Steam burn as a late complication of nonsensate DIEP flap after breast reconstruction

The breast is an erogenous, sexual sensory region. Autologous breastreconstruction operations have increased, but studies continue toexamine tissue innervation (Magarakis et al., 2013). As some sensesare regained with the regeneration of nerves from the adjacent residual postmastectomy skin, this avoids an additional operationrequired for nerve coaptation (Spiegel, Menn, Eldor, Kaufman, &Dellon, 2013).This letter presents a late burn injury of a patient with an autologous breast reconstruction with a Deep Inferior Epigastric ArteryPerforator flap.A 40-year-old woman with nonspecific invasive breast cancerunderwent a mastectomy and immediate reconstruction with a DIEPflap. Postoperative follow-up was performed routinely. The patientwas admitted 1.5 years later when her reconstructed right breast wasburned by steam. While the patient was using a pressure cooker, shewas exposed to the steam for less than a minute. The steam penetrated through the skin directly. After a few hours when she took offher clothes, she realized that she had burns. The working principle ofa pressure cooker is that the temperature of the steam must beabove 100C. On physical examination, there was 8 × 6 cm necroticeschar and third degree burn (Figure 1). The patient stated that shedid not feel any pain when she was burned. Burn escharectomy wasperformed and the defect was left to heal secondarily. Wound healing was complete by 4 weeks and patient was followed up for2 months.

Functional Improvement with Free Vascularized Toe-to-hand Proximal Interphalangeal (PIP) Joint Transfer

Background: Reconstruction of small joints of fingers is still challenging in handsurgery. Implant arthroplasty and arthrodesis have some limitations in the reconstruction of small finger joints. Free vascularized PIP joint transfer from second toeto finger is a promising autogenous reconstructive alternative.Methods: In this prospective study, 7 cases of free vascularized PIP joint transferwere analyzed. The measurements for active and passive range of motion (ROM),grip, and pinch strength has been done preoperatively and 1-year postoperatively.The functional change in daily life quality and work-related activities was evaluatedwith Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.Results: Mean follow-up period was 20.3 months (12–25). Preoperative mean active and passive ROM values were 3.6º (0–14º) and 11.9º (0–29º), respectively.Postoperative 1-year measurements revealed a mean active ROM of 24.1º and amean passive ROM of 31.6º. Mean grip and pinch strength increased from 52.1 to58.6 lbs and from 5.1 to 5.9 lbs, respectively. Mean preoperative and postoperativeDASH-scores were 41.3 and 30.3.Conclusion: The improvement in ROM, increasing grip strength, and declining DASHscores in our study support that free vascularized joint transfer improves patients’ dailylife quality and work-related activities via providing a functional joint if performed withappropriate indications, careful planning, and meticulous surgical execution. Free vascularized joint transfer provides an autogenous, painless, mobile, and stable joint. Italso has the advantages of composite tissue reconstruction and lacks the disadvantagesof arthrodesis and synthetic joint implants. (Plast Reconstr Surg Glob Open 2018;6:e1775;doi: 10.1097/GOX.0000000000001775; Published online 9 July 2018.)

The planning of propeller perforator flap on previously transferred musculocutaneous flap via multidetector computed tomography for the reconstruction of tissue defect overlying Achilles tendon

The mapping of peripheral vascular system and imaging perforatorsare essential before perforator flap surgery. Magnetic resonance imaging (MRI), Doppler ultrasonography (US), and computed tomography(CT) are widely used techniques to determine the location of recipientvessels and perforators in donor site (Demirtas, Cifci, Kelahmetoglu,Demir, & Danacı, 2009). CT imaging is found to be an effectivemethod for perforator selection at donor site prior to autologousbreast reconstruction (Hamdi, Van Landuyt, Van Hedent, & Duyck,2007). Backup perforator flap was described as the use of a perforatorflap derived from a previously transferred free musculocutaneous flap(Topalan, Guven, & Demirtas, 2010). This letter presents the reconstruction of a tissue defect on Achilles tendon using a backup propeller perforator flap, three-dimensional (3-D) CT imaging was used todetermine the perforators of previously transferred free latissimusdorsi musculo-cutaneous flap (LDMC).

Double-Layer Reconstruction of the Achilles’ Tendon Using a Modified Lindholm’s Technique and Vascularized Fascia Lata

Loss of the Achilles’ tendon with overlying soft tissue and skin defects remains acomplex reconstructive challenge. Herein we present our experience using a freecomposite anterolateral thigh (ALT) flap with vascularized fascia lata and a modifiedLindholm’s technique to repair the Achilles’ tendon. A 37-year-old man suffered fromtertiary Achilles’ tendon rupture. For reconstruction, the free composite ALT flap withvascularized fascia lata was used to wrap Achilles’ tendon. A modified Lindholm’stechnique was used to cover overlying soft tissue defects. The patient was followed upfor 12 months. No wound healing problems were reported, and the patient was able towalk and return to his daily ambulating activities without any support after 5 monthspostoperatively. This technique may be useful to achieve satisfactory outcomes inpatients with ruptured Achilles’ tendons following tertiary repair.


