The subcutaneous pedicle tensor fascia lata flap

Descriptive Analysis of Surgical Outcomes and Stoma Formation for Treating Sacral and Anal Pressure Injuries in Spinal Cord Injury: A Retrospective Study of Selected Cases

Introduction

Pressure injuries (PIs) arise from sustained pressure on tissue, leading to reduced blood flow to the affected area. In patients with spinal cord injuries (SCIs), these PIs can significantly diminish their independence and overall quality of life. This research sought to assess the frequency of surgical complications in treatment regimens for large sacral PIs involving the anus. Specifically, the study focused on the incorporation of stoma formation in patients with SCIs.

Methods

A retrospective review identified 25 SCI patients who had extensive sacral PIs. These patients underwent intestinal stoma formation as a preparatory step before plastic reconstructive surgery to address the wounds between 2015 and 2020.

Results

Successful wound closure was achieved in all instances. Notably, each patient had experienced a minimum of three unsuccessful reconstructive surgeries elsewhere before this intervention. The observed rate of surgical complications aligned with findings from previous analogous studies.

Conclusion

While often viewed as a treatment of last resort, an intestinal stoma might serve as a valuable strategy, particularly for SCI patients with extensive PIs near the anal region, to promote the healing of such injuries. Tailored decision-making is essential to ensure the best possible patient outcomes.

The Marriage of Sartorius and Tensor Fasciae Latae in Treating Vascular Prosthetic Graft Infections

Background:

Vascular prosthetic graft infection in the groin is associated with high morbidity and mortality. This article presents a case series on the use of 2 flaps in the treatment of this condition.

Methods:

Five patients, mean age 65 years (range, 49–74 years), with significant comorbidity were treated for an exposed and infected vascular prosthetic graft in the groin with a combination of sartorius muscle (SM) flap and tensor fascia lata (TFL) myocutaneous flap after debridement and start of microbiologic culture–guided antibiotic treatment. The SM flap was used to cover the exposed graft. To obtain stable wound coverage, the SM and remaining groin defect were closed with a pedicle TFL flap.

Results:

All flaps survived, with only 1 TFL flap suffering a small tip necrosis. All patients obtained stable wound coverage. Donor-site morbidity was minimal. During the follow-up, mean 46 months (range, 15–79 months), 1 patient had a recurrence after 15 months due to a kink in the elongated prosthetic graft that protruded through the skin alongside the SM and TFL flaps.

Conclusions:

The combination of SM and TFL flaps could be a new treatment option for patients who have an exposed and infected vascular prosthetic graft in the groin. This flap combination could also be used as a prophylactic procedure for those patients with a high risk to develop such a serious complication.

Reconstruction of Radiated Gluteal Defects following Sarcoma Resection with Pedicled Sensate Tensor Fascia Lata Flaps

Sarcomas of the gluteal region often result in sizable defects following resection that are challenging to reconstruct due to their location, particularly in patients who have received radiation therapy. Reconstruction of these defects has been seldom discussed in the literature. We present two patients with large radiated gluteal defects following sarcoma resection, of which one patient received neoadjuvant radiation and the other received intraoperative radiation therapy. As a result of the resection and radiation, local tissues and recipient vessels were unsuitable for use in reconstruction. A pedicled tensor fascia lata (TFL) flap was therefore performed in both cases, which resulted in durable sensate reconstruction with good functional outcomes and no complications. We believe the pedicled TFL flap represents an important option for the reconstruction of oncologic gluteal defects that provides well-vascularized and sensate tissue from outside the zone of radiation without the need for microsurgical techniques.

Tensor fascia lata flap reconstruction following groin dissection: is it worthwhile?

OBJECTIVE

To compare the morbidity of primary skin closure with elective Tensor Fascia Lata (TFL) flap cover in groin dissections.

MATERIALS AND METHODS

This was a retrospective study between January 2007 and December 2009. All patients undergoing groin dissections without skin involvement were included.

