The new reconstructive ladder: modifications to the traditional model

The Hierarchy of Needs: A Problem-based Framework for Extremity Reconstruction

Plastic and reconstructive surgeons continually evolve their surgical strategies with the aim of achieving the optimal patient outcome. Numerous well-known frameworks intended to guide reconstructive planning have been introduced and are entrenched in plastic surgery education, but are limited in their scope due to their procedure-based construct. Here, we introduce the hierarchy of reconstructive needs: a problem-based reconstructive framework that shifts operative planning to the specific needs of the defect and goals for restoration of normality while allowing for further innovation and evolution beyond our existing surgical capabilities.

Urinary bladder matrix versus dermal regeneration template for lower extremity wound coverage

PURPOSE

To compare dermal regenerative template (DRT), with and without split-thickness skin-grafting (STSG), and urinary bladder matrix (UBM) for coverage of lower extremity wounds.

METHODS

A retrospective review of 56 lower extremity wounds treated with either DRT and STSG (DRT-S) (n = 18), DRT only (n = 17), or UBM only (n = 21). Patient characteristics, comorbidities, American Society of Anesthesiology (ASA) classification, injury characteristics, wound characteristics, use of negative pressure wound therapy, surgical details, postoperative care, and failure of primary wound coverage procedure were documented.

RESULTS

The DRT group, compared to the DRT-S group, was older [median difference (MD) 17.4 years, 95% confidence interval (CI) 9.1-25.7; p = 0.0008], more diabetic (proportional difference (PD) 54.2%, CI 21.2-76.1%; p = 0.002), had smaller wounds (MD - 91.0 cm2, CI - 125.0 to - 38.0; p = 0.0008), more infected wounds (PD 49.0%, CI 16.1-71.7%; p = 0.009), a shorter length of stay after coverage (MD - 5.0 days, CI - 29.0 to - 1.0; p = 0.005), and no difference in primary wound coverage failure (41.2% vs. 55.6%; p = 0.50). The UBM group, compared to the DRT group, was younger (MD - 6.8 years; CI - 13.5 to - 0.1; p = 0.04), had fewer patients with an ASA > 2 (PD - 35.0%, CI - 55.2% to - 7.0%; p = 0.02), diabetes (PD - 49.2%, CI - 72.4% to - 17.6%; p = 0.003), and had no difference in primary wound coverage failure (36.4% vs. 41.2%; p = 1.0). Failure of primary wound coverage was found to only be associated with larger wound surface areas (MD 22.0 cm2, CI 4.0-90.0; p = 0.01).

CONCLUSIONS

DRT and UBM coverage had similar rates of primary wound coverage failure for lower extremity wounds.

LEVEL OF EVIDENCE

Diagnostic, Level III.

Reconstruction after Mohs Surgery for Digit Melanoma: Description of Techniques and Postoperative Limb Function

Introduction

Mohs surgery and reconstruction has enabled tissue-preserving resection of cutaneous malignancies. The goal of our case series evaluation is to present reconstructive techniques and functional outcomes in patients undergoing digit-sparing treatment for primary melanoma.

Materials and Methods

A chart review was performed to identify consecutive patients undergoing Mohs surgery and reconstruction for melanoma of the digits. Quality of life (QOL) survey was performed to assess function after the procedure.

Results

Thirty-two patients (13 hand, 19 foot, Age: 65.03 +/-17.78 years) who were undergoing Mohs surgery were identified. No recurrence was identified with an average follow-up of 16.1 months (1-95 months). The average defect size was 5.79 +/-4.54 cm2. Reconstruction was performed 0-4 days after resection. The most common techniques included full-thickness skin graft (FTSG) (N = 7), collagen matrix + FTSG (N = 4), and volar advancement flap (N = 7). The reconstructive technique choice appears correlated with defect size (p = 0.0125). Neuro-QOL upper extremity survey results showed a difference that approached statistical significance between patients who underwent digit-sparing treatment (n = 7) versus direct to amputation controls (n = 5) (p = 0.072). No survey differences between digit-sparing treatment (n = 10) and amputation (n = 8) were identified in the lower extremity (p = 0.61).

Conclusion

Our results show digit-sparing treatment can confirm clear surgical margins and a trend toward improvement in upper extremity function compared with immediate amputation.

Managing Vascular Pedicle Exposure in Free Tissue Transfer Using a Reprocessed Micronized Dermal Substitute in Lower Extremity Reconstructions

Lower extremity reconstruction is challenging because of its intricate anatomy and dynamic biomechanics. Although microsurgical free tissue transfer offers pivotal solutions to limited local tissue availability, vascular pedicle exposure after free tissue transfer is common. We evaluated a novel method of managing pedicle exposure after free tissue transfer using a reprocessed micronized dermal substitute. Ten patients who underwent lower-extremity reconstruction using free tissue transfer and micronized dermal substitute between January and December 2023 were retrospectively reviewed. When native tissue could not be closed over the pedicle, reprocessed micronized artificial dermal matrix (rmADM) was cut and stacked to protect and stabilize it. Epithelialization was achieved by secondary skin grafting or healing by secondary intention. Flap dimensions, recipient artery and vein, ADM size, time required for granulation tissue maturation and complete epithelialization, and flap outcomes were analyzed. The mean age was 55.80 ± 20.70 years, and six patients (60%) were diabetic. The mean rmADM coverage area was 8.70 ± 8.41 cm2, and the average time required for complete epithelialization was 50.89 ± 14.21 days. Except for one total necrosis due to bypass graft failure, nine limbs were successfully salvaged. Application of rmADM offers numerous advantages, including vascular collapse prevention, moisture maintenance, granulation tissue growth promotion, and pedicle stabilization.

A Rare Complication of Maxillary Third Molar Extraction

The removal of tuberosity post extraction of the maxillary third molar is a very rare complication and there has not been ample discussion in the literature. Forceful extraction of a maxillary third molar can lead to soft and hard tissue loss. Various techniques have been used for the management of such defects such as local flaps, free soft tissue flaps, free bone flaps, and even tissue engineering. We present a case report of a large post-traumatic defect of maxillary tuberosity caused by forceful extraction of the maxillary third molar, which was managed conservatively by secondary healing, and the patient is on regular follow-up.

Use of a collagen-elastin matrix with split-thickness skin graft for defect coverage in complex wounds

OBJECTIVE

Severe soft tissue damage with destruction of the dermis requires plastic reconstructive treatment. For multimorbid patients or patients unable to undergo major reconstructive surgery, use of dermal substitutes, such as a collagen-elastin matrix (CEM) with a split-thickness skin graft (STSG), instead of local or free flap surgery, may be a valid and easy treatment option. We aimed to investigate and compare the outcomes and rate of successful defect reconstruction using CEM plus STSG, using either a one-step approach (simultaneous CEM and STSG) or a two-step approach (CEM and negative wound pressure therapy (NPWT), with secondary STSG transplantation).

METHOD

A single-centre, retrospective follow-up study of patients who had received CEM was conducted. Wounds had been treated with an STSG transplantation covering a CEM (MatriDerm, MedSkin Solutions Dr. Suwelack AG, Germany). Previous attempts at wound closure with conventional methods had failed in the selected patient population, which would usually have resulted in flap surgery.

RESULTS

Overall, 46 patients were included (mean age 60.9±20.0 years), with a total of 49 wound sites. We analysed 38 patients with wounds that did not require flap coverage; 18 patients received the one-step approach and 20 patients received the two-step approach. The mean follow-up in these patients was 22±11.5 months, and one patient was lost to follow-up. Overall, 29 (78.4%) wounds remained closed. Wounds which did not successfully heal were related to comorbidities, such as diabetes, alcohol misuse and smoking. Using the one-step approach, long-term defect coverage was achieved in 13 (76.5%) wounds and 16 (80.0%) wounds were closed using the two-step approach. However, there was no statistically significant differences between the one- or two-step approaches regarding the rate of development of a wound healing disorder.

