Chin-Ta Lin

Free fasciocutaneous flaps for reconstruction of complete circumferential degloving injury of digits

Complete circumferential degloving injury of the digits usually results in a large cutaneous defect with tendinous structure and bone and joint exposure. When revascularization is not possible, a thin and adequately sized flap is required to resurface the defect, restore finger function, and prevent amputation. In this report, we present our experience with reconstruction of the entire circumferential degloving injury of the digits using free fasciocutaneous flaps. Between February 2006 and January 2011, 9 male patients with circumferential degloving injury of 9 digits underwent reconstruction using free fasciocutaneous flap transfer with the posterior interosseous artery flap, medial sural artery flap, anteromedial thigh flap, or radial forearm flap. The average flap size was 14.2 × 6.9 cm. Donor sites were closed primarily or covered with split‐thickness skin graft. All flaps survived completely and the donor sites healed without complications. The mean follow‐up period was 34.8 months. A maximum Kapandji score (10/10) was seen in 2 cases with crushed thumbs. All patients could achieve good key pinch and grasping functions. All skin flaps showed acceptable static 2‐point discrimination and adequate protective sensation. Patient satisfaction for resurfaced digits averaged 9 on a 10‐points visual analogic scale. In conclusion, the free fasciocutaneous flaps used were thin and did not interfere with finger movements. The patients finger formed a smooth contour and acceptable functional results were obtained after reconstruction. This method may be a valuable alternative for reconstruction of entire circumferential avulsion injury of the digits.

Successful management of osteoradionecrotic precoccygeal defect with the free latissimus dorsi muscle flap: Case report and literature review

Perineal wound complications following abdominoperineal resection (APR) are still frequent and most troublesome complications. We report the case of a 79‐year‐old male found to have the huge precoccygeal defect with infection after APR for rectal carcinoma. Before surgery, the patient received a complete course of chemoradiation therapy to treat for downgrade staging of the rectal malignancy. Extensive debridement of the perianal wound was performed for three times, followed by perianal reconstruction and packing and augmentation of the precoccygeal dead space with free latissimus dorsi (LD) muscle flap. Although persisted wound infection was still observed after reconstruction, the patient still led a good result after one time of further debridement and split‐thickness skin graft. We selected free LD muscle flap to fill and seal off the large pelvic dead space without the needs to change the jackknife position of the patient after debridement. To the best of our knowledge, this is the first case reported in the literature with the radiation‐associated perianal wound infection after APR reconstructed successfully by free LD muscle flap.

Modification of the superior gluteal artery perforator flap for reconstruction of sacral sores

BACKGROUND Despite advances in reconstruction techniques, the treatment of sacral sores remains challenging to plastic surgeons. The superior gluteal artery perforator (SGAP) flap is reliable and preserves the entire contralateral side as a future donor site. The ipsilateral gluteal muscle is preserved, and the inferior gluteal artery flaps are viable. However, dissection of the perforator is tedious and may compromise the perforator vessels. METHODS Between April 2003 and March 2013, we performed two modified flap-harvesting techniques: a rotational and a tunnel method, with only a short pedicle dissection to cover 30 sacral defects. Patient characteristics including sex, age, cause of sacral defect, flap size, perforator number, use and postoperative complications were recorded. RESULTS All flaps survived except two, which developed partial flap necrosis and were finally treated by contralateral V-Y advancement flap coverage. The mean follow-up period was 14.8 months (range, 3-24 months). No flap surgery-related mortality or recurrence of sacral pressure sores or infected pilonidal cysts were noted. CONCLUSIONS Perforator-based flaps have become popular in modern reconstructive surgery because of low donor-site morbidity and good preservation of muscle. The advantages of our modification procedure include shorter operative time, lesser bleeding and lesser pedicle trauma, which make the SGAP flaps an excellent choice for sacral sore coverage.

Reconstruction of perineoscrotal defects in Fournier's gangrene with pedicle anterolateral thigh perforator flap

Fourniers gangrene is an acute and potentially lethal necrotizing fasciitis that involves the scrotum and perineum. This disease can result in the extensive loss of skin and soft tissues of the perineoscrotal area with exposure of the testes. To reconstruct the large defects of scrotal and perineal remains a surgical challenge.

Intraoperative indocyanine green fluorescent angiography-assisted modified superior gluteal artery perforator flap for reconstruction of sacral pressure sores

Pressure sores are often observed in patients who are bedridden. They can be a severe problem not only for patients and their caregivers but also for plastic surgeons. Here, we describe a new method of superior gluteal artery perforator flap harvesting and anchoring with the assistance of intraoperative indocyanine green fluorescent angiography. In this report, we describe the procedure and outcomes for 19 patients with grades III and IV sacral pressure sores who underwent the operation between September 2015 and November 2016. All flaps survived, and two experienced wound‐edge partial dehiscence. With the assistance of this imaging device, we were able to acquire a reliable superior gluteal artery perforator flap and perform modified operations with it that are safe, easy to learn and associated with fewer complications than are traditional.