RESULTS

Of the twenty-five patients, who underwent groin dissections, 14 had primary skin closure (28 groin dissections)-group I. Eleven had TFL flap cover as a means of primary reconstruction (20 groin dissections)-group II. In group I, there were 16 (57%) inguinal dissections and 12 (43%) ilioinguinal block dissections, whereas 82% in group II underwent ilioinguinal dissections (p = 0.09). Wound infection requiring treatment with a culture specific antibiotic was required in 4 (14%) in group I (n = 28) and only 1 (5%) in group II (n = 20) (p = 0.38). In group I, 7 (25%) had major flap necrosis and minor necrosis was seen in another 7 (25%). Only three (15%) in group II developed minor flap necrosis (p = 0.01). Following an ilioinguinal dissection, flap necrosis occurred in 75% of groins that underwent primary closure and in 17% of those which were reconstructed with TFL (p = 0.001). Seroma formation was seen in 5 (18%) in group I and 3 (15%) in group II (p = 1.0). Lymphoedema occurred in equal numbers in both groups. The duration of hospital stay was 20 ± 14 days in the primary closure group and 16 ± 3 days in the TFL group.

CONCLUSION

The TFL flap can reduce postoperative morbidity and decrease hospital stay. Prophylactic TFL flap reconstruction following ilioinguinal dissections is advisable.

Sensibility following innervated free radial forearm flap for penile reconstruction

BACKGROUND

The free radial forearm flap has proven to be reliable for penile reconstruction. The purpose of this study was to determine whether neurotization of this flap improved sensation of the reconstructed penis.

METHODS

A long-term follow-up study of 45 patients undergoing penile reconstruction using free radial forearm flap was performed; 28 of the 45 patients received an innervated flap, and 17 received a noninnervated flap. A nerve repair between the dorsal nerve of the penis and the lateral antebrachial cutaneous nerve was performed for innervation. Sensory testing, including pain perception, temperature perception, vibratory threshold, and static two-point discrimination, was performed by one blinded examiner in a standardized pattern.

RESULTS

Mean follow-up time was 9.1 years. Mean patient age was 26.4 years (range, 18 to 48 years). Postoperative pain perception and vibratory threshold were similar between the two groups in the proximal part of the neophallus but were significantly better in the innervated flaps (p < 0.01) in the distal part. Noninnervated flaps displayed a pattern of increasing sensibility from the distal part toward the proximal part, whereas innervated flaps regained sensation throughout. The innervated group had a better result of temperature perception and static two-point discrimination in both the proximal and the distal parts.

CONCLUSIONS

Innervation of free radial forearm flap provides improved sensation to the reconstructed penis. If it is possible to find the functional recipient nerve, innervation should always be conducted.

Immediate repair of major abdominal wall defect after extensive tumor excision in patients with abdominal wall neoplasm: a retrospective review of 27 cases [corrected]

BACKGROUND

The treatment of abdominal wall neoplasm continues to present a challenging problem because it is not easy to repair the giant defect which is resulted from extensive tumor excision. Some techniques and materials have been reported, but most report a certain technique or material for abdominal wall reconstruction. Therefore, we retrospectively reviewed the treatment of such patients in our department and assessed the reconstruction algorithm in such a situation.

METHODS

We studied 27 patients undergoing immediate abdominal wall reconstruction between 1999 and 2008 who sought care for major defects after extensive tumor excision of malignancy. We categorized the defects into three types: type I, defects involving only the loss of skin (15 cases); type II, myofascial defects with intact skin coverage (6 cases); and type III, myofascial defects without skin coverage (6 cases). Different techniques and materials were used. Postoperative morbidities, sign of herniation, and other follow-up data were recorded.

RESULTS

The immediate abdominal wall reconstruction was successful in all patients. There was no severe morbidity after the operation. Only one patient developed hernia.

CONCLUSIONS

Most type I defects can be corrected with primary suture. For type II defects, a prosthetic or biological mesh, or alternatively an autologous fascial substitute, may be used. For type III defects, the resulting full-thickness defect will require a myocutaneous flap, such as the tensor fascia lata flap, with or without a mesh for abdominal wall reconstruction. Human acellular dermal matrix, a biological mesh, is an ideal alternative for synthetic mesh, especially in situations of infection or contamination.