CONCLUSION

Wound closure was achieved in 38 complex wounds using CEM plus STSG, while 11 wounds needed secondary flap coverage. In the flap-free wounds, there were no statistically significant differences between the one-step versus two-step approach. Using a simple defect reconstruction algorithm, we successfully used CEM plus STSG to treat complex wounds.

Pressure Ulcer Trends in the United States: A Cross-Sectional Assessment from 2008-2019

INTRODUCTION

Decubitus ulcers are a morbid and costly problem faced by healthcare systems and patients across the country. We aim to examine current patterns and characteristics of patients admitted to the hospital with a pressure ulcer.

MATERIALS AND METHODS

From a nationally representative sample of hospital discharge records, the Nationwide Inpatient Sample (NIS), patients with a diagnosis of pressure ulcer 2008-2019 were identified. Patient volume, demographic and clinical data were analyzed for change over time.

RESULTS

The volume of pressure ulcer patients as a proportion of all hospital patients remained constant from 2008 to 2019 (P = .479). During the study period, the proportion of ulcer patients that underwent an ulcer-related procedure significantly decreased (P < .001) while the proportion of ulcers considered severe significantly increased (P < .001).

CONCLUSIONS

Our analysis suggests the prevalence of decubitus ulcers remained stable during the time period, with increased severity but reduced frequency of operative intervention.

[Reconstruction of Head and Neck Defects after Cancer Surgery]

Cancer surgery in the head and neck region often results in complex defects. The reconstructive ladder was developed to guide treatment decisions. In the head and neck region the most straightforward reconstructive technique is often not the most suitable, because it is comprised of many functional and aesthetic subregions that lie close together. If primary closure, secondary wound healing or negative wound pressure therapy are not an option, skin grafting is the next step. Larger or aesthetically and functionally challenging defects are often reconstructed with flap surgery. It is distinguished between local or regional flaps that are rotated or transposed into the defect and distant flaps. The blood supply of local/regional flaps is either random pattern or axial pattern, distant flaps are pedicled or free flaps. The vessels of free flaps are connected to the blood supply in the defect by microvascular anastomoses. The radial forearm flap, the pectoralis major flap and the anterolateral thigh flap are the most common distant flaps in the head and neck region. Preoperative planning is the most important step in reconstructive surgery. The method of reconstruction must be suited to the functional and aesthetic requirements of the defect but also to the morbidity and compliance of the patient and the surgical expertise of the clinic. Not only immediate postoperative complications such as insufficient anastomosis, infections or hematoma but also later, mostly functional complications such as dysphagia or dyspnea must be taken into consideration when planning the reconstruction of a defect in the head and neck region.

3D-Printed Auxetic Skin Scaffold for Decreasing Burn Wound Contractures at Joints

For patients with severe burns that consist of contractures induced by fibrous scar tissue formation, a graft must adhere completely to the wound bed to enable wound healing and neovascularization. However, currently available grafts are insufficient for scar suppression owing to their nonuniform pressure distribution in the wound area. Therefore, considering the characteristics of human skin, which is omnidirectionally stretched via uniaxial stretching, we proposed an auxetic skin scaffold with a negative Poisson's ratio (NPR) for tight adherence to the skin scaffold on the wound bed site. Briefly, a skin scaffold with the NPR effect was fabricated by creating a fine pattern through 3D printing. Electrospun layers were also added to improve adhesion to the wound bed. Fabricated skin scaffolds displayed NPR characteristics (-0.5 to -0.1) based on pulling simulation and experiment. Finger bending motion tests verified the decreased marginal forces (<50%) and deformation (<60%) of the NPR scaffold. In addition, the filling of human dermal fibroblasts in most areas (>95%) of the scaffold comprising rarely dead cells and their spindle-shaped morphologies revealed the high cytocompatibility of the developed scaffold. Overall, the developed skin scaffold may help reduce wound strictures in the joints of patients with burns as it exerts less pressure on the wound margin.

Using an Elastomeric Skin Protectant to Manage Donor Site Wounds of Split-thickness Skin Grafts: A Case Series

ABSTRACT

Split-thickness skin grafting (STSG) is a common surgical procedure to manage acute and chronic wounds. A plethora of dressings exists to treat STSG donor site wounds (DSWs). Recently, a new elastomeric skin protectant was adopted (Cavilon Advanced Skin Protectant; 3M) in the treatment of incontinence-associated dermatitis. In this report, the authors assess the effects of this elastomeric skin protectant as an alternative wound dressing for STSG donor sites.The authors report a single-center prospective case series that was performed to establish a treatment protocol. Nine consecutive patients with different indications for treatment with an STSG from May to September 2018 were included. Collected data included general patient information, comorbidities, complications, blood loss, pain during dressing change, and the duration of DSW healing.This case series showed promising results in terms of duration of DSW healing when applying the elastomeric skin protectant. The authors also observed less blood loss and less pain during dressing changes. No infections were seen during the trial.

Reconstructive Surgery for the Neglected Tropical Diseases: Global Gaps and Future Directions

Several neglected tropical diseases (NTDs) are highly disfiguring, particularly those in resource-poor countries that lack access to basic surgery. There has been a push to integrate surgery into treatment programs for NTDs. In this article, we provide an overview of the major disfiguring NTDs and discuss the processes and barriers that impede access to reconstructive surgical treatments or their integration into health systems.

Methods

A review of the literature was conducted using the online database PubMed, from 2008 to 2021 with the specific diseases listed as NTDs either on the World Health Organization or the PLoS Neglected Tropical Disease websites. Reference lists of identified articles and reviews were also searched, as were databases from the World Health Organization's Weekly Epidemiological Record.

Result

Success in the surgical treatment and postoperative care of disfiguring NTDs would benefit from standardization and harmonization of surgical approaches and procedures. In some settings, reconstructive surgery should be used cautiously, emphasizing appropriate use of antibiotics, partnerships with global and local surgical teams, and local capacity building. Preventative hygiene approaches remain paramount in resource-poor areas.

Conclusions

Surgery is a promising treatment for NTDs that result in disfigurement and disability. The expansion of local capacity building, with medical trips and surgical training of local health workers, together with the development of universal surgical protocols remain essential cornerstones for NTD reconstructive surgery. Antibiotics and drug management should comprise key first steps before turning to surgery.

Comparison of skin graft donor site management using oxidised regenerated cellulose (ORC)/collagen/silver-ORC with absorptive silicone adhesive border and transparent film dressing vs semi-occlusive dressings

Split-thickness skin grafts (STSG) are widely used in wound reconstruction. However, donor site wounds are created as a result. Traditionally, moist wound healing and transparent film dressings have been used to promote donor site wound healing. This retrospective study evaluated the use of oxidised regenerated cellulose (ORC)/collagen/silver-ORC dressing (ORC/C/Ag-ORC) with an absorptive silicone adhesive border dressing and transparent film dressing (treatment) compared with petrolatum-based gauze dressing (control) over donor site wounds. Patients underwent an STSG procedure between January and December 2020. Donor sites received treatment (n = 10) or control (n = 10) dressings. Dressing changes occurred as necessary. Time to epithelialisation, narcotic pain medication requirements, and the number of office/hospital visits were examined. Twenty patients were managed (9 males, 11 females, average age: 49.7 ± 13.9 y). Patient comorbidities included hypertension, diabetes, and hyperlipidemia. Wound types included traumatic and cancer excision. Time to epithelialisation was significantly reduced in the treatment group (11.1 ± 1.4 d vs 18 ± 2.4 d, P < 0.0001). The number of office visits for dressing changes was significantly lower in the treatment group (0.1 ± 0.3 vs 2 ± 0.7, P < 0.0001). No patients in the treatment group required a hospital visit, compared with 3 patients in the control group. One patient in the treatment group required narcotic pain medication, compared with 5 in the control group. In this patient population, the use of ORC/C/Ag-ORC, an absorptive silicone adhesive border dressing, and transparent film dressing resulted in a shorter time to epithelialisation and less analgesic requirement compared with petrolatum-based gauze dressing use.