Is monitor flap monitoring

Reconstruction of through and through buccal defects after ablation of head and neck cancer is a challenge for the plastic surgeons that requires three-dimensional restoration of the missing tissue. The chimeric anterolateral thigh (ALT) flap first developed by Hallock in 1991 is a combined composite free flap using the lateral circumflex femoral system that has separate skin paddles with different perforators physically attached to the same mother vascular source. The features of this flap made it possible to repair the oral mucosal lining and cheek skin simultaneously with one anastomosis of pedicle. Free flap success is enhanced by the rapid identification and salvage of failing flaps. Constant monitoring of such flaps in free tissue transfer is very crucial to flap survival and salvage. Abnormal appearance of the monitoring component may suggest a compromised flap and this demands emergency pedicle exploration. On the other hand, good viability seen on the monitoring component gives strong indication of a successful free tissue transfer. Many techniques have been developed including implanting devices to monitor the flap, and new imaging techniques to check the flap’s viability. Monitoring-muscle flap or externalizing a component of the flap for monitoring has been used with good benefits. The main disadvantage for these techniques was increased donor site morbidity or the involvement of another donor site for the harvest of skin grafts. The chimeric flaps reported to provide a useful method of external monitoring is reliable, easy to perform, easily interpreted by the nursing staff, and needs no special equipment and provides very sensitive monitoring of a buried flap. However, is monitor flap is really monitoring? We reported a 53-year-old male, a victim of head and neck squamous cell carcinoma, received tumor ablation and simultaneous free flap reconstruction. After ablative excision, an ALT flap with vastus lateralis (VL) muscle was harvested in a chimeric fashion based on a common source vessel-descending branch of the circumflex femoral vessels to reconstruct the resultant two widely separated defects: the first was the tongue-oral cavity and the second the extensive skin and soft tissue defect at the right cheek. The skin paddle was splitted in two skin islands during flap inset. The distal skin island (11 3 8.5 cm) based on the distal perforator was used to reconstruct the cheek defect and the proximal one (10 3 8 cm) based on the proximal perforator to cover the tongue-oral base defect (Fig. 1A). The VL muscle was placed at the right side of maxillary sinus to fill the dead space. Before ligation of the pedicle, both skin and muscle portions had robust blood supply. After microanastomosis to the recipient vessels (superior thyroid artery and external jugular vein), both portions of this chimeric flap regained reperfusion well. However, only the proximal skin island remained revascularized rather than the distal one that reconstructed the right cheek defect after 1 day have passed (Figs. 1B and 1C). At that time, primary thrombosis at the anastomotic site was ruled out by immediately rechecking the flap at the operation room. Under the impression of pedicle injury, we immediately replaced the failing external skin flap using the pedicled pectoris major muscle flap (Fig. 1D). Postoperative course was uneventful and the patient was discharged from the hospital 10 days later. *Correspondence to: Yuan-Sheng Tzeng, M.D., Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Gung Road, Taipei, 11490, Taiwan. E-mail: aarondakimo@yahoo.com.tw Received 24 May 2013; Revised 2 July 2013; Accepted 19 July 2013 Published online 3 September 2013 in Wiley Online Library (wileyonlinelibrary. com). DOI: 10.1002/micr.22173

Reconstruction of a Large Abdominal Wall Defect by Using a Pedicled Vastus Lateralis Muscle Flap: A Case Report and Literature Review

The pedicled anterolateral thigh (ALT) flap is safe and reliable for repairing abdominal wall defects. This flap has a long pedicle and a wide arc of rotation, and it can extend from above the umbilicus and the lower back to the upper thigh, including the groin and perineum. The ALT flap is a technically simple muscle flap that permits primary closure and minimal morbidity of the donor site. We report a case of successful reconstruction of a large abdominal defect after tumor resection by using a pedicled vastus lateralis muscle flap. Literature review on the clinical applications of the ALT and pedicled vastus lateralis muscle flap for reconstruction of soft tissue defects were performed.

Functional results of free tissue transfer for complex heel‐calcaneal defects

Loss of soft tissue in heel‐calcaneal region is frequently caused by trauma, infection, or tumors. Limited availability of similar tissue becomes challenging, therefore, the use of free tissue transfer offers a solution. Our aim is to describe long term functional outcome of different free tissue transfers for these defects.

Chylous ascites after pedicled transverse rectus abdominis myocutaneous flap harvest.

Abstract Chylous ascites is a rare clinical condition that occurs as a consequence of disruption of the abdominal lymphatics. Here, we present the case of a 58-year-old woman with sustained chylous ascites after pedicled transverse rectus abdominis myocutaneous (TRAM) flap harvest. The chylous ascites did not decrease despite conservative therapy. For the diagnosis and localization of the chyle leakage, lymphangiography with lipiodol delivery was performed. Chylous drainage continued in a decreasing manner for the next 4 d because lipiodol accumulated to the point of leakage outside the lymphatic vessel causing a regional inflammatory reaction and obstructing the lymphatic vessels. To our knowledge, there is no case of chylous ascites related to pedicled TRAM flap harvest that has been reported in the English literature, in which the chyle leakage spontaneously resolved after lymphangiography.

Preserve the lower limb in a patient with calcaneal osteomyelitis and severe occlusive peripheral vascular disease by partial calcanectomy

Heel ulcers in patients with severe peripheral artery occlusive disease represent a challenge to the treating physician. They become more difficult to treat with underlying medical comorbidities. We report a case of 76-year-old man with hypertension, diabetes mellitus, and end-stage renal disease in uremia status presented to our hospital with a 3-month history of a diabetic foot ulcer on his right heel. He was diagnosed with near total artery occlusion below the knee at the local hospital, and vascular reconstruction failed. After admission, surgical debridement was performed with subsequent partial calcanectomy facilitating wound closure without tension. After surgery, the foot was immobilized with a short-leg splint for 2 weeks. Thereafter, ankle immobilization was accomplished using a thermal protective plastic splint and cast shoes with a posterior window for wound care. The wound healed well with no recurrence during the 12-month follow-up period, and the patient may return to an ambulatory status, including a normal gait pattern. In this case, we demonstrate that the partial calcanectomy is practical for the treatment of plantar heel ulcers in a patient with severe comorbidities. With proper surgical planning and postoperative care, partial calcanectomy is a viable alternative to below-the-knee amputation and may better serve the patient who would otherwise be restricted to a sedentary lifestyle.