Maxillary and total nasal reconstruction with a scapulo dorsal perforator flap

Facial gunshots injuries remain challenging and present functional and aesthetic problems. Such defects generally require composite tissue flaps for reconstruction. Rebuilding the palate and the maxilla is especially delicate because it requires reconstitution of the facial buttresses, and replacement of bony hard palate, based on occlusion, as well as the restoration of the thin intraoral and intranasal lining which normally constitute the soft palate. Various methods of reconstruction have been applied to this area in search of an ideal soft tissue and bone flap to restore the bony framework of the maxilla and palate while providing an internal lining. The scapula dorsal perforator flap is used in the case of a patient to successfully reconstruct the palate, the maxilla and the nasal pyramid in one stage. Free tissue transfer using thoracodorsal perforator flaps and scapula bone free flap have been already described in literature but never to perform the nasal pyramid reconstruction at the same time. Good functional and aesthetic results have been obtained in this case. This article also reviews, through the authors experience and literature, anatomical landmarks, indications, technical surgical tricks, advantages and disadvantages of this flap for palatal, maxillary and nose reconstruction.

[Cytosteatonecrosis after breast reconstruction by fat flap with or without ischemic preconditioning]

INTRODUCTION

Cytosteatonecrosis (CTN) is a frequent postoperative complication after breast autologous reconstruction using DIEP (deep inferior epigastric perforator) flap. CTN radiological diagnostic reveals different types of lesions, as nodes or extended fat necrosis, which become in some cases infected, or pass for tumor recurrence after breast cancer treatment. CTN is caused by intraoperative ischemia of the flap, and no current method can prevent postoperative CTN development after DIEP breast reconstruction. Mechanical ischemic preconditioning, consisting in intraoperative briefs consecutive cycles of ischemia reperfusion using vascular clamp upon the graft pedicle, is used in transplantation surgery. This procedure improves the graft tolerance towards ischemic surgical lesions. The aim of this retrospective observational study was to assess PCIM effects on CTN development after DIEP surgery, comparing CTN occurrence after breast reconstruction using DIEP flap with or without intraoperative PCIM.

MATERIAL AND METHODS

All patients breats reconstructed using DIEP flap between novembre 2020 and may 2022, presenting 6 months postoperative breast echography were retrospectively included. Primary outcome was the ultrasonic existence of CTN, according to the Wagner classification. Clinical data, postoperative outcomes such as infection, hematoma or surgical revision, and length of stay in hospital were also recorded.

RESULTS

Twenty nine patients among which 8 PCIM were included. CTN occurrence rate after PCIM (25%) was quite lower than CTN rate without PCIM (71,4%), although the difference was not significant (P=0,088). Other postoperative complications rates were not significantly different with or without PCIM.

CONCLUSION

PCIM seems to improve CTN occurrence after DIEP breast reconstruction, improving fat flap tolerance to ischemic perioperative lesions. Those preliminary results need to be confirmed with clinical prospective study.

Spare part's free contralateral medial plantar flap for emergency reconstruction in a bilateral lower legs ballistic trauma

The medial plantar flap is frequently used in heel reconstruction and has been described since 1969. We took care of a 25-year-old patient with a bilateral ballistic trauma and open fractures to the distal third of both legs. Given the seriousness of the damage to the left lower limb, a trans-tibial amputation had to be performed. Concerning the right lower limb, we decided to cover the defect with a spare part's free medial plantar flap thanks to the amputated fragment. The extremity spare tissues principle is already known and described, more particularly concerning hands, in emergency traumatic surgery and in planned surgery, mainly concerning thumb reconstruction, for example for hypoplasia or after traumatic amputation. Apart from an article on the use of foot spare part in the coverage of amputation stumps, no article has reported the use of a foot spare part in reconstructive surgery, even more in traumatic surgery. We believe that the use of an extremity spare tissues should be considered in rare cases where this is possible, in order to reduce donor-site morbidity in the context of reconstructive surgery.

Effect of ischemic preconditioning on skeletal tissue tolerance after warm venous ischemia

PURPOSE

Free muscular flaps are commonly used in plastic surgery. The main reason of failure is thrombosis induced by a phenomenon called ischemia reperfusion. Preconditioning showed an interest to prevent ischemia reperfusion injury in transplantation surgery. The aim of the study is to evaluate the effect of ischemic preconditioning on skeletal tissue tolerance after warm venous ischemia.

