Haruo Ogawa, Haruki Nakayama, S. Nakayama, S. Tahara
Abstract Background Necrotizing fasciitis is a well-known disease that causes extensive tissue infection and requires radical debridement of the infected tissue. It can occur in all parts of the body, but there are few reports of necrotizing fasciitis in the axilla. We treated three patients with axillary necrotizing fasciitis. Methods In all cases, patients were referred to us after radical debridement of the infected soft tissue in the emergency department. At the first visit to our department, there were fist-sized soft tissue defects in the axilla. Moreover, the ipsilateral pectoralis major and latissimus dorsi muscles were partially resected because of the debridement of necrotizing fasciitis. In all cases, the ipsilateral thoracodorsal vessels were severely damaged and free-flap transfer was performed to close the axillary wound. Results All free flaps survived without complications. The patient's range of motion for shoulder abduction on the affected side was maintained postoperatively. Conclusion If necrotizing fasciitis occurs in the axilla, tissue infection can spread beyond it. In such a case, free-flap transfer can be an optimal treatment. Radical resection of the infected tissue results in the absence of recipient vessels in the axilla. Surgeons should bear in mind that, because of radical resection of the infected tissue, they may need to seek recipient vessels for free-flap transfer far from the axilla.
{"title":"Reconstruction of Axillary Defect due to Necrotizing Fasciitis and Debridement Using a Free-Flap Transfer: A Report of Three Cases","authors":"Haruo Ogawa, Haruki Nakayama, S. Nakayama, S. Tahara","doi":"10.1055/s-0041-1736422","DOIUrl":"https://doi.org/10.1055/s-0041-1736422","url":null,"abstract":"Abstract Background Necrotizing fasciitis is a well-known disease that causes extensive tissue infection and requires radical debridement of the infected tissue. It can occur in all parts of the body, but there are few reports of necrotizing fasciitis in the axilla. We treated three patients with axillary necrotizing fasciitis. Methods In all cases, patients were referred to us after radical debridement of the infected soft tissue in the emergency department. At the first visit to our department, there were fist-sized soft tissue defects in the axilla. Moreover, the ipsilateral pectoralis major and latissimus dorsi muscles were partially resected because of the debridement of necrotizing fasciitis. In all cases, the ipsilateral thoracodorsal vessels were severely damaged and free-flap transfer was performed to close the axillary wound. Results All free flaps survived without complications. The patient's range of motion for shoulder abduction on the affected side was maintained postoperatively. Conclusion If necrotizing fasciitis occurs in the axilla, tissue infection can spread beyond it. In such a case, free-flap transfer can be an optimal treatment. Radical resection of the infected tissue results in the absence of recipient vessels in the axilla. Surgeons should bear in mind that, because of radical resection of the infected tissue, they may need to seek recipient vessels for free-flap transfer far from the axilla.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"06 1","pages":"e63 - e69"},"PeriodicalIF":0.0,"publicationDate":"2021-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44922352","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
E. Rodriguez-Collazo, Asim A.Z. Raja, Shawn Ward, Stephanie Oexeman, A. Khan
Abstract Background A proximal deep peroneal nerve (DPN) injury can significantly impact the functional capacity of the leg, to include compromised motor function of the tibialis anterior (TA) muscle. Clinical examination can range from weakness in ankle dorsiflexion, to complete foot drop. Diagnostic nerve conduction velocity (NCV) testing can demonstrate abnormalities at select areas of impingement (or) entrapment (i.e., regions affected by a demyelinating compression mono-neuropathy), along the proximal course of the common peroneal nerve. Methods We retrospectively report on 17 patients with clinical weakness involving ankle dorsiflexion. All patients underwent surgical end-to-side anastomosis, transferring a muscular nerve branch from the superficial peroneal nerve (SPN) to a segment of the DPN responsible for TA muscle innervation. Outcomes were based on comparisons of preoperative and postoperative DPN motor function to the TA muscle, standardized to the British Medical Research Council Scale for Muscle Strength. Preoperative scores were generally M2 or below. Results Postoperative outcome scores of M4 to M5 were considered good (or) successful. 94.1% of patients demonstrated successful outcomes. Conclusion An end-to-side SPN motor branch anastomosis, into the motor branch of the DPN responsible for TA muscle innervation, can be a viable treatment option for weakness in ankle dorsiflexion. All reported cases involved a compromised segment of deep peroneal nerve within the proximal one-third of the leg.