Abdominal Wall Reconstruction in a Trauma Setting

According to the World Health Organization "Global burden of disease study", future demographics of trauma are expected to show an increase in morbidity and mortality. In the past few decades, the field of trauma surgery has evolved to provide global and comprehensive care of the injured. While the modern day trauma surgeon is well trained to deal with multitrauma patients with injuries involving several systems, the ever-increasing nature and variety of multitrauma has left lacuna in certain areas. One such area is the management of abdominal wall injuries, which has been the domain of both plastic and reconstructive and general surgeons. The trauma surgeon is adept at treating the contents of the abdomen but not always the container. If not managed properly complications associated with abdominal wall injuries can lead to increased morbidity and mortality. In considering reconstruction of the abdominal wall in multitrauma patients proper evaluation, scrupulous planning, appropriate, and meticulous technique improve the chances for success with minimal complications. In the present article, we provide a brief description of the most commonly used procedures, and more importantly we outline the principles and guidelines applied to abdominal wall reconstruction in order to inform the trauma surgeon of different available treatment options. In doing so, we hope that this review will assist trauma surgeons in their overall care of patients that present with abdominal injuries.

The "duck" modification of the tensor fascia lata flap

Various common locations of pressure sores require specific considerations. The most commonly used flap for the treatment of trochanteric ulcers is the tensor fascia lata (TFL) flap. According to our experience with the original flap, excessive tension and eventual suture separation at the confluence of the donor site flaps and the TFL flap is the most common problem. The purpose of this article is to present a new design for the TFL flap for the coverage of trochanteric pressure sores. An anterior triangular extension is designed exactly at a point where the flaps that will cover the donor site unite after transposition. The desepithelialized proximal part of the flap is folded into the pouch and sutured. The duck flap was applied to 31 trochanteric pressure sores in 27 patients with no major complications. This modification has many advantages: (1) the flap is reliable and easily designed, (2) formation of dead space and cone-shaped dog-ear deformity due to rotation is prevented, (3) better esthetic results are achieved, (4) suture separation is prevented via a tension-free closure, (5) the desepithelialized part produces tight attachment of the flap to the recipient bed, (6) as no muscle tissue is included, the flap is more resistant to pressure.

A single tensor fasciae latae musculocutaneous and fascia flap for composite reconstruction of urogenital and groin defect

The tensor fasciae latae flap is a well known musculocutaneous flap used for many indications in the field of plastic surgery. The flap has some modifications to fit different reconstructive requirements of the defects. Osseous-muscle flap, osseous musculocutaneous flap, muscle flap, muscle-fascial flap and musculocutaneous-fasciocutaneous flap are some known alternatives. We used a modification of this well-known flap as musculocutaneous and fascia flap for a composite reconstruction of groin and urogenital defect. We reconstructed the groin defect with musculocutaneous part of the flap, and the defect over neourethra with the fascial extension and grafting. The aim of this modification was to reconstruct a genital defect with a thin and more pliable tissue to overcome the problem of distortion, kinking and thickness of the flap.

Modification of the tensor fasciae latae flap for reconstruction of the abdominal wall: a case report

Full-thickness periumbilical wounds after extensive abdominal surgery present a major challenge. In this case report the traditional tensor fasciae latae flap was modified, improving flap mobility while also facilitating donor defect repair.

Penile resurfacing with vascularized fascia lata

Penis resurfacing is a challenging procedure, and should simultaneously ensure erectile function, tactile sensibility, sexual satisfaction, and aesthetic integrity. This article presents three cases with penile skin defects treated by means of a pedicled fascia lata attached either to the tensor fascia lata (one case) or an anterolateral thigh flap (two cases). The cause of the wounds included electrical burn, Fournier's gangrene, and self-mutilation. The size of flaps ranged from 10-13 cm in width and 15-30 cm in length. All flaps included vascularized fascia lata, which covered part or the circumference of the penis. All flaps survived completely. The lateral cutaneous nerve of the thigh was included in the designed flaps in all instances, and normal protective sensation was recorded postoperatively. The patients reported normal erectile function and ability to perform intercourse. The flaps, though relatively bulky and hairy, had a good color and texture match with the penis and suprapubic region. Based on our limited experience, we believe that the anterolateral thigh flap has greater dimensions with a longer pedicle, and allows for greater flexibility in flap design compared to the tensor fascia lata flap. An anterolateral thigh flap can be safely thinned in a second stage, and it is our flap of choice for penis resurfacing.