Regenerative vs flap-based limb salvage: a multi-centered, prospective, randomized controlled trial

Aim: The goal of this study was to compare success rates of a regenerative limb salvage approach (rLS) using dehydrated human chorion amnion membrane (dHACM) to traditional flap-based limb salvage (fLS). Materials & methods: This prospective RTC enrolled patients presenting with complex extremity wounds over a 3-year period. Primary outcomes included success of primary reconstruction, persistence of exposed structures, time to definitive closure, and time to weight bearing. Results: Patients meeting inclusion criteria were randomized to fLS (n = 14) or rLS (n = 25). The primary reconstructive method was successful for 85.7% of fLS subjects and 80% of rLS subjects (p = 1.00). Conclusion: This trial provides strong evidence that rLS is an effective option in the setting of complex extremity wounds, with success rates comparable to traditional flaps. Clinical Trial Registration: NCT03521258 (ClinicalTrials.gov).

Pedicled buccal flaps as a backup procedure for intraoral reconstruction

BACKGROUND

Intraoral soft tissue deficiency and impaired wound beds are common problems after cleft and tumour surgery or after dental trauma. Frequently, limited defects are overtreated with extensive microvascular reconstruction procedures, but pedicled flaps remain useful, as they are simple to harvest, and they provide a reliable outcome. The buccal flap, first described in the 1970s, has been used for palatine lengthening in cleft patients over decades. In the following, we present an expanded indication in cases of palatal fistula, complex vestibulum, exposed bone in orthognathic surgery, and osteoradionecrosis.

METHODS

We conducted a retrospective chart review and report on all buccal flaps harvested in our department within the last 3 years with a follow-up period of at least half a year after flap surgery. Patients of all age groups and treatment indications in which a buccal flap was used were implicated in the evaluation.

RESULTS

Sixteen buccal flaps were performed in 10 patients. The median age at the time of surgery was 42 years, reaching from 12 up to 66 years. Fourteen buccal flaps were used for upper jaw or palatal coverage; two buccal flaps were used in the mandible. In terms of complications (four flaps; 25%), there were two partial flap failures, one wound dehiscence and one wound dehiscence. There were no failures of the remaining mucosal flap islands after pedicle dissection.

CONCLUSION

The buccal flap is a reliable and straightforward approach to challenging intraoral wound beds with soft tissue deficiency. We thoroughly discuss the additional indications for buccal flap surgery, describe the harvest technique, and provide strategies to prevent intra- and postoperative complications.

Efficacy and safety of external tissue expansion technique in the treatment of soft tissue defects: a systematic review and meta-analysis of outcomes and complication rates

Background

Currently, various external tissue expansion devices are becoming widely used. Considering the scarcity of relevant application standards, this systematic review was performed to explore the effectiveness and safety of external tissue expansion techniques for the reconstruction of soft tissue defects.

Method

A systematic review and meta-analysis on the efficacy and safety of external tissue expansion technique was conducted. A comprehensive search was performed in the following electronic databases: PubMed/Medline, Embase, Cochrane Library (Wiley Online Library), and Web of Science. Studies reporting patients with soft tissue defects under the treatment of external tissue expansion technique were included.

Results

A total of 66 studies with 22 different types of external tissue expansion devices met the inclusion criteria. We performed a descriptive analysis of different kinds of devices. A single-arm meta-analysis was performed to evaluate the efficacy and safety of the external tissue expansion technique for different aetiologies. The pooled mean wound healing time among patients with defects after fasciotomy was 10.548 days [95% confidence interval (CI) = 5.796-15.299]. The pooled median wound healing times of patients with defects after excisional surgery, trauma, chronic ulcers and abdominal defects were 11.218 days (95% CI = 6.183-16.253), 11.561 days (95% CI = 7.062-16.060), 15.956 days (95% CI = 11.916-19.996) and 12.853 days (95% CI=9.444-16.227), respectively. The pooled wound healing rates of patients with defects after fasciotomy, excisional surgery, trauma, chronic ulcers and abdominal defects were 93.8% (95% CI=87.1-98.2%), 97.2% (95%CI=92.2-99.7%), 97.0% (95%CI=91.2-99.8%), 99.5% (95%CI=97.6-100%), and 96.8% (95%CI=79.2-100%), respectively. We performed a subgroup analysis in patients with diabetic ulcers and open abdominal wounds. The pooled median wound healing time of patients with diabetic ulcers was 11.730 days (95% CI = 10.334-13.125). The pooled median wound healing time of patients with open abdomen defects was 48.810 days (95% CI = 35.557-62.063) and the pooled successful healing rate was 68.8% (95% CI = 45.9-88.1%). A total of 1686 patients were included, 265 (15.7%) of whom experienced complications. The most common complication was dehiscence (n = 53, 3.14%).

Conclusions

Our systematic review is the first to demonstrate the efficacy and safety of external tissue expansion in the management of soft tissue defects. However, we must interpret the meta-analysis results with caution considering the limitations of this review. Large-scale randomized controlled trials and long-term follow-up studies are still needed to confirm the effectiveness and evaluate the quality of healing.

A comparison of healing and complication rates between common flaps utilized in total knee arthroplasty: a review of the literature

Background

Flap reconstruction with perforator, fasciocutaneous, muscular, and/or free microvascular flaps is utilized to cover wound defects and improve vascularization and antibiotic/nutrient delivery. Flap use in revision procedures for total knee arthroplasty has been explored previously; however, current data are limited and studies comparing healing and complication rates between different flap types are lacking.

Methods

A literature review was performed using PubMed on 13 January 2022. Studies were included if they reported healing and complication rates for either gastrocnemius, rectus abdominis, latissimus dorsi, fasciocutaneous, chimeric, or gracilis flaps in the setting of revision total knee arthroplasty (TKA).

Results

The final cohort included gastrocnemius (n = 421, healing rate 73.8%, complication rate 59.9%), gracilis (n = 9, healing rate 93%, complication rate 55.6%), latissimus dorsi (n = 41, healing rate 67%, complication rate 46.3%), rectus abdominis (n = 3, healing rate 100%, complication rate 0%), fasciocutaneous (n = 78, healing rate 70%, complication rate 19.2%), and chimeric flaps (n = 4, healing rate 100%, complication rate 25%). There was no significant difference when comparing healing rates across flap types (p = 0.39). There was a significant difference when comparing complication rates across flap types (p < 0.0001), with a significant difference being noted between gastrocnemius and fasciocutaneous complication rates (p < 0.0001). All other comparisons between flap types by complication rate were not significantly different.

Conclusions

Gastrocnemius flaps are the workhorse flap in the setting of revision TKA, as evidenced by this review. Healing rates did not vary significantly across flap types, which suggests that determining the appropriate flap for coverage of soft-tissue defects in revision TKA should be driven by defect size and location as well as physician experience and patient tolerance.

Surgical amputation for patients with diabetic foot ulcers: A Chinese expert panel consensus treatment guide

BACKGROUND

Diabetic foot disease is a serious complication of diabetes mellitus. Patients with diabetes mellitus have a 25% lifetime risk for developing a foot ulcer, and between 14% and 24% of patients require a major or minor lower limb amputation due to severe gangrene. However, decisions concerning whether to amputate or whether to perform a major or minor lower limb amputation, and how best to determine the amputation plane remain unclear.

