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Yu Z, Jin S, Zang M, Zhu S, Li S, Han T, Chen Z, Liu Y. Successful Reconstruction of Complex Sacrococcygeal Defects Using Chimeric Perforator Propeller Flap. Ann Plast Surg 2023; 91:597-603. [PMID: 37823625 DOI: 10.1097/sap.0000000000003698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Complex soft tissue defects, which result from the surgical resection of sacral tumors, manifest as a combination of skin defects, dead space, infection, and prosthesis exposure. Because the traditional musculocutaneous flap lacks flexibility because of the close connection between the skin flap and the muscle component, the musculocutaneous flap is not suitable for reconstructing complex soft tissue defects where the dead space and skin defects are located at different sites. Furthermore, the perforator flap is also not appropriate for reconstructing complex defects because it lacks the muscular component. We considered the possibility of using the chimeric perforator propeller flap for reconstructing complex sacrococcygeal defects. METHODS This study included 7 patients who underwent, between July 2007 and July 2021, the reconstruction of complex soft tissue defects of the sacrococcygeal region using a chimeric perforator propeller flap. RESULTS Among the included cases, the etiologies were chordoma (n = 3), sacral tumor (n = 3), and squamous cell carcinoma (n = 1). In all the cases, vacuum-assisted closure therapy was used to treat wound infections before surgery. The average sizes of the skin and muscle flaps were 195.8 cm 2 (range, 100-350 cm 2 ) and 83.6 cm 2 (range, 60-140 cm 2 ), respectively. The superior gluteal artery was the source artery for the chimeric perforator propeller flap. The donor sites were primarily closed in all cases. One patient had delayed wound healing, and the secondary wound healed using conservative dressing changes. The other 6 flaps had no complications. The average follow-up time was 5.3 months (range, 1-9 months). Muscle weakness and compromised ambulation in the affected lower extremities were not observed in any of the patients. Furthermore, all 7 patients had no tumor recurrence, prosthesis exposure, and infection events in the sacrococcygeal region. CONCLUSIONS The chimeric perforator propeller flap may be an option for reconstructing complex soft tissue defects in the sacrococcygeal region.
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Affiliation(s)
- Zouzou Yu
- From the Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Pu LLQ, Song P. Advancing the Specialty of Plastic Surgery While Helping and Supporting Other Surgical Services at an Academic Medical Center. Ann Plast Surg 2021; 87:369-376. [PMID: 33512821 DOI: 10.1097/sap.0000000000002728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT While helping and supporting other surgical services at our academic medical center, we noticed that many clinical problems presented to our plastic surgery team are truly unique and challenging. Many of the necessary reconstructive procedures, performed by the senior author, had never been published in plastic surgery textbooks or the literature before. Because of the plastic surgeon's creative problem-solving ability, we use reconstructive treatment plans that also innovate and advance the field of plastic surgery. In this case series, we share our experience with creative solutions for the management of novel and challenging clinical problems faced by our plastic surgery service. The resultant and effective solutions for each challenging case have all been published in reputable plastic surgery journals by the senior author. Once published, our inventive reconstructive solutions can be harnessed by other plastic surgeons and trainees and new standardized techniques or solutions for these unique and challenging clinical problems can be established. Ultimately, plastic surgeons can evolve their specialty through helping and supporting other surgical services at an academic medical center by establishing innovative solutions for ever arising challenging clinical problems. Once again, the plastic surgery team in a tertiary hospital supports many surgical services so that more complex surgical procedures can be performed safely and complications from other surgical services can be managed successfully. Therefore, adequate support for a plastic surgery service, by the hospital or department, is critical in developing a strong plastic surgery program at an academic medical center.
