查看更多>>摘要：? 2022 Elsevier LtdBackground: Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa. Methods: Seven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates. Results: Ninety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84). Conclusion: This meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care. Review registration: Registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.
查看更多>>摘要：? 2022Background: Microsurgical free tissue transfer is the gold standard for reconstruction of significant soft tissue and bony defects following cancer resection and trauma. Many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources or training required to perform microsurgical procedures. Long-term international collaborations have been formed with annual reconstructive programmes conducting microsurgery. Aims: To critically analyze outcomes of microsurgical free tissue transfer performed on international reconstructive collaborations in LMICs. Methods: PRISMA-compliant systematic review and meta-analysis of outcomes for free tissue transfer performed during international collaborations in LMICs using an inverse variance model. The study protocol was published prospectively and registered with PROSPERO (ID: CRD42021225613). Results: Seven studies, included 290 flaps on 284 patients. The most common sites requiring reconstruction were Head and neck (53% (n = 153)) and lower limb (7.9% (n = 23)) were lower limb reconstruction. The most common free flaps were radial forearm (22%; n = 64) and anterolateral thigh (18%; n = 51). Total Flap Failure rate was 3.8% (n = 13; 95% confidence interval (CI) = 1.9–6.3%) Overall complication rate was 38% (95% CI =27–48%), with 19% of flaps requiring emergency return to theatre (95% CI =14–26%). Flap salvage was successful in 52% of take-backs (95% CI =15% - 88%). Conclusions: Free flaps performed during international surgical collaborations in LMICs have comparable failure rates to those performed in higher-income settings. However, there are higher complication and take-back rates. This should be taken into account when planning international collaborations. These results should help preoperative counselling and the consent process.
查看更多>>摘要：? 2022 British Association of Plastic, Reconstructive and Aesthetic SurgeonsIntroduction: Traditional subfascial harvest of the profunda artery perforator (PAP) flap results in a thick flap, which routinely requires secondary thinning. The aim of this study was to characterize the suprafascial perforator anatomy of PAPs on preoperative computed tomography angiography (CTA) and correlate radiological findings with our clinical experience in extremity reconstruction. Methods: Suprafascial PAP anatomy was reviewed in CTAs in 159 thighs. Findings on CTA were correlated with intraoperative findings in a cohort of patients who had a PAP flap for extremity reconstruction. Results: Two main perforator patterns, a “T” (superficial bifurcation) and “Y” (deeper bifurcation) were identified. The ratio between the total skin thickness and the distance from the skin to the perforator bifurcation point and the total skin thickness was higher in the “T” perforator pattern. A dominant “T” perforator (n = 97) was more common than “Y” (n = 62). A dominant “T” perforator was more common in women and with higher body mass index (BMI). In the clinical study, we found a positive correlation between the skin thickness of the bifurcation point of a dominant “T” perforator and the thickness of the superficial fascia where a thin PAP flap is elevated. Conclusions: A dominant “T” perforator on preoperative CTA accurately predicts thickness of a PAP flap elevated at the level of the superficial fascia.
查看更多>>摘要：? 2022 Elsevier LtdIntroduction: Complex cubital fossa injuries with bony and vascular injuries are not an uncommon clinical presentation after trauma to the elbow. The revascularization of the upper limb by brachial artery repair with the venous graft is paramount, followed by immediate cover with a sturdy flap to salvage the limb. The use of local muscle and fasciocutaneous flaps is limited in the setting of vascular injury. The pedicled latissimus dorsi muscle flap and abdominal flaps are routinely used with few advantages. This article describes the use of a pedicled thoracodorsal artery perforator flap in the management of acute traumatic cubital fossa defect. Material and methods: A retrospective observational study was performed from September 2015 to December 2020 with patients who underwent the pedicled TDAP flap as a soft-tissue cover of cubital fossa injuries primarily. Patient variables, including the size of defect and flap, the number of perforators, the complications, and the outcome, were recorded. Results: Eleven patients were included in the study. The majority of the patients were males (n = 10) and presented with a history of trauma in a road traffic accident (n = 6) or because of a fall from height (n = 4). All of them (n = 11) had some form of bony injury. Seven patients in this group required brachial artery repair with an interposition vein graft successfully covered with a TDAP flap. There was a constant dominant musculocutaneous perforator about 10–13 cm from the apex of the axilla. At discharge, all flaps had settled well. On follow-up ranging from 2 months to 2 years, the patients reported satisfactory outcomes.