MATERIALS AND METHODS

We realized an experimental study with latissimus dorsi flaps of 12 pigs, divided in 6 groups in function of their time of preconditioning and duration of warm venous ischemia. A morphologic analysis was performed measuring cell's diameter and interstitial tissue area and notifying the presence or absence of neutrophils, necrosis or intravascular thrombosis. To detect inflammation, necrosis or hypoxia, immunohistochemistry was effectuated using the follow primary antibodies, AIF, HIF1 alpha, caspase 3, SOD 1 and PKC epsilon. TUNEL assay showed apoptosis cells, were realized. One way Anova test was performed to compare the quantitative evolution over time of histological parameters and rate of apoptosis.

RESULTS

Preconditioning of 40min or 1hour allowed to reduced ischemia reperfusion lesions: no cellular or interstitial oedema, reduction of neutrophils infiltrate and intravascular thrombus. TUNEL assay showed a higher rate of apoptosis nucleus for the control group E compared to preconditioning group C and D. Immunohistochemistry results were no relevant.

CONCLUSION

We showed a diminution of lesions of ischemia reperfusion for experimental groups with preconditioning: diminution of interstitial oedema, of cellular oedema, diminution of neutrophils infiltrated and level of apoptosis cells. Preconditioning of 40minutes were as efficient as one hour.

[Emergency free flap in reconstruction of the lower limb: About 23 cases over 11 years]

OBJECTIVES

To study the coverage period influence and various parameters concerning the microsurgical act on the patient clinical outcomes.

METHODS

We report 23 cases of reconstruction of lower limb loss of substance by free flap operated from 2010 to 2021. Among them, 9 patients were operated on as an emergency versus 14 in the secondary or late phase of the trauma.

RESULTS

The average age of injured patients operated on emergency was 42 years (17-68 years) and 34 years for the patients who undergo deferred surgery (17-57 years). The sex ratio (female/male) was 22% in patients operated on urgently and 7% in patients operated on later. Regarding the type of free flap, it was Serratus anterior muscle flap in 10 cases, Latissismus dorsi flap in 9 cases, ALT flap in 3 cases and Gracilis muscle flap in 1 case. There were 2 failures of vascularized free transfer (8.7%) with complete necrosis of the flap and 3 revision surgeries on venous thrombosis which finally made it possible to obtain 3 flap successes. We analyze the results (complications/osteitis) according to the time to coverage.

CONCLUSIONS

In our study, we did not find any significant difference between the groups operated in emergency and at a distance concerning the rate of infection and failure of the flaps.

Shape-modified radial forearm flap: does it still have a role in upper extremity reconstruction?

OBJECTIVES

To carry out a radial forearm flap, the radial artery is usually harvested, incurring severe donor site morbidity. Advances in anatomical knowledge discovered constant radial artery perforating vessels, enabling the subdivision of the flap into smaller components suitable for a wide range of differently shaped recipient sites, with marked reduction of downsides.

MATERIAL AND METHODS

Eight pedicled or free shape-modified radial forearm flaps were used to reconstruct upper extremity defects between 2014 and 2018. Surgical technique and prognosis were examined. Skin texture and scar quality were assessed on the Vancouver Scar Scale while function and symptoms on the Disabilities of the Arm, Shoulder and Hand score.

RESULTS

At a mean follow-up of 39 months, no cases of flap necrosis, impaired hand circulation or cold intolerance were found.

CONCLUSION

The shape-modified radial forearm flap is not a new technique, but is poorly known by hand surgeons; in contrast, our experience showed it to be reliable, with acceptable functional and esthetic outcomes in selected cases.

"Extensive necrosis following extravasation of alkali in the crease of the elbow after voluntary intravenous injection: A case report"

Chemical burns are often deep with difficult initial clinical evaluation, especially those due to alkalic agents, which have a strong penetrating power. They therefore require specialized care in a Burn Unit. Self-inflicted burns are infrequent but their management represents a real challenge. We report the case of a 47-year-old referred to our Burn Center for the evaluation of a self-inflicted corrosion with an alkalic agent (soda), injected at the crease of the left elbow. The patient, right handed, was a nurse and had notably a psychiatric history of depressive syndrome. We observed a deep, well-defined necrosis area, associated with intense peri-lesional inflammation and extensive cellulitis. Faced with this unusual clinical appearance for a chemical burn, the patient's questioning was repeated and the patient finally admitted to having injected himself with a basic caustic product intravenously. Surgical treatment was carried out in two stages: debridement with exposure of vascular and neural structures then coverage with a free anterolateral thigh flap. The postoperative consequences were uneventful with a satisfactory functional result. Factitious disorders are underestimated and often misleading. Among factitious disorders, self-inflicted wounds remain a real challenge requiring multidisciplinary management. Many etiologies exist, among which injection of drugs or substances, in any anatomical localization, leading to variable loss of substance. The use of a free flap for acute extravasation is rare but sometimes essential. The anterolateral thigh flap allows good resurfacing on areas with important functional requirements.

