstruction.
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23
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Yuan K, Zhang F, Lineaweaver WC, Chen X, Li Z, Yan H. The Coverage of Soft-Tissue Defects Around the Foot and Ankle Using Free or Local Flaps: A Comparative Cohort Study. Ann Plast Surg 2021; 86:668-673. [PMID: 33833186 DOI: 10.1097/sap.0000000000002811] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to compare the reconstructive outcomes of soft-tissue defects around foot and ankle with local or free flaps and attempt to provide an optimal strategy for these patients in comparison with the conventional guidelines. METHODS A retrospective review of all continuous patients with foot and ankle reconstruction using different flaps from 2010 to 2018 was performed. Based on the flap types, the patients were divided into 2 groups: local flap group and free flap group. Outcomes were assessed according to the flap survival rate, recipient complications, aesthetic outcomes, and donor-site complications. RESULT A total of 130 flaps including 47 free flaps and 83 local flaps were collected. There was no difference in flap survival rate between the 2 groups; however, a significant difference in aesthetic outcomes was noted between them: the free flap group presented a better overall aesthetic outcomes in comparison with the local flap group in terms of color and contour match. Moreover, local flaps had more donor-site morbidities including the need for skin grafting and wound infection. CONCLUSIONS Free flaps in wound coverage of foot and ankle can achieve better outcomes than local flaps in terms of recipient benefits and donor-site compromise with a comparable flap survival rate.
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Affiliation(s)
| | - Feng Zhang
- Joseph M. Still Burn and Reconstructive Center, Jackson, MS
| | | | - Xinglong Chen
- From the Department of Orthopedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Key Laboratory of Orthopedics of Zhejiang Province, Wenzhou
| | - Zhijie Li
- From the Department of Orthopedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Key Laboratory of Orthopedics of Zhejiang Province, Wenzhou
| | - Hede Yan
- From the Department of Orthopedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Key Laboratory of Orthopedics of Zhejiang Province, Wenzhou
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24
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Efficacy and safety of free medial plantar flap in repair of the high-voltage electrical burns in hands. Eur J Trauma Emerg Surg 2021; 48:1381-1387. [PMID: 34057553 DOI: 10.1007/s00068-021-01700-5] [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: 01/26/2021] [Accepted: 05/13/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this work was to validate the efficacy and safety of free medial plantar flap in repair of hand wounds resulted from high-voltage electrical burn. METHODS 22 patients with high-voltage electrical burn wounds were retrieved between July 2016 and July 2018 in the Affiliated Zhengzhou Central Hospital of Zhengzhou University. All the wounds were the entrance of high-voltage electrical current. After thorough debridement, the blood vessels, nerves, tendons, joints were exposed to defects with different degrees. The soft tissue defects were repaired with the free medial plantar flap repair in 12 patients and medium-thickness skin graft in 10 patients. Postoperative management was similar between the two groups. RESULTS All the operations were completed within 6 h. In the free medial plantar flap group, the mean follow-up period was (11.3 ± 2.4) months, ranging from 9 to 15 months, and all flaps survived; there were no vessel crises. Flaps of 10 patients healed without any complications, and local necrosis occurred in two cases, with healing after debridement. The two-point discrimination (TPD) was 7.0-11.0 mm, and the mean DASH score was 45.6 ± 7.4. In the medium-thickness skin graft group, the mean follow-up period was (10.9 ± 1.8) months. All flaps survived, and local contracture occurred in 3 cases. The TPD was 8.0-11.0 mm, and the mean DASH score was 60.7 ± 9.3. CONCLUSIONS The free medial plantar flap is an ideal option for repairing the hand soft defects resulted from the high-voltage electrical burn.