{"title":"End-to-Side Nerve Transfer for the Management of Chronic Leg Compartment Ankle Dorsiflexion Weakness","authors":"E. Rodriguez-Collazo, Asim A.Z. Raja, Shawn Ward, Stephanie Oexeman, A. Khan","doi":"10.1055/s-0041-1740979","DOIUrl":"https://doi.org/10.1055/s-0041-1740979","url":null,"abstract":"Abstract Background A proximal deep peroneal nerve (DPN) injury can significantly impact the functional capacity of the leg, to include compromised motor function of the tibialis anterior (TA) muscle. Clinical examination can range from weakness in ankle dorsiflexion, to complete foot drop. Diagnostic nerve conduction velocity (NCV) testing can demonstrate abnormalities at select areas of impingement (or) entrapment (i.e., regions affected by a demyelinating compression mono-neuropathy), along the proximal course of the common peroneal nerve. Methods We retrospectively report on 17 patients with clinical weakness involving ankle dorsiflexion. All patients underwent surgical end-to-side anastomosis, transferring a muscular nerve branch from the superficial peroneal nerve (SPN) to a segment of the DPN responsible for TA muscle innervation. Outcomes were based on comparisons of preoperative and postoperative DPN motor function to the TA muscle, standardized to the British Medical Research Council Scale for Muscle Strength. Preoperative scores were generally M2 or below. Results Postoperative outcome scores of M4 to M5 were considered good (or) successful. 94.1% of patients demonstrated successful outcomes. Conclusion An end-to-side SPN motor branch anastomosis, into the motor branch of the DPN responsible for TA muscle innervation, can be a viable treatment option for weakness in ankle dorsiflexion. All reported cases involved a compromised segment of deep peroneal nerve within the proximal one-third of the leg.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"07 1","pages":"e35 - e43"},"PeriodicalIF":0.0,"publicationDate":"2021-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45305573","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
S. L. Peterson, H. de Vries, Kami Collins, Hilde Geraedts, M. Wheatley
Abstract Introduction Symptomatic neuroma with neuropathic pain can develop following peripheral nerve injury. Current interventions for symptomatic neuroma have unpredictable results. NEUROCAP (Polyganics, Groningen, The Netherlands) is a bioresorbable nerve capping device intended to protect a peripheral nerve end and separate the nerve from the surrounding environment, to prevent the recurrence of a symptomatic neuroma. Materials and Methods This study aims to assess the implantation effects of the NEUROCAP device in a rat sciatic nerve model during 12 months (±2 days). Forty-one adult male Sprague-Dawley rats were used in this study. They were randomly divided into a capping or test group, or a noncapping or control group for different time points of survival (12 weeks, 6 months, and 12 months). The objective of this study was evaluated regarding procedural data, adverse events, clinical observations, and histopathology. Results The overall general health of the animals was adequate throughout the study, with the exception of autotomy during the first 4 months of survival. Eight animals were euthanized early due to autotomy, excluded from the study and seven of them have been replaced. Autotomy was an expected outcome and a known limitation of the animal model, particularly as this was a full sciatic nerve transection model. Neuroma formation was observed in the control group while there was no neuroma formation present in the test group. The control group showed increased nerve outgrowth and more chaotic fascicles in comparison with the test group. The test group also had a higher percentage of myelinated fibers compared to the control group. These results indicate a preventive mode of action of the NEUROCAP with regard to neuroma formation after nerve transection in a rat sciatic nerve model. Conclusion The results indicate that NEUROCAP is safe and effective in preventing the recurrence of neuroma formation and inhibiting nerve outgrowth.
