urgical reconstruction of soft-tissue defects in the knee, popliteal fossa, and upper lower leg area is a challenging task. One has to not only restore an aesthetic appearance but also enable proper function. Because of the limited availability and mobility of the adjacent skin, defects involving these areas often require complex reconstruction procedures.Many techniques, such as skin grafting, local skin flaps, pedicled muscle flaps, and free flaps, have already been described for the reconstruction of these regions; however, these regions should optimally be repaired using thin and pliable flaps. Based on basic plastic surgery principles to replace "like with like" with minimal donor-site morbidity and without sacrificing a major vessel, perforator flaps designed from the medial calf area represent a viable option. In particular, the medial sural artery perforator flap, which is harvested from this region, is therefore ideal for the
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Consecutive or simultaneous contralateral breast reduction is a frequent request from patients undergoing unilateral breast reconstruction. Both procedures can be combined using otherwise discarded tissue as a split breast graft for reconstruction of the contralateral side. There have been few reports on the use of pedicled split breast grafts. We present a 75‐year‐old female with multicentric mammary carcinoma following chemotherapy, mastectomy, axillary lymph node dissection and radiotherapy. She requested a reconstruction of the left breast as well as reduction of the right breast. Risk factors, including heavy alcohol and tobacco dependence and COPD, limited the surgical options. While a free flap breast reconstruction was the standard feasible option, we opted for a procedure with minimal surgery‐related morbidity. The right breast was evidently tumor‐free, and the patient had no family history of breast cancer. Reconstruction was performed 22 months postmastectomy. The split‐breast free flap was based on the right internal mammary artery (IMA) perforator and harvested during the right‐sided breast reduction. Microsurgical anastomosis was performed on the IMA perforator on the left side. Mastopexy was performed on the right side and the nipple‐areola complex (NAC) was transferred to its new position as a free graft to complete the breast reduction. A tattoo of the left NAC was performed 4 months postreconstruction. There was complete flap survival with a pleasant cosmetic result. Split breast reconstruction could be an alternative to more common procedures. However, this approach is only feasible in patients with hypertrophic contralateral breast and absence of risk factors for developing a second primary breast cancer.
This work has been presented at scientific meetings: ESPRAS Congress, Limassol, 2018 (oral presentation) and BAPRAS Winter scientific meeting, London 2018 (oral presentation). The Systematic Review was performed according to a pre-developed protocol which underwent peerreview and was published open-access in Systematic Reviews.
BackgroundA patent microvascular anastomosis is of paramount importance in free tissue transfer. Anastomotic coupler devices provide an alternative to technically demanding hand-sewn venous anastomosis. Various advantages of these devices have been discussed but previous systematic reviews had methodological flaws or did not perform a meta-analysis. This review aims to evaluate the quality of the evidence and quantify the efficacy and safety of venous couplers compared to hand-sewn anastomosis.MethodsA PRISMA-compliant systematic review and meta-analysis will be performed. A comprehensive search strategy has been developed and will be applied to the databases MEDLINE and Embase from inception to October 2018. All clinical studies using anastomotic coupler devices for venous anastomoses in free tissue transfer will be eligible for inclusion. Screening of studies and data extraction will be performed independently by two authors. Our primary outcome is anastomotic venous thrombosis. Secondary outcomes will include time to complete the venous anastomosis, tearing of veins, anastomotic leakage, flap loss/failure and fiscal outcomes. The risk of bias for included studies will be assessed by using the ROBINS-I tool, and recommendations based on the evidence will be made using the GRADE approach. Descriptive statistical analyses will be used and if two or more studies report the same outcome, data will be pooled for comparative analysis. A direct comparison meta-analysis will be performed if possible.DiscussionThere has been no comparison of coupled and hand-sewn venous anastomoses using a robust and validated methodology preceded by a protocol and performing meta-analysis. Included studies are expected to be mainly observational and prone to bias; however, there is value in summarising the evidence, assessing its risk of bias and performing meta-analysis to guide clinicians. By using a broad approach including all types of flaps, we foresee inherent differences regarding the unit of analysis and different anatomic sites. This will limit the validity of our conclusions but is unavoidable. We will seek unpublished data from authors and perform subgroup analysis where appropriate. Limitations and areas of uncertainty will be discussed to guide future research.Systematic review registrationPROSPERO CRD42018110111
Diabetic foot ulcers (DFUs) occur in up to 25% of patients with diabetes mellitus. 1 These complex, chronic wounds are associated with increased patient morbidity 2 and decreased health-related quality of life. 3 Approximately 15% of DFUs result in lower extremity amputations, 4 and the presence of foot ulceration is an independent predictor of excess all-cause mortality among patients with diabetes. 5 Despite the global burden of DFU and its adverse sequelae, 6 outcomes following standard wound care (SWC) measures remain suboptimal. 7 As a result, a number of novel interventions and treatment approaches have been trialed with varying success. 8 One particularly promising strategy is based on the use of tissue engineered advanced wound therapy products. Cellular advanced wound therapies may be broadly categorized into either "living" skin substitutes (containing theoretically viable cells) or placental membrane allografts (containing theoretically viable or nonviable cells). Separately, both bioengineered skin substitutes 9 and human placental membrane products 2,10 have been shown to improve DFU wound healing outcomes. However, it is unclear which tissue engineered approach is superior and, as yet, there has been no comparative evaluation of the available evidence. Furthermore, previous studies of bioengineered skin substitutes in the context of DFU made no
This is a case report of a 64‐year‐old male with cancer with an unknown primary and bilateral cervical lymph node metastases. Twelve months after chemo‐, radio‐, immunotherapy, and radical neck dissection, he presented with recurrent cervical metastases. The patient underwent radical revision neck dissection including the deep neck muscles of the cervical plexus and reconstruction with a free anterolateral thigh flap. During tumor resection, parts of the thoracic duct were removed which resulted in a large lymph leak. This was addressed by creating a lymphovenous anastomosis to a branch of the subclavian vein. The flow of lymph was reinstated, and no leak has been observed up to a recent 6‐month follow‐up.
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