Free flap for lower limb salvage in infectious purpura fulminans

BACKGROUND

Infectious purpura fulminans is a disabling disease often leading to amputations. Free flaps preserve limb length, covering exposed areas. We examined the efficacy of free flaps for lower limb salvage in infectious purpura fulminans survivors by evaluating surgical management, walking ability and quality of life.

METHODS

This single-center, observational, descriptive, retrospective study was conducted in from 2016 to 2019. Adult purpura fulminans survivors who received a free flap for lower limb salvage were included. Patient characteristics and data on surgical management and rehabilitation were collected. Quality of life (SF-36 questionnaire), limb function and walking ability were later evaluated post-surgically.

RESULTS

The 6 patients included, mean age 38 years, had all required amputations. Nine free flaps were performed to cover important structures in 7 cases and for stump resurfacing in 2. All flaps were successful. Patients resumed walking at a mean of 204±108 days after the onset of purpura fulminans. Post-surgical evaluation was performed at a mean of 30±9.3 months. Five patients required secondary revision. All were independent for the activities of daily living. Mean physical component score was 37.6±9.4 and mental component score was 44.6±13.2 (minimum 0, maximum 100).

CONCLUSIONS

Use of the free flap in patients with infectious purpura fulminans, after multidisciplinary reflection, is an appropriate procedure that preserves limb length. In spite of secondary complications, preservation of limb length enables patients to resume walking, with relatively good independence and quality of life.

[Secondary surgery of breast reconstructions by breast implant. Assessment of patient satisfaction based on surgical technique implant conservation vs. autologous conversion]

INTRODUCTION

Breast reconstruction with implants has long-term disadvantages and is leading an increasing number of patients to request secondary corrective surgery. Two surgical strategies are possible: implant replacement (associated with capsulectomy/capsulotomy and/or lipofilling procedures) and implant removal associated with the provision of autologous tissue (flap and/or lipofilling).

METHOD

Between 2010 and 2018, 54 patients underwent secondary surgery for correction of a first implant breast reconstruction. The reasons for dissatisfaction with the initial reconstruction, the procedures performed, and postoperative complications were analysed. Patient well-being and satisfaction were evaluated using the BREAST-Q questionnaire.

RESULTS

Thirty-four patients benefited from a prosthesis change and 20 patients benefited from a permanent removal of their prosthesis combined with the addition of autologous tissue. The presence of a periprosthetic shell, pain, fixed appearance of the breast and breast asymmetry were the most frequent reasons for dissatisfaction. With a mean follow-up of 2.6 years, autologous conversion patients were generally more satisfied with the appearance of their breasts than patients who retained a breast implant (P<0.0001).

CONCLUSION

In cases of poor esthetic or functional outcomes of implant-based breast reconstruction, removal of the prosthesis in combination with autologous reconstruction provides better results in terms of well-being and satisfaction than implant replacement.

Partial DIEP flap loss in a patient with history of abdominal liposuction

Classically, history of prior abdominal liposuction has been considered a relative contraindication for breast reconstruction using deep inferior epigastric perforator (DIEP) flap. The rationale for this is based on the fact that liposuction can possibly damage perforating vessels, which could compromise flap survival. However, multiple recently published reports have shown that imaging using CT angiography or colour Duplex ultrasonography could be used to accurately assess the adequacy of the perforating vessels before DIEP flap harvest. This contraindication is currently being reconsidered in the scientific literature. We present a case of partial DIEP flap loss in a patient with history of abdominal liposuction that happened despite preoperative identification of adequate perforators using CT angiography and intraoperative clear evidence of patent anastomoses. This occurrence reopens in our view the question of whether DIEP flaps can be safely performed on patients with a history of abdominal liposuction, even in the presence of adequate perforators on regular CT angiography or Doppler ultrasonography. While abdominal liposuction may not injure perforating vessels, its detrimental effect on linking micro-vessels within the flap cannot be fully evaluated using CT Angiography. Therefore, the use of another imaging modality, such as the indocyanine green laser angiography, to assess perfusion before DIEP flap harvesting is performed and could be considered in patients with history of abdominal liposuction.