{"title":"Neuroma Prevention and Implantation Effects of NEUROCAP in Rat Sciatic Nerve Model","authors":"S. L. Peterson, H. de Vries, Kami Collins, Hilde Geraedts, M. Wheatley","doi":"10.1055/s-0040-1722201","DOIUrl":"https://doi.org/10.1055/s-0040-1722201","url":null,"abstract":"Abstract Introduction Symptomatic neuroma with neuropathic pain can develop following peripheral nerve injury. Current interventions for symptomatic neuroma have unpredictable results. NEUROCAP (Polyganics, Groningen, The Netherlands) is a bioresorbable nerve capping device intended to protect a peripheral nerve end and separate the nerve from the surrounding environment, to prevent the recurrence of a symptomatic neuroma. Materials and Methods This study aims to assess the implantation effects of the NEUROCAP device in a rat sciatic nerve model during 12 months (±2 days). Forty-one adult male Sprague-Dawley rats were used in this study. They were randomly divided into a capping or test group, or a noncapping or control group for different time points of survival (12 weeks, 6 months, and 12 months). The objective of this study was evaluated regarding procedural data, adverse events, clinical observations, and histopathology. Results The overall general health of the animals was adequate throughout the study, with the exception of autotomy during the first 4 months of survival. Eight animals were euthanized early due to autotomy, excluded from the study and seven of them have been replaced. Autotomy was an expected outcome and a known limitation of the animal model, particularly as this was a full sciatic nerve transection model. Neuroma formation was observed in the control group while there was no neuroma formation present in the test group. The control group showed increased nerve outgrowth and more chaotic fascicles in comparison with the test group. The test group also had a higher percentage of myelinated fibers compared to the control group. These results indicate a preventive mode of action of the NEUROCAP with regard to neuroma formation after nerve transection in a rat sciatic nerve model. Conclusion The results indicate that NEUROCAP is safe and effective in preventing the recurrence of neuroma formation and inhibiting nerve outgrowth.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"06 1","pages":"e1 - e10"},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0040-1722201","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45458365","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
R. Kwasnicki, Ching-Mei Chen, A. Noakes, S. Hettiaratchy, Guang-Zhong Yang, A. Darzi
Abstract Objective Technologies facilitating continuous free tissue flap monitoring such as near infrared spectroscopy (NIRS) have been shown to improve flap salvage rates. However, the size and associated costs of such technology create a barrier to wider implementation. The aim of this study was to develop and validate a wearable sensor for continuous tissue oxygenation monitoring. Materials and Methods A forearm ischemia model was designed by using a brachial pressure cuff inflation protocol. Twenty healthy subjects were recruited. The forearm tissue oxygenation of each subject was monitored throughout the pressure cuff protocol by using a new optical sensor (Imperial College London), and a gold standard tissue spectrometry system (O2C, Medizintecknik, LEA, Germany). Data were processed to allow quantitative deoxygenation episode comparisons between inflations and sensor modalities. Results The correlation between O2C and optical sensor oxygenation measurements was moderate (average R = 0.672, p < 0.001). Incremental increases in cuff inflation duration resulted in a linear increase in deoxygenation values with both O2C and optical sensors, with significant differences recorded on consecutive inflations (wall shear rate, p < 0.005). The presence or absence of pulsatile blood flow was correctly determined throughout by both sensor modalities. Conclusion This study demonstrates the ability of a small optical sensor to detect and quantify tissue oxygenation changes and assess the presence of pulsatile blood flow. Low power, miniaturized electronics make the device capable of deployment in a wearable form which may break down the barriers for implementation in postoperative flap monitoring.
