Pedicled abdominal flap using deep inferior epigastric artery perforators for forearm reconstruction: A case report

BACKGROUND Pedicled abdominal flaps are a widely used surgical technique for forearm reconstruction in patients with soft tissue defects.However,some drawbacks include restricted flap size,partial flap loss,and donor-site morbidity.To address these concerns,we present a case of a pedicled abdominal flap using the deep inferior epigastric artery perforators(DIEP)for forearm reconstruction in a patient with a large soft tissue defect.CASE SUMMARY A 46-year-old male patient was admitted to our hospital with forearm injury caused by a pressing machine.A 15 cm×10 cm soft tissue defect with complete rupture of the ulnar side structures of the forearm was found.One week after orthopedic management of the neurovascular injury and fractures using the first stage of Masquelet technique,the patient was referred to the plastic and recon-structive surgery department for wound coverage.Surgical debridement and negative-pressure wound therapy revealed a 20 cm×15 cm soft tissue defect.A pedicle abdominal flap with the DIEP was used to cover the defect.Three weeks later,the flap was detached from the abdomen,and the abdominal defect was directly closed.Subsequently,the second stage of Masquelet technique was performed at the fracture site at week 10.Finally,all donor and recipient sites healed without complications,such as flap dehiscence,infection,hematoma,or necrosis.Fracture site osteosynthesis was achieved without complications.CONCLUSION Pedicled abdominal flap using the DIEP provides a reliable option for forearm reconstruction in patients with large soft tissue defects.

Lateral circumflex femoral artery perforator flap for the reconstruction of head soft tissue defects:Cross-region venous anastomosis

Background:Owing to its unique characteristics,the lateral circumflex femoral artery perforator(LCFAP)flap is often preferred for repairing head wounds with exposed skulls.However,given the vascular distribution in the head,particularly the veins,can lead to postoperative complications such as venous congestion of the flap.The rates of vascular exploration and necrosis in these flaps are significantly higher than in other body regions.Therefore,it is crucial to identify a safe and effective method for venous anastomosis of free flaps in the head region.Methods:This retrospective case series study included 10 patients with large head soft tissue defects treated at the Burn and Plastic Surgery Department of the Affiliated Hospital of Zunyi Medical University from January 2020 to December 2022.The head defects were reconstructed using LCFAP flaps,with flap veins anastomosed to the external jugular vein in the neck,either directly or via a bridging technique.Results:Among the 10 adult patients with massive head wound defects,7(70%)were men.The patients’mean age was 53.0 years(48–59 years).The wound defects were caused by trauma in 6(60%)patients and by tumors in 4(40%)patients.Postoperatively,no significant complications occurred,and all LCFAP flap survived without necrosis.Conclusion:The descending branch of the LCFAP flap effectively repairs massive head wound defects.The venous anastomosis method for this flap is associated with a low incidence of venous complications and a high patency rate,making it a clinically valuable reference.

Utility of Preoperative Positron Emission Tomography (PET) in Localizing Perforator Vessels of Anterolateral Thigh Free Flap

Objectives: The anterolateral thigh (ALT) flap is often considered the workhorse in soft tissue reconstruction of head and neck defects secondary to trauma, infection, or tumor resection. Despite its many advantages, ALT flaps have been criticized due to variability in vasculature, which may result in inadequate or non-existent perforators. This retrospective study aims to investigate the utility and validity of positron emission tomography (PET) scan to identify the location and characteristics of perforators to the ALT flap. Methods: We performed a 10-year retrospective review of ALT flaps at our institution to identify patients with preoperative PET scans available for analysis. Three reviewers (attending physician, fellow, and resident) were asked to identify the number, location, and characteristics (myocutaneous versus septocutaneous) of ALT perforators on imaging, and reviewer agreement was assessed. Results were then compared to available operative data. Results: One hundred twenty-one patients were identified who underwent ALT free flap surgery. Thirty-eight preoperative PET scans were identified for review. At least one perforator was identified in 92.1% of scans. Agreement percentages regarding the number of perforators ranged from 53% - 61% whereas agreement regarding the location of a single perforator ranged from 79% - 90%. However, reviewers did not agree regarding the type of perforator, with agreement ranging from 34% - 53%. Poor agreement was observed when compared to intraoperative data, with the number of perforators ranging from 26% - 34% and the type of perforator 11% - 24%. These findings are likely due to insufficient data available in operative reports. Conclusion: Although initial studies suggest that PET scan shows promising evidence to support the capacity to preoperatively identify ALT perforators, future prospective studies are warranted to fully validate these findings.