METHODS

To consolidate the current literature with expert opinion to make recommendations that will guide surgical amputation for patients with diabetic foot ulcers. A total of 23 experts experienced in surgical treatment of patients with diabetic foot ulcers formed an expert consensus panel, and presented the relevant evidence, discussed clinical experiences, and derived consensus statements on surgical amputation for patients with diabetic foot ulcers. Each statement was discussed and revised until a unanimous consensus was achieved.

RESULTS

A total of 16 recommendations for surgical amputation for patients with diabetic foot ulcers were formulated. The experts believe that determination of the amputation plane should be comprehensively evaluated according to a patient's general health status, the degree of injury, and the severity of lower limb vasculopathy. The Wagner grading system and the severity of diabetic lower extremity artery disease are important criteria when determining the degree of amputation. The severity of both diabetic foot infection and systemic underlying diseases are important factors when considering appropriate treatment. Moreover, consideration should also be given to a patient's socioeconomic status. Given the complexities of treating the diabetic foot, relevant issues in which consensus could not be reached will be discussed and revised in future.

CONCLUSION

This expert consensus could be used to guide doctors in clinical practice, and help patients with diabetic foot ulcers gain access to appropriate amputation treatment.

Management of the Charcot Foot and Ankle: Nonreconstructive Surgery

Diabetic neuroarthropathy is a complication of diabetes mellitus that results in instability of the foot, structural deformity, and soft-tissue breakdown. Commonly, midfoot collapse of the medial, lateral, or both longitudinal arches may result in increased plantar pressures and subsequent midfoot ulceration. Many of these wounds can be successfully managed with local wound care and off-loading; however, surgical intervention becomes necessary in cases of osteomyelitis or when the wound fails to heal despite conservative efforts. In cases where surgical reconstruction may not be indicated, nonreconstructive surgical efforts have shown effectiveness in resolving wounds and allowing patients to return to ambulatory lifestyles. This article serves as an update to current treatment recommendations for the nonreconstructive surgical management of Charcot neuroarthropathy.

Use of a bilayer biodegradable synthetic dermal matrix for the management of defects arising from necrotising fasciitis

The aim of this article is to provide a brief overview of necrotising fasciitis, including causative factors, incidence, diagnosis and clinical outcomes. Various surgical treatment options are outlined, including methods of soft tissue reconstruction after wide excision of infected and necrotic tissues. The role of dermal matrices, including a synthetic biodegradable temporising matrix made of polyurethane, are described in terms of wound bed preparation, surgical application and clinical outcomes.

Multifocal cutaneous angiosarcoma of the scalp—A challenging reconstructive case managed with skin substitutes

Background

Cutaneous angiosarcoma (AS) of the head and neck is a rare highly aggressive tumor, often associated with difficult local control of the disease and poor prognosis. This article describes a case of multifocal cutaneous AS of the scalp, mainly addressing its difficult surgical management and challenging reconstruction and concludes with a review of the literature.

Methods

A 70‐year‐old Caucasian male was referred to our hospital with a growing scalp lesion initially suspected to be benign, but later diagnosed with AS.

Results

The patient had tumor recurrence and a difficult reconstruction for which dermal substitutes proved very useful.

Conclusion

AS can mimic a benign lesion in its early stages. Skin substitutes, namely dermal templates, can be useful to meet the complex needs of reconstruction and oncological surveillance of patients with AS.

Integra Dermal Regeneration Template in reconstructive surgery for cutaneous tumours: a two-year retrospective review

OBJECTIVE

Integra Dermal Regeneration Template (IDRT) (Integra LifeSciences, US) is a bioengineered dermal matrix that has been widely used in burn reconstruction since its first description. However, little is reported on its use in oncologic dermatological defects. Our objective was to evaluate reconstruction using IDRT on cutaneous tumour defects.

METHOD

We conducted a two-year retrospective review of patients with skin tumours who had an excision surgery, followed by reconstruction with IDRT, as a mid-step towards a final autograft procedure: a split-thickness skin graft. The records of all patients at a single academic institution were queried from the electronic medical record using data obtained from the operating surgeon.

RESULTS

We identified 13 patients with different tumour types and locations. The mean defect size was 105.92cm². The matrix take rate was 92.3% and average postoperative day for definite autograft was 20 days. Patients were followed for a period of up to 12 months. Of the patients, one had exposed bone without periosteum; another patient showed recurrence six months after matrix placement, requiring a new second two-stage IDRT-autograft procedure before radiation therapy. Patients reported complete satisfaction with the cosmetic, functional and oncological results. No cases of infection were encountered.

CONCLUSION

IDRT is a valid option for the reconstruction of oncologic surgical defects of the skin and can be used in different anatomical locations. Specifically, it is an alternative to the reconstructive ladder when grafts and local flaps are not possible in those patients, and an option for patients who will eventually need adjuvant radiotherapy.

Posttraumatic Soft Tissue Coverage of the Lower Leg for the Orthopedic Surgeon

Soft tissue reconstructive techniques are powerful tools for the orthopedic surgeon caring for lower extremity trauma. This article seeks to inform orthopedic surgeons about useful techniques for skin closure, secondary wound closure techniques, and rotational flaps of the lower leg. Split thickness skin grafting, piecrusting, and the use of negative pressure wound therapy for skin closure, as well as rotational gastrocnemius, soleus, and reverse sural artery flaps are discussed with emphasis on techniques for the nonvascular and nonmicrovascular orthopedic surgeon.

Clinical outcome of multidisciplinary treatment of vulvar necrotising fasciitis

OBJECTIVE

Vulvar necrotising fasciitis (VNF) is a severe soft tissue infection associated with substantial morbidity and high mortality. At Stony Brook Medicine, US, patients with known or suspected VNF are treated by a structured multidisciplinary team consisting of members of the Departments of Emergency Medicine and Medicine, the Divisions of Gynecologic Oncology, Burn and Surgical Intensive Care Units, Infectious Disease and Plastic Surgery, and the nursing, nutrition, physical/occupational therapy and social work services.

METHOD

This is a retrospective review of patients presenting to Stony Brook University Hospital with VNF over an 18-month period.

RESULTS

A total of 10 patients were treated for VNF during the study period. All patients were treated by the structured multidisciplinary team, including extensive initial surgical debridement by the gynaecologic oncologists. All patients survived to discharge.

CONCLUSION

The results of this review demonstrated that prompt diagnosis, rapid implementation of appropriate antibiotic coverage, surgical debridement of necrotic tissue, and comprehensive care delivered by a structured multidisciplinary team contributed to positive clinical outcomes and decreased the risk of death from VNF.

Pediatric Wound Closure by a Tension-Relief System

Surgical reconstruction in pediatric patients can often be complex. Primary wound closure is almost always the preferred technique in the reconstructive ladder; however, it is not always possible in pediatric patients. We report the pediatric use of the TopClosure Tension-Relief System, an innovative skin-stretching technique for secure primary wound closure of large defects. We modified the technique by fixating it to a protective dressing instead of the patient's skin, thus avoiding both staple scars and pain. A retrospective review of 112 patients aged 7 days to 18 years who underwent Tension-Relief System-assisted surgery at a tertiary medical center from 2010 to 2020 was conducted. Cases included congenital deformities, traumatic wounds, burn scars, and complicated-wounds, with or without hardware or deep tissue exposure. The use of the system avoided the need for multiple surgical sessions and for local or regional flaps. The technique was simple to use, with few complications, and led to satisfactory aesthetic and functional outcomes. The findings support using the technique in children and adolescents with challenging tension wounds. Herein, we report on our experience with the Tension-Relief System and detail four cases in which early or immediate closure was successfully achieved.