Coverage of cutaneous substance loss in the leg: Techniques and indications

Cutaneous substance loss in the leg is frequent; more often than not, it is trauma-related. It calls for complex management and necessitates the application of all current reconstruction techniques, particularly microsurgery. As regards treatment, the available therapeutic arsenal is highly diversified, ranging from a simple free flap skin graft to local and locoregional flaps. During reconstruction, the surgeon is subjected to several constraints insofar as the objectives of the operation are esthetic as well as functional. Ideally, the fineness of the skin covering the anterior side of the leg will have been scrupulously respected. Reconstruction is aimed at producing a stable and reliable cutaneous envelope while limiting the morbidity of the donor site. The development of free perforator flaps corresponds to these two criteria by producing a fine flap adapted to the cutaneous thickness of the leg and limiting any functional and esthetic sequelae at the donor site.

Management of complex forearm defects: A multidisciplinary approach

Complex forearm defects with significant damage to, or loss of skin, tendon, muscle, bone and neurovascular structures represent a great challenge for surgeons. The management of such injuries, whether a result of trauma or tumor resection, is focused on preservation of the damaged limb and restoration of hand function. A multidisciplinary approach combining plastic and orthopedic surgical expertise in a coordinated team is proposed to address these challenging cases. The authors have laid emphasis on adequate debridement for wound bed preparation, bone stabilization and reconstruction for a stable bony framework, vascular repair for early revascularization, musculotendinous and nerve reconstruction as well as vascularized tissue coverage on a case-to-case basis to facilitate optimal functional recovery. They also maintain that besides expedient surgical treatment, early mobilization based on an individualized rehabilitation program as well as psychological and socio-professional supports are necessary means of achieving rapid and successful social integration.

The two-stage free flap strategy: An alternative to reconstruct major oncological surgical defects with noble organ exposure

BACKGROUND

To minimize the risk of viscera exposure for parietal or calverial reconstruction after tumor removal, we used the two-stage free flap strategy. The flap was transferred a few days before tumor resection and left in a standby position until the second stage.

PATIENTS AND METHOD

We conducted a retrospective monocentric study. All patients who underwent reconstruction with the two-stage free flap strategy after tumor resection since 2000 were included.

RESULTS

We performed 14 two-stage flaps (8 for calvaria, 3 for abdomen, and 3 for thorax) on 12 patients. The average skin paddle surface was 318 cm². The mean operative time was 274min for the first stage and 172min for the second stage. The average time between the two stages was 8.8 days (2 to 24 days). One flap necrosis, one venous thrombosis, and one hematoma were observed after the first stage. Partial skin paddle necrosis (2 flaps) and infections (3 flaps) occurred after the second stage. The mean follow-up was 20 months (6 to 61 months), and two patients had tumor recurrence.

CONCLUSIONS

The two-stage free flap strategy is another option for major oncological reconstructions, to be safe and reliable some rules must be followed. The flap must contain a large skin paddle to ensure flap autonomization and to allow for complete tight plication of the flap between the two stages, which limits germ colonization. A short delay between the two stages (<12 days) decreases the risk of infection. The presence of a plastic surgeon during the second stage decreases the risk of pedicle trauma.

[Reconstruction by thoracodorsal perforator flap after petrosectomy]

Petrosectomy is a debilitating intervention, consisting of a resection of the bone forming the external auditory canal, the middle ear and sometimes the internal ear as well. The cavity formed after this surgery can lead to infectious complications. Reconstruction is an essential element for patients' rehabilitation. Most cases require local rotation flaps such as temporal muscle flap. However, when the remaining defect is too large or when the structures have been altered by radiotherapy, free flaps are the most adequate solution for repair. Upon review of the literature, there are very few articles providing options regarding reconstruction possibilities post-petrosectomy. Plastic surgeons are often unfamiliar with this indication, therefore, it is essential to call their attention in order to provide the best options of care in these difficult and complicated cases where possibilities are limited. That is why, it is important for us to share our experience in this domain through the example of our patient presenting with a large osteoradionecroses of the petrous bone, requiring resection and immediate reconstruction using a free flap.

[Use of coupler for venous anastomoses in cervico-facial reconstruction. Retrospective study on 51 free flaps]

OBJECTIVE

The aim of our study was to evaluate the interest of the mechanical anastomosic coupling device for venous anastomoses in a series of cervico-facial reconstructions after carcinologic excision.