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Affiliation(s)
- Lee L Q Pu
- From the Division of Plastic Surgery, Department of Surgery, University of California, Davis, Sacramento, CA
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Yan M, Rose PS, Houdek MT, Moran SL. Outcomes of the keystone perforator island flap for oncologic reconstruction of the back. J Surg Oncol 2021; 124:1002-1007. [PMID: 34324204 DOI: 10.1002/jso.26629] [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] [Received: 04/02/2021] [Revised: 05/23/2021] [Accepted: 07/18/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Coverage of posterior trunk defects after tumor resection can be challenging due to the intricate anatomy. The keystone perforator island flap (KPIF) provides coverage of the defect without the need for distant flap coverage or microsurgery, matches the recipient's skin color and contour, and requires a short operative time. METHODS A retrospective review of all oncological back reconstructions with KPIF was performed at our institution. The patient comorbidities and surgical outcomes were collected. RESULTS A total of 17 patients underwent 20 KPIF (15 single and 2 double) for back reconstruction. Surgical indications were sarcoma (n = 12) and melanoma (n = 5). The mean age at surgery was 47.3 years (SD 23.3). The flaps were located in the upper back (n = 8), paraspinal (n = 4), middle back (n = 6), and lower back (n = 2). The average wound size after sarcoma and melanoma excision were 231.6 ± 297.4 and 156.7 ± 269.7 cm2 , respectively. Four patients required an additional planned skin graft and one patient underwent a simultaneous myocutaneous latissimus dorsi flap. The mean operative time, including tumor resection, was 256 min (SD 118). The median length-of-hospital stay was 3 days (Q1-3: 1-6.5) and the median follow-up time was 35.3 months (Q1-3: 13.3-53.1). All flaps survived with minor surgical complications which included hematoma (n = 1), surgical site infection requiring debridement (n = 1), superficial wound dehiscence (n = 1), cellulitis (n = 1), and seroma (n = 1). The reconstructions were successful in 100% of patients. CONCLUSIONS The KPIF is a reliable and safe option for reconstruction of oncological back defects with minimal perioperative complications. This flap option avoids the use of free flaps and myocutaneous flaps for moderate-sized back defects.
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Affiliation(s)
- Maria Yan
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter S Rose
- Department of Orthopedics, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew T Houdek
- Department of Orthopedics, Mayo Clinic, Rochester, Minnesota, USA
| | - Steven L Moran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Orthopedics, Mayo Clinic, Rochester, Minnesota, USA
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Datlı A, Karasoy İ, Zeynal M. Treating surgical site infection following posterior instrumentation with free-style deepithelialized propeller flap: A case report. Jt Dis Relat Surg 2021; 32:531-535. [PMID: 34145835 PMCID: PMC8343835 DOI: 10.52312/jdrs.2021.78727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 02/17/2021] [Indexed: 11/14/2022] Open
Abstract
Surgical site infection is a challenging situation for all types of surgeons. Extensive debridement with or without implant removal can create soft tissue defects. A well-vascularized, adequate soft tissue is needed to cover the wound and to fill the dead space for proper healing. Herein, we describe our approach to a large posterior trunk defect with dead space and our solution to manage an intraoperative complication using a free-style deepithelialized propeller flap.
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Affiliation(s)
| | - İsmail Karasoy
- Gümüşhane Devlet Hastanesi Ortopedi ve Travmatoloji Kliniği, 29000 Gümüşhane, Türkiye.
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Hernekamp JF, Cordts T, Kremer T, Kneser U. Perforator-Based Flaps for Defect Reconstruction of the Posterior Trunk. Ann Plast Surg 2021; 86:72-77. [PMID: 32541540 DOI: 10.1097/sap.0000000000002439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Full-thickness soft tissue defects of the back remain challenging clinical problems for reconstructive surgeons. Among a vast variety of local flap options, perforator-based local flaps gain increasing popularity lately. Because mostly heterogeneous patient cohort comparison of different perforator flaps is difficult and decision-making algorithms are lacking. METHODS Patients, who received a local perforator-based soft tissue reconstruction between 2012 and 2019, were evaluated retrospectively. Patients' data were evaluated in terms of flap type and dimension, wound size and cause, surgery time, postoperative complications, and hospitalization. A focus was set on decision making concerning reconstructive techniques and flap choice for defect closure. RESULTS Thirty-six patients (17 women, 19 men) were included, who received 40 perforator-based local flaps to reconstruct extended defects of the posterior trunk. Mean patient age was 56.3 years and mean hospitalization was 29 days. Average time of flap surgery was 179.7 minutes. Mean flap size was 160.8 cm and average defect size was 110 cm. Defects occurred because of tumor resection (50%), orthopedic/trauma surgery (16.7%), or pressure sores (33.3%). Twenty-eight propeller flaps (PPFs, 70%) and 12 perforator-based VY-advancement flaps (P-VYF, 30%) were transferred. In 4 patients, a bilateral approach using more than one flap was necessary. Revision surgery was required in 9 patients (25%) because of postoperative hematoma (n = 3), postoperative wound infection (n = 3), partial flap necrosis (1× P-VYF) and 2 flap losses (2× PPFs). CONCLUSIONS Pedicled perforator flaps are a reliable option for soft tissue reconstruction of complex wounds of the posterior trunk. A flexible surgical strategy is mandatory, and the individual perforator anatomy has to be considered. In most cases, P-VYFs or PPFs are reliably possible and allow sufficient defect reconstruction. However, skin incisions should always be performed in a way that classic random pattern flaps are still possible. Even in large defects combined, local perforator flaps may lead to sustainable soft tissue reconstructions without functional donor site deficits.
