Haitham Khalil

The reverse sural flap: modifications to improve efficacy in foot and ankle reconstruction.

The aim of this work is to evaluate the efficacy of the reverse sural flap in covering defects in the foot and ankle region when certain technical modifications are employed. We provide a retrospective review of 32 consecutive reverse sural flaps for foot and ankle defects, and compare the technique and results with other reports. There were 23 fasciocutaneous flaps, 7 fascial flaps, and 2 tissue-expanded flaps. Four flaps (12.5%) suffered significant flap loss, and 4 patients had delayed healing. Several modifications are suggested to increase the versatility of the sural flap in covering foot and ankle defects, including preserving the mesentery connecting the sural nerve to the deep fascia, inclusion of skin of the upper third of the leg, limiting pedicle width to 2 cm with preservation of a tongue-like skin process all along its length, and generous release of the fascia over the peroneal compartment. In addition, we describe the use of tissue expanded sural flaps.

Breast implant associated anaplastic large cell lymphoma: The UK experience. Recommendations on its management and implications for informed consent

BACKGROUNDnBreast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare, Non-Hodgkin lymphoma arising in the capsule of breast implants. BIA-ALCL presents as a recurrent effusion and/or mass. Tumours exhibit CD30 expression and are negative for Anaplastic Lymphoma Kinase (ALK). We report the multi-disciplinary management of the UK series and how the stage of disease may be used to stratify treatment.nnnMETHODSnBetween 2012 and 2016, 23 cases of BIA-ALCL were diagnosed in 15 regional centres throughout the UK. Data on breast implant surgeries, clinical features, treatment and follow-up were available for 18 patients.nnnRESULTSnThe mean lead-time from initial implant insertion to diagnosis was 10 years (range: 3-16). All cases were observed in patients with textured breast implants or expanders. Fifteen patients with breast implants presented with stage I disease (capsule confined), and were treated with implant removal and capsulectomy. One patient received adjuvant chest-wall radiotherapy. Three patients presented with extra-capsular masses (stage IIA). In addition to explantation, capsulectomy and excision of the mass, all patients received neo-/adjuvant chemotherapy with CHOP as first line. One patient progressed on CHOP but achieved pathological complete response (pCR) with Brentuximab Vedotin. After a mean follow-up of 23 months (range: 1-56) all patients reported here remain disease-free.nnnDISCUSSIONnBIA-ALCL is a rare neoplasm with a good prognosis. Our data support the recommendation that stage I disease be managed with surgery alone. Adjuvant chemotherapy may be required for more invasive disease and our experience has shown the efficacy of Brentuximab as a second line treatment.

Chest Wall Mechanics In Vivo With a New Custom-Made Three-Dimensional–Printed Sternal Prosthesis

PURPOSEnReconstruction after sternal resection is performed according to surgeon intuition; physiologic evidence for selection of prostheses is lacking. We present our experience of the inxa0vivo function of a novel device for sternal reconstruction.nnnDESCRIPTIONnA three-dimensional-printed titanium and porous polyethylene sternal prosthesis was made according to the patients computed tomographic scan. The titanium arms slot over adjacent ribs and are fixed in place with screws. The porous element allows ingrowth of native tissue while preventing lung herniation around the narrow titanium bars.nnnEVALUATIONnWe performed optoelectronic plethysmography to assess the physiologic function of the device compared with a muscle flap reconstruction. Asynchronous and paradoxical movements of the thoracoabdominal surface were apparent with the muscle flap reconstruction but not with the new device. Considerably higher tidal volumes and a lower respiratory rate achieved the same minute volume with the new device compared with the muscle flap.nnnCONCLUSIONSnRigid sternal reconstruction with a three-dimensional-printed prosthesis demonstrated superior respiratory mechanics compared with reconstruction with an autologous muscle flap.

Active range of motion outcomes after reconstruction of burned wrist and hand deformities.

This works aim is to evaluate the efficacy of skin grafts and flaps in reconstruction of post-burn hand and wrist deformities. A prospective study of 57 burn contractures of the wrist and dorsum of the hand was performed. Flaps were used only if there was a non-vascularized structure after contracture release, otherwise a skin graft was used. Active range of motion (ROM) was used to assess hand function. The extension deformity cohort uniformly underwent skin graft following contracture release with a mean improvement of 71 degrees (p<0.0001). The flexion deformity cohort was treated with either skin grafts (8 patients) or flaps (9 patients) with a mean improvement of 44 degrees (p<0.0001). Skin grafts suffice for dorsal hand contractures to restore functional wrist ROM. For flexion contractures, flaps were more likely for contractures >6 months. Early release of burn contracture is advisable to avoid deep structure contracture.