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Thomas B, Warszawski J, Falkner F, Nagel SS, Vollbach F, Gazyakan E, Schmidt VJ, Kneser U, Bigdeli AK. A Retrospective Comparative Functional and Aesthetic Outcome Study of Muscle versus Cutaneous Free Flaps for Distal Upper Extremity Reconstruction. J Reconstr Microsurg 2021; 38:64-74. [PMID: 34010966 DOI: 10.1055/s-0041-1729882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Function and cosmesis are crucial in upper extremity reconstruction. Yet, there persists a lack of outcome evaluations, particularly regarding differences between free flap types. METHODS In a single-center retrospective analysis, outcomes were compared between patients with cutaneous or muscle free flaps for distal upper extremity reconstruction between 2008 and 2018. The Disabilities of Arm, Shoulder and Hand -Score, Michigan-Hand (MHQ), and Short Form 36 Health Survey (SF-36) Questionnaires were assessed, motor function was quantified, and self-reported measures of cosmesis were compared, including the Vancouver Scar-Scale (VSS), MHQ aesthetics-subscale (MAS), and Moscona's cosmetic validation-score (CVS). RESULTS One-hundred forty-one cases were identified, with a shift toward cutaneous flaps over the study period. Muscle flaps were used for larger defects (251 vs. 142 cm2, p = 0.008). Losses, thromboses, and donor-site complications were equally distributed. Partial necroses were more frequent in muscle flaps (11 vs. 1%, p = 0.015). Seventy patients with 53 cutaneous versus 17 muscle flaps were reexamined. There was no difference in the timing of flap coverage (after 16 vs. 15 days, p = 0.79), number of preceding (2 vs. 1.7, p = 0.95), or subsequent operations (19/53 vs. 5/17, p = 0.77). Patients with cutaneous flaps showed higher grip strength (25 vs. 17 kg, p = 0.046) and reported better hand function (MHQ: 58 vs. 47, p = 0.044) and general health (SF-36: 70 vs. 61, p = 0.040), as well as more favorable appearance (MAS: 71 vs. 57, p = 0.044, CVS: 77 vs. 72, p = 0.048), and scar burden (VSS: 0 vs. 3, p < 0.001). CONCLUSION Cutaneous flaps yielded better motor function, self-perceived cosmesis, patient satisfaction, and quality of life in our cohort of distal upper extremity reconstructions.
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Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany.,Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Jan Warszawski
- Department for Plastic, Hand and Reconstructive Surgery, BG Trauma Center Frankfurt am Main, Frankfurt, Germany
| | - Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Sarah S Nagel
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Felix Vollbach
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Volker J Schmidt
- Department of Plastic and Breast Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany.,Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
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Role, Management, and Outcome of Free Flap Reconstruction for Acute Full-Thickness Burns in Hands. Ann Plast Surg 2021; 85:115-121. [PMID: 32472799 DOI: 10.1097/sap.0000000000002412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Severe thermal trauma to the hand can result in major impairment and reduced function due to defective healing or even extremity loss. Full-thickness injuries frequently incur exposure of tendons or bone and require an early and stable coverage with soft tissue transplants to allow for rapid induction of exercise and to preserve structures and hand function. Free tissue transfer to the hand after thermal trauma is a rare indication, and safety, management, and outcome of free flap surgery for severe acute burn injuries to the hand remains underreported. METHODS Patients with primary reconstructions of full-thickness burn injuries to the hand undergoing microsurgical free tissue transfer surgery were retrospectively assessed in a period from 2013 to 2016. Salvage strategy of the extremity, postoperative complications, length of hospital stay, and primary reconstructive result were quantified and analyzed. Functional outcome measures (range of motion and grip strength) were assessed during clinical follow-up examinations. RESULTS During the investigated period, 13 patients were identified undergoing reconstruction of 14 hands via free flap transplantation after severe burn injury in the acute phase. Nine anteriolateral thigh flaps (64%), 3 latissimus dorsi flaps (18%), 1 serratus anterior flap, and 1 tensor fasciae lata flap (7%) were performed. In all cases, salvage of the affected extremity was achieved, although 1 flap (7%) was lost during the early postoperative period requiring secondary reconstruction via pedicled groin flap. Further complications were venous thrombosis (n = 2; 14%) and hematoma (n = 2; 14%). Mean length of hospital stay was 51 days. Functional outcome during follow-up examination after an average of 9.3 months was inhomogeneous depending on the pattern of injury and ranged from complete recovery to nearly entire loss of hand function. CONCLUSIONS Free flap transfer can be a mandatory and valuable tool to cover full-thickness burn injuries of the hand early in the clinical course of thermal trauma and may provide extremity salvage by favorable means of reconstruction to achieve acceptable functional outcomes, in the most severe cases. Although microsurgical failure rates in burn patients are slightly higher than in free flap transfer to the upper extremity in general, it can be performed with reasonable risk-to-benefit ratio.