{"title":"Developing a Wearable Sensor for Continuous Tissue Oxygenation Monitoring: A Proof of Concept Study","authors":"R. Kwasnicki, Ching-Mei Chen, A. Noakes, S. Hettiaratchy, Guang-Zhong Yang, A. Darzi","doi":"10.1055/s-0041-1723995","DOIUrl":"https://doi.org/10.1055/s-0041-1723995","url":null,"abstract":"Abstract Objective Technologies facilitating continuous free tissue flap monitoring such as near infrared spectroscopy (NIRS) have been shown to improve flap salvage rates. However, the size and associated costs of such technology create a barrier to wider implementation. The aim of this study was to develop and validate a wearable sensor for continuous tissue oxygenation monitoring. Materials and Methods A forearm ischemia model was designed by using a brachial pressure cuff inflation protocol. Twenty healthy subjects were recruited. The forearm tissue oxygenation of each subject was monitored throughout the pressure cuff protocol by using a new optical sensor (Imperial College London), and a gold standard tissue spectrometry system (O2C, Medizintecknik, LEA, Germany). Data were processed to allow quantitative deoxygenation episode comparisons between inflations and sensor modalities. Results The correlation between O2C and optical sensor oxygenation measurements was moderate (average R = 0.672, p < 0.001). Incremental increases in cuff inflation duration resulted in a linear increase in deoxygenation values with both O2C and optical sensors, with significant differences recorded on consecutive inflations (wall shear rate, p < 0.005). The presence or absence of pulsatile blood flow was correctly determined throughout by both sensor modalities. Conclusion This study demonstrates the ability of a small optical sensor to detect and quantify tissue oxygenation changes and assess the presence of pulsatile blood flow. Low power, miniaturized electronics make the device capable of deployment in a wearable form which may break down the barriers for implementation in postoperative flap monitoring.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"06 1","pages":"e11 - e19"},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0041-1723995","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48046575","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
B. Tatar, C. Uslu, M. Erdem, Fahri Sabancıogullarından, Caner Gelbal, M. Bozkurt
Abstract Background Volar finger defects where critical structures exposed are always challenging for plastic surgeons. In these types of defects, local flaps, cross finger flaps, abdominal flaps, and free flaps are used. Free dorsoulnar artery perforator (DUAP) flaps and superficial palmar branch of radial artery (SPBRA) flaps are also used. In this case, we present a patient who was scheduled to receive a DUAP flap to address defect on the second finger of right hand; however, we repaired the defect with a SPBRA flap because intraoperative absence of the ulnar artery was observed. Materials and Methods A 34-year-old male patient was admitted with a wound that exposed the tendon and neurovascular bundle on the volar side of the second finger of the right hand. A free DUAP flap was planned for the patient. A perforator was detected during the preoperative Doppler ultrasound examination. While dissecting the perforator, we noted the absence of an ulnar artery proximal to the perforator vessel. The elevated SPBRA flap from same extremity and the defect were closed. Results Postoperative computer tomography showed an absence of the ulnar artery distal to the right antecubital region. No complications were seen in the donor and recipient areas. Long-term motor movements were natural, and the patient's quality of life was good. Conclusion Determining the perforator site using Doppler alone may not be sufficient in preoperative evaluation of patients scheduled to receive DUAP flaps. Performing an Allen test and using advanced imaging methods can prevent surgeons from encountering a bad surprise.
{"title":"Observation of the Absence of Ulnar Artery in a Patient Planned to Free Dorsoulnar Artery Perforator Flap for Finger Defect: Is Preoperative Doppler evaluation of Perforator Alone Sufficient?","authors":"B. Tatar, C. Uslu, M. Erdem, Fahri Sabancıogullarından, Caner Gelbal, M. Bozkurt","doi":"10.1055/s-0041-1726303","DOIUrl":"https://doi.org/10.1055/s-0041-1726303","url":null,"abstract":"Abstract Background Volar finger defects where critical structures exposed are always challenging for plastic surgeons. In these types of defects, local flaps, cross finger flaps, abdominal flaps, and free flaps are used. Free dorsoulnar artery perforator (DUAP) flaps and superficial palmar branch of radial artery (SPBRA) flaps are also used. In this case, we present a patient who was scheduled to receive a DUAP flap to address defect on the second finger of right hand; however, we repaired the defect with a SPBRA flap because intraoperative absence of the ulnar artery was observed. Materials and Methods A 34-year-old male patient was admitted with a wound that exposed the tendon and neurovascular bundle on the volar side of the second finger of the right hand. A free DUAP flap was planned for the patient. A perforator was detected during the preoperative Doppler ultrasound examination. While dissecting the perforator, we noted the absence of an ulnar artery proximal to the perforator vessel. The elevated SPBRA flap from same extremity and the defect were closed. Results Postoperative computer tomography showed an absence of the ulnar artery distal to the right antecubital region. No complications were seen in the donor and recipient areas. Long-term motor movements were natural, and the patient's quality of life was good. Conclusion Determining the perforator site using Doppler alone may not be sufficient in preoperative evaluation of patients scheduled to receive DUAP flaps. Performing an Allen test and using advanced imaging methods can prevent surgeons from encountering a bad surprise.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"06 1","pages":"e45 - e50"},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0041-1726303","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48461133","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Christopher M. Fleury, B. Chang, Robert P Slamin, Jonathan A. Schwitzer, Arjun Kanuri, D. Masden
Abstract Background Although the novel 2019 coronavirus (COVID-19) pandemic delayed elective microsurgical reconstruction cases, traumatic injuries requiring microsurgical reconstruction for limb salvage still presented to our hospital. Recent data suggests a link between COVID-19 and increased venous and arterial thromboembolic events, theoretically increasing the risk of microvascular anastomotic thrombosis and flap failure. Methods We provide a single case report of microsurgical limb salvage in a COVID-19-positive patient with a Gustilo IIIb open tibial-fibular fracture. Results A free latissimus dorsi muscle flap was used to successfully cover a Gustilo IIIb open tibial-fibular fracture with exposed orthopedic hardware and large soft tissue defect, with 5-month follow-up demonstrating a well-healed flap allowing for preserved ambulation. Conclusion Although there is a theoretical increased incidence of venous and arterial thrombotic microvascular failure in COVID-19-positive patients, microsurgical reconstruction is occasionally the lone option for salvage. Microsurgical reconstruction in this population must be carefully considered, meticulously executed, and closely monitored.
