Zoran Marij Arnež

Delaying the superficial inferior epigastric artery flap: A solution to the problem of the small calibre of the donor artery

BACKGROUND Superficial inferior epigastric artery (SIEA) flap has a great advantage over other flaps of the area, that is, readily non-existent donor-site problems. The main reason why the SIEA flap has never been extensively used in breast reconstruction is the small diameter and variable anatomy of its donor artery. This study presents a possibility of enlarging the SIEA diameter using the delay-phenomenon mechanism. METHODS A prospective clinical study of 26 patients was undertaken. Prior to surgery, ultrasound examinations were performed, measuring the diameter of SIEA and the velocity of blood flow in SIEA. The ipsilateral deep inferior epigastric artery (DIEA) was then ligated in all patients who had a measurable SIEA preoperatively. Two weeks later, measurements were repeated. The blood flow through SIEA was calculated and statistical analysis was applied. RESULTS Twenty-one patients had an identifiable SIEA on preoperative measurements. On postoperative measurements, we confirmed ligation of DIEA in 19 patients, of these 17 patients had an augmentation in diameter (mean: 29%) and 18 in blood flow (mean: 127%). CONCLUSIONS This study shows that ligating a single of the three main arteries (DIEA, SIEA and superficial circumflex iliac artery) irrigating skin/soft tissue of the lower abdomen, although the dominant one, results in widening of diameter and enlarging of blood flow of another artery (SIEA) supplying the same angiosome. The results of the present study might be used in future to increase the diameter and flow in SIEA when the vessel diameter found on preoperative imaging was too small for clinical microsurgical transfer. The drawback of the proposed delay procedure is the sacrifice of ipsilateral DIEA and an added operative procedure. STATEMENT: The clinical trial is registered with Clinical Trials (http://www.clinicaltrials.gov/). The clinical trial registration number is NCT01247129.

How we fix free flaps to the bone in oral and oropharyngeal reconstructions.

PURPOSE The use of suture anchors has been described in orthopedic, hand, oculoplastic, temporomandibular joint and in aesthetic surgery, but no study reports the use of the Mitek® anchors (Depuy Mitek Surgical Products, Inc. Raynham, Massachusetts) for fixing the free flaps used in oncologic oral and oropharyngeal reconstruction. MATERIALS AND METHODS In this prospective non-randomized study, 9 patients underwent surgical resection of oral or oropharyngeal cancer followed by a free flap reconstruction; mini anchors were used to fix the flap directly to the bone. We collected data regarding the patients, the tumor stage, the surgical procedure, the radiotherapy and the number of anchors used. RESULTS The average follow-up was 28months (range 24-38).We observed no complications with trans-oral, sub-mandibular and trans-mandibular approach in both oral and oropharyngeal reconstructions. All anchors became osteo-integrated and no complications occurred after radiotherapy. CONCLUSIONS In our opinion this device favors free flap adhesion to the bone. We registered no postoperative complications related to the use of the device which looks suitable for use in irradiated tissues. The radiotherapy did not cause any long-term complications related to the use of Mitek® mini bone anchors.

An uncommon treatment of totally extruded and lost talus: a case report

IntroductionTotal extrusion and loss of the talus is a rare injury with a wide choice of appropriate treatment, but rarely resulting in a fully functional recovery. We report on an uncommon case, both for the severity of the injury and for the uncommon treatment due to the patient’s rejection of secondary surgery.Case presentationWe treated a 16-year-old Caucasian man with the most extreme variant of a totally extruded and lost talus, accompanied with complex injury of the soft tissues of the ankle and foot. The treatment included urgent microvascular foot reimplantation, microvascular muscle free flap transfer, and temporary fixation. This kind of injury should typically be treated by tibiocalcaneal arthrodesis. However, this was not performed, as after the successful early stages of the treatment he strongly objected to another surgery due to his fully functional status and the successful therapeutic results of our early treatment.ConclusionsThe injury described in this case study would ordinarily be treated by amputation, but due to the well-executed treatment in the early stages after the injury, the outcome was satisfying. Surprisingly and against our expectations, the late results of the treatment were successful even without arthrodesis. He is now 37 years old and has a functional foot 21 years after the injury.

The Use of Near Infrared Spectroscopy (NIRS) for Monitoring of Free Flaps

Ever since the introduction of free flaps in reconstructive plastic surgery, the success rates have improved. Nevertheless, postoperative complications leading to flap failure still occur in 6–25 % of cases. As salvage rate depends on the time interval from vascular impairment to surgical reintervention (revision), alternative monitoring devices have been introduced in order to detect flap vascular impairment before their clinical signs become evident. Near infrared spectroscopy (NIRS) has proven to be effective. It is non-invasive, reliable, simple to use, objective, recordable, capable of prolonged continuous monitoring and rapidly responds to circulatory changes. The introduction of this device led to improvement of salvage rates and overall flap survival in our department.

