The large full-thickness abdominal wall defect has to be treated by considering anatomical and functional requirements. The abdominal wall must regain total physiological function, which means that ...the full thickness abdominal wall defect must be reconstructed anatomically, not only according to the anatomical requirements but also maintaining the functional dynamic voluntary movement. Defects in the abdominal wall alter respiratory mechanics and can impair the diaphragm function. Additionally, muscles of the anterolateral abdominal wall increase the stability of the lumbar region of the vertebral column by tensing the thoracolumbar fascia and by increasing intraabdominal pressure.
The timing and method of reconstruction must be chosen depending upon the etiology of the defect. Severe traumatic injuries, abdominal wall infections, necrotizing soft tissue loss, or sepsis needs to undergo staged reconstruction following adequate debridement to control the infectious process, establish the zone of injury, and for proper treatment of intraabdominal pathology, thereby achieving temporary primary closure using split-thickness skin grafting to the viscera. At the time of definitive reconstruction, deep skin graft dermabrasion give us a facial-like layer with adequate strength to stabilize the static abdominal wall. This dermal layer is supported by free functional (innervated) latissimus dorsi muscle (fLDM), giving full anatomical coverage and functional stability. After oncologic resections full-thickness abdominal wall reconstruction was performed immediately with a combination of fLDM flaps and meshes.
A total of 14 patients underwent abdominal wall reconstruction using the fLDM flap. Staged reconstruction was applied in 8 cases. In the remaining six cases, two had no mesh support, three had synthetic mesh, and one had a fascial graft, which were covered with fLDM flap. There were no free flaps failure. One flap revision due to venous anastomosis thrombosis was performed. Donor site seromas occurred in 5 cases and were treated with punction and direct doxycycline injection. Electromyographic testing postoperatively confirmed reinnervation of transplanted LDM.
Using fLDM as a definitive solution, we are not only able to repair soft tissue defects, but also reconstruct voluntary contractility and dynamic natural functional abdominal wall. Transplanted LDM offers enough contractile capacity and strength to replace the function of the missing abdominal wall muscles.
Abstract Introduction Free tissue transfers are a highly reliable procedure routinely performed for reconstruction of a wide range of defects. Main complication in free flap surgery is usually venous ...thrombosis. Many technical controversies exist regarding the technical details of the microvascular anastomosis in order to prevent occurrence of thrombosis and optimize outcomes. We therefore evaluated our results regarding the execution of one versus two venous anastomoses in a variety of free flaps (fasciocutaneous- or muscle free flap) utilized for lower limb reconstruction. Patients and methods Between 2009 and 2015, 354 patients underwent 386 free ALT- or gracilis flaps for lower limb defect reconstruction after trauma, infection, or malignancies at our institution. The data was retrospectively screened for patients’ demographics, perioperative details, flap survival, and surgical complications. The cases were divided into two groups regarding the number of microsurgically performed venous anastomosis: one versus two veins. Results Regarding the preoperative evaluation, there were no significant differences regarding comorbidities between the two groups. Overall, there was no significant difference regarding the rate of major (1 vein: 20.38% versus 2 veins: 18.78%, p > 0.05) and minor (1 vein: 1.27% versus 2 veins: 2.18%, p > 0.05) surgical complications during our 3-months follow-up period. Major complications included total flap losses of 5.73% (1 vein) versus 8.78% (2 veins). Conclusion This study analyzed a large series of microsurgical reconstructions, with a focus on the impact of the number of venous anastomosis. The findings suggest that successful free tissue transfer for lower limb reconstruction can be achieved independent of the number of venous anastomoses, however two should be performed when technically feasible.
Conceptually, premature initiation of post-wound angiogenesis could interfere with hemostasis, as it relies on fibrinolysis. The mechanisms facilitating orchestration of these events remain poorly ...understood, however, likely due to limitations in discerning the individual contribution of cells and extracellular matrix. Here, we designed an in vitro Hemostatic-Components-Model (HCM) to investigate the role of the fibrin matrix as protein factor-carrier, independent of its cell-scaffold function. After characterizing the proteomic profile of HCM-harvested matrix releasates, we demonstrate that the key pro-/anti-angiogenic factors, VEGF and PF4, are differentially bound by the matrix. Changing matrix fibrin mass consequently alters the balance of releasate factor concentrations, with differential effects on basic endothelial cell (EC) behaviors. While increasing mass, and releasate VEGF levels, promoted EC chemotactic migration, it progressively inhibited tube formation, a response that was dependent on PF4. These results indicate that the clot's matrix component initially serves as biochemical anti-angiogenic barrier, suggesting that post-hemostatic angiogenesis follows fibrinolysis-mediated angiogenic disinhibition. Beyond their significance towards understanding the spatiotemporal regulation of wound healing, our findings could inform the study of other pathophysiological processes in which coagulation and angiogenesis are prominent features, such as cardiovascular and malignant disease.