Distally based perforator sural flaps for foot and ankle reconstruction

Distally based perforator sural flaps from the posterolateral or posteromedial lower leg aspect are initially a neurofasciocutaneous flap that can be transferred reversely to the foot and ankle region with no need to harvest and sacrifice the deep major artery. These flaps are supplied by a perforating artery issued from the deep peroneal artery or the posterior tibial artery, and the chainlinked adipofascial neurovascular axis around the sural/saphenous nerve. It is a versatile and reliable technique for soft-tissue reconstruction of the heel and ankle region with 180-degrees rotation. In this paper, we present its developing history, vascular basis, surgical techniques including flap design and elevation, flap variations in pedicle and component, surgical indications, and illustrative case reports with different perforating vessels as pivot points for foot and ankle coverage.

Keystone design perforator island flap in facial defect reconstruction

Facial defect coverage is a common subject in the field of reconstructive surgery.There are many methods for facial defect reconstruction,and reconstructive surgeons should choose the most appropriate method on a case-by-case basis to achieve both functional and aesthetic improvement.Among various options for facial reconstruction,the local flap technique is considered the best reconstructive modality to provide good tissue matches of color and texture,which is consistent with the ideal goal of reconstruction(replacement of like-with-like).Keystone design perforator island flap(KDPIF),devised by Behan in 2003,has been applied to various fields of reconstructive surgery in the past decade due to its design simplicity,robust vascular supply,and reproducibility.Several studies have reported KDPIF reconstruction of facial defects,such as large parotid defects,small-to-moderate nasal defects,and eyelid defects.However,KDPIF has been used relatively less in facial defects than in other body regions,such as the trunk and extremities.The purpose of this review is to provide an organized overview of facial KDPIF reconstruction including the classification of KDPIF,modifications,physiology,mechanism of flap movement,consideration of facial relaxed skin tension lines and aesthetics,surgical techniques,clinical applications,and precautions for successful execution of KDPIF reconstruction.

Strengthening strategy for high-performance friction stir lap welded joints based on 5083 Al alloy

During aircraft,ship,and automobile manufacturing,lap structures are frequently produced among Al alloy skins,wall panels,and stiffeners.The occurrence of welding defects severely decreases mechanical properties during friction stir lap welding(FSLW).This study focuses on investigating the effects of rotation rate,multipass welding,and cooling methods on lap defect formation,microstructural evolution,and mechanical properties.Hook defects were eliminated by decreasing welding speed,applying two-pass FLSW with a small welding tool,and introducing additional water cooling,thus leading to a remarkable increase in effective sheet thickness and lap width.This above strategy yielded defect-free joints with an ultrafine-grained microstructure and increased tensile shear force from 298 to 551 N/mm.The fracture behavior of FSLW joints was systematically studied,and a fracture factor of lap joints was proposed to predict their fracture mode.By reducing the rotation rate,using two-pass welding,and employing additional water cooling strategies,an enlarged,strengthened,and defect-free lap zone with refined ultrafine grains was achieved with a quality comparable to that of lap welds based on 7xxx Al alloys.Importantly,this study provides a valuable FSLW method for eliminating hook defects and improving joint performance.

Safety of Single Vein Anastomosis versus Double Venous Anastomosis in ALT Perforator Flap in Foot and Leg Reconstruction

Introduction: Single or double venous anastomosis in free flap in general and ALT, in particular, is still a matter of debate between micro vascular surgeons. In this study, we will present our experience in single vein anastomosis versus double venous anastomosis in ALT perforator flap used in leg and foot reconstruction as regarding flap outcome, complications, operation time and the need for re-exploration. Patient and Methods: We retrospectively evaluate 60 patients with post traumatic foot and leg defects in the period between January 2014 and January 2018 where free ALT flap was done. The patients were divided into two groups, Group 1 where single vein anastomosis was done and Group 2 where double venous anastomosis was done;we utilize the deep venous system for the anastomosis in all cases. Results: Complete flap survival noticed in 56 cases (93.3%), defect size ranged from 70 to 200 cm (mean 126.35 ± 33.78). There was no difference between the 2 groups as regarding Flap survival, hospital stay, flap complications, donner site morbidity and vascular insufficiency. There is statistically significant difference between both groups as regarding Ischemia time, Operation time, and overall re-exploration rate. Conclusions: Our study suggests that the use of a single venous anastomosis in the venous drainage of anterolateral thigh free flaps is as safe and feasible as the two veins anastomoses.

