Successful treatment of bilateral empyema with bilateral fistulae using free intercostal muscle flap

Background Bilateral empyema is rare and can be life-threatening. Few cases have ever been reported about bilateral empyema with fistula on both sides. We herein report a case of bilateral empyema with bilateral fistulae that was treated with a 2-stage operation. Case presentation The patient was a 40 year-old man with uncontrolled diabetes mellitus, severe emaciation and remarkably decayed teeth. On his admission, computed tomography showed bilateral pneumothorax and pleural effusion. Thoracentesis revealed a cream-colored purulent pleural effusion from both sides of the pleural cavity. Bilateral empyema with fistulae on both sides due to a ruptured lung abscess was diagnosed. 7 days after his administration, we performed the first surgery. There were 3 fistulae in the right lateral basal segment (S9), right posterior basal segment (S10), and left posterior basal segment (S10). At the first operation, the S9 fistula was directly sutured; however, the right S10 fistula could not be closed because the surrounding tissue was fragile. The left lung fistula was deep and crater-shaped; it was closed with the suturing of a plugged free muscle flap. At the second operation, the right S10 fistula was closed with the superimposition of a pedicled intercostal muscle flap. Conclusion Patients with bilateral empyema tend to be with poor general condition and, therefore, less invasive treatments are required initially. Closure of fistulae is an essential process for the treatment of empyema with fistulae. We could manage the fistulae using several techniques with 2-stage operation. Although the efficacy of using a free intercostal muscle flap to close the fistula has not been adequately verified, it is simple and less invasive and, thus, might be a useful option in cases where the patient is too ill to undergo a more invasive operation or when the surgical approach should be done in a short time

Simultaneous debridement, Ilizarov reconstruction and free muscle flaps in the management of complex tibial infection

Chronic bone infections often present with complex bone and soft tissue loss. Management is difficult and commonly delivered in multiple stages over many months. This study investigated the feasibility and clinical outcomes of reconstruction in one stage. Fifty-seven consecutive patients with chronic osteomyelitis (n=27) or infected non-union (n=30) were treated with simultaneous debridement, Ilizarov method and free muscle flap transfer. 41 patients (71.9 %) had systemic co-morbidities (Cierny-Mader group Bs hosts). Infection was confirmed with strict criteria. 48 patients (84.2 %) had segmental defects. The primary outcome was eradication of infection at final follow-up. Secondary outcomes included bone union, flap survival and complications or re-operation related to the reconstruction. Infection was eradicated in 55∕57 cases (96.5 %) at a mean follow-up of 36 months (range 12–146). No flap failures occurred during distraction but 6 required early anastomotic revision and 3 were not salvageable (flap failure rate 5.3 %). Bony union was achieved in 52∕57 (91.2 %) with the initial surgery alone. After treatment of the five un-united docking sites, all cases achieved bony union at final follow-up. Simultaneous reconstruction with Ilizarov method and free tissue transfer is safe but requires careful planning and logistic considerations. The outcomes from this study are equivalent or better than those reported after staged surgery.

Recycling of flap pedicle in complex lower extremity reconstruction: A proof of free muscle flap neovascularization

This article portrays the authors’ clinical experience of a complex case of lower extremity reconstruction using a recycled pedicle from 10 years old free latissimus dorsi musculocutaneous flap to supply a new free anterolateral thigh flap for proximal tibia wound defect reconstruction. It provides clinical evidence that muscle neovascularization occurs and supports the dogma peripheral tissue neovascularization. This case stipulates that recycling of pedicle is feasible, when used with appropriate strategy and safety and also provides evidence for the long-term survival of greater saphenous vein grafts in lower extremity reconstruction.

Successful Free Tissue Transfer in the Profoundly Hypercoagulable Glioblastoma Multiforme Patient: Surgical Experience and Anticoagulation Protocol

Background Glioblastoma multiforme (GBM) produces a hypercoagulable environment and is associated the highest rates of deep venous thrombosis (DVT) and pulmonary emboli (PE) of any malignancy. The use of postoperative radiation in this generally compromised patient group is associated with the development of complex scalp wounds. Free tissue transfer reconstruction will be essential in selected cases despite the presence of an underlying hypercoagulable state. Methods A 67-year-old female with a history of previous DVT presented with osteoradionecrosis and infected scalp wound following GBM treatment. She underwent reconstruction with a free vastus lateralis flap and skin graft. Initial anticoagulation was provided with intravenous heparin and transitioned to oral apixaban. Wound cultures demonstrated coagulase-negative Staphylococcus, Actinomyces neuii, and Peptoniphilus harei and were treated with a 6-week course of intravenous cefepime and vancomycin. Results Despite the initial failure of a local scalp rotation flap, successful wound healing was achieved with a free muscle flap and a course of culture specific antibiotics. The patient succumbed to recurrent disease 22 months after surgery, underscoring the importance of limiting hospitalization and maximizing quality of life in this group of patients. Conclusion Free tissue transfer can be successfully achieved in the hypercoagulable GBM patient. Heparin and apixaban were employed successfully in the prevention of thrombotic events. Antiplatelet therapy should also be considered to counteract platelet aggregation induced by the transmembrane glycoprotein (podoplanin) that is expressed on GBM tumor cells. Enzyme-linked immunosorbent assay testing (ELISA) of blood soluble podoplanin may help determine the degree of hypercoagulability and guide therapy.