The vascular territory of the superficial inferior epigastric artery (SIEA) remains to be clarified. The SIEA flap has traditionally been classified as a hemiabdominal flap, but recent evidence ...points to the fact that a sizable superficial artery is capable of supplying the entire abdominal ellipse.
Twenty-five patients who met the anatomical criteria for undergoing SIEA flap surgery were studied. The abdominal flap was raised on a superficial inferior epigastric pedicle; the dominant musculocutaneous perforators were preserved and clamped above the abdominal fascia on either side. The vascular territory of the superficial epigastric artery and the contribution of the deep epigastric system were visualized using laser-induced fluorescence of indocyanine green. The surgical technique was modified (SIEA, deep inferior epigastric perforator, or bipedicle) based on perfusion measurements and the indication for surgery.
The SIEA vascular territory did not cross the midline in 16 patients (64 percent), and ranged from 0 percent (two patients) to the entire abdominal ellipse (five cases). Fourteen patients (56 percent) were operated on with a unipedicle SIEA flap, five patients (20 percent) were operated on with a bipedicle flap, and in six (24 percent), a conventional deep inferior epigastric perforator flap was used. As a SIEA flap was originally intended in all patients, intraoperative perfusion measurements changed the surgical plan in 11 patients (44 percent).
The SIEA angiosome is variable and ranges from 0 to 100 percent of the lower abdominal flap. Intraoperative perfusion measurements are indispensable for evaluating the sufficiency of this pedicle for tissue transfer, especially if the contralateral flap zones are needed for reconstruction.
When treating burn injuries, to date, there still remains significant disagreement whether presence of hypothermia (HT) on burn centers' intensive care unit (BICU) admission improves or worsens ...outcomes. The presented single burn center experiences set out to further evaluate the incidence, cause, and potential effects of HT on outcomes in severely burned patients. Between January 2015 and February 2017, 142 severely burned patients were admitted to a BICU. Temperature at BICU admission of <36.0°C was defined as HT and ≥36.0°C as normothermia (NT). The cases were divided into two groups: HT vs NT. Fifty-four patients met inclusion criteria and were analyzed retrospectively regarding encountered complications, time of hospitalization, and overall survival. The overall incidence of HT on arrival was 62.9%. Mean duration from burn accident to BICU admission did not differ significantly, but the groups showed significant differences regarding total body surface area (TBSA; P < .05). Both groups showed a similar distribution, regarding number of surgeries, duration until first burn excision, length of ventilation, and mortality rate of patients (P > .05). However, time until death was significantly shorter in the HT group. HT at admission remains a common problem following burn injury. Main risk factors include inappropriate temperature management after injury and during transport, extent of TBSA burn, and quantity of resuscitation. Given the high incidence, the involved health care and, especially, also prehospital providers should be further educated about existing recommendations and guidelines to prevent HT.
Bladder acontractility affects several thousand patients in the United States, but the available therapies are limited. Latissimus dorsi detrusor myoplasty (LDDM) is a therapeutic option that allows ...patients with bladder acontractility to void voluntarily. Our goal was to conduct a systematic review of the literature to determine whether LDDM is a better option than clean intermittent catheterization (CIC) (standard treatment) in patients with bladder acontractility. On January 17, 2020, we conducted a systematic review of the PubMed/MEDLINE, Cochrane Clinical Answers, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov databases, without time frame limitations, to identify articles on the use of LDDM for bladder acontractility. Of 75 potential articles, 4 fulfilled the eligibility criteria. The use of LDDM to treat patients with bladder acontractility was reported in four case series by the same group in Europe. Fifty-eight patients were included, and no comparison groups were included. The most common cause of bladder acontractility was spinal cord injury (n=36). The mean (±standard deviation) operative time was 536 (±22) minutes, postoperative length of hospital stay ranged from 10 to 13 days, and follow-up ranged from 9 to 68 months. Most patients had complete response, were able to void voluntarily, and had post-void residual volume less than 100 mL. Although promising outcomes have been obtained, evidence is still weak regarding whether LDDM is better than CIC to avoid impairment of the urinary tract among patients with bladder acontractility. Further prospective studies with control groups are necessary.