Lower extremity reconstruction is one of the challengingareas for reconstructive surgeons. The reliability of thevascularity of a perforator flap is important in reconstructive surgery. To increase flap viability and to preventvenous insufficiency we performed an extra vein anastomosis in pedicled propeller perforator flap concept.This letter presents the reconstruction of a tissuedefect after radical excision of an acute variant type ofMarjolin’s ulcer in the lower extremity using a superdrained propeller perforator flap.A 61 year old male was referred to dermatology outpatient clinic with a leg ulcer. Six months earlier, he had acar accident and two ulcers developed on his leg: one healedwithin a few weeks, while the other persisted. Initially, theulceration was deep. With time, the ulcer changed shape; thebase of the ulcer rose toward the surface and became wartlike in appearance. Clinically, there was a 3-cm diameter,yellow, verrucous, indurated mass on the right anterior tibia.A 4-mm punch biopsy was taken from the lesion. Thepatient’s history and histopathological findings led to a diagnosis of Marjolin’s ulcer. The patient underwent surgicaltreatment at the Department of Plastic Surgery

The Multiple Osteotomized Free Iliac Osteocutaneous Flap for Reconstructions of Complex Maxillofacial and Oromandibular Defects

Abstract: The vascularized iliac osteocutaneous flap has been usedsuccessfully for jaw reconstruction. To obtain a better contour of thereconstructed area in large upper and lower jaw resections, thetransferred bone actually needs to be osteotomized. Single closingwedge osteotomy of the iliac flap for mandibular reconstruction hasbeen previously described. In this article, the modified multipleosteotomized perforator-based versatile free iliac osteocutaneousflap is described. Eleven cases were enrolled. Seven patients hadwide anterior mandibular resections due to oral cavity and mandibular tumors; 3 patients had a defect due to explosive injury and 1patient had complicated orbitomaxillary defect due to blast injury.Skin paddle was based on the perforators. In 8 patients, the bonysegment was divided into 3 segments by 2 osteotomies, whereas in 2patients the bony segment was divided into 4 segments by 3osteotomies. In 10 cases, the flap was used for anterior mandibulardefects, whereas in 1 case the flap was customized to fit an L-shapeddefect at the naso-orbito-maxillary region. The overall flap successrate was 100%. No resorption or morbidity related to the osteotomyof the bony segments was observed. The size of perforator skinpaddle was 6 to 8  15 to 18 cm. Physical and radiologic examinations showed proper bone healing without any additional complications. The modified multiple osteotomized free osteocutaneousiliac flap can provide a safe and versatile bony segment to be

Transaxillary-Subclavian Transfer of Pedicled Latissimus Dorsi Musculocutaneous Flap to Head and Neck Region

Abstract: Free-tissue transfer is the reconstruction of choice formost head and neck defects. However, pedicled flaps are also used,especially in high-risk patients and after failure of a free flap. Theaim of this study was to compare transaxillary-subclavian pedicledlatissimus dorsi musculocutaneous (PLDMC) flap, pectoralis majormusculocutaneous flap, and free-tissue transfer for head and neckreconstruction in American Society of Anesthesiologists grades IIand III patients.During the last 4 years, PLDMC flap with a modifiedtransaxillary-subclavian route for transfer to the neck was used in8 patients, pectoralis major musculocutaneous flap was used in 7patients, and free flaps were used in 12 patients for head and neckreconstructions. These 3 methods were compared regarding the flapdimensions, complications, flap outcome scores, hospitalizationtime, and cost of the treatment.Mean age of the patients, mean American Society of Anesthesiologists scores, mean dimensions of the flaps, and mean hospitalization time did not differ significantly among the 3 groups. Regardingthe operation time, flap complications, outcomes, and cost of totaltreatment, although statistically not significant, PLDMC group offeredthe fastest reconstruction with highest flap outcome scores andminimum cost.Free-tissue transfer is the procedure of choice especially forfunctional reconstruction of head and neck region. Occasionally,there exist cases in whom a pedicled flap could offer a safer option.The PLDMC flap transferred via the transaxillary-subclavian routemay be preferred than, with advantages including increased arc ofrotation, safer pedicle location, shorter duration of the procedure,and reduced complication rates and costs.Key Words: Head and neck reconstruction, pedicled latissimusdorsi flap, musculocutaneous flap, pectoralis major flap,transaxillary-subclavian transfer, free flap