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Affiliation(s)
| | - Tomke Cordts
- From the Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen
| | | | - Ulrich Kneser
- From the Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen
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Abstract
The reconstruction of complex posterior trunk defects remains challenging. But now with an increased knowledge of angiosomes and the practice of perforator flaps, the posterior trunk offers a new plethora of options for reconstruction. Propeller flaps based on such perforator(s) offer an elegant solution for managing defects while achieving primary donor-site closure without significant morbidity. We will discuss the relevant anatomy and design principles for propeller flaps based on a review of the literature and our experience. Steps beginning with preoperative planning, perforator selection, and intraoperative surgical technique will be discussed, together with pearls on both avoiding and managing complications.
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Affiliation(s)
- Daniel J Kedar
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Changsik John Pak
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyunsuk Peter Suh
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Best Local Flaps for Lower Extremity Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2774. [PMID: 32440438 PMCID: PMC7209892 DOI: 10.1097/gox.0000000000002774] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 02/24/2020] [Indexed: 12/05/2022]
Abstract
Supplemental Digital Content is available in the text. The ideal reconstruction of lower limb defects should replace like with like and minimize morbidity to the donor site, achieving the best possible esthetic and functional outcome. The goal is to obtain stable healing and to resume daily life in an efficient manner. Although the classical local flaps such as gastrocnemius, soleus muscle flap, and the reverse sural flap have allowed to achieve those goals, perforator flaps are now added on to the armamentarium in lower extremity reconstruction using local flaps. A perforator-based local flap, such as a propeller or keystone flap, has made reconstruction efficient while further reducing donor-site morbidity. This article aims to provide a useful review of the best available local flaps for lower limb defects.
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Chang JW, Oh SW, Oh J, Choi MSS. Treatment of deep cavities using a perforator-based island flap with partial de-epithelization. BMC Surg 2018; 18:96. [PMID: 30419885 PMCID: PMC6233539 DOI: 10.1186/s12893-018-0431-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 10/29/2018] [Indexed: 11/11/2022] Open
Abstract
Background The perforator-based island flap is a popular option for defect coverage. In cases with deep cavities, however, the classical island flap may not be a suitable option. By de-epithelization of the peripheral portion of a perforator-based island flap, the distal part of the flap can be used to fill deep spaces, as the flap can be folded and inserted into the spaces. Methods From June 2015 to April 2017, 21 cases of deep internal defects were reconstructed with perforator-based island flaps with peripheral de-epithelization. A fasciocutaneous flap was elevated and rotated with the pivot point on the perforator. After performing de-epithelization on the periphery of the flap, the de-epithelized portion of the flap was inserted and anchored into the internal defect. Demographic information about the patients, the size of the defects, the perforators that were used, and complications were recorded. Results During the follow-up period (mean, 14.2 months) of total 21 cases, no major complications such as flap loss occurred. In 2 cases, a minor complication was observed. Temporary flap congestion was seen in 1 case, and was treated with a short period of leech therapy, and the other case was partial necrosis on the flap margin, which was cured with minimal debridement and conservative treatment. No major problems have occurred, especially on the de-epithelized part of the flap and in the occupied space. Conclusions With performing careful procedure, a perforator-based island flap with partial de-epithelization can be a useful option for the surgical treatment of deep cavities. Trial registration This study was retrospectively registered in the institutional review board on human subjects research and the ethics committee, Hanyang University Guri Hospital (Institutional Review Board File No. 2018–01–003-002 https://www.e-irb.com:3443/devlpg/nlpgS200.jsp).
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Affiliation(s)
- Jung Woo Chang
- Department of Plastic and Reconstructive Surgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, 249-1, Gyomun-dong, Guri-si, Gyeonggi-do, 471-701, Korea
| | - Se Won Oh
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, 17 Haengdang-Dong, 133-792 Seongdong-Gu, Seoul, Korea
| | - Jeongseok Oh
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, 17 Haengdang-Dong, 133-792 Seongdong-Gu, Seoul, Korea
| | - M Seung Suk Choi
- Department of Plastic and Reconstructive Surgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, 249-1, Gyomun-dong, Guri-si, Gyeonggi-do, 471-701, Korea.
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Living with Dead Spaces: Closing Complex Posterior Midline Defects with Midline-Based Perforator Flaps. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1453. [PMID: 28894672 PMCID: PMC5585445 DOI: 10.1097/gox.0000000000001453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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