{"title":"Successful Microsurgical Reconstruction for Limb Salvage in a COVID-19-Positive Patient: A Case Report","authors":"Christopher M. Fleury, B. Chang, Robert P Slamin, Jonathan A. Schwitzer, Arjun Kanuri, D. Masden","doi":"10.1055/s-0041-1729955","DOIUrl":"https://doi.org/10.1055/s-0041-1729955","url":null,"abstract":"Abstract Background Although the novel 2019 coronavirus (COVID-19) pandemic delayed elective microsurgical reconstruction cases, traumatic injuries requiring microsurgical reconstruction for limb salvage still presented to our hospital. Recent data suggests a link between COVID-19 and increased venous and arterial thromboembolic events, theoretically increasing the risk of microvascular anastomotic thrombosis and flap failure. Methods We provide a single case report of microsurgical limb salvage in a COVID-19-positive patient with a Gustilo IIIb open tibial-fibular fracture. Results A free latissimus dorsi muscle flap was used to successfully cover a Gustilo IIIb open tibial-fibular fracture with exposed orthopedic hardware and large soft tissue defect, with 5-month follow-up demonstrating a well-healed flap allowing for preserved ambulation. Conclusion Although there is a theoretical increased incidence of venous and arterial thrombotic microvascular failure in COVID-19-positive patients, microsurgical reconstruction is occasionally the lone option for salvage. Microsurgical reconstruction in this population must be carefully considered, meticulously executed, and closely monitored.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"06 1","pages":"e40 - e44"},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0041-1729955","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48387621","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Background The aim of this study is to analyze the impact of the number and location of perforators harvested and the recipient vessels used on deep inferior epigastric perforator (DIEP) flap survival and the occurrence of flap necrosis requiring re-operation. Patients and Methods Four hundred and seventy-one DIEP flap reconstructions, performed between January 2008 and December 2019, were retrospectively analyzed. Results Flap necrosis requiring re-operation was observed in 40 (9%) of flaps and total flap loss rate was 1% (n = 6). No significant differences were observed between internal mammary vessels (IMV, n = 287, 61%) and thoracodorsal vessels (TDV, n = 184, 39%) regarding postoperative re-anastomosis (p = 0.529) or flap survival (p = 0.646). Intraoperative conversion from IMV to TDV was performed on 64 (14%) patients. TDV were more commonly associated with problems in preparation of the vessels than IMV (p < 0.001). Second vein anastomosis was performed on 18 (4%) patients. In total, 81 flaps (17%) had one perforator, 165 (35%) had two, 218 (46%) had three to five, and 7 (2%) had more than five perforators. Flaps with three to five perforators were more commonly associated with flap necrosis (p < 0.001) than flaps with one or two perforators. Independent factors associated with necrosis were body mass index (BMI) > 30 (odds ratio [OR]: 2.28; 95% confidence interval: 1.06–4.91, p = 0.035) and perforator/s located on the lateral row (OR: 3.08, 95% CI 1.29–7.33, p = 0.011). Conclusion We conclude that the occurrence of flap necrosis requiring re-operation may be higher in DIEP flaps with more than two perforators or perforator/s located on the lateral row and in obese patients. Neither the recipient vessels used nor the number of perforators harvested had any impact on the flap survival rate.
