De-epithelialized fasciocutaneous turnover flap for recurrent calcaneal wound with osteomyelitis

Reverse Dermis Flap for Coverage of Distal Leg and Ankle Defects

Soft tissue defects of the distal third of the leg and ankle, which frequently expose tendon, bone or osteosynthesis material, are difficult to cover and pose a major challenge to the plastic surgeon. Traditional reconstructive options for this region usually require complex flaps which made them unsuitable for elderly patients or those with multiple comorbidities. We hereby present the reverse dermis flap as an easy and reliable choice to cover this type of wounds and refer our experience in 9 cases in which clinical, operative, and follow-up data were recorded. Of the 9 flaps performed, 8 survived completely and 1 presented a partial flap necrosis, requiring additional surgery. No other operative procedure was required. In conclusion, the reversed dermis flap is a simple, quick, noninvasive, and safe technique for coverage of noble structures such as tendon or bone in the distal third of the leg that every plastic surgeon should incorporate in his surgical armamentary.

Coverage of residual defects by using previous flaps: Flip flap puzzle flap

INTRODUCTION

Terminal flap necrosis and flap retraction is a difficult problem faced by surgeons. These require some other flap for coverage of defect with limited local tissue availability. Flip flap puzzle flap is an option for small defect coverage using previous flap.

METHODOLOGY

This flap is harvested from previous flap and raised at sub-dermal level. The flap is flipped 180° on itself to cover the defect. The residual area is finally covered with split skin graft.

RESULTS

This is a prospective study conducted on 10 patients, with 9 flap survival and 1 flap failure. In 7 out of 10 cases partial graft failure was observed, but all the defects healed eventually.

DISCUSSION AND CONCLUSION

This flap is a less morbid and rapid option for coverage of small sized defects. It has no donor site morbidity as flap is raised from the previously harvested flap.

Use of Local Flaps for Soft-Tissue Closure in Diabetic Foot Wounds: A Systematic Review

"A systematic review was undertaken to assess the outcomes of local random flaps in diabetic foot wound closure. The review was conducted using the following databases: Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, Excerpta Medica dataBASE, Google Scholar, MEDLINE, Ovid, and PubMed. Search terms were local random flap, diabetes, foot, wound, ulceration, neuropathy, tissue transfer, V-Y, bilobed, monolobed, rotational, advancement, transpositional, rhomboid, and Limberg. English language studies, studies published from 1997 to 2017, patients with diabetes mellitus treated for foot wounds, use of local random flaps, follow-up period of 6 months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery were included. Isolated literature reviews and descriptions of only surgical technique and/or cadaveric studies were excluded. The initial search identified 53 eligible studies with 28 being excluded. The remaining 25 studies used for data extraction had a total of 512 patients in which 199 of these underwent 204 local random flap procedures. Average follow-up for the flaps was approximately >2 years, and successful wound closure at last follow-up was demonstrated in 75.5% of the studied population. Studies were found to be of generally low quality, with the majority composed of retrospective case series. Based on current available evidence found in this systematic review, local random flaps demonstrated a relatively high success rate when utilized for the definitive closure of diabetic foot wounds. However, because of a lack of high-quality evidence and substantial heterogeneity among the studies, the results should be interpreted with caution. Levels of Evidence: Level III: Systematic review.

Vascularized dermal autograft for the treatment of irreparable rotator cuff tears

BACKGROUND

Irreparable rotator cuff tears (IRCTs) are a challenging problem with diverse treatment modalities. We propose a technique for the treatment of IRCTs in which a vascularized dermal autograft is transferred to the posterosuperior region of the rotator cuff using the supraclavicular artery (SCA) island flap.

MATERIALS AND METHODS

Dissection of 11 fresh cadavers (19 shoulders) was performed, and the SCA island flap was harvested in all specimens. A full-thickness posterosuperior rotator cuff defect was created, and the flap was tunneled under the acromion and secured into position over the defect using multiple suture anchors. Simulated flap perfusion was then assessed, and flap measurements were recorded.

RESULTS

There were 4 male and 7 female cadavers (19 shoulders). Flap perfusion was assessed in 10 shoulders. On average, the flap thickness was 4.7 mm (range, 3.5-7.1 mm); width, 32.6 mm (range, 25.5-38.0 mm); and length, 169.2 mm (range, 132.0-235.0 mm). The average distance from the flap tip to the Neviaser portal was 76.2 mm (range, 48.0-99.6 mm), and that from the flap tip to the anterolateral acromial edge was 54.1 mm (range, 29.5-75.1 mm). The pedicle-to-footprint distance was 113.7 mm (range, 88.5-147.0 mm). The average flap length exceeded the pedicle-to-footprint distance by 55.5 mm (range, 43.5-88.0 mm), indicating adequate excursion of the flap. All flaps demonstrated adequate simulated perfusion after fixation.

CONCLUSION

The SCA island flap may be an option for a vascularized dermal autograft for IRCTs, as shown in this cadaveric study. This illustrates a possible technique with vascular viability.

A Modified Technique to Improve Reliability of Distally Based Sural Fasciocutaneous Flap for Reconstruction of Soft Tissue Defects Longitudinal in Distal Pretibial Region or Transverse in Heel and Ankle

Partial flap loss is a common complication of the distally based sural fasciocutaneous flap. We present a modified technique of a sloped skin island design to improve the reliability of the flap when used to reconstruct a longitudinal distal pretibial defect or transverse heel and ankle defect. Thirty-one flaps with the slope-designed skin island were used to reconstruct such defects in 30 patients. In the modified technique, the skin island was rotated toward the vascular axis of the flap. The defects were located in the distal pretibial region in 7 cases and the ankle and heel region in 24. The horizontal dimension of the skin island decreased by an average of 5.6 (range 2.5 to 14.8) cm with the sloped design, and the rotation angle varied from 42° to 90° (mean 69°). Of the 31 flaps, 29 survived, 1 developed marginal necrosis, and 1 developed lateral partial necrosis. The sloped design of the skin island is applicable to reconstruction of longitudinal distal pretibial or transverse heel and ankle defects. The modified technique can decrease the horizontal dimension and increase perfusion of the skin island, thus improving the reliability of the flap.