Inferior part of rectus abdominis muscle flap: A case report

Background: Abdominoperineal resection (APR) is the standard surgical treatment for low-lying anorectal malignancies. It seems that immediate flap reconstruction has fewer complications compared to primary closure. There are several options for local flap reconstruction of perineal wound closure, and each specific flap method has its own advantages and disadvantages.

Case presentation: In this case report, a new method of reconstruction is presented which contains only the inferior part of the rectus abdominis muscle in 2 patients, one with unilateral and the other with bilateral involvement and they both underwent APR. Both patients were referred to the colorectal surgery clinic for APR by an oncologist. Both patients had severe constipation and both reported pain on defecation and rectorrhagia. Patient 1 received a unilateral inferior part of rectus abdominis muscle flap and patient 2 received a bilateral flap.

Conclusion: Immediate flap reconstruction after APR has fewer complications than primary closure and the inferior part of rectus abdominis muscle flap seems to be a possible means of reconstruction after APR.

[Chest wall replacement]

The optimal surgical reconstruction of chest wall defects especially in the context of posttraumatic, oncological and congenital etiologies has a large impact on the recovery of the patients. Regardless of the etiology, various complications, such as a generally impaired respiratory physiology in an unstable thorax or decreased pulmonary clearance associated with acute and chronic pulmonary infections, may impair the recovery of affected patients. The postoperative occurrence of an intrathoracic dead space may lead to a difficult to treat empyema. Each thoracic wall defect must be accurately assessed and treated according to size, depth and location on the chest. The complexity of this condition and the resulting complications require the highest degree of surgical care which should be interdisciplinary both preoperatively and postoperatively.

Salvage of planned ALT flap with rectus femoris free flap for pediatric lower extremity reconstruction: A demonstrative case report

INTRODUCTION

Free tissue transfer in children represents a good option for reconstruction in skilled hands despite the technical difficulties, and represent a significant challenge in microsurgery. With Anteriorlateral thigh flap is a popular option even in pediatric age group.

PRESENTATION OF CASE

We report here a case of 9 year old girl that sustained a lower extremity trauma with exposed ankle joint secondary to Motor Vehicle Crash, That was planned for (ALT) Anterior Lateral Thigh flap reconstruction, and was not completed and salvaged by rectus femoris flap as an alternative option on table to complete the reconstruction.

DISCUSSION

Such case was successfully reconstructed by rectus femoris muscle free flap when ALT (Anterior lateral thigh) flap could not be completed as planned although it's the workhorse flap in majority of cases, due to absence of perforator utilizing the same vascular anatomical blood supply with no significant donor site morbidity.

CONCLUSION

Based on this case report the rectus femoris flap was successfully performed, and we believe it's an effective and reliable backup option to reconstruct complex lower extremity wound even in pediatric age group.

[Effects of perforator flaps combined with muscle flaps for repairing grade Ⅳ pressure ulcers in ischial tuberosity of elderly patients]

Objective: To explore effects of perforator flaps combined with muscle flaps for repairing grade Ⅳ pressure ulcers in ischial tuberosity of elderly patients. Methods: Nine elderly patients with grade Ⅳ pressure ulcers in ischial tuberosity were hospitalized in our burn ward from April 2014 to April 2017. Size of wounds ranged from 5 cm×3 cm to 12 cm×7 cm, and depth of sinus ranged from 6 to 22 cm. After admission, emergency debridement or debridement in selective time was performed. After debridement, the wounds were treated with continuous vacuum assisted closure therapy. After the treatment for 1 to 2 weeks, tissue flaps repair operations were performed. Four patients were repaired with inferior gluteal artery perforator flaps combined with long head of biceps femoris muscle flaps. Three patients were repaired with inferior gluteal artery perforator flaps combined with semimembranous muscle flaps. One patient was repaired with inferior gluteal artery perforator flap combined with gracilis muscle flap. One patient was repaired with femoral profound artery perforator flap combined with gluteus maximus muscle flap, and the distal area of femoral profound artery perforator flap of the patient which showed intraoperative cyanosis of 6 cm×4 cm was thinned to medium thickness skin to cover the muscle flap. The other eight patients showed no abnormality during operation. Size of perforator flaps ranged from 7 cm×5 cm to 14 cm×12 cm, and size of muscle flaps ranged from 11 cm×4 cm to 24 cm×6 cm. The donor sites of flaps were all sutured directly. Results: The tissue flaps and skin graft of all patients survived well after operation. During follow-up of 8 to 35 weeks, operative area of all patients showed good shape and texture, with no local diabrosis or recurrence of pressure ulcers. Conclusions: The combination of perforator flaps and muscle flaps is effective in repairing and reducing recurrence of grade Ⅳ pressure ulcers in ischial tuberosity of elderly patients.