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Kotsougiani-Fischer D, Fischer S, Platte J, Nagel SS, Kneser U, Harhaus L. [Evaluation of secondary refinement procedures following free microvascular tissue reconstruction of the upper extremity]. HANDCHIR MIKROCHIR P 2021; 53:356-363. [PMID: 33851377 DOI: 10.1055/a-1294-9593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND The primary cosmetic and functional outcome following successful upper limb salvage using free tissue transfer can often be unfavourable, which may motivate patients to undergo secondary procedures. In this study, we sought to identify predictors for secondary procedures and to analyse the type and number of these procedures. PATIENTS AND METHODS Patients who underwent free tissue transfer to the upper extremity between 2010 and 2017 were included in a retrospective cohort study: patients with secondary procedures to optimise the functional and aesthetic flap design (S cohort) vs. control cohort (C cohort). A multivariate regression analysis was used to identify predictors for secondary procedures. RESULTS One hundred and twenty-eight patients were included in the study (S cohort 36, C cohort 92). All in all, 56 secondary refinement procedures were performed in a mean of eight months after the initial free flap reconstruction. Most of the defects in the S cohort were localised at the hand (53 %), and upper limb salvage was mostly accomplished by fasciocutaneous and adipocutaneous free flaps (S cohort 89 %). The most frequently performed secondary refinement procedures were direct partial flap excision (61 %), followed by liposuction (16 %) and the combination of both (17 %). Furthermore, 64 % of the secondary refinement procedures from the S cohort were combined with further surgical interventions to improve hand function, e. g. tenolysis and arthrolysis. Patients with defects of the hand received secondary procedures 2.4 times more frequently (p = 0.05). Also, patients with a good general health condition (ASA 1 and 2) were six times more likely to undergo a secondary procedure (p = 0.03). CONCLUSION Secondary procedures are safe and frequently requested by patients following successful free flap upper limb salvage. In particular, this applies to patients who are in a good health condition and with free flaps to the hand. Therefore, we recommend the implementation of secondary refinement procedures in the reconstructive plan to increase patient compliance and satisfaction.
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Affiliation(s)
- Dimitra Kotsougiani-Fischer
- BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg
| | - Sebastian Fischer
- BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg
| | - Juliana Platte
- BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg
| | - Sarah Sophie Nagel
- BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg
| | - Ulrich Kneser
- BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg
| | - Leila Harhaus
- BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg
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Schulz T, Leuschner S, Siemers F, Marotz J, Houschyar K, Corterier CC. Assessing flap perfusion after free tissue transfer using hyperspectral imaging (HSI). EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01784-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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29
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Liu X, Sun Y, Jia Y, Hong SM, Xu J, Wang C, Wen G, Lineaweaver WC, Chai Y. Free extended posterior tibial artery perforator flap with the neurovascular plexus of a saphenous nerve branch for large soft tissue and sensory reconstruction: Anatomic study and clinical application. Microsurgery 2020; 41:133-139. [PMID: 33165984 DOI: 10.1002/micr.30675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 10/10/2020] [Accepted: 10/16/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND The posterior tibial artery perforator (PTAP) flap is a useful tool for reconstruction of soft tissue defects in the leg. However, the size and reliability of the flap largely depends on the quality of the perforator by which the flap is supplied, and the sensory recovery of the flap is limited. In this study, the anatomy of the saphenous nerve branches and their accompanying vessels was investigated, and a free extended PTAP flap with the neurovascular plexus of a saphenous nerve branch was designed for large soft tissue and sensory reconstruction in a series of clinical cases. METHODS Sixteen adult cadaveric legs perfused with red latex in the femoral artery were dissected. The number and location of the saphenous nerve branches and the features of their accompanying vessels were dissected and studied. From January 2016 to December 