PATIENTS AND METHODS

Between January 2010 and December 2017, 46 patients underwent free flap cervico-facial reconstruction. We performed 54 venous anastomoses for 51 free flaps. Mechanical venous anastomoses were performed with a coupler (Coupler®). Thrombotic complications and choice of recipient vessels were assessed for the entire series.

RESULTS

Venous anastomoses were performed using a coupler in 33.3% of the flaps (n=18). Mean operative time was lower for reconstructions with mechanical coupler anastomoses, and significantly for fibula flaps. Of eight thromboses, six were venous, two of which after the coupler anastomosis. The thrombosed veins were the branches of the internal jugular vein and the anterior jugular veins. The diameter of the couplers used was respectively 2.5mm and 2mm.

CONCLUSION

The use of the microvascular coupling system for venous anastomoeis would help reduce the occurrence of venous thrombosis, but larger and prospective studies should be conducted. This coupling system, relatively easy to use, would overcome the lack of congruence of anastomosing veins and reduce the risk of intimal injury. Regarding the recipient vessels, the anterior jugular vein should not be used as first line because the risk of vascular complications seems more important.

[Free latissimus dorsi flap lacing and local care in two-stage scalp reconstruction]

Surgical treatment of large and multiple lesions of irradiated scalp may require subtotal scalp exeresis and reconstruction in two-stage free flap surgery: harvesting and placing the flap first, then scalp removing and defect covering in a second step. This strategy raises the question of how to care the flap between the two surgeries. We report an original technique of free latissimus dorsi flap lacing. A 70-year-old male, afflicted with familial cylindromatosis and treated by brachytherapy 18years ago, received a free latissimus dorsi myocutaneous flap in two-stage surgery, allowing 25×25cm pathological scalp exeresis. During first step, suture clips were fixed in two rows around the future scalp defect, in order to be used as anchors for the flap lacing. Braided wire were chosen for a better steerability, and to prevent knots untightening. Thus, the flap were placed in "anatomical" place, next to the scalp, pending secondary procedure. This situation permitted to avoid flap or pedicle compression or plication, and to ease flap care. The wires were tighten as shoelaces, allowing them to be undone and done as desired. The two-stage free latissimus dorsi flap reconstruction of scalp large defect permitted us to assess the flap reliability before final reconstruction. The lacing solution allowed us regular local care and convenient flap handling, while favoriting its optimal placing next to its future location.

[Tongue reconstruction by thoracodorsal perforator flap: A new harvesting technique to reduce morbidity]

The thoracodorsal artery perforator flap is increasingly used in head and neck reconstructions. One of its multiple advantages is the low donor site morbidity compared to the other free flaps usually used for this type of surgery, such as the radial forearm free flap and the anterolateral flap of the thigh. However, the current harvesting technique of the thoracodorsal artery free perforator flap needs a vertical incision rising high in the axillary hollow for the dissection of the pedicle, thus impeding optimal discretion of the donor site, especially for women. We describe an original technique to harvest a pure transversal skin paddle on its own perforator, leaving a horizontal scar thoroughly hidden in the bra and preserving the thoracodorsal pedicle. We detail the requirements for this new type of harvesting.

[Breast reconstruction with free flap of gracilis]

Breast reconstruction with free flap of gracilis has been described since 2004. The procedure consists in harvesting a flap made of the gracilis muscle and a transverse cutaneous paddle originating from the internal root of the thigh. The pedicle of the flap is the main pedicle of the gracilis muscle. After weaning, the vessels are anastomosed to the internal thoracic artery and vein. The modeling of the breast is done by folding the cut points in front of the muscle to obtain the shape of a cone. This surgical technique allows the realization of autologous breast reconstructions of small to medium size, immediate or delayed, unilateral or bilateral.

[To harvest a SIEA flap instead of a DIEP flap in breast reconstruction: A technical note]

Breast reconstruction by abdominal flap has evolved to ensure minimal donor-site morbidity with the description of Deep Inferior Epigastric artery Perforator flap (DIEP flap). Being of the same thickness and the same surface, the Superficial Inferior Epigastric Artery flap (SIEA flap) does not require, for it harvesting, to open the abdominal fascia or to dissect through the muscles minimizing again donor-site sequelae. However, it is little used because of the variability of its vascularization and a higher failure rate than the DIEP in the literature. We believe that it is reasonable, in some cases, to harvest a SIEA flap instead of DIEP flap in mammary reconstruction. We present a technical note explaining our operative strategy for reliably taking a SIEA when the caliber of the vessels allows.