Devastating complication of negative pressure wound therapy after deep inferior epigastric perforator free flap surgery:A case report

BACKGROUND Thermal injuries on free transferred or replanted tissues resulting from loss of sensibility are an infrequent occurrence.They require immediate and appropriate management before they progress to an irreversible condition.Although negative pressure wound therapy(NPWT)can prevent wound progression by increasing microcirculation,the inappropriate application of NPWT on complicationthreatened transferred and replanted tissues can induce an adverse effect.CASE SUMMARY A 48-year-old woman who underwent immediate breast reconstruction with a deep inferior epigastric artery perforator free flap.While applying a heating pad directly to the flap site,she sustained a deep second to third-degree contact burn over 30%of the transferred flap on postoperative 7 d.As the necrotic changes had progressed,we applied an NPWT dressing over the burned area after en-bloc debridement of the transferred tissues on postoperative 21 d.After 4 d of NPWT application,the exposed fatty tissues of the flap changed to dry and browncolored necrotic tissues.Upon further debridement,we noted that the wound gradually reached total necrosis with a collapsed vascular pedicle of deep inferior epigastric artery.CONCLUSION Although NPWT has been shown to be successful for treating various wound types,the significant risk of NPWT application in short-lasting reconstructed flap wounds after thermal injury should be reminded.

Summary of the current guidelines for managing iatrogenic colorectal perforations and the evolving role of endoluminal vacuum therapy

Colonoscopy represents a safe procedure that is widely used in medical practice either to diagnose or treat various gastrointestinal diseases.During the last few years,the incidence rate of perforations in colonoscopic procedures has increased,especially in therapeutic colonoscopies.The recent advancements in endoscopic techniques and gastrointestinal tumoral resection procedures such as endoscopic mucosal resection,endoscopic full-thickness resection,and endoscopic submucosal dissection(ESD)could be a risk factor for this increased risk.The incidence rate of mortality of serious colonoscopic perforations is 7.1%.The management plan for these perforations starts with conservative treatment in mild cases,endoscopic closure,and surgical management in severe cases.Recently,endoluminal vacuum therapy was found to be effective in the management of colorectal perforations and this has been reported in multiple case reports.This editorial provides an overview of the current guidelines for the management of iatrogenic colorectal perforations.These insights are from the perspectives of endoscopists and gastroenterologists.We also present a management algorithm based on the guidelines of the European Society of Gastrointestinal Endoscopy,the American Gastroenterological Association,and the World Society of Emergency Surgery.We also discussed in brief the use of endoluminal vacuum therapy in colorectal perforations.

Free Anterolateral Thigh Perforator Flap for Head and Neck Cancer Resection in a Nonagenarian

With an aging population, free flap reconstruction for head and neck cancer ablation in the elderly is becoming more commonplace. In nonagenarians, however, such major operations are still rarely offered due to its physiological demands. We report the first case of successful resection and reconstruction of head and neck cancer with a free perforator flap in a 96 year old patient. We feel that with careful patient and flap selection, careful preoperative workup and close collaboration between treating teams, age alone should not preclude patients from receiving the best possible curative treatment and reconstruction in head and neck cancers. Even in nonagenarians, perforator free flaps, such as the anterolateral thigh flap, can be used safely to achieve good functional and aesthetic outcomes.