{"title":"Necrosis or Flap Loss After Deep Inferior Epigastric Perforator Reconstruction: Impact of Perforators and Recipient Vessels","authors":"J. Palve, T. Luukkaala, M. Kääriäinen","doi":"10.1055/s-0041-1729638","DOIUrl":"https://doi.org/10.1055/s-0041-1729638","url":null,"abstract":"Abstract Background The aim of this study is to analyze the impact of the number and location of perforators harvested and the recipient vessels used on deep inferior epigastric perforator (DIEP) flap survival and the occurrence of flap necrosis requiring re-operation. Patients and Methods Four hundred and seventy-one DIEP flap reconstructions, performed between January 2008 and December 2019, were retrospectively analyzed. Results Flap necrosis requiring re-operation was observed in 40 (9%) of flaps and total flap loss rate was 1% (n = 6). No significant differences were observed between internal mammary vessels (IMV, n = 287, 61%) and thoracodorsal vessels (TDV, n = 184, 39%) regarding postoperative re-anastomosis (p = 0.529) or flap survival (p = 0.646). Intraoperative conversion from IMV to TDV was performed on 64 (14%) patients. TDV were more commonly associated with problems in preparation of the vessels than IMV (p < 0.001). Second vein anastomosis was performed on 18 (4%) patients. In total, 81 flaps (17%) had one perforator, 165 (35%) had two, 218 (46%) had three to five, and 7 (2%) had more than five perforators. Flaps with three to five perforators were more commonly associated with flap necrosis (p < 0.001) than flaps with one or two perforators. Independent factors associated with necrosis were body mass index (BMI) > 30 (odds ratio [OR]: 2.28; 95% confidence interval: 1.06–4.91, p = 0.035) and perforator/s located on the lateral row (OR: 3.08, 95% CI 1.29–7.33, p = 0.011). Conclusion We conclude that the occurrence of flap necrosis requiring re-operation may be higher in DIEP flaps with more than two perforators or perforator/s located on the lateral row and in obese patients. Neither the recipient vessels used nor the number of perforators harvested had any impact on the flap survival rate.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"06 1","pages":"e20 - e27"},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0041-1729638","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48778109","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
N. Lombana, Reuben A. Falola, M. Scott, M. Saint-Cyr
Abstract Background The radial forearm flap (RFF) is a versatile flap that can be used for soft-tissue coverage or as a source of vascularized bone during reconstruction. A problem that can arise after RFF harvest is tendon exposure in the donor site, which may lead to tendon injury and restriction of the hand and wrist’s range of motion. Many different methods for providing adequate tendon coverage in the donor site after RFF harvest have been reported. We present a novel technique for coverage of exposed tendon in the volar forearm with an epimysial transposition flap and a split-thickness skin graft (STSG). Methods Retrospective review of two cases: one salvage case with exposed tendon after harvesting an RFF and another with exposed volar forearm tendon after traumatic injuries. Variables of interest were post-operative STSG integration and hand/wrist range of motion. Results Both cases demonstrated 100% graft take at 5-week follow-up. No decrease in hand/wrist range of motion in the patient that could undergo testing. Conclusion We introduce two cases for coverage of exposed flexor tendon in the volar forearm with an epimysial transposition flap. This can be used as a salvage operation for coverage of exposed tendon or as an acute method of tendon coverage prior to skin grafting. In both cases, the skin graft had excellent incorporation.