The gracilis muscle flap is a popular choice in reconstructive surgery to repair soft tissue defects or for functional restoration. Little is known on the influence of postoperative application of ...VAC (vacuum-assisted closure; Kinetic Concepts Inc., San Antonio, Tex.) therapy on perfusion and postoperative flap edema of free gracilis muscle flaps.
In total, 26 patients with soft tissue defects of lower extremity underwent gracilis muscle flap reconstruction. The study group (VAC, n = 13) was supplied with postoperative negative pressure therapy as a dressing; the control group (NVAC, n = 13) was supplied with conventional fat gauze dressing. Postoperative measurements of micro- and macroperfusion were performed intraoperatively, on postoperative day (POD) 3 and POD 5. Flap edema measurement was performed intraoperatively, on POD 5 and 2 weeks after operation.
The VAC group showed significantly better macroflow during intraoperative VAC treatment, as well on POD 3 and POD 5. Venous outflow was also better with lower hemoglobin levels. Microflow was better in the NVAC group with higher measured oxygen levels. All gracilis muscle flaps of the VAC group showed significantly less flap edema compared with the control group.
VAC application on free gracilis muscle flaps leads to significantly less postoperative flap edema, improved arterial macroflow, and improved venous outflow. VAC therapy can be used without any danger for patient's safety, as flap survival is not endangered, and presents an easy to handle and pleasant dressing regimen for nursing staff and patients.
Blood-derived growth factor preparations have long been employed to improve perfusion and aid tissue repair. Among these, platelet-rich plasma (PRP)-based therapies have seen the widest application, ...albeit with mixed clinical results to date. Hypoxia-preconditioned blood products present an alternative to PRP, by comprising the complete wound healing factor-cascade, i.e., hypoxia-induced peripheral blood cell signaling, in addition to platelet-derived factors. This study set out to characterize the preparation of hypoxia preconditioned serum (HPS), and assess the utility of HPS-fibrin hydrogels as vehicles for controlled factor delivery. Our findings demonstrate the positive influence of hypoxic incubation on HPS angiogenic potential, and the individual variability of HPS angiogenic factor concentration. HPS-fibrin hydrogels can rapidly retain HPS factor proteins and gradually release them over time, while both functions appear to depend on the fibrin matrix mass. This offers a means of controlling factor retention/release, through adjustment of HPS fibrinogen concentration, thus allowing modulation of cellular angiogenic responses in a growth factor dose-dependent manner. This study provides the first evidence that HPS-fibrin hydrogels could constitute a new generation of autologous/bioactive injectable compositions that provide biochemical and biomaterial signals analogous to those mediating physiological wound healing. This therefore establishes a rational foundation for their application towards biomimetic tissue regeneration.
An original surgical technique for the correction of drop foot is demonstrated.
Eighteen patients with drop foot underwent transfer of the lateral, medial, or both heads of the gastrocnemius muscle ...to the tendons of the anterior and/or lateral muscle group of the lower leg. The transferred muscle was reinnervated by nerve coaptation between the undamaged proximal part of the deep peroneal nerve and the motor branch of the tibial nerve supplying the gastrocnemius muscle.
In all patients, the transferred gastrocnemius muscle showed signs of reinnervation within an average of 6 months after operation. Ten patients achieved excellent results, having regained stable, fully automatic walking without foot inversion/eversion and active range of foot movement of at least 40 degrees. Four patients achieved good results with active range of movement of less than 40 degrees but very stable functional gait. Satisfactory results were presented in three cases with stable ankle motion. Two of three cases had dual transfer of the gastrocnemius muscle and had a very stable ankle joint. In one fair case, the treatment improved stability and the patient was able to walk.
To compensate for the loss of function of the anterior muscle compartment, neuromusculotendinous transfer of the gastrocnemius muscle has proved to be highly successful. Voluntary movement of the transferred muscle and fully automatic walking was achieved in the majority of patients treated. In contrast to the commonly used treatment of tibialis posterior muscle transfer, no reeducation of the transferred muscle was needed.
The main goal of reconstructive microsurgery must be an optimal functional and esthetic reconstruction meeting the individual trauma site requirements with minimal donor site morbidity. The authors ...discuss new microsurgical options for extremity salvage: indications for reconstruction versus amputation, timing of free tissue transfer, reconstruction of soft tissue and bone, and functional muscle transfer. They discuss indications and contraindications for these procedures, along with emphasizing the important points of each.
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