Rhomboid Flap vs. Keystone Perforator Island Flap (KPIF) in the Treatment of Pilonidal Sinus Disease: Comparison of Short-Term Results

Background: Pilonidal disease is a chronic inflammatory disease of the sacrococcygeal region that mainly affects young people. Its incidence is 26 cases per 100,000 persons. Although many techniques have been described, there is no consensus on the treatment of pilonidal sinus disease (PSD). Materials and Methods: This study included 30 patients with PSD who were treated between May 2014 and September 2017. All cases underwent excision and flap reconstruction. The operative time, postoperative complications, the length of hospital stay, painless sitting and walking time, patient satisfaction and recurrence were evaluated prospectively. Results: The results of this prospective, randomized and comparative study are based on experience of a single surgical centre. All patients were followed up 18 months after discharge from the hospital. There is a difference in surgery durations (minutes) between the two groups (33.86 ± 2.89 min. in “keystone” flap vs. 41.26 ± 4.19 in the “rhombic” flap group) (p = 0.001). There were no significant differences in the length of hospital stay, painless sitting and walking time or patient satisfaction. The total complication rate was 66.6% after rhomboid flap compared with 6.6% after keystone flap. There was no flap necrosis. Conclusions: Both of these methods have shown to be successful in treatment of PSD. The KPIF is associated with the advantages of very simple design, abundant blood supply from the perforator vessels and lower rate of complication.

Adipo Fascio Cutaneous Perforator Based, Shape Modified Radial Forearm Flap: Vascular Analysis of Perforators &Its Clinical Applications in Head &Neck Reconstruction

Resume of the study & Background: Radial forearm free flap with all its present day modifications is the workhorse of soft tissue reconstruction. Although there are several advantages, it requires sacrifice of a major artery of forearm. Several modifications are described in harvesting a forearm flap. In order to achieve a reliable, safe flap harvest & design one must have a very clear understanding of radial artery perforators, relative to its distribution, territory & flow. The purpose of this study is to determine the location, size & vascular territory of the radial artery cutaneous perforators & to demonstrate application of shape modification of radial forearm free flap based on its distal & proximal perforators in various head & neck defects. Materials & Methods: Anatomical Study: 12 fresh human cadavers & 24 cadaveric forearms were dissected to determine the number, location, size & vascular territory of radial artery perforator. The cutaneous territory of distally dominant perforators was analyzed using methylene blue injections & three-dimensional computed tomographic angiogram to determine the vascular network. Clinical Study: 15 patients with various head neck defects following oncological resections were reconstructed with shape modified adipo-fascio cutaneous free forearm flap. All these patients were prospectively followed for donor site healing, motor & sensory nerve deficit, function & quality of life questioner for donor site assessment. Results: 12 fresh human cadavers & 24 cadaveric forearms were dissected, and a total of 222 perforators were dissected for an average of 18.5 perforators per forearm. 118 were smaller than 0.5 mm in diameter (53.15%) & were not clinically significant. 104 perforators were greater than 0.5 mm in diameter (46.84%) & were clinically significant. 127 perforators (57.20%) were radially distributed & 95 perforators (42.79%) had ulnar distribution. 90 perforators (40.54%) were identified on distal side (Radial styloid) & 132 perforators (59.45%) were identified on proximal side (Lateral epicondyle). Mean number of perforators, on radial side was 10.6 & 7.9 on ulnar side;comparison of both using student t paired test gives a P value of 0.006, which is significant. Comparison of mean number of perforators on the distal side was 7.5 & proximal side was 11.0;Student Paired t test gives a P value of 0.003, which was statistically significant. Comparison of mean diameter of perforators on Distal side (1.11) & Proximal side (0.86), side using Student Paired t test gives a P value of 0.01 which was statistically significant. A chi square test was done to compare mean diameter of perforators on distal side, which was more than 1 mm (80%) & less than 1 mm (20%) & on proximal side more than 1 mm (35.6%) & less than 1 mm (64.4%). Chi square value of 42.406 was obtained, degree of freedom value was 1 & P value of Conclusion: Increase in knowledge of vascular territory of radial artery perforators with regards to numbers, size, location, & cutaneous territory can lead to expanded use of radial forearm flap based on either distal or proximal perforator alone. Shape modified technique for harvesting radial forearm flap allows primary closure of donor site. Donor site is better healed and shows a predicted pattern, which is functionally and aesthetically good.