{"title":"Epimysial Transposition Flap: A Novel Technique for Coverage of Exposed Tendon after Tissue Transfer","authors":"N. Lombana, Reuben A. Falola, M. Scott, M. Saint-Cyr","doi":"10.1055/s-0041-1729954","DOIUrl":"https://doi.org/10.1055/s-0041-1729954","url":null,"abstract":"Abstract Background The radial forearm flap (RFF) is a versatile flap that can be used for soft-tissue coverage or as a source of vascularized bone during reconstruction. A problem that can arise after RFF harvest is tendon exposure in the donor site, which may lead to tendon injury and restriction of the hand and wrist’s range of motion. Many different methods for providing adequate tendon coverage in the donor site after RFF harvest have been reported. We present a novel technique for coverage of exposed tendon in the volar forearm with an epimysial transposition flap and a split-thickness skin graft (STSG). Methods Retrospective review of two cases: one salvage case with exposed tendon after harvesting an RFF and another with exposed volar forearm tendon after traumatic injuries. Variables of interest were post-operative STSG integration and hand/wrist range of motion. Results Both cases demonstrated 100% graft take at 5-week follow-up. No decrease in hand/wrist range of motion in the patient that could undergo testing. Conclusion We introduce two cases for coverage of exposed flexor tendon in the volar forearm with an epimysial transposition flap. This can be used as a salvage operation for coverage of exposed tendon or as an acute method of tendon coverage prior to skin grafting. In both cases, the skin graft had excellent incorporation.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"06 1","pages":"e51 - e56"},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0041-1729954","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42646554","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Robertson, Charles W Patterson, H. Hilaire, F. Lau
Abstract Background Pressure ulcers (PUs) affect 2.5 million people in the United States annually and incur health-care costs of 11 billion dollars annually. Stage III/IV PU often require local flap reconstruction. Unfortunately, PU recurrence is common following reconstruction; recurrence rates as high as 82% have been reported. When local flap options are inadequate, free tissue transfer may be indicated but the indications have yet to be delineated. To develop evidence-based guidelines for the use of free flaps in PU reconstruction, we performed a systematic review. Methods A systematic review of the available English-language, peer-reviewed literature was conducted using PubMed/MEDLINE, Google Scholar, Scopus, EMBASE, and the Cochrane Database of Systematic Reviews. Articles were manually reviewed for relevance. Results Out of 272 articles identified, 10 articles were included in the final analysis. Overall, this systematic review suggests that free-flap PU reconstruction yields fewer recurrences compared with local flaps (0–20 vs. 13–82%). Further, several types of free flaps for PU reconstruction were identified in this review, along with their indications. Conclusion Free tissue transfer should be considered for recurrent PU. We offer specific recommendations for their use in PU reconstruction.
背景:在美国，每年有250万人患有压疮，每年的医疗费用高达110亿美元。III/IV期PU通常需要局部皮瓣重建。不幸的是，重建后PU复发很常见;据报道复发率高达82%。当局部皮瓣选择不足，自由组织转移可能指征，但指征尚未划定。为了制定以证据为基础的游离皮瓣在PU重建中的应用指南，我们进行了系统的回顾。方法采用PubMed/MEDLINE、谷歌Scholar、Scopus、EMBASE和Cochrane系统综述数据库对现有的英文同行评议文献进行系统综述。文章的相关性是手工审查的。结果在鉴定的272篇文献中，有10篇纳入最终分析。总的来说，本系统综述表明，与局部皮瓣相比，自由皮瓣PU重建的复发率更低(0 - 20% vs. 13-82%)。此外，本文还介绍了几种用于PU重建的自由皮瓣，以及它们的适应症。结论复发性PU应考虑游离组织移植。我们对它们在PU重建中的应用提出了具体的建议。
{"title":"Free Tissue Transfer in Pressure Ulcer Reconstruction: A Systematic Review","authors":"C. Robertson, Charles W Patterson, H. Hilaire, F. Lau","doi":"10.1055/s-0041-1729640","DOIUrl":"https://doi.org/10.1055/s-0041-1729640","url":null,"abstract":"Abstract Background Pressure ulcers (PUs) affect 2.5 million people in the United States annually and incur health-care costs of 11 billion dollars annually. Stage III/IV PU often require local flap reconstruction. Unfortunately, PU recurrence is common following reconstruction; recurrence rates as high as 82% have been reported. When local flap options are inadequate, free tissue transfer may be indicated but the indications have yet to be delineated. To develop evidence-based guidelines for the use of free flaps in PU reconstruction, we performed a systematic review. Methods A systematic review of the available English-language, peer-reviewed literature was conducted using PubMed/MEDLINE, Google Scholar, Scopus, EMBASE, and the Cochrane Database of Systematic Reviews. Articles were manually reviewed for relevance. Results Out of 272 articles identified, 10 articles were included in the final analysis. Overall, this systematic review suggests that free-flap PU reconstruction yields fewer recurrences compared with local flaps (0–20 vs. 13–82%). Further, several types of free flaps for PU reconstruction were identified in this review, along with their indications. Conclusion Free tissue transfer should be considered for recurrent PU. We offer specific recommendations for their use in PU reconstruction.