查看更多>>摘要：? 2022 British Association of Plastic, Reconstructive and Aesthetic SurgeonsIntroduction: The soleus perforator flap and the peroneal perforator flap could be alternatives to the radial forearm flap for head and neck reconstruction. However, their flap dimensions remain unknown. This study aims to determine the dimensions of both flaps and allow preoperative planning for reconstruction based on clinical parameters. Materials & Methods: Computed tomography records of 296 patients dated from 2009 through 2019 were retrospectively analyzed. Virtual three-dimensional flap models of the soleus perforator flap and peroneal perforator flap were aligned to segmented leg models, and flap thickness and volume were determined. Associations of flap thickness and volume with clinical parameters were evaluated, and a calculation method was derived. Results: The soleus perforator flap had an average thickness of 8.7 mm (4.8 mm) and an average volume of 0.9 cm3 (0.5 cm3) per square centimeter surface area. The peroneal perforator flap had an average thickness of 6.4 mm (3.8 mm) and an average volume of 0.8 cm3 (0.4 cm3) per square centimeter surface area. The soleus perforator flap was thicker and more voluminous than the peroneal perforator flap (both p<0.001). For both flaps, leg circumference was the strongest predictor of flap thickness (?=0.524, p<0.001 and ?=0.700, p<0.001, respectively) and flap volume (?=0.535, p<0.001 and ?=0.712, p<0.001, respectively). Conclusion: Dimensions of the soleus perforator and the peroneal perforator flaps are similar to those of the radial forearm flap. Preoperative planning of flap dimensions, such as flap thickness and volume, can help the surgeons select the appropriate flap.
查看更多>>摘要：? 2022 Elsevier LtdBackground: Delays to postoperative radiotherapy (PORT) are frequent and associated with poorer oncologic outcomes in head and neck cancer (HNC) patients. Free flap patients have been suggested as the most at-risk group. Thus, PORT delivery experienced by HNC patients who required a free flap reconstruction was analysed, identifying reasons for the delays if any. Methods: A retrospective analysis of a single tertiary unit's PORT delivery to HNC patients undergoing major resection followed by free flap reconstruction between 2017 and 2020. Results: Eighty-seven patients were identified. Thirty-two patients received PORT within 6 weeks of their surgery date. Reasons for the delays could be categorised into surgery-derived, system-derived and patient-derived reasons. Five patients (5.74%) received PORT >6 weeks after their surgery due to surgical complications. No patients experienced surgical complications during their PORT. Conclusion: In our experience, surgical aspects of free flap reconstructions do not appear to overtly delay or interrupt PORT.
查看更多>>摘要：? 2022 Elsevier LtdBackground: Muscle-sparing vertical rectus abdominis myocutaneous (MS-VRAM) flaps are widely used in pelvic reconstruction. Aiming at optimal reconstructive outcomes, flap design and modification should be individualized to restore various kinds of defects. Objective: Summarize an empirical strategy about MS-VRAM selection for different pelvic and perineal reconstructions. Methods: Thirty patients who underwent total pelvic exenteration and pelvic reconstruction surgery from 2009 to 2017 were enrolled. The patients were divided into four groups according to the type of MS-VRAM-based flap used in the procedure: the modified long vertical flap (n = 10), the wrapping flap (n = 6), the de-epithelialized flap (n = 6), and the cork flap (n = 8). The follow-up period was 1 year after the surgery. Flap size, drainage volume, postoperative satisfaction, and complications were recorded, and postoperative photographs were collected. Results: All of the patients achieved satisfying effect under the targeted reconstruction strategy. Of the four groups, the accurate cork flap finally acquires higher satisfaction, the shortest hospital stay, and the least total drainage volume. Meanwhile, the incidence of complications was not increased compared with the other groups. Conclusions: A new reconstructive strategy for pelvic reconstruction was established. Functional or non-functional reconstruction was accomplished by using various MS-VRAM flaps. Among them, the cork flap is the most economical flap to reconstruct pelvic floor defects with minimal tissue requirement and donor trauma.