Extended Abdominoperineal Resection Is Oncologically Advantageous and when Undertaken in the Prone Position Offers an Optimal Position for Bilateral Inferior Gluteal Artery Perforator Reconstruction

We agree with Peter B Arnold and colleagues that primary losure of the perineal defect after abdominoperineal resecion (APR) is enhanced by bilateral inferior gluteal artery erforator (BIGAP) fasciocutaneous flaps. However, we isagree that the patient should be operated on in a ynchronous-combined manner and advocate that an exended APR should be undertaken in the prone position or patients with low rectal cancer. Conventional APR is associated with a high incidence f circumferential resection margin (CRM) involveent, with rates up to 40%. The CRM involvement in conventional APR specimens is thought to be related to removal of inadequate tissue volumes at the level of the tumor, as the mesorectum narrows to a bare muscle tube at the level of the anal sphincter complex. In 2005, Marr and associates examined local recurrence and patient survival after APR and anterior resection for rectal cancer. They analyzed 561 patients and found that patients undergoing APR had a higher local recurrence (22.3% vs 13.5%) and a lower 5-year survival (52.3% vs 65.8%). They noted that the total volume of surgically removed tissue outside the muscularis propria was less in the APR specimens and advocated a more radical approach to the surgical management of low rectal cancers. In 2007, Holm and coworkers from the Karolinska Institute in Stockholm reported a low risk of bowel perforation, CRM involvement, and perineal wound complications when implementing extended APR with flap reconstruction of the perineal defect. In this case series, the

Complete resection of a large phosphaturic mesenchymal tumour by chest wall resection and reconstruction

Phosphaturic mesenchymal tumour is an extremely rare mesenchymal neoplasm of bone or soft tissue. It is associated with paraneoplastic oncogenic osteomalacia through secretion ofxa0fibroblast growth factor-23 (FGF-23) which inhibits renal proximal tubule phosphate re-uptake. We report a case of a 36-year-old woman with a large chest wall tumour completely excised by extensive chest wall resection and reconstruction with polypropylene mesh–methylmethacrylate composite and pedicled muscle flaps.

Internal Pudendal Artery Perforator Island Flap for Management of Recurrent Benign Rectovaginal Fistula.

Summary: The management of recurrent rectovaginal fistula after obstetric injury and cryptoglandular sepsis is considered a major surgical challenge. The fistula poses a significant negative psychosocial and sexual morbidity. In addition, the poor quality of local tissues due to previous attempts at surgical repair adds to this challenge. There are few data regarding the management of persistent or recurrent fistula in the literature; however, several studies reported high failure rates after 2 or more procedures. We present 4 cases managed successfully in a multidisciplinary approach involving fistulectomy and immediate reconstruction with an internal pudendal artery perforator island flap.

Triangular lipodermal flaps in Wise pattern reduction mammoplasty (superomedial pedicle): A novel technique to reduce T-junction necrosis

Background Although Wise pattern reduction mammoplasty is one of the most prevalent procedures providing satisfactory cutaneous reduction, it is at the expense of inevitable lengthier scars and wound complications, especially at the inverted T junction. Objective To describe a novel technique providing tension-free closure at the T junction through performing triangular lipodermal flaps. The aim is to alleviate skin tension, thus reducing skin necrosis, dehiscence and excessive scarring at the T junction. Methods One hundred seventy-three consecutive procedures were performed on 137 patients between 2009 and 2013. Data collected included demographics, perioperative morbidity and resected breast tissue weight. The follow-up period ranged from three to 30 months; early and late postoperative complications and patient satisfaction were recorded. Results Superficial epidermolysis without T-junction dehiscence was experienced in eight (4.6%) procedures while five (2.9%) procedures developed full-thickness wound dehiscence. Ninety-four percent of patients were highly satisfied with the outcome. Conclusions The technique is safe, versatile and easy to execute, providing a tension-free zone and acting as internal dermal sling, thus providing better wound healing with more favourable aesthetic outcome and maintaining breast projection.

Pedicled vertical myocutaneous gracilis (VMG) flap for reconstruction of a large composite lower abdominal defect

Management of the complex abdominal wall defect after tumour extipiration represents a challenge and requires careful planning. We report a case of a 76-year-old gentleman treated initially for a T4N0M0 Dukes B sigmoid cancer with anterior resection in 2008. He re-presented 6xa0months after chemotherapy with a histopathologically proven anterior abdominal wall adenocarcinoma of colonic origin with involvement of the underlying parietal wall and rectus muscle. En bloc resection was undertaken with the harvesting of a vertical myocutaneous gracilis, VMG, pedicled flap (11u2009×u200922 cm) to fill the abdominal soft tissue defect. A concurrent supraumbilical incisional hernia, poor coverage from other local pedicle flap options and multiple co-morbidities made the pedicled VMG the only viable option. We report its success as a valuable option in the reconstructive armamentarium for complex abdominal defects.