Perfusion of muscle flaps independent of the anatomical vascular pedicle: Pedicle autonomy

INTRODUCTION

Free muscle flaps are being used more commonly for complex lower limb reconstruction. Up to 33% of flaps used to reconstruct lower limb trauma will require an orthopaedic procedure after reconstruction. To date there have been only case reports detailing the variable survival of muscle flaps after actual or simulated pedicle injury and the process and timeframe of neovascularisation remains undefined. We aim to show that perfusion of a muscle flap is possible after injury to its anatomical vascular pedicle.

METHODS

Pedicled muscle flaps were raised and transposed to a cutaneous inset on the chest wall in a rodent model. Each flap was subjected to simulated pedicle injury at a variable time. Allocation was by computer randomisation. Flap perfusion was assessed before and after pedicle injury followed 48 h later by sacrifice of the animal and static angiography of the flaps.

RESULTS

By the 21st day after inset, all flaps survived simulated pedicle injury. Prior to this, flap survival was significantly lower (p = 0.017, Fisher's Exact Test). Clinical signs at the time of pedicle injury did not predict flap survival. Most new vessels form at the distal part of the inset (p < 0.01, ANOVA). The total number does not change with time (p = 0.82, ANOVA). New vessels anastomose preferentially with skin. The fall in perfusion after pedicle ligation was significant for all groups except the day 35 group (p = 0.53).

CONCLUSIONS

Muscle flaps can perfuse after an injury to the anatomical vascular pedicle through neovascularisation at the inset. These new vessels are evident early but may not function adequately to perfuse the flap. Regional variations in neovascularisation suggest that a gradient of ischaemia drives this process. Inset at the cutaneous level is important, which has implications for buried muscle flaps. The correlation between change in flap perfusion after pedicle injury and flap necrosis suggests a role for the former in determining the capacity of a muscle flap to tolerate a pedicle injury and thereby the approach to re-raising it.

Predicting the need for muscle flap salvage after open groin vascular procedures: a clinical assessment tool

Groin wound complications after open vascular surgery procedures are common, morbid, and costly. The purpose of this study was to generate a simple, validated, clinically usable risk assessment tool for predicting groin wound morbidity after infra-inguinal vascular surgery. A retrospective review of consecutive patients undergoing groin cutdowns for femoral access between 2005-2011 was performed. Patients necessitating salvage flaps were compared to those who did not, and a stepwise logistic regression was performed and validated using a bootstrap technique. Utilising this analysis, a simplified risk score was developed to predict the risk of developing a wound which would necessitate salvage. A total of 925 patients were included in the study. The salvage flap rate was 11.2% (n = 104). Predictors determined by logistic regression included prior groin surgery (OR = 4.0, p < 0.001), prosthetic graft (OR = 2.7, p < 0.001), coronary artery disease (OR = 1.8, p = 0.019), peripheral arterial disease (OR = 5.0, p < 0.001), and obesity (OR = 1.7, p = 0.039). Based upon the respective logistic coefficients, a simplified scoring system was developed to enable the preoperative risk stratification regarding the likelihood of a significant complication which would require a salvage muscle flap. The c-statistic for the regression demonstrated excellent discrimination at 0.89. This study presents a simple, internally validated risk assessment tool that accurately predicts wound morbidity requiring flap salvage in open groin vascular surgery patients. The preoperatively high-risk patient can be identified and selectively targeted as a candidate for a prophylactic muscle flap.

The management of perineal wounds

Management of perineal wounds can be very frustrating as these invariably get contaminated from the ano-genital tracts. Moreover, the apparent skin defect may be associated with a significant three dimensional dead space in the pelvic region. Such wounds are likely to become chronic and recalcitrant if appropriate wound management is not instituted in a timely manner. These wounds usually result after tumor excision, following trauma or as a result of infective pathologies like hideradenitis suppurativa or following thermal burns. Many options are available for management of perineal wounds and these have been discussed with illustrative case examples. A review of literature has been done for listing commonly instituted options for management of the wounds in perineum.