[Autologous breast reconstruction by deep inferior epigastric free flap: Classic and minimally invasive extraperitoneal approaches]

Perforator free flaps allow breast reconstructions « like with like » with skin and fat, excluding mammary gland, with a low morbidity. Those autologous reconstructions prevent material associated infections, capsular contracture and implant replacements, associated to breast reconstructions including implants. DIEP flap was described in 1994 to reduce the morbidity faced with TRAM flaps harvest. It only includes sub-umbilical skin and deep epigastric vessels. Deep inferior epigastric vessels harvest requires rectus abdominis muscle sheet opening and traction on rectus muscles, both associated with increased risks of abdominal bulges. Since 2014, we developed a minimally invasive DIEP harvest by totally extra-peritoneal laparoscopic dissection of epigastric vessels with a 70% reduction of aponeurosis opening and avoiding traction on rectus' motor nerves. We report both classic and minimally invasive DIEP harvest techniques. Bresat reconstructions by DIEP require that the ombilicus can be transposed and are indicated for all patients with need for skin inset, particularly secondary breast reconstructions. The reconstructed breast as a volume that follows patients weight variations and allows for improved quality of life on a long term. Its minimally invasive totally extra peritoneal harvest by laparoscopy, with or without robotic assistance, offers a reduced morbidity and might allows for reduced risks of abdominal wall weakness on a long-term.

Multiple extensor tendons reconstruction with hamstring tendon grafts and flap coverage for severe dorsal hand injuries

Treatment of patients with traumatic loss of skin and multiple extensor tendons on the dorsum of the hand is a challenge. The aim of this study was to assess the outcome after reconstruction of soft tissues and multiple extensor tendons in patients who suffered traumatic loss of skin and multiple extensor tendons. Ten patients were enrolled in the study. These patients underwent single-stage reconstruction with autogenous hamstring tendon grafts for multiple extensor tendon defects and fasciocutaneous flaps for coverage of dorsal hand defects. In total, 25 tendons (2 tendons in 5 patients and 3 tendons in 5 patients) were reconstructed. The semitendinosus tendon was used in all patients and the gracilis tendon was added in five patients for tendon reconstruction. Total tendon length requiring reconstruction was between 9cm and 31cm. Free anterolateral thigh flaps were used in six patients and reverse pedicled forearm flaps were used in four patients. According to Miller's scoring system, 8 fingers had excellent results, 12 fingers had good results and 5 fingers had fair results at the final follow-up. Hamstring tendons can be used satisfactorily for primary reconstruction of multiple digital extensor tendons due to their availability and compatibility, with a fasciocutaneous flap.

LEVEL OF EVIDENCE

IV.

[Microsurgery in children]

While we celebrated the fortieth anniversary of the first free flap in children, new techniques emerged in reconstructive surgery (NPT, artificial dermis…) and reduced microsurgery procedures. However, microsurgery in children as in adults still have clinical applications in reconstructive surgery. Free flaps remain essential in clinical situations where they are the only ones to provide capacity for growth and stability scarring, two elements essential to the future quality of life of the children.

[Superficial ulnar artery: Case report]

The anatomical variations of arterial axes of the upper limb are not uncommon and must be known to allow for safe surgical procedures and in order to limit the morbidity of these procedures. The superficial ulnar artery represents, after the variations in origin of the radial artery, the second most frequent variation in this area. When present, reconstructive procedures may be modified, especially when harvesting forearm free flaps, in order to choose this vessel as nourishing pedicle. The authors present the case of a superficial ulnar artery revealed intraoperatively while harvesting a radial forearm free flap, and a review of their cases in order to assess the frequency of this variation, and correlate it to literature.

Composite neuromusculo-fasciocutaneous triceps brachii free flap for complex foot reconstructive surgery