Comparison of Free Muscle and Perforator Skin Flaps for Soft Tissue Reconstruction of the Foot and Ankle

Background: Free tissue transfer is generally required forreconstruction of soft-tissue defects of the foot and ankle regionbecause of the limited local tissue available. This type ofreconstruction may interfere with postoperative function andfootwear if a bulky flap is used. Materials and Methods: Twentynine patients had free tissue transfers to the foot and ankleregion during a period of 3 years. Sixteen had reconstructionwith free anterolateral thigh perforator flaps (ALT) and 13had reconstruction with free muscle flaps. The outcomes ofboth types of reconstructions were compared according to flapscores and complications, operative time, hospitalization, gaitand shoewear problems. Results: The patients in the ALT groupwere younger compared with those of the free muscle flapgroup (p = 0.022). The operative time and flap complicationrate was significantly higher (p = 0.007 and 0.040, respectively)in the ALT group. ALT was generally used for reconstructionof the dorsal foot, heel and plantar regions. Muscle flaps werepreferred in the ankle region, where open fractures of thetibia and fibula were frequently present, and for the patientswith increased risk of perioperative morbidity. Conclusion: FreeALT flap consisting of skin and adaptable subcutaneous tissue,both diminishes donor site morbidity and is ideally suited formost soft-tissue reconstruction of the dorsal foot, heel andplantar foot. Free muscle flaps, however, may offer relativelyless complicated tissue transfers and are preferred at the ankleregion in the presence of open tibia fractures, and in high riskpatients to decrease the perioperative morbidity.

Free Anterolateral Thigh Flap for Reconstruction of Car Tire Injuries of Children’s Feet

Background: Grade IV and V car tire injuries occurring inchildren cause extensive soft tissue defects with exposure orloss of tendons and bone on the dorsum of the foot. Freetissue transfer is indicated for reconstruction of these defectsbecause of the limited local tissue available. We describe ourmanagement of high-grade car tire foot injuries in children withfree anterolateral thigh flap (ALT). Materials and Methods: Fivepre-school children with car tire injuries (one grade IV and fourgrade V) were treated with free ALT flap in the last 4 years.The mean age was 4.8 years. In four patients, immediate flapcoverage after initial debridement was performed and delayedreconstruction was used as a secondary procedure in onepatient. Results: One of the flaps was re-explored for hematomaevacuation and salvaged. All of the flaps survived completelyand there were no donor site complications. None of the flapsrequired a debulking procedure and custom shoe wear has notbeen necessary in any of the patients. Minor gait abnormalitieswere detected in two of the patients. Conclusion: With minimaldonor site morbidity, long vascular pedicle allowing anastomosisoutside of the trauma zone, we believe free ALT flap providesthe ideal soft tissue reconstruction for high grade car tireinjuries of foot in children. ALT flap can be further thinned toadapt to the defect, contracts less than muscle flaps and containsa vascularized fascia which can be used for extensor tendonreconstruction.Level of Evidence: IV, Retrospective Case SeriesKey Words: Car Tire Injury; Foot Reconstruction; AnkleReconstruction; Free Flap; Anterolateral Thigh Flap; ThinFlap; Children Injury

A Hemodynamic Study of the Effects of Arterial Anastomoses With Interrupted Simple Versus Horizontal Mattress Sutures on Rat Epigastric Flap Perfusion

Abstract: The effects of interrupted simple versus horizontal mattress sutures and of the internal diameter of the arterial pedicle at thelevel of the anastomosis on rat epigastric flap perfusion wereinvestigated. In the first group, a microclip was applied to thefemoral artery for 30 minutes. In the second group, the artery wascut, and a classic 7- to 8-suture microarterial end-to-end anastomosis was performed. In the third group, the artery was cut, and amicroarterial end-to-end anastomosis with 3 horizontal mattresssutures at 120-degree intervals was performed. Perfusion was measured using a laser Doppler flowmeter (Periflux 2B, Perimed, Sweden) at 3 zones of the flap at 30 and 60 minutes and at 21 days afterthe procedure. Internal vascular diameters were measured histopathologically. Perfusion was better in the control group than inthe experimental groups. However, the internal vascular diameterswere greater with the classic method than with the new method, andthe perfusion did not differ statistically in the anastomosis groups. Inconclusion, even when significant narrowing develops at the anastomosis, flap viability is not affected.Key Words: microsurgery, microvascular surgery, vesselanastomosis, vascular anastomosis method, internal vasculardiameter, perfusion, rat epigastric flap, laser Doppler flowmeter