Application of a jigsaw puzzle flap based on free-style perforator to repair large scalp defects after tumor resection:A case series

Background:Reconstruction of large scalp defects after tumor resection is common and challenging.Free skin grafting or free flap transfer is always performed.However,these techniques can result in poor functional and cosmetic outcomes.Methods:In the Second Affiliated Hospital of Soochow University and the Second Affiliated Hospital of Chengdu Medical College,35 patients underwent jigsaw puzzle flap procedures based on a free-style perforator to repair large scalp defects after tumor resection from May 2013 to November 2022.The key to this procedure was to divide a large defect into several smaller parts that correspond to adjacent free-style perforators around the scalp defect.The free-style perforator flaps were designed in different ways,such as propeller flaps,rotation flaps,and V-Y advancement flaps,which were pedicled with free-style perforators.All of the small flaps were then mobilized to the defect and sutured to each other to create a new,large jigsaw puzzle-like flap to cover the large scalp defect.Finally,all the donor sites were closed directly.Results:Overall,35 patients were treated.The average defect size was 72 cm^(2)(range,25-91 cm^(2)).All flaps had a satisfactory appearance after follow-up periods of 6 months-10 years.Local tumor recurrence occurred in one case.Conclusion:The application of a jigsaw puzzle flap based on a free-style perforator is a suitable option for the reconstruction of large scalp defects after resection,yielding satisfactory functional and cosmetic results.

Surgical Outcomes Following Partial Breast Reconstruction with Chest Wall Perforator Flaps

Introduction: In the last two decades, chest wall perforator flaps (CWPF) have become a versatile tissue replacement technique for partial breast reconstruction following breast-conserving surgery (BCS) in well-selected cases. We present the surgical outcome of 81 patients with chest wall perforator flaps used for breast-conserving surgery. Methods: We recorded the outcomes of three oncoplastic breast surgeons who performed partial breast reconstruction with chest wall perforator flaps from 1st January 2018 to 30th June 2022 at Sherwood Forest Hospitals NHS Foundation Trust. Data were collected on patient demographics, including age, BMI, smoking status, bra size, previous treatments, type of CWPF procedure, tumor size (measured clinically, via imaging and histologically), biopsy results, specimen weight, margins involvement, re-operation rate, surgical site infection (SSI), flap loss, flap shrinkage, hematoma, and seroma rates. Results: A total of 81 patients were included in this study, with an average age of 55.7 years and a body mass index (BMI) of 26.7 kg/m2. The bra size varied between A to FF with A (7.4%), B (28.3%), C (38.2%), D (13.6%), DD (11.1%), and FF (1.2%). 14.8% of the patients had neoadjuvant chemotherapy (NACT). For 45 patients, LICAP (lateral intercostal artery perforator), 16 AICAP (anterior intercostal artery perforator), 13 MICAP (medial intercostal artery perforator), and for seven patients, LTAP (lateral thoracic artery perforator) flaps were used. The average tumor was measured at 15.75 mm clinically, 19.1 mm via imaging, and 19.6 mm histologically. Biopsy showed that 16% of the tumors were ductal carcinoma in situ (DCIS), and 84% were invasive. 16% of patients had involved margins, and re-excision was required in 10 patients, and completion mastectomy was performed in 2 patients. A thirty-day SSI rate was 6.2%, with flap-related complications, including flap loss and shrinkage, at 3.7% and 4.9%, respectively. In addition, 3.7% had a hematoma, and 17.3% had other complications. Conclusion: Partial breast reconstruction with perforator flaps is an excellent volume replacement technique in breast-conserving surgery with acceptable complications in well-selected cases.

Clinical applications of paraumbilical perforator flaps in multiple angiosomes for the reconstruction of the upper limbs

Background:Repair of extensive deep wounds in the forelimb remains challenging for surgeons.The objective of this study was to evaluate the surgical technique and clinical significance of multiple-territory paraumbilical perforator(PUP)flaps in patients with massive soft tissue defects in the upper limbs.Methods:Between January 2017 and September 2021,16 patients(6 women and 10 men)aged 24–54 years(average,41.4 years)who were hospitalized at the First Affiliated Hospital of Soochow University and the North District of the Suzhou Municipal Hospital were investigated.Their injuries included damage to the fingers,dorsal skin of the hands,wrist,or forearm.Their tendons or bones were exposed after debridement.In some patients,multiple-territory PUP flaps that encompassed adjacent angiosomes were transplanted to cover the soft tissue defects.Results:All flaps survived and healed well.After a follow-up of 2–54 months,all patients recovered satisfactorily in terms of characteristic and functional review.Conclusions:The application of PUP flaps,especially those encompassing multiple angiosomes(multiple-territory PUP flaps),can be an optimal reconstruction method for repairing massive soft tissue defects in the forelimb.