Use of single-layer artificial dermal template in patients with trauma and burns

Objective:

Artificial dermal templates (ADTs), were designed initially to provide extracellular matrix and skin substitute for extensive burn injuries. Use of ADTs in a variety of other indications, has also been described in the literature. In this study, we describe our experience of using ADTs for different indications in burn contractures and wound coverage.

Method:

In this retrospective study, patients requiring burn scar contracture release, permanent wound coverage for acute traumatic wounds and temporary wound coverage to prepare for complex reconstructions, and where the ADT Pelnac (Gunze Ltd., Japan) was applied, were evaluated. Data regarding patient sex, age, type and location of injury, comorbidities, operations and complications were recorded.

Results:

A total of 24 patients were included in the study, of whom 12 patients were operated on for burn contractures. ADTs were used with split-thickness skin grafts (STSGs) or Z-plasties in a single-stage procedure. In six patients, ADT and STSGs were used to cover defects with exposed bone or tendon. Of the patients, six had their wounds covered temporarily while they were stabilised for complex reconstructions or were awaiting definitive histopathological results. Revisional surgeries due to graft failures or insufficient contracture releases were required by 12 patients. All temporary wound coverage patients had successful flap reconstructions after stabilisation of their general status, had tumour-free margins in the histopathological examination, and no necrosis or infection was seen on follow-up.

Conclusion:

In this study, ADTs had positive effects on selected patients, but comprehensive and comparative clinical studies are needed for different indications to choose between these templates.

Overview of Biologic Agents Used in Skin and Soft Tissue Reconstruction

Wound healing is a highly complex process mediated by cellular interactions at the microscopic level. Increased understanding of wound healing physiology has served as the foundation for translational research to develop biologic wound care technologies that have profoundly affected patient care. As the reader will see throughout this series in Seminars in Plastic Surgery , biologic wound technologies have broad applications and have greatly impacted the reconstructive ladder. Despite their frequent use, many surgeons lack familiarity with the myriad of products available on the market along with each product's relative advantages and shortcomings. This overview will discuss the classification of biologic wound agents used to reconstruct defects of the skin and soft tissue along with the advantages and disadvantages associated with their use.

Strategies for extremity reconstruction with exposed bones and tendons using acellular dermal matrices: concept of sequential vascularization

We report 3 cases of patients treated with Bilayer Wound Matrix over exposed structures. In all patients, dermal matrices revascularization occurred sequentially over the course of 6–12 weeks, leading to successful wound closure. Acellular dermal matrices allow more difficult areas with poor vascularity to be covered from the ‘inside-out’.

Skin Graft Versus Local Flaps in Management of Post-burn Elbow Contracture

Introduction

Contracture is a pathological scar tissue resulting from local skin tissue damage, secondary to different local factors. It can restrict joint mobility, resulting in deformity and disability. This study aimed to investigate the outcomes of skin grafts compared to local flaps to reconstruct post-burn elbow contractures. These parameters included regaining function, range of movement, recurrence, and local wound complications.

Methodology

A retrospective study reviewed 21 patients for elbow reconstruction over 12 months. Only patients with post-burn elbow contracture were included. Other causes, including previous corrective surgery, associated elbow stiffness, and patients who opted out of post-operative physiotherapy, were excluded. Patients were categorized according to the method of coverage into three groups: graft alone (G1), local flap (G2), or combined approach (G3). 

Results

Females were three times at higher risk to suffer a burn injury, while almost half of the cases were children. Scald injury represented 81% of burn causes. G1,2,3 were used in 47.6%, 42.9% and 9.5% of cases retrospectively. The overall rate of infection was 28.6%. Hundred percent graft taken was recorded in 83.3 % of cases; however, flap take was 91.1%. After 12 months of follow-up, re-contracture was 60% and 22.8% in G1 and G2; however, the satisfaction rate was 70% and 100% in both groups retrospectively. The overall satisfaction was 85.7% in all groups.

Conclusion

Grafts and local flaps are reasonable options for post contracture release; however, flaps are superior. Coverage selection depends on the lost tissue area and exposure of underlying deep structures. Physiotherapy and patient satisfaction are crucial in the outcomes. 

Comparison of Efficacy among Three Dermal Substitutes in the Management of Critical Lower-Limb Wounds: The Largest Biases-Reduced Single-Center Retrospective Cohort Study in Literature

Background and objectives: The skin recently became the main focus of regenerative medicine and, in this context, skin substitutes are fully entering into the plastic surgeon’s armamentarium. Among the various types of skin substitutes, dermal substitutes (DSs) are the most used. Our study aims to retrospectively compare three renowned and extremely similar DS in the management of critical lower limb wounds in the largest cohort analysis currently present in literature. Materials and Methods: We followed a strict protocol of application and evaluation of the DS for each patient and wound and, after a meticulous bias reduction process, we compared final outcomes in terms of efficacy and speed in achieving the defect coverage. Results: Among patients who did not receive a skin graft after the DS, we registered a wound healed surface of 50% for Pelnac, 52% for Integra, and 19% for Nevelia, after 30 days from the external silicon layer removal; among those who received a skin graft after the DS, we observed a significantly lower mean percentage of graft take after 7 days with Pelnac (53%) compared to Integra and Nevelia (92% and 80%, respectively). The overall percentage of wound healed surface obtained after 30 days from the external silicon sheet removal, either with or without skin graft, was 71% for Pelnac, 63% for Integra and 63% for Nevelia. We also ran a sub-group analysis only including grafted wounds with a negative microbiological test and the mean percentage of graft take was similar this time. Eventually, we assessed the influence of the wound’s “chronicity” on its healing, comparing the mean graft take only in “acute” wounds who received a skin graft and it resulted 63% for Pelnac, 91% for Integra and 75% for Nevelia. Conclusions: Integra demonstrates the highest rate of skin graft viability and the highest rate of skin graft takes after 7 days. Pelnac shows the quickest induction of secondary healing in acute wounds. Nevelia is not different from Integra and shows a superior graft take compared to Pelnac, but features the lowest secondary healing induction rate. No differences exist between the three DSs in terms of wound healing after 30 days from the skin graft or from the removal of the external silicon layer.

Utility of Dermal Wound Matrices Compared with Local-Tissue Rearrangement and Free Flap Reconstruction for Oncologic Scalp Wounds: A Multidisciplinary Dual Matched-Pair Analysis

BACKGROUND

Local tissue rearrangement, free flap reconstruction, and Bilayer Wound Matrix represent reconstructive modalities for coverage of scalp defects; however, preferred indications are less clear. The authors aimed to evaluate the efficacy of these interventions.

METHODS

A retrospective review (2008 to 2019) was performed of subjects requiring soft-tissue reconstruction of oncologic scalp wounds. Subjects were dual matched into two comparative cohorts based on age and wound size/wound age: (1) local tissue rearrangement versus Bilayer Wound Matrix, and (2) free flap reconstruction versus Bilayer Wound Matrix. Ninety-day wound coverage, reoperation rates, hospital length of stay, operative time, and wound complications were compared.

RESULTS

In total, 361 subjects were included. Following matching, 126 subjects constituted the local tissue rearrangement versus Bilayer Wound Matrix cohort, and 56 constituted the free flap reconstruction versus Bilayer Wound Matrix cohort. Local tissue rearrangement/Bilayer Wound Matrix median defect size was 35 ± 42.5 cm2. Local tissue rearrangement provided significantly better wound coverage at 90 days (95.2 percent) compared to Bilayer Wound Matrix (84.1 percent) (p < 0.040), although reoperation rates (7.9 percent versus 15.9 percent) did not differ (p < 0.271). Median defect size in the free flap reconstruction/Bilayer Wound Matrix cohort was 100 ± 101.1 cm2. Ninety-day success (free flap reconstruction, 92.9 percent; Bilayer Wound Matrix, 96.4 percent; p < 1.00) and reoperation rates (14.3 percent versus 3.6 percent; p < 0.352) were similar between groups. Free flap reconstruction had significantly greater operative time (418 minutes versus 100 minutes; p < 0.001) and length of stay (3 days versus 0.5 days; p < 0.001).