Since it was first described by Song in 1982, then by Katsaros in 1984, the lateral arm flap has become a workhorse technique for upper limb reconstruction. Herein we describe a clinical case of complex foot defect and bring up the possibility of using a composite neuromusculo-fasciocutaneous lateral arm/triceps free flap for its reconstruction. A 19-year-old male nonsmoker suffered ballistic trauma to his right foot with open multifragment Gustilo-IIIb fractures of the first to fifth metatarsal bones. Two weeks after debridement and V.A.C.™ therapy performed in another hospital, we decided to reconstruct the remaining defect with a neuromusculo-fasciocutaneous medial triceps/lateral arm free flap anastomosed with the anterior tibial pedicle. The posterior brachial cutaneous nerve was sutured to a sensory branch of the superficial fibular nerve. The advantages and drawbacks of this technique are discussed and other options for this type of complex foot reconstruction are reviewed. After 3 years' follow-up, the metatarsal bones were consolidated without residual defect or chronic infection. The foot had sensation with full mobility and no pain. At the donor site, there was no complaint of scarring. Elbow extension/flexion was 0-0-130. Wrist extension/flexion was 60-0-60 and there was no extension deficit of the metacarpophalangeal joints. The composite neuromusculo-fasciocutaneous triceps brachii free flap was an excellent option for this complex foot defect. The choice of this reconstructive procedure among other options was made during our reconstruction board meeting while taking the patient's specific condition and our own experiences into account.

[Benefit of simultaneous contralateral breast symmetry procedure with unilateral breast reconstruction using DIEP flaps. About 33 cases]

BACKGROUND

After unilateral breast reconstruction, a procedure on the contralateral breast is often needed to achieve symmetry. Here, we present a single surgeon's experience with performing contralateral symmetry procedures simultaneously with DIEP flap.

METHODS

We evaluated 33 consecutive patients (mean age, 52.1 years) who underwent DIEP flap unilateral breast reconstruction and a simultaneous contralateral breast procedure performed and 2 patients with delayed controlateral symmetry procedures. A single-stage breast cancer reconstruction is successful if after the original reconstruction no correction for revision of breast mound, or contralateral breast procedures are performed, under general anesthetic, to complete the reconstruction.

RESULTS

In 24 patients (73%), breast reconstruction was completed after a single stage with one general anesthetic, and in 8 patients (24%), revisions were performed with two general anesthetic (7 patients) and three general anesthetic in one case. Reconstructions requiring more than one general anesthetic were due to 4 of 39 (10%) postoperative complications. Mean operating time was 485 minutes.

CONCLUSIONS

For patients who need contralateral reduction mammoplasty or mastopexy for symmetry, performing these procedures and breast reconstruction simultaneously facilitates single-stage breast reconstruction in most patients.

[Reconstruction of lower limb involving free serratus anterior with rib myo-osseous composite flap: 20 patients followed for 5 years]

INTRODUCTION

In our team, free flap and especially serratus anterior muscle is the first option for the coverage of lower limb post-traumatic defects. For complex tissue loss, it may be advantageous to harvest the free serratus anterior with rib myo-osseous composite flap. We performed 20 osteomuscular serratus anterior composite flap between 2008 and 2010.

MATERIALS AND METHODS

We retrospectively studied the records of 20 patients, by separately analyzing the characteristics of the bone defect and the soft tissue loss. Patients have been recently reviewed by an independent operator. We compared our results to other reconstruction techniques and other similar series reported in the literature.

RESULTS

The average age of our patients was 43 years and 11 months. In all cases, defect was traumatic. The average follow-up was 5 years (4.5 to 5.8). The average flap area was 135cm(2) and the average rib length was 9.21cm. Our microsurgical success rate is 95%. Our global consolidation rate is 82%.

DISCUSSION

Use of vascularized rib in the treatment of lower limb traumatic defects is rare. The bone quality of rib is lower than fibula, but the coverage provided is better, due to serratus anterior muscle. The length and diameter of the vascular pedicle is very useful too. Our results are comparable to other series using this flap. Its coverage properties and the possibility of simultaneous bone reconstruction is useful. It allows one stage procedure for complex tissue losses with satisfactory results in the short and long term. The further realization of a free fibular transfer in cases of persistent non union remains possible.

[The abdominal drop flap]

The skin between the mastectomy scar and the future infra-mammary fold may be managed in different ways in delayed breast reconstruction using a DIEP (deep inferior epigastric perforator). Conserving this skin and positioning the flap skin paddle in the middle of the breast usually highlights skin color disparity because of two visible transition zones. Resection of the entire skin under the scar may be more aesthetic but limits direct closure possibility in case of flap failure. In order to benefit from both aesthetic result and safe surgical method, we propose the abdominal drop flap. The inferior thoracic skin flap is detached from the thoracic wall beyond the future infra-mammary fold, preserved and pushed under the breast.