2017, six patients with soft tissue defects ranged from 8 × 2.5 cm to 21 × 4 cm were repaired by the free extended PTAP flap. The patients' average age was 48 years. The causes of the defects included machine injuries in three patients and traffic injuries in the other three. The defects located at the hand in three cases, foot in two cases, and ankle in one case. The flap was designed based on the perforators of the posterior tibial artery and included a branch of saphenous nerve. The perforator pedicle and the nerve branch were connected to the vessels and nerve in the recipient site, respectively. RESULTS The saphenous nerve gave off 5.8 ± 1.1 branches, with a relatively constant one issuing 8.1 ± 0.7 cm distal to the medial femoral condyle. Every nerve branch had an accompanying vessel, which connected with the PTAPs and supplied the skin. The size of the flap ranged from 10 × 3.5 cm to 23 × 5 cm. All of the flaps survived completely without complications. Follow-up varied from 6 to 12 months. All the patients obtained cold/hot sensation and pain sensation. The results of Semmes-Weinstein monofilament test ranged from 4.31(2 g) to 5.46 (26 g), and the 2-point discrimination test varied from 20 to 35 mm. CONCLUSION The free extended PTAP flap, containing the saphenous nerve branch and its accompanying vessels, may be an alternative for large soft tissue reconstruction with improved sensation recovery.
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Affiliation(s)
- Xuanzhe Liu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yi Sun
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yachao Jia
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Sung Min Hong
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jia Xu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Chunyang Wang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Gen Wen
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | | | - Yimin Chai
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Ren GH, Xiang DY, Wu XH, Chen YB, Li R. A neglected problem in the utilization of free anterolateral thigh flap toward reconstructing complicated wounds of extremities: the obliteration of deep dead space. J Orthop Surg Res 2020; 15:483. [PMID: 33087149 PMCID: PMC7579970 DOI: 10.1186/s13018-020-01914-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/24/2020] [Indexed: 11/10/2022] Open
Abstract
Background Deep dead space may be thought as an independent risk factor of the poor infection control after flap reconstruction in complex limb wounds. But it can be easily neglected. The conventional skin flap and musculocutaneous flap are difficult to obliterate the deep dead space in irregular shape effectively. It was investigated that the clinical application of chimeric anterolateral thigh perforator flap in the treatment of complex wounds complicated with deep dead space of the extremities in the paper. Methods Fifty-six cases complicated with deep dead space wounds were registered in group. Following thorough debridement and treatment with VSD, the granulation tissues grew with well-controlled infection. And then the chimeric anterolateral thigh perforator flap was used to obliterate the deep dead space and repair the wounds. The postoperative flap survival and infection conditions were evaluated. Results Overall, the infection was effectively controlled, without persistent exudation or sinus tract formation after wound healing. While 5 cases lost to follow-up, the remaining 51 cases were followed up until 15 months on average. Generally, the affected extremities recovered satisfactorily with normal appearances and texture of the flaps, along with normal functions. Importantly, no recurrence of infection was observed. Conclusion During the grafting of chimeric perforator flap pedicled with lateral thigh muscle flap, the muscle flap is recommended to obliterate the deep dead space while the skin flap is being used to cover the wound. The combination of these two technologies performed well in the repair and reconstruction of the complex wounds of the extremities, possessing potential for broader clinical application.
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Affiliation(s)
- Gao-Hong Ren
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Da-Yong Xiang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Xiao-Hu Wu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yun-Biao Chen
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Runguang Li
- Department of Orthopedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510610, China. .,Orthopaedic Hospital of Guangdong Province, Guangzhou, 510610, China. .,Academy of Orthopaedics, Guangzhou, 510610, Guangdong Province, China. .,Department of Orthopedics, Linzhi people's hospital, Linzhi, 860000, China.