Suture anchors to fix free flaps in oral and oropharyngeal reconstruction

F he use of suture anchors has been widely described in rthopaedic, oculoplastic, temporomandibular, and aesthetic urgery,1,2 and they have also been used to fix pedicle flaps in ases of ulcers or post-traumatic deficiency.3 Other authors ave described their use in oncological head and neck surgery, ut only when a free flap was not needed.4 We have recently ested the use of the anchors for fixing free flaps to reconstruct oth the oral cavity and the oropharynx after resections for ancer.5 The Mitek® suture anchors (Depuy Mitek Surgical Prodcts, Inc. Raynham, Massachusetts) are produced in a number f different sizes (micro, mini, GII, and Super) but we use the ini. It is composed of a body and two wings, the body being ade of titanium alloy, and the wings of nickel-titanium alloy, hich benefits from superelasticity and its memory of shape. he packaging includes both the anchor and the insertion evice, in which the anchor is already preloaded. The bottom f the anchor has a loop that contains the suture, which is harged on to the insertion device (Fig. 1). The first step is the exposure of the bone. A calibrated ole is then drilled with the drill bit supplied in the package hat corresponds to the size of the anchor. The drilling is one slowly, perpendicular to the bone, and under abundant rrigation (Fig. 2). It is important to realise that the drill is not equired to pierce the entire thickness of the bone, because he anchor has to be positioned within the cortical bone to inimise the risk of overpenetration. Once the pilot hole has

Surgical Therapy: Forearm Free Flap Phalloplasty

Since its first description more than 20 years ago, phalloplasty using a free sensate flap is commonly considered as the gold standard for phallic reconstruction in female-to-male (FTM) transsexuals. Surgeons performing this procedure have to face different patient’s needs, including a good cosmetic result, a good rigidity, a tactile sensitivity and voiding while standing. The procedure may include the reconstruction of the urethra. Different techniques have been adopted during decades. Free flaps from nearly all parts of the body were described for penile reconstruction, but after an initial and euphoric phase, more recent publications of larger series of patients revealed a restriction to only two favourite donor sites: forearm flaps and fibula flaps.

Treatment of Subacute Traumatic Lower Limb Wounds by Assisted Healing and Delayed Selective Reconstruction

From 2007 to 2017, 34 patients with subacute wounds to lower limbs were treated by the assisted healing and delayed selective reconstruction method (AH-GSR). Sixteen patients (47%) presented with a concomitant fracture; 18 patients (53%) sustained degloving with a soft tissue injury only. Negative pressure wound therapy was used in 28 patients (82.3%). Antibiotics were given to all patients, in 12 (35.3%) as prophylaxis and in 22 (64.7%) as therapy. The reconstruction was performed by split-thickness skin grafts (SG) in 16 patients (47%), by dermal substitutes (DS) in 8 patients (23.5%), by local fascio-cutaneous flaps in 2 patients (5.9%), and by free flaps in 8 patients (23.5%). In this case series, three (8.8%) complications were recorded. Adhering to the AH-GSR method of treatment of lower extremities subacute wounds guarantees results comparable to the ones obtained with the treatment of acute wounds during the first week after injury.

Limb and Flap Salvage in Gustilo IIIC Injuries Treated by Vascular Repair and Emergency Free Flap Transfer

Background Gustilo classification system defines IIIC fractures as open fractures associated with an arterial injury that requires repair. The aim of our study was to analyze the early outcome in terms of limb and flap salvage, early amputation, and early complication rate in patients with Gustilo IIIC open fractures treated in an emergency setup. Methods We retrospectively reviewed 20 patients with Gustilo IIIC injuries treated by the “fix and flap” principle during the first surgical procedure in the first 24 hours after injury (emergency free flap transfer). All patients underwent surgery with radical debridement, wound irrigation, skeletal stabilization, vascular repair, and immediate free flap coverage. Results In this study, 18 patients were men (90%) and 2 were women (10%). In all patients, a vascular repair was performed and in 17 cases (85%), the lower limb/foot was avascular and limb salvage was performed. Three patients had one vessels injured (15%) and 17 had two or three vessels injured (85%). In 9 out of 20 (45%), a revision surgery was needed for arterial (10%, 2 patients), arterial‐venous (15%, 3 patients), and venous thrombosis (20%, 4 patients), while 4 patients required an early amputation (20%) and 1, a late one (5%). In three patients (15%), a flap loss occurred. Superficial infection occurred in seven cases (35%) and deep infection (osteomyelitis) in one (5%). Conclusion A single‐stage procedure performed in an emergency operating room could lead to an effective outcome with a high rate of limb salvage and satisfying long‐term results.

Assisted Healing–Selective Delayed Reconstruction for Subacute Traumatic Wounds of the Lower Limb

1 BACKGROUND Patients often are being referred to plastic surgery for reconstruction of complex wounds in the subacute phase of healing. According to Godina,1 the time interval for the acute reconstruction (early free flaps) is less than 72 hours.2 Byrd et al,3 however, believe that the acute period of the wound lasts 1 week. Only after that, the wound enters in the subacute phase in which treatment of complex wounds becomes more prone to complications (bone and soft-tissue infection, free flap failure).

Arterial Pressure Management in a Reconstructive Microsurgery Patients by Dopamine Infusion in a Nonintensive Care Ward

1 BACKGROUND Free flap perfusion and arterial pressure management have always had a crucial role in free flap reconstruction. Blood pressure values requested can be reached either by using vasoactive agents or fluid replacement or the combination of both.1,2 In contrast to the most frequently tested phenylephrine, norepinephrine, and dobutamine,3,4 this work evaluates dopamine efficacy in perioperative blood pressure management. In our institution, dopamine infusion is the only vasoactive agent authorized in a non-intensive care unit department. This drug stimulates αand β-adrenergic receptors with positive chronotropic and inotropic effects and reduces peripheral vascular resistance helping in this way to achieve an increase of blood pressure and free flap perfusion.5