Nasolabial perforator flap for nasal defects

Nasal defects can be reconstructed with a nasolabial perforator flap,resulting in good aesthetic outcomes based on the facial subunit principle,owing to the combined advantages of the traditional nasolabial flap and the perforator flap.However,the localization of perforators makes the clinical application of a nasolabial perforator flap difficult.This review aims to provide a comprehensive summary of the nasolabial perforator flap from anatomical,methodological,and clinical application aspects,intending to provide plastic surgeons with a reference on conducting nasal reconstruction with a nasolabial perforator flap.

Application of radial collateral artery perforator flap in severe posterior elbow skin defect

exposed wound of deep tissue behind elbow. Methods From April 2016 to December 2018, 28 patients with posterior elbow skin and soft tissue defect with exposed bone and tendon were treated in our hospital. the radial collateral artery perforator flap was used to repair the wound. There were 19 cases of skin defect with ulna exposure after electric shock injury, 5 cases of hot compression injury and 4 cases of bone exposure caused by skin contusion after traffic accident. Results There is no complication after the operation, all the flaps were survived. The flaps had good quality and satisfactory recovery of appearance and function. Conclusion The lateral upper arm flap designed by perforating branch of radial collateral artery is an effective method for posterior elbow skin and soft tissue defect because of its constant anatomic position and long vascular pedicle.

Repairing small wounds around ankle by medial planta island flaps pedicled with anterior tibial artery perforator in front of inner malleolus

Objective To discuss the application of medial planta island flaps pedicled with anterior tibial artery perforator in front of inner malleolus for repairing small wounds around ankle Methods From Jan. 2005 to Jun. 2009,10 cases with small wounds around ankle

Laparoscopic treatment of perforated appendicitis

The use of laparoscopy has been established in improving perioperative and postoperative outcomes for patients with simple appendicitis. Laparoscopic appendectomy is associated with less wound pain, less wound infection, a shorter hospital stay, and faster overall recovery when compared to the open appendectomy for uncomplicated cases. In the past two decades, the use of laparoscopy for the treatment of perforated appendicitis to take the advantages of minimally invasiveness has increased. This article reviewed the prevalence, approaches, safety disclaimers, perioperative and postoperative outcomes of the laparoscopic appendectomy in the treatment of patients with perforated appendicitis. Special issues including the conversion, interval appendectomy, laparoscopic approach for elderly or obese patient are also discussed to define the role of laparoscopic treatment for patients with perforated appendicitis.

EFFECT OF Z-PINS’ DIAMETER,SPACING AND OVERLAP LENGTH ON CONNECTING PERFORMANCE OF CMC SINGLE LAP JOINT

The effect of through-thickness reinforcement by composite pins （Z-pins） on the static tensile strength and failure mechanisms of the joints made from ceramic matrix composite （CMC） is investigated. Overlap length of the single lap joint is 15 mm, 20 mm, 23 mm, 37 mm, and 60 mm, respectively. The experimental results indicate that the final failure modes of the joints can be divided into two groups, （a） the bond-line stops debonding until crack encounters Z-pins; and then the adherends break at the location of Z-pins, when overlap length is more than 20 mm; （b） the bond-line detaches entirely and Z-pins are drawn from adherends, when overlap length is equal to 15 mm. A simple efficient computational approach is presented for analyzing the benefit of through-thickness pins for restricting failure in the single lap joints. Here, the mechanics problem is simplified by representing the effect of the pins by tractions acting on the fracture surfaces of the cracked bond-line. The tractions are prescribed as functions of the crack displacement, which are available in simple forms that summarize the complex deformations to a reasonable accuracy. The resulting model can be used to track the evolution of complete failure mechanisms, for example, bond-line initial delamination and ultimate failure associated with Z-pin pullout, ultimate failure of the adherends. The paper simulates connecting performance of the single lap joints with different Z-pins＇ diameter, spacing and overlap length; the numerical results agree with the experimental results; the numerical results indicate enlarging diameter and decreasing spacing of Z-pins are in favor of improving the connecting performance of the joints. By numerical analysis method, the critical overlap length that lies between two final failure modes is between 18 mm and 19 mm, when Z-pins＇ diameter and spacing are 0.4 mm, 5 mm, respectively.