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Goffinet L, Dantzer E. Coverage of soft tissue defects in acute surgery for deep burns of the limbs. ANN CHIR PLAST ESTH 2020; 65:345-379. [PMID: 32928577 DOI: 10.1016/j.anplas.2020.07.012] [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: 07/26/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022]
Abstract
Burns of the limbs affect 48.6% of burn patients. Injury mechanisms condition their depth and degree of extension. Injury of the hands and/or the joint areas entails considerable risk of retraction. Coverage is consequently doubly challenging, it is a matter not only of compensating for a soft tissue defects, but also of striving to prevent early (infectious) and late (amplitude limitation, pain, loss of function…) complications. Thoroughgoing assessment of the initial injury and associated lesions is conducive to rapid determination of a therapeutic strategy tailored to the relevant functional issues and subsequent rehabilitation. Following a summary of the epidemiological elements and the medical context of management, a review of existing treatments has been drawn up based on the data in the literature and current professional recommendations. Emergency procedures, the different types of excision and the possibilities of autologous covering and skin substitutes are reported. Last but not least, routinely validated indications are synthesized.
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Affiliation(s)
- L Goffinet
- Service de chirurgie infantile orthopédique/pediatric orthpedic surgery unit, hôpital d'enfant/children's hospital, université de Lorraine/university of Lorraine, CHRU de Nancy, 11, rue du Morvan, 54510 Vandœuvre-lès-Nancy, France.
| | - E Dantzer
- Centre des brûlés/burn treatment, hôpital d'instruction des armées Sainte-Anne/Sainte-Anne armed forces teaching hospital, boulevard Sainte-Anne, BP 20545, 83041 Toulon, France.
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Cordts T, Bigdeli AK, Hirche C, Hernekamp JF, Grützner PA, Reiter G, Kneser U. [Options for soft tissue reconstruction in pseudarthrosis]. Unfallchirurg 2020; 123:694-704. [PMID: 32737514 DOI: 10.1007/s00113-020-00852-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pseudarthrosis can develop as a complication after conservative or operative fracture treatment and after elective orthopedic surgery. The treatment is challenging and is made more difficult when accompanied by large soft tissue defects or impairments in wound healing. In this case close and early coordination between trauma and plastic surgeons is crucial in order to develop a coherent and interdisciplinary treatment plan. METHODS Due to the positive effects on bone consolidation and osteomyelitis, timely soft tissue reconstruction via a pedicled vascularized flap or free flap coverage should be preferred. If blood circulation in the affected extremity appears to be compromised, this should first be optimized by vascular intervention or bypass surgery. In atrophic, aseptic pseudarthrosis, bone and soft tissue reconstruction can be performed consecutively in one single procedure, whereas septic pseudarthrosis always require complete resection of all infected debris prior to wound closure. Examples of two commonly used free flaps are the latissimus dorsi muscle flap and the fasciocutaneous anterolateral thigh (ALT) flap. As multiple variations have been described for both procedures, the reconstructive portfolio lists many additional options available for soft tissue reconstruction. Fasciocutaneous flaps should be preferred whenever bone consolidation requires additional surgical interventions in the future.
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Affiliation(s)
- T Cordts
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland.
| | - A K Bigdeli
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
| | - C Hirche
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
| | - J F Hernekamp
- Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Handchirurgie, Martin Luther Krankenhaus, Berlin, Deutschland
| | - P A Grützner
- Klinik für Unfallchirurgie und Orthopädie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
| | - G Reiter
- Klinik für Unfallchirurgie und Orthopädie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
| | - U Kneser
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
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Thomas B, Warszawski J, Falkner F, Nagel SS, Schmidt VJ, Kneser U, Bigdeli AK. A comparative study of preoperative
color‐coded
Duplex ultrasonography versus handheld audible Dopplers in
ALT
flap planning. Microsurgery 2020; 40:561-567. [DOI: 10.1002/micr.30599] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/03/2020] [Accepted: 04/24/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Jan Warszawski
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Florian Falkner
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Sarah S. Nagel
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Volker J. Schmidt
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
| | - Amir K. Bigdeli
- Department of Hand, Plastic and Reconstructive SurgeryBurn Center, BG Trauma Center Ludwigshafen, University of Heidelberg Ludwigshafen Germany
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