查看更多>>摘要：? 2022 Elsevier LtdBackground: Clinical outcome data in the United Kingdom, Europe, and the United States have yet to facilitate appropriately specific surveillance for liposarcoma histological subtypes, despite being one of the most common soft tissue sarcomas. Therefore, this study aims to demonstrate histologic-specific differences in liposarcoma recurrence, disease progression, and survival and discuss the implications. Methods and findings: This cohort study involves patients from a regional sarcoma service in the UK who have had a primary surgical excision of liposarcoma between October 2002 and September 2019. The median follow-up is five years. Confirmed histopathological diagnoses of liposarcoma (n = 193) are organised according to the World Health Organisation recognised subtypes: atypical lipomatous tumours (ALT), myxoid, pleomorphic, and dedifferentiated liposarcomas. In addition, retroperitoneal variants (n = 34) are included to illustrate the broader spectrum of phenotypes. The primary outcomes were local recurrence, distant disease progression, and disease-specific death, and compared using Kaplan–Meier analyses and tumour variables using Cox proportional hazard analyses. All three primary outcomes significantly differed (P < 0.0001, n = 193). There were no metastases or disease-specific death in patients with ALT (n = 92) and no metastases of their retroperitoneal counterparts (n = 17). Amongst the metastasising cases of rarer subtypes, there were pulmonary spread of pleomorphic (8/9, n = 20), dedifferentiated (4/5, n = 18), and myxoid (2/3, n = 29) liposarcomas. Conclusion: An absence of metastases of ALT should be considered alongside global evidence. Surveillance protocols could better differentiate between these subtypes and, in doing so, save patients a considerable amount of irradiation, time, fear, and anxiety.
查看更多>>摘要：? 2022Background: We describe the first clinical series of a novel bone replacement technique based on regenerative matching axial vascularisation (RMAV). This was used in four cases: a tibial defect after treatment of osteomyelitis; a calvarial defect after trauma and failed titanium cranioplasty; a paediatric tibial defect after neoadjuvant chemotherapy and resection of Ewing sarcoma; and a paediatric mandibular deficiency resulting from congenital hemifacial microsomia. Method: All patients underwent reconstruction with three-dimensional (3D)-printed medical-grade polycaprolactone and tricalcium phosphate (mPCL-TCP) scaffolds wrapped in vascularised free corticoperiosteal flaps. Outcome: Functional volumes of load-sharing regenerate bone have formed in all cases after a moderate duration of follow-up. At 36 cm, case 1 remains the longest segment of load bearing bone ever successfully reconstructed. This technique offers an alternative to existing methods of large volume bone defect reconstruction that may be safe, reliable, and give predictable outcomes in challenging situations. It achieves this by using a bioresorbable scaffold to support and direct the growth of regenerate bone, driven by RMAV. Conclusion: This technique may facilitate the reconstruction of bone defects previously thought unreconstructable, reduce the risk of long-term implant-related complications and achieve these outcomes in a hostile environment. These potential benefits must now be formally tested in prospective clinical trials.
查看更多>>摘要：? 2022 British Association of Plastic, Reconstructive and Aesthetic SurgeonsBackground: Massive bone allograft with an intramedullary vascularized fibula (Capanna technique) represents one of the most widely used methods for the reconstruction of massive bone defect. However, the mechanisms, healing process, and underlying influential factors were poorly understood due to the lack of suitable experimental animal models. Methods: Critical-sized defects (CSD) in bone were constructed in the proximal tibia of 24 rabbits and randomly divided into two groups. Allogeneic bone segments of the same size as CSDs were obtained from another 12 rabbits and then inactivated. In group Ⅰ, an ipsilateral pedicled vascularized fibula was dissociated and transferred into the intramedullary cavity of allograft to assemble a composite for CSD reconstruction (Capanna technique), while group Ⅱ received a reconstruction with allogeneic bone alone. Radiographic evaluation was performed every week after the operation to assess union status. All animals were sacrificed at 16th week, and the specimens were histologically analyzed. Results: All animals survived without severe intraoperative complications. There was one rabbit (8.33%) in group Ⅰ developed a postoperative infection and died, while three rabbits (25%) had postoperative complications in group Ⅱ (two died of infection and one died of internal fixation fracture). Radiographically, the mean time to union at the allograft-host junction in group Ⅰ was 12.8 ± 1.80 weeks, significantly shorter than in group II (>15.18±1.12 weeks; p<0.001). The grade of graft union of group Ⅰ was significantly higher than that of group Ⅱ both at 8th and 16th week (8th week: p = 0.035; 16th week: p = 0.033). Fully bone union at the junctions was histologically confirmed in all specimens in group Ⅰ and 66.67% (8/12) in group Ⅱ. Conclusion: Combined allograft and intramedullary vascularized fibula transfer in rabbit's tibia represent an ideal model that accurately simulates the Capanna technique for CSD reconstruction.
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