Cross-leg flaps: Case series, review, and proposed classification

Background

Cross-leg (CL) flap procedures have a long history in reconstructive surgery, having been described for the first time in 1854. The application of these flaps can potentially solve many reconstructive issues with satisfactory outcomes.

Patients and methods

During our research into the history and development of CL flaps, we identified a variety of flaps for which a classification system can be proposed based on blood supply and flap modifications. In this study, 10 patients with different complaints were managed using posterior tibial artery (PTA) perforator CL flap and superiorly based sural CL flap with satisfactory outcomes.

Results

All flaps survived and healed smoothly; consequently, the flaps provided stable coverage, and the donor sites were reconstructed using skin grafts, which provided satisfactory results to the patients and/or their guardians.

Conclusion

To our knowledge, this is the first study to propose a simple classification and group different types of flaps mentioned in the literature under one category. CL flaps are a common reconstructive option for patients with injuries that limit their mobility.

Local Random Pattern and Axial Flaps for Reconstruction of Nasal Surgical Defects: Retrospective Analysis with an Attempt to Inspire ENT Surgeons

Aim: Reconstruction of the surgical defects of the external nose has been challenging and largely considered to be the domain of plastic reconstructive surgeons. The present study aims to share our experience in reconstructing such defects. Materials and methods: A retrospective analysis of 11 patients who underwent external nasal reconstruction secondary to surgical defect at our otolaryngology department in a tertiary care hospital from 2017 to 2019 was done. All the patients underwent surgical excision of a part of the external nasal dorsum followed by reconstruction by our team of otolaryngology surgeons using local random pattern/ axial flaps. The patients were followed up postoperatively for a period ranging from 3 months (for benign pathologies) to 2 years (malignant pathologies). Results: The flaps were taken up in all the patients. Minor complications like postoperative infection were seen in 2 cases, resulting in wound dehiscence in one that required resuturing that was uneventful. The appearance was bulky in all the patients, although the patients were satisfied with the overall cosmetic appearance. The average hospital stay was 2 to 4 days. Conclusion: Reconstruction of external nasal surgical defects is a challenging task. Thorough knowledge of relevant anatomy, proper planning, and availability of abundant vascularized donor tissue in the near vicinity of the defect makes this challenge acceptable with good outcomes even in the hands of otolaryngologists.

Axial flap for giant basal cell carcinoma of the anterior chest wall: Case report

Introduction and importance

Anterior chest wall Giant Basal Cell Carcinoma (GBCC) is rare amongst GBCC cases and results in a large defect that is challenging to resect and reconstruct. It requires multidisciplinary approach to prevent recurrence.

Case presentation

A 72-year-old man with giant basal cell carcinoma at the anterior chest wall measuring 10 × 6 cm. Wide resection of 1 cm margin with axial flap was performed to close the defect. The follow-up report stated that the patient was satisfied with the result and there was no recurrence observed.

Clinical discussion

Review of literatures concludes that GBCC is excised with a minimum of 4-6 mm margin outside the tumor area. The axial IMAP flap is ideal to close the upper chest wall defect because of the better aesthetic outcome compared to other conventional flaps, especially in stable elderly male, patients with noninfected wound. Increased skin laxity and more relaxed skin tension associated with aging allows easier tissue mobilization and transfer to close the defect.

Conclusion

Axial flap for GBCC in anterior chest wall is ideal, safe, and has the advantage of aesthetic reasons of suitable skin tone, particularly for stable elderly male patients.

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A 72-year-old man presented with a seven-year history of ulcerating mass on his anterior chest wall.

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Histopathologic examination confirmed the diagnosis of giant basal cell carcinoma (GBCC).

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We performed wide resection with 1 cm margin and reconstruct the defect with axial flap.

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No evidence of recurrence observed after 1 year of resection.

[Brief introduction of perforator flap]

In 600 BC, the first pedicled direct cutaneous artery perforator flap-the supravicular artery perforator flap was harvested by Sushruta. In 1973, the first free perforator flap-the superficial circumflex iliac artery flap in the groin was reported by Daniel and Taylor. In 1982, the septocutaneous perforator flap was reported by academician Zhong Shizhen. In 1989, the misculocutaneous perforator flap was reported by Koshima. Reviewing the history of flap surgery, there was a fact that the main evolutionary line was the course of perforator flap. In the future, the clinical application of the traditional random flap (reticulated blood supply flap) and traditional axial flap will be more and more less, whereas the clinical application of perforator flap, especially the direct cutaneous perforator flap and the special type of perforator flap will be more and more extensive.

Effect of Platelet-Rich Plasma on Ischemia-Reperfusion Injury in a Skin Flap Mouse Model

Background: Ischemia-reperfusion (I/R) injury is a leading cause of surgical skin flap compromise and organ dysfunction. Platelet-rich plasma (PRP) is an abundant reserve of various growth factors. Activated platelets play a role in endothelial damage during I/R injury; however, exogenous PRP could inhibit the production of reactive oxygen species. The goal of this study was to investigate the effect of PRP on I/R injury. Methods: Four groups (n=30) of C57BL/6N mice with lateral thoracic artery island flaps were used. Group A, the control group, received flap elevation and repositioning. Group B received PRP and repositioning. Group C had 4 hours of ischemia and then were reperfused. Group D received PRP, had 4 hours of ischemia, and then were reperfused. The survival area of flap tissue and blood perfusion were assessed. Histological evaluation included neutrophil counts. Reactive oxygen species and proinflammatory cytokines were measured to evaluate I/R injury. Protein expression of phosphorylated apoptosis signaling regulating kinase-1 (pASK-1), p38MAPK, and pNF-κB was measured by western blot. Results: PRP treatment enhanced the survival area and perfusion of the flap, reduced neutrophil accumulation in mice subjected to I/R injury. PRP treatment also showed a protective effect, with decreases in nitric oxide, myeloperoxidase, malondialdehyde concentrations. Additionally, PRP suppresses monocyte chemotactic protein-1, TNF-α, IL-1β, and IL-6. Finally, PRP decreased ASK-1 and NF-κB expression in tissues with I/R injury. Conclusion: PRP acts as a protective factor during flap I/R injury by reducing reactive oxygen species level and proinflammatory cytokines via decreased expression of pASK-1 and pNF-κB.