Primary anatomic reconstruction in upper and lower lips: case report

Extensive lip injuries reconstructions require a strategy of treatment. First, the strategy can follow the anatomical references in order to closure the injury reestablishing the lip functions. This article report a reconstruction of an extensive lip injury after a convulsion and a fall in height in a male patient. The lip reconstruction by anatomical reconstruction was effective for immediate structural maintenance and allowed a favorable healing for the second surgical stage.Descriptors: Lip; Wounds and Injuries; Surgery, Oral.ReferencesMatin MB, Dillon J. Lip reconstruction. Oral Maxillofac Surg Clin North Am. 2014;26(3):335-57.Lubek JE, Ord RA. Lip reconstruction. Oral Maxillofac Surg Clin North Am. 2013;25(2):103-14.Cakmak MA, Cinal H, Barin EZ, Sakat MS, Karaduman H, Tan O. Total lower lip. reconstruction with functional gracilis free muscle flap. J Craniofac Surg. 2018;29(3):735-37.Larrabee YC, Moyer JS. Reconstruction of mohs defects of the lips and chin. Facial Plast Surg Clin North Am. 2017;25(3):427-42.Coppit GL, Lin DT, Burkey BB. Current concepts in lip reconstruction. Curr Opin Otolaryngol Head Neck Surg. 2004;12(4):281-87.Daraei P, Calligas JP, Katz E, Etra JW, Sethna AB. Reconstruction of upper lip avulsion after dog bite: case report and review of literature. Am J Otolaryngol. 2014;35(2):219-25.Sanniec KJ, Carboy JA, Thornton JF. Simplifying Lip Reconstruction: An Algorithmic Approach. In Semin Plast Surg. 2018;32(2):69-74.Neligan PC. Strategies in lip reconstruction. Clin Plast Surg. 2009;36(3):477-85.Bai S, Li RW, Xu ZF, Duan WY, Liu FY, Sun CF. Total and near-total lower lip reconstruction: 20 years experience. J Craniomaxillofac Surg. 2015;43(3):367-72.Ogawa R. Surgery for scar revision and reduction: from primary closure to flap surgery. Burns Trauma. 2019;7:7 doi: 10.1186/s41038-019-0144-5.Siqueira EJ, Alvarez GS, Laitano FF, Martins PDE, Oliveira MP. Estratégias em reconstrução do lábio inferior. Rev Bras Cir Plást.2012;27(4):536-41.Estlander JA. Eine methode aus der einen lippe substanzverluste der anderen zu erstzen. Arch Klin Chir. 1872;14:622. Reprinted in English in Plast Reconstr Surg. 1968;42:361.Robotti E, Righi B, Carminati M, Ortelli L, Bonfirraro PP, Devalle L et al. Oral commissure reconstruction with orbicularis oris elastic musculomucosal flaps. J Plast Reconstr Aesthet Surg. 2010;63(3):431-39.Yamauchi M, Yotsuyanagi T, Ezoe K, Saito T, Yokoi K, Urushidate S. Estlander flap combined with an extended upper lip flap technique for large defects of lower lip with oral commissure. J Plast Reconstr Aesthet Surg. 2009;62(8):997-1003.

The Effect of Age on Outcome in Excision of Chronic Osteomyelitis with Free Muscle Flap Reconstruction

Introduction: Curative surgical treatment of chronic osteomyelitis often requires free tissue transfer if there is significant soft tissue compromise. We investigated whether age influenced outcomes of curative osteomyelitis excision in those patients requiring free muscle flap soft tissue reconstruction.Methods: We assessed ninety-five consecutive patients treated with excision of chronic osteomyelitis, skeletal stabilisation/reconstruction and free muscle transfer between 2006 and 2012. We compared outcomes of those aged ≥60 years (n=23) with those <60 years old (n=72).Results: Groups were similar with regard to Cierny and Mader anatomic type and physiological host classification. Length of procedure and length of hospital stay were similar for both groups. There was a greater proportion of ASA grade III patients in the older cohort. Infection recurrence occurred in one of the older cohort (4.3%) and in seven patients in the younger cohort (9.9%) at a mean follow-up of 42 months (range 11-131 months), this was not statistically significant (p=0.27874). There were five free flap losses (6.9%) in the younger group and none in the older group. A greater proportion of patients from the younger cohort required further unplanned surgery (28%) compared to the older group (4.3%), which was statistically significant (p=0.01174). Seven patients (7.4%) had serious medical complications - five of whom were in the younger cohort, including one mortality.Conclusions: Both the young and old can enjoy satisfactory outcomes from surgical resection of chronic osteomyelitis with simultaneous orthoplastic reconstruction including free tissue transfer. Age alone should not be a barrier to potentially curative surgical treatment.

Microneurovascular Reconstruction for Facial Reanimation

Microneurovascular muscle flaps can be effectively employed to reanimate the paralyzed mid-face. This chapter explores the indications and contraindications for free muscle flap smile restoration. Various sources of innervation are examined including the motor nerve to masseter and cross-face nerve grafts, as are different muscle flap donor sites. A detailed description of facial nerve exploration, sural nerve graft harvest, and the cross-face nerve graft procedure are provided. Single and two-staged facial reanimation procedures utilizing free gracilis muscle flaps are also described in detail, including technical nuances, postoperative care, and physical therapy. The technique is well suited for individuals whose native muscles of facial expression have failed to develop in utero, undergone irreversible atrophy, sustained significant trauma, or have been sacrificed during oncologic resection.