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"06 1","pages":"e35 - e39"},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0041-1729640","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44906699","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jackson S. Lindell, Breanna L. Blaschke, Arthur J. Only, Harsh R. Parikh, Tiffany Gorman, S. Vang, Ashish Y. Mahajan, Brian P. Cunningham
Abstract Background Microvascular free tissue transfer (FTT) is a reliable method for reconstruction of complex soft tissue defects. The goal of this study was to utilize time-driven activity-based cost (TDABC) accounting to measure the total cost of care of FTT and identify modifiable cost drivers. Methods A retrospective review was performed on patients requiring FTT at a single, level-I academic trauma center from 2013 to 2019. Patient and surgical characteristics were collected, and six prospective FTT cases were observed via TDABC to collect direct and indirect costs of care. Results When stratified by postoperative stay at intensive care units (ICUs), the average cost of care was $21,840.22, while cases without ICU stay averaged $6,646.61. The most costly category was ICU stay, averaging $8,310.99 (40.9% of nonstratified overall cost). Indirect costs were the second most costly category, averaging $4,388.07 (21.6% of nonstratified overall cost). Overall, 13 of 100 reviewed cases required some form of revision free-flap, increasing cumulative costs to $7,961.34 for cases with non-ICU stay and $22,233.85 for cases with ICU stay, averaging up to $44,074.07 for patients who stayed in the ICU for both procedures. An increase in cumulative cost was also observed within the timeframe of the investigation, with average costs of $8,484.00 in 2013 compared to $45,128 for 2019. Conclusion Primary drivers for cost in this study were ICU stay and revision/reoperation. Better understanding the cost of FTT allows for cost reduction through the development of new protocols that drive intraoperative efficiency, reduce ICU stays, and optimize outcomes.
{"title":"The Cost of Care Associated with Microvascular Free Tissue Transfer by Anatomical Region: A Time-Driven Activity-Based Model","authors":"Jackson S. Lindell, Breanna L. Blaschke, Arthur J. Only, Harsh R. Parikh, Tiffany Gorman, S. Vang, Ashish Y. Mahajan, Brian P. Cunningham","doi":"10.1055/s-0041-1729639","DOIUrl":"https://doi.org/10.1055/s-0041-1729639","url":null,"abstract":"Abstract Background Microvascular free tissue transfer (FTT) is a reliable method for reconstruction of complex soft tissue defects. The goal of this study was to utilize time-driven activity-based cost (TDABC) accounting to measure the total cost of care of FTT and identify modifiable cost drivers. Methods A retrospective review was performed on patients requiring FTT at a single, level-I academic trauma center from 2013 to 2019. Patient and surgical characteristics were collected, and six prospective FTT cases were observed via TDABC to collect direct and indirect costs of care. Results When stratified by postoperative stay at intensive care units (ICUs), the average cost of care was $21,840.22, while cases without ICU stay averaged $6,646.61. The most costly category was ICU stay, averaging $8,310.99 (40.9% of nonstratified overall cost). Indirect costs were the second most costly category, averaging $4,388.07 (21.6% of nonstratified overall cost). Overall, 13 of 100 reviewed cases required some form of revision free-flap, increasing cumulative costs to $7,961.34 for cases with non-ICU stay and $22,233.85 for cases with ICU stay, averaging up to $44,074.07 for patients who stayed in the ICU for both procedures. An increase in cumulative cost was also observed within the timeframe of the investigation, with average costs of $8,484.00 in 2013 compared to $45,128 for 2019. Conclusion Primary drivers for cost in this study were ICU stay and revision/reoperation. Better understanding the cost of FTT allows for cost reduction through the development of new protocols that drive intraoperative efficiency, reduce ICU stays, and optimize outcomes.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"06 1","pages":"e28 - e34"},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0041-1729639","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47533256","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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