[Use of a free antero-lateral thigh flap for two-stage reconstruction of a large thoracic defect]

In case of extremely large thoracic full-thickness defects where no pedicled flap is available, very large free flaps are sometimes the only options. Dealing with such full-thickness defects where failure of the flap could be lethal, Servant and al described the concept of "two stage free flap" using Latissimus Dorsi muscular or myocutaneous flap. We present a reconstruction of a wide right posterior trunk radionecrosis with exposure of an underlying infected prosthesis using this two-stage free flap strategy with a fasciocutaneous antero-lateral thigh flap.

[Scapular/parascapular double skin-paddle free flap for transfixing blast injuries of the hand. A case report]

Balistic transfixing hand traumas require a complex reconstruction management. Stabilization and reconstruction of the injuried tissues need a double skin-paddle coverage. We present an original case report of a double skin-paddle scapular/parascapular free flap used to cover a through and through gunshot injury of the right hand. A 14-years-old patient presents a severe and extensive wound with full-thickness palmar and dorsal skin defects, dislocation of the carpal bones, median nerve and flexor tendons losses. Distal vascularization is maintained by the deep palmar arch system supplied by the ulnar artery. The radial artery is severed at the level of the first dorsal interosseous space. The measured defect of the dorsal skin was 12×7cm and the palmar one was 6×3cm. After skeletal stabilization, tendinous and nerve preparation, the hand coverage was performed using a double skin-paddle scapular/parascapular free flap. The vascular anastomoses include an end-to-side arterial suture between the circumflex scapular and the radial arteries, and an end-to-end venous suture between the circumflex scapular and the dorsal radial veins. The scapular/parascapular double skin-paddle free flap is a safe and reliable technique to achieve a dorsal and palmar hand coverage in lack of local flaps alternatives. It can be used as a good option prior to bone graft, tendinous and nervous reconstruction.

[A surgical follow-up platform to reduce complications in free flap surgery]

STUDY OBJECTIVE

In 2007, the WHO adopted surgical safety as the theme for the 2nd global patient safety challenge. Measurement of surgical services was identified as a surgical care area in need of major improvements. Aware of this recommendation, a preliminary study was conducted in our hospital and showed that the incidence of complete necrosis in free flap surgery was 10.0 %, a rate among the highest found in medical literature. In that context, an interactive surgical follow-up platform (PICS) was implemented to monitor outcomes in free flap surgery. The hypothesis was to reduce the short-term failure of microsurgical reconstructions.

PATIENTS AND METHODS

In Summer 2010, the tool for capturing and analyzing data (PICS) was implemented. All patients who underwent free flap reconstruction were prospectively registered in the platform. The primary endpoints to evaluate the effectiveness of the tool are the rates of surgical re-exploration and complete necrosis of the flap.

RESULTS

From May 2010 to December 2011, 129 cases of free flap reconstruction were recorded. The rate of total flap necrosis was 10.0 % before database introduction and declined to 3.1 % afterwards (P<0.05). Take-backs occurred in 27.0 % of free flap reconstructions at baseline and in 10.1 % after implementation (P<0.01).

CONCLUSION

The implementation of PICS is associated with a significant improvement of postoperative short-term outcomes in free flap surgery. This tool is effective to evaluate care services and provides an increased surgical safety for patients. Surgical teams are encouraged to implement a data collection tool in order evaluate operative care on a routine basis.

Capillary measurement of lactate and glucose for free flap monitoring

BACKGROUND

It is reported that the salvage rate of free flaps is inversely related to the time interval between the onset of pedicle impairments and their clinical recognition. Monitoring of free flaps is therefore of major importance and clinical monitoring remains the most used technique because of lack of low-cost and non-invasive techniques. The authors suggested an efficient, simple and cheap technique to detect early thrombotic events in monitoring free flaps with skin paddle.

METHODS

In this multicentre prospective study, measurements of capillary glucose and lactate in the flaps were done. These parameters were compared to standardized clinical monitoring during the first five days. Two sets of data (eventful versus uneventful postoperative period) were analyzed to define the thresholds of lactate and glucose values for diagnosis of pedicle complications, and to establish parameters for this screening test.

RESULTS

Over a period of 19 months, 37 patients were included. With 5 pedicle impairments, complication thresholds were defined as lactate ≥ 6.4 mmol L(-1) and glucose ≤ 3.85 mmol L(-1), in order to obtain a sensitivity of 98.5% and a specificity of 99.5% for the test. Modifications of capillary glucose and lactate measurements appeared in average 5.7 hours earlier than clinical symptoms in pedicle impairments. The mean cost of a five-day monitoring was about 90 USD.

CONCLUSION

This simple and cheap technique could be used as a routine technique in monitoring free flaps to improve safety of this reconstructive technique.