CONCLUSIONS

Local tissue rearrangement may be more reliable for smaller wounds (<100 cm2) when compared to Bilayer Wound Matrix. Bilayer Wound Matrix may have comparable efficacy to free flap reconstruction for larger defects (150 to 250 cm2), and may be more cost-effective, given greater operative time and length of stay associated with free flap reconstruction. Free flap reconstruction is preferentially used in complicated large defects in the setting of radiation therapy, and for large defects that have failed Bilayer Wound Matrix.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Reconstruction of Achilles region defects: A single-centre experience

BACKGROUND

Reconstruction of Achilles tendon and the overlying tissue defects is a challenging undertaking. The spectrum of available repair methods range from secondary healing to the use of free flaps. The aim of this study was to discuss reconstruction options and to help the surgeon to select reliable approach to achieve favourable outcomes.

METHOD

In this study, we retrospectively evaluated 14 patients who underwent reconstruction of Achilles region defect between 2016 and 2019 at a single centre.

RESULTS

Reconstructions were performed with secondary healing (n = 2), negative pressure wound therapy and skin grafting (n = 2), free flaps (n = 6) and local and distant flaps (n = 4). Satisfactory aesthetic and functional outcomes were achieved in all patients. One patient developed partial skin graft loss. Marginal necrosis occurred in one of the local flaps. Wound dehiscence and flap retraction occurred in one of the free (superficial circumflex iliac artery perforator) flaps. One patient undergoing reconstruction with ulnar artery perforator flap developed intraoperative atrial fibrillation; the operation was terminated and reconstruction completed with skin grafting.

CONCLUSION

Orthoplastic reconstruction should be kept in mind for Achilles tendon defects. The use of special digital imaging techniques facilitates flap surgery and helps minimise the risk of flap complications. Conventional approaches are suitable for shallow small skin lesions. Local flaps are good options for deeper skin defects owing to superior aesthetic outcomes. Super-thin free flaps offer a distinct advantage in skillful hands. The use of multi-content free chimeric flaps for reconstruction of complex defects facilitates better anatomical repair. Cross leg or flow-through flaps may be considered in patients with compromised distal circulation. Selection of the most reliable approach for Achilles reconstruction is a key imperative to achieve favourable outcomes.

The Efficacy of Local Flaps in the Treatment of Traumatic Scalp Defects

BACKGROUND

 Scalp defects represent a therapeutic challenge. The aim of this study is to present our experience with local and regional flaps in the treatment of trauma-induced scalp defects. Furthermore, a comparison with other surgical techniques was performed.

METHODS

 A retrospective evaluation of patient records was performed. Only patients who underwent surgery using local flaps between January 2010 and September 2020 due to traumatic scalp defects were included in the study.

RESULTS

 In all, 10 cases were identified (3 females, 7 males, average age at surgery of 46.5 years [range: 18-82 years]). Six patients underwent surgery due to tissue defects and four due to scar keloids. Three patients experienced minor postoperative complications, one of which required additional surgery. The mean defect size was 35.75 cm² (range: 4-79 cm²) among the four patients where the defect size could be determined retrospectively. The mean inpatient follow-up was 12.4 days (range: 2-34 days).

CONCLUSIONS

 Local flaps can be widely used. In carefully selected cases, they have the fewest disadvantages of all surgical techniques. In our experience, large angiosomes of the main scalp arteries allow the treatment of defects larger than 30 cm² with local flaps. Our experience also suggests that the dimensions of flap length to flap width can exceed a ratio of 2:1 in the scalp.

A Concept of "Boundary Determination" by the Combination of a Local Flap and Free Tissue Transfer Useful for the Prevention of Postoperative Complications After Complex and Widespread Skull Base Reconstruction

ABSTRACT

The transplanted tissue is sutured to the stumps of the bones in skull base reconstruction. Concerning reconstruction by free tissue transfer, it is difficult that the tissue is accurately sutured/fixed to a complex three-dimensional structure. The authors devised a technique in which free tissue transfer is combined with a local flap. A pericranial flap is sutured/fixed onto the irregular border between the cranial and nasal cavities. A free tissue graft is transplanted cranial or caudal to the determined border. Clinical presentation 1 is a patient with carcinoma of the frontal sinus (T4bN0M0). Resection of the frontal bone/nasal bone/medial and superior walls of the orbit, frontal lobectomy was performed. Clinical presentation 2 is a patient with carcinoma of the maxillary sinus (T4aN0M0). Extended total maxillectomy, simultaneous resection of the facial skin/temporal muscle were performed. There were no serious postoperative complications related to compression or occlusion of the cerebral parenchyma or paranasal sinus.

Future applications of 3D bioprinting: A promising technology for treating recessive dystrophic epidermolysis bullosa

Three-dimensional (3D) bioprinting is a rapidly developing technology that has the potential to initiate a paradigm shift in the treatment of skin wounds arising from burns, ulcers and genodermatoses. Recessive dystrophic epidermolysis bullosa (RDEB), a severe form of epidermolysis bullosa, is a rare genodermatosis that results in mechanically induced blistering of epithelial tissues that leads to chronic wounds. Currently, there is no cure for RDEB, and effective treatment is limited to protection from trauma and extensive bandaging. The care of chronic wounds and burns significantly burdens the healthcare system, further illustrating the dire need for more beneficial wound care. However, in its infancy, 3D bioprinting offers therapeutic potential for wound healing and could be a breakthrough technology for the treatment of rare, incurable genodermatoses like RDEB. This viewpoint essay outlines the promise of 3D bioprinting applications for treating RDEB, including skin regeneration, a delivery system for gene-edited cells and small molecules, and disease modelling. Although the future of 3D bioprinting is encouraging, there are many technical challenges to overcome-including optimizing bioink and cell source-before this approach can be widely implemented in clinical practice.

Split-Thickness Skin Grafting: A Primer for Orthopaedic Surgeons

Soft-tissue defects pose a unique challenge to the treating orthopaedic surgeon. Such defects are commonly encountered after orthopaedic injuries or infection, and the management of these wounds varies significantly. Skin grafting has gained popularity in the management of such soft-tissue defects due to its ability to provide coverage, re-epithelialize, and have a relatively high success rate. One of the most frequently used types of skin graft in orthopaedics is the split-thickness skin graft (STSG). Understanding the proper indications, technique, and management of the STSG foreshadows its success or failure. This review focuses on the indications, technique, alternatives, and complications surrounding the utilization of the STSG in the management of orthopaedic injuries.

