Microsurgery
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Free flap reconstruction after lower extremity trauma remains challenging with various factors affecting overall success. Increasing defect and flap size have been demonstrated to be a surrogate for overall injury severity and correlated with complications. In addition, larger free flaps that encompass more tissue theoretically possess high metabolic demand, and may be more susceptible to ischemic insult. Therefore, the purpose of our study was to determine how flap size affects microsurgical outcomes in the setting of lower extremity trauma reconstruction. ⋯ Increasing flap size is independently predictive of flap complications. In particular, a flap size cutoff value of 250 cm2 was associated with significantly increased flap failure and complications particularly among muscle-based flaps. Therefore, we suggest that fasciocutaneous flaps be utilized for injuries requiring large surface area of soft tissue reconstruction.
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Case Reports
Lower medial thigh perforator (LMTP) propeller flap for reconstruction of soft tissue defects around the knee.
Skin and soft-tissue defects around the knee are common and their reconstruction is still challenging and argued. Thin, pliable and well-vascularized tissues are required in order to restore the aesthetic appearance of the knee and facilitate joint function. Historically local muscle flaps were employed for the upper third of the lower limb reconstruction; however, since their introduction, different perforator flaps have been proposed for this purpose. The aim of this report is to share our clinical experience with the pedicled lower medial thigh perforator (p-LMT) flap for the reconstruction of skin and soft tissue defects around the knee. ⋯ Fasciocutaneous flaps are currently the first reconstructive option for the soft tissue defects around the knee. The p-LMT flap reconstruction in this case series achieved good aesthetic and functional outcomes and this flap may be a valuable option for the reconstruction of the small to medium soft tissue defects around the knee.
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Despite the common use of intraoperative vasopressors in hand microsurgery, the association between intraoperative vasopressor use and digital replant failure has not yet been examined. Our study aims to examine the association between intraoperative vasopressor use (phenylephrine and/or ephedrine) and postoperative digital failure of replanted or revascularized digits. ⋯ The use of vasopressors was not associated with failure if administration of vasopressors was before tourniquet deflation. The administration of vasopressors after tourniquet deflation should be cautioned.
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Large upper medial thigh defects in prior irradiated tissue require challenging reconstructions. Several techniques have been reported to reconstruct this region and according to the literature, pedicled perforator flaps are the first reconstructive option. The anterolateral thigh flap is considered the gold standard, while surprisingly the pedicle deep inferior epigastric (DIEP) flap in vertical fashion has not been frequently employed, if compared with its muscular counterpart, the pedicle vertical rectus abdomins flap (vRAM). ⋯ The s-vDIEP had 2 islands: a cranial de-epithelialized island to fill the dead space and a caudal for the skin closure. The postoperative follow-up was complicated by seroma formation and it was managed by sclerotherapy and at the 6 months follow-up the patient showed good cosmetic and functional outcomes with no sign of tumor relapse. Our result suggests that the proposed multilayered reconstruction may be employed for the restoration of large and deep upper medial thigh defects.
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Elbow flexion deficit is a frequent problem in traumatic brachial plexus injuries and reestablishment of this function is the primary treatment goal. When management is delayed, or the initial acute approach fails, free functional transfer of the gracilis muscle for elbow flexion is the treatment of choice. In this report, the authors present the results of a comparison study on different donor nerves (spinal accessory and ulnar) in elbow flexion reconstruction with gracilis flap for traumatic adult brachial plexus injuries. ⋯ No statistical difference for final muscle strength was found between donor nerve groups.