Use of the cross-leg distally based sural artery flap for the reconstruction of complex lower extremity defects

Cross-leg flaps are a useful reconstructive option for complex lower limb defects when free flaps cannot be performed owing to vessel damage. We describe the use of the extended distally based sural artery flap in a cross-leg fashion for lower extremity coverage in three patients. To maximise the viability of these extended flaps, a delay was performed by raising them in a bipedicled fashion before gradual division of the tip over 5 to 7 days for cross-leg transfer. Rigid coupling of the lower limbs with external fixators was critical in preventing flap avulsion and to promote neovascular takeover. The pedicle was gradually divided over the ensuing 7 to 14 days before full flap inset and removal of the external fixators. In all three patients, the flaps survived with no complications and successful coverage of the critical defect was achieved. One patient developed a grade 2 pressure injury on his heel that resolved with conservative dressings. The donor sites and external fixator pin wounds healed well, with no functional morbidity. The cross-leg extended distally based sural artery flap is a reliable reconstructive option in challenging scenarios. Adequate flap delay, manoeuvres to reduce congestion, and postoperative rigid immobilization are key to a successful outcome

Gracilis pull-through flap for the repair of a recalcitrant recto-vaginal fistula

Recto-vaginal fistulas are difficult to treat due to their high recurrence rate. Currently, no single surgical intervention is universally regarded as the best treatment option for rectovaginal fistulas. We present a case of recurrent recto-vaginal fistula surgically treated with a gracilis pull-through flap. The surgical goals in this patient were complete excision of the recto-vaginal fistula and introduction of fresh, vascularized muscle to seal the fistula. A defunctioning colostomy was performed 1 month prior to the present procedure. The gracilis muscle and tendon were mobilized, pulled through the freshened recto-vaginal fistula, passed through the anus, and anchored externally. Excess muscle and tendon were trimmed 1 week after the procedure. Follow-up at 4 weeks demonstrated complete mucosal coverage over an intact gracilis muscle, and no leakage. At 8 weeks post-procedure, the patient resumed sexual intercourse with no dyspareunia. At 6 months post-procedure, her stoma was closed. The patient reported transient fecal staining of her vagina after stoma reversal, which resolved with conservative treatment. The fistula had not recurred at 20 months post-procedure. The gracilis pull-through flap is a reliable technique for a scarred vagina with an attenuated rectovaginal septum. It can function as a well-vascularized tissue plug to promote healing

A modified technique of percutaneous subclavian venous catheterization in the oedematous burned patient

Abstract Infraclavicular subclavian venepuncture in the oedematous burned patient is often difficult because of increased depth of the vein. In addition, proper patient positioning is not easily achieved because of extensive burns, generalised oedema and bulky dressings. To overcome these difficulties, a modified technique of infraclavicular subclavian venepuncture has been developed. The introducer needle is bent to create a mild curvature. It is inserted at a point 1-2 cm inferior to the palpable lower border of the clavicle along the junction of the middle and medial thirds of the bone, advanced along the deep surface of the clavicle and directed at the superior border of the suprasternal notch. This medial point of insertion shortens the distance of access to the subclavian vein. The curve allows the tip to be kept close to the undersurface of the clavicle as the needle is advanced, thereby reducing the risk of injury to deep structures. The advantages of the modified technique are demonstrated in anatomical dissections. This technique is a viable alternative when conventional techniques fail.

Precise breast implant placement using percutaneous chest wall markings

Background: Traditionally, pre-operative breast markings are usually made using an indelible marker. These markings are at risk of being removed by pre-operative cleaning, positional changes and parenchymal changes post-incision. We present our approach to breast surgery with rib or intercostal markings using methylene blue. Methods: Using an indelible marker, markings are made on the breast and the inframammary crease. A blue needle (23 G) mounted on a 1 ml syringe is prepared, and aliquots of 0.1 ml of methylene blue are injected. Excessive infiltration and pre-operative local anaesthetic infiltration result in diffusion of the dye and difficulty with accuracy. Dye is injected directly over the bony periosteum closest to the inframammary fold. Results: We achieved good symmetry of bilateral breast implants. Photographs were taken pre-operative and 3 months post-operative and were evaluated independently by medical officers. All results were rated as good or very good. We had 39 patients and follow-up was between 3 and 24 months. There were no implant-related complications. Conclusions: For accurate implant placement, a fixed position must be found. Our technique utilises the relative immobility of the ribs for accurate implant placement. Disadvantages to our method were few, and we had two cases of dizziness or patients feeling faint due to pain. There is also a potential allergic or anaphylaxis reaction, but we did not experience any allergic reaction

The “Nipple-Licus”: the Everted Umbilicus for Immediate Nipple Reconstruction in Mid-Abdominal Transverse Rectus Abdominis Myocutaneous Breast Reconstruction

In this paper, we present a technique for immediate nipple reconstruction in two patients who underwent ipsilateral mid-abdominal transverse rectus abdominis myocutaneous breast reconstruction. The umbilical stalk and surrounding skin were included in the harvested flap. The flap was transferred and inset placing the umbilicus in the ideal nipple position. The umbilicus was then everted with traction, and its height was maintained with cerclage suturing, dermal grafts, and horizontal-to-vertical skin closure. This “nipple-licus” achieves immediate nipple reconstruction without a need for a second surgery or an additional donor site

Innervation of the Temporalis Muscle: Anatomical Study and Clinical Implications in Smile Reconstruction Techniques

Objectives: The temporalis muscle flap is regaining popularity for facial reanimation since recent modifications have improved its efficacy as a single-stage technique. Nevertheless, in all these procedures, the deep temporal nerve innervating the muscle is not visualized. Thus, the purpose of this anatomical study is to track the deep temporal nerve's course and provide a visual guide of it. Methods: Eighteen hemifacial cadaveric specimens were dissected to trace the deep temporal nerve's course from its origin to its entry point in the temporalis muscle. This was performed without disturbing the native course of the deep temporal nerve in relation to the undetached temporalis muscle. Multiple craniofacial osteotomies were performed for exposure while maintaining the spatial relationship of the deep temporal nerve to the muscle. Results: In 14 specimens (78%), the deep temporal nerve arose from the mandibular nerve. In four specimens (22%), it originated from the maxillary nerve. The deep temporal nerve was approximately 1.7 cm in length from its origin to its point of entry into the muscle. It entered at an average of 0.91 cm directly above the tip of the coronoid process. Conclusions: With respect to mobilizing temporalis muscle flap, the high origin of the deep temporal nerve from the maxillary nerve may impact the descent of muscle. Because of the proximity of the nerve entry point to the temporalis tendon, special care must be taken when detaching the tendon from the coronoid process to avoid nerve traction and avulsion. The maxillary nerve is mixed with both sensory and motor components in some cases, which is in contrast to the established concept that it is purely sensory