Fibroblast growth factor-impregnated collagen-gelatin sponge improves keratinocyte sheet survival

Commercially available cultured epithelial keratinocyte sheets (KSs) have played an essential role in wound healing over the last four decades. Despite the initial uptake by the dermal elements, the survival rate of KS on the dermis-like tissue generated by conventional artificial dermis (AD) is low, making this method unsuitable for standard treatments. Therefore, an innovative AD such as collagen/gelatin sponge (CGS) that maintains the release of human recombinant basic fibroblast growth factor (bFGF) may promote wound healing. In this study, we examined whether combination therapy with KSs and CGS with bFGF (bFGF-CGS) could enhance KS survival by heterologous grafting by transplantation of human-derived KSs in an athymic nude rat wound model of staged skin reconstruction. The CGSs were implanted into skin defect wounds on athymic nude rats, which were then divided into two experimental groups: the bFGF group (CGSs containing bFGF, n = 8) and control group (CGSs with saline, n = 8). Two weeks after implantation, human epithelial cell-derived KSs were grafted onto the dermis-like tissue, followed by assessment of the survival and morphology at one week later using digital imaging, histology (hematoxylin and eosin and Masson's trichrome staining), immunohistology (von Willebrand factor), immunohistochemistry (cytokeratin 1-5-6, Ki-67), and immunofluorescence (collagen IV, pan-cytokeratins) analyses. The bFGF group showed a significantly higher KS survival area (86 ± 58 vs. 32 ± 22 mm2; p < 0.05) and increased epidermal thickness (158 ± 66 vs. 86 ± 40 µm; p < 0.05) compared with the control group, along with higher dermis-like tissue regeneration, neovascularization, epidermal maturation, and basement membrane development. These results indicate that the survival rate of KSs in the dermis-like tissue formed by bFGF-CGS was significantly increased. Therefore, combination treatment of bFGF-CGS and KSs shows potential for full-thickness skin defect reconstruction in clinical situations.

The Versatility of the Pedicled Medial Sural Artery Perforator Flap: From Simple to Its Chimeric Pattern and Clinical Experience with 37 Cases

BACKGROUND

Defects in the knee area, popliteal fossa region, and upper third of the lower extremity can pose a challenge for reconstructive plastic surgeons. The purpose of this article is to report the authors' experience with the use of the pedicled medial sural artery perforator flap in its simple and chimeric form for reconstruction of defects in three different regions: knee, popliteal fossa, and proximal lower leg.

METHODS

From April of 2018 to April of 2019, 37 patients (29 men and eight women) with a mean age of 51 years (range, 18 to 78 years) underwent reconstruction with 37 pedicled medial sural artery perforator flaps. All flaps were harvested as pedicled perforator flaps in conventional or chimeric fashion and were based on one or two perforators. The defect locations included the knee (18 cases), popliteal fossa (seven cases), and proximal lower leg (12 cases). The cause of reconstruction was trauma in 22 patients (59 percent), tumor in 10 patients (27 percent), and donor-site closure of free medial sural artery perforator in five patients (14 percent).

RESULTS

The flap sizes varied from 3.5 × 5 cm to 5 × 10 cm. All but one flap, which showed distal tip necrosis, survived completely after surgery. The donor sites were all closed primarily. Minor complications included flap dehiscence (two cases) and minor wound infection delaying the healing process (four cases). All complications were treated conservatively. Follow-up observations were conducted for 3 to 12 months, and all patients had good functional recovery with satisfactory cosmetic results.

CONCLUSION

The pedicled medial sural artery perforator flap can be considered an optimal method of reconstruction for covering defects not only in the knee area but also in the popliteal fossa and upper lower leg.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Practical Review of the Management of Animal Bites

Animal bites are common worldwide. Due to the plethora of animals, there are diverse pathogens with specific associated risks and treatment algorithms. It is crucial to understand these to develop and execute appropriate management plans. This practical review was designed to amalgamate the most common bites worldwide and synthesize data to help guide treatment plans.

METHODS

A PubMed literature search was performed focusing on the major animal bites. High-level studies were preferred and analyzed but lower-level studies were also used if high-level studies did not exist.

RESULTS

The tables presented in this article cover the pertinent information regarding the incidence, common presentation, initial treatment, and potential complications associated with bites from dogs, cats, horses, rodents, snakes, marine life, and spiders. Many of the pathogens associated with the bites are treatable with various and somewhat common antimicrobials, though some are less easy to access. Basic irrigation, debridement, and wound culture are common to almost every animal and should be the first step in treatment.

CONCLUSIONS

Based on the current studies, the most important factor in treating animal bites is timely presentation to a medical facility and/or physician. It is critical that the offending animal be accurately identified to help guide medical and surgical algorithms, including specific antimicrobial treatment guided by the most commonly presenting pathogens specific to certain animals.

Consistent Value of Two-Stage Pedicle Flaps in the Age of Microsurgical Maxillofacial Reconstruction

Introduction

Up to the second half of the twentieth century, pedicled flaps marked the gold standard in reconstructive surgery. Followed by the introduction of microsurgical techniques, these flaps were increasingly abandoned. We conducted a retrospective study to determine the value of two-stage pedicle flaps in modern maxillofacial reconstruction.

Material & Methods

A chart review from October 2017 to November 2020 was performed to identify patients who were treated by a two-stage pedicle flap in our Department of Oral and Maxillofacial Surgery.

Results

A total of 31 patients, 17 female and 14 males received 36 two-stage pedicle flaps. All patients were in noticeably impaired health condition with a majority of ASA-score 3. The defect location mainly contained extraoral resections (58.3%). A variety of flaps were harvested consisting of buccal flaps, Abbe flaps, forehead flaps, deltopectoral flaps, nasolabial flaps, and a tubed flap.

Discussion

The study outlines two indications for the use of two-stage pedicle flaps. Firstly, as a back-up strategy in heavily pre-treated wound beds and secondly in an almost contrarily indication as a first-choice reconstructive option of the facial skin in esthetic demanding cases.

Conclusion

The timesaving and straight forward surgical approach as well as their low postsurgical complications and strong long-time success rates secure the two-stage pedicle flap a justified niche role in times of microsurgical maxillofacial reconstruction.

Reconstructive Techniques in Melanoma for the Surgical Oncologist

Wounds resulting from wide local excision of melanoma vary in size and complexity, and require individualized solutions to achieve satisfactory closure. Goals of reconstruction include restoration of form, function, and aesthetics while minimizing donor site morbidity without compromising the effectiveness and safety of oncologic melanoma treatment. Optimal reconstruction relies on an in-depth understanding of the defect, locoregional anatomy and vasculature, available donor tissues, and basic wound healing and surgical principles. This article provides a broad overview of preoperative patient, timing, and wound considerations; various surgical techniques for complex reconstruction throughout the body; and postoperative care and complication management.

Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma

The complex lower extremity wound is frequently encountered by orthopedic and plastic surgeons. Innovations in wound care, soft tissue coverage and surgical fixation techniques allow for improved functional outcomes in this patient population with highly morbid injuries. In this review, the principles of reconstruction of complex lower extremity traumatic wounds are outlined. These principles include appropriate initial evaluation of the patient and mangled extremity, as well as appropriate patient selection for limb salvage. The authors emphasize proper planning for reconstruction, timing of reconstruction and the importance of an understanding of the most appropriate reconstructive option. The role of different reconstructive and wound care modalities is discussed, notably negative pressure wound therapy and dermal substitutes. The role of pedicled flaps and microvascular free-tissue transfer are discussed, as are innovations in understanding of perforator anatomy and perforator flap surgery that have broadened the reconstruction surgeon’s armamentarium. Finally, the importance of a multidisciplinary team is highlighted via the principle of the orthoplastic approach to management of complex lower extremity wounds. Upon completion of this review, the reader should have a thorough understanding of the principles of contemporary lower extremity reconstruction.