Tensor Fasciae Latae Combined With Tangentially Split Vastus Lateralis Musculocutaneous Flap for the Reconstruction of Pressure Sores

Pressure sores in the ischial and the trochanteric regions are usually encountered in long-term bedridden and wheelchair-dependent patients. A number of techniques have been developed for the reconstruction of pressure sores. Tensor fasciae latae musculocutaneous flap has been extensively employed to close the trochanteric defect. Despite its utility of having a constant pedicle and proximal bulky muscle, the relative shortness of the flap and insufficient padding in the distal portion limit the applications for distant locations of pressure sores. From January 2001 to December 2003, 8 patients with ischial and trochanteric pressure sores underwent tensor fasciae latae reconstruction in combination with tangentially split vastus lateralis muscle. The descending branches of the lateral circumflex femoral arteries were also included in these flaps. All of the procedures have been successful, and no flap necrosis has been observed. Sufficient bulk of the flap and reliable distal skin paddle constitute the advantages of this flap.

Repair of a giant inguinoscrotal hernia

We present a case of a long-standing, giant inguinoscrotal hernia extending to the patient's knees, complicated by intestinal obstruction. Initial management involved conservative treatment of the intestinal obstruction and optimising the patient's general condition. Surgical treatment included debulking the contents of the hernia sac by performing a right hemicolectomy and a small bowel resection, and reconstruction of the abdominal wall using Marlex mesh and a tensor fasciae latae flap. Although abdominal wall reconstruction for massive ventral or incisional herniae is well reported, inguinoscrotal herniae of this magnitude are much rarer and pose additional problems, which are discussed in this paper.

Neophalloplasty in female-to-male transsexuals with the island tensor fasciae latae flap

In the past 60 years, several different procedures have attempted to achieve a postoperative neophallus that is as aesthetic and as functional as possible after penile amputation or sex reassignment. Recently, with improvements in free tissue transfer and microvascular technique, many free flap procedures have been developed with the goal of an aesthetically acceptable neophallus of adequate bulk that enables urination in a standing position and sexual intercourse, with minimal functional and aesthetic donor-site defects. Most authors currently agree that the method of choice for penile reconstruction is microsurgical free tissue transfer, although it does not always fulfill all of the aforementioned goals in a predictable manner. In fact, complete urethroplasty, penile rigidity, and donor-site disfigurement remain challenges, thus making this operation one of the most difficult in plastic surgery. The vascular anatomy of the lateral circumflex femoral artery, which we studied in 1991 with the anatomic dissection of 27 cadavers, gave us the idea to use a long tensor fasciae latae neurovascular island flap as a donor source for neophalloplasty. Grounds for the procedure and its surgical planning have been carefully evaluated with 10 additional fresh cadaver dissections. Since 1991, we have performed five neophalloplasties using this procedure; all patients were female-to-male transsexuals. In four cases, the healing was uneventful; in one case, there was a marginal necrosis of the flap because of poor venous drainage, probably from a twisting of the pedicle. The island tensor fasciae latae provides a safe and sensate flap for phalloplastic procedure and leaves a less conspicuous donor scar.

Island V-Y tensor fasciae latae fasciocutaneous flap for coverage of trochanteric pressure sores

The distal fasciocutaneous portion of the lateral thigh is supplied by the direct cutaneous branch of the lateral descending branch of the lateral circumflex femoral artery and the third perforating artery of the deep femoral artery. This consistent vascular anatomy allows raising a distal skin island based on both arteries on the lateral thigh, and this flap can be advanced into a trochanteric defect according to the V-Y technique. Based on anatomic and clinical study, a new design has been developed of the tensor fasciae latae fasciocutaneous flap, which is supplied by two pedicles. Seven island V-Y tensor fasciae latae fasciocutaneous flaps have been used for the coverage of trochanteric pressure sores in six patients. It is believed that the island V-Y tensor fasciae latae fasciocutaneous flap could overcome the traditional drawbacks of the conventional tensor fasciae latae flap and its modifications, and this is an ideal flap for covering trochanteric pressure sores without any donor site deformity and morbidity, which greatly improves the aesthetic result.