Dermal Regeneration Templates in Maxillo-Facial District: A Multipurpose Aid

ABSTRACT

Since 1980s, the use of dermal regeneration templates (DRT) for reconstructive purposes has been described in Literature.1 The authors present their experience of 13 patients treated with integra dermal regeneration template and a single-stage surgery for different indications like oncologic reconstruction, trauma injuries, and preprosthetic surgery in the maxillo-facial district.The authors retrospectively reviewed a total of 13 patients treated with DRT at Maxillo-Facial Department of S. Maria Hospital in Terni.Inclusion criteria included the presence of a defect nonapproachable primarily or by secondary intention with an easy locoregional flap reconstruction, a complete clinical record, and a minimum 6 months follow-up.A total of 12 patients underwent surgical reconstruction with DRT at the S. Maria Hospital from June 2018 to February 2020.During follow-up, all patients in which intraoral reconstruction was performed showed first signs of re-mucosization and neovascularization after 10 days.Only in 1 patient (8%) a seroma underneath the silicon sheet was observed. Afterward, the patient healed correctly with no other complications.Dermal regeneration template represents an option that should be considered in the head and neck district reconstruction, especially for intraoral defects where, thanks to its long-term functional results and limited alternatives, should represent a relevant choice.

Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap

INTRODUCTION

Achilles tendon rupture and soft tissue infections with wound dehiscence and tendon exposure following the tendon repair are not infrequent. Various procedures have been described for the reconstruction of soft tissue defects at the Achilles tendon region, yet there is lack of consensus on the ideal method. In this article we report our experience using the distally based peroneal artery perforator flap in reconstruction of combined defects of the Achilles tendon and overlying soft tissue.

METHODS

7 patients with Achilles tendon injury and full-thickness soft tissue defects over the Achilles region underwent tendon repair and soft tissue reconstruction with the distally based peroneal artery perforator flap. Perforator vessels were identified at the septum between the peroneus longus and soleus muscles. After choosing the perforator with the largest diameter, meticulous deep dissection of the perforator was performed and completed 6 cm proximal to the lateral malleolus. The peroneal artery was transected and ligated and transposition of the flap to the defect was performed through a subcutaneous tunnel.

RESULTS

The size of the soft tissue defects and flaps ranged between 2×3 cm to 4×10 cm and 4×5 cm to 5×12 cm, respectively. Six out of 7 flaps survived completely without any complications. Post-operative venous congestion was observed in one patient which resulted in partial tip necrosis of the flap. The resulting wound healed with conservative treatment. Donor sites healed uneventfully in all patients. All flaps had excellent contour and provided stable soft tissue coverage.

CONCLUSION

Distally based peroneal artery perforator flap can be considered as a reliable alternative for the reconstruction of soft tissue defects around the Achilles tendon region. Advantages include (1) extended reach of the flap for the defects around the plantar and dorsal aspects of the foot, provided by the perforator dissection, (2) convenience with footwear and walking, provided by the skin texture similarity with the target region, (3) creating a protective surface to allow tendon gliding and prevent tissue adhesions after the tendon repair, provided by the crural fascia included in the flap, (4) obviating the need for microsurgical anastomosis and associated length of the operation.

Extracellular matrix graft for reconstruction over exposed structures: a pilot case series

OBJECTIVE

Soft tissue defects, especially those involving exposed vital structures, present a reconstructive challenge because poor vascularity of such defects typically makes immediate skin grafting unviable. Where flap procedures are inappropriate or not possible, dermal matrices represent an alternative reconstructive option for defects with denuded vital structures. With dermal matrices becoming increasingly available and technologically advanced, we evaluated an ovine-derived extracellular matrix graft in the reconstruction of complex soft tissue defects involving exposed vital structures.

METHOD

Six cases of soft tissue defects exhibiting denuded vital structures underwent reconstruction using an ovine forestomach matrix graft as a dermal matrix. Grafts were fixed directly into defects for immediate coverage and subsequently temporised defects via granulation tissue formation for later skin graft or secondary closure. Defect granulation and epithelialisation were monitored until closure and the final aesthetic and functional outcomes were evaluated.

RESULTS

Complete healing was achieved in all cases, with defect granulation becoming observable within one to two weeks and complete granulation occurring within one to six weeks. Granulation tissue resulting from the graft was suitable for skin grafting, with 100% take of skin grafts after one week and complete re-epithelialisation in two to three weeks in the four cases that received a skin graft. Good cosmetic, functional and patient satisfaction outcomes were achieved in all cases.

CONCLUSION

The present series demonstrates our initial use of an extracellular matrix-based dermal matrix in reconstructing defects with exposed vital structures. While such dermal matrices do not supersede or replace flap procedures, they represent an alternative option on the reconstructive ladder in cases where flap procedures are not appropriate or possible.

Manejo de heridas traumáticas de difícil cicatrización con colgajos microvasculares

OBJECTIVE

Present different flap alternatives when performing microvascular free-flap reconstruction in acute hard-to-heal wounds.

METHOD

A retrospective review of patients whose acute hard-to-heal wounds were treated with microvascular free-flap reconstruction. Data on demographics, wound aetiology, diagnostic, previous treatment, free-flap type, free-flap size, complications and follow up were analysed.

RESULTS

A total of 20 patients received microvascular free-flap reconstruction. The median age was 39.5 years. Twenty free-flap reconstructions were performed. These included: 3 cross-leg free flap, 1 cross-leg vascular cable bridge flap, 2 fibula osteocutaneous flap, 6 anterolateral thigh (ALT) flap, 3 thoracodorsal artery perforator (TDAP) flap, 3 fasciomyocutaneous flap, and 2 femoral artery fasciocutaneous flap. A patient required microvascular anastomosis due to hematoma; the rest did not present complications during their postoperative. Previous treatment included negative pressure wound therapy (12 patients) and surgical debridement with silver hydrogel dressings (8 patients).

CONCLUSION

Hard-to-heal wounds can be unresponsive to traditional wound healing practices or local flaps. They often require free-flap reconstruction, using tissues similar to those compromised. Microvascular techniques can be an effective alternative.

Reconstruction of Craniofacial Skin Cancer Resection Defect in Octogenarian Patients Using Fenestrated-type Artificial Dermis Without Skin Grafting

ABSTRACT

Reconstructive surgery following skin cancer resection in octogenarian patients can be challenging. Despite current advancements in reconstructive options, most of these wide excision defects require local or even free flap coverage, causing physical and emotional impairment. Few reports have been published on the management of these complex craniofacial defects. We present our experience in 2 octogenarian patients with craniofacial skin cancer treated with wide excision under wide-wake local anesthesia and subsequently reconstructed with fenestrated-type artificial dermis. Both patients had uneventful recovery. The wounds healed by secondary intention without skin grafting.

Algorithm for covering circumferential wound on limbs with ALTP or/and DIEP flaps based on chain-linked design and combined transplantation

INTRODUCTION

Coverage of circumferential wounds on limbs is a challenging reconstructive job. Here, we propose a skin flap-based algorithm to reconstruct circumferential wound with the chain-linked design and combined transplantation of ALTP and DIEP flap, which could achieve full-coverage and simultaneously primary donor-site closure.

PATIENT AND METHODS

From December 2007 to December 2018, 14 patients with circumferential would on upper or lower limbs underwent reconstruction with ALTP or DIEP flap, by the technique of combined transplantation or chain-linked design, or both. The wound was classified into five different types according to the width compared to the donor site (overall magnitudes and regularity), which was separately reconstructed by five different wound decomposition and corresponding flap design. Flap survivorship, complication on recipient or donor site and any secondary surgeries have been recorded.

RESULTS

14 patients were successfully treated with 22 flaps, including seven patients reconstructed with one flap (4 bi-pedicled, 2 tri-pedicled), 6 patients reconstructed with two flaps (1 in mono-pedicled, 5 in multi-pedicled), one with 3 flaps and skin grafts. Only one donor site was not directly closed, and one experienced dehiscence but finally healed. All flaps survived uneventfully but three had minor edge necrosis and later treated with skin graft.

CONCLUSION

The algorithm is practical in circumferential wound resurfacing on limbs for allowing flexible design, sufficient coverage, and low donor site morbidity.