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Background: Various methods of corrective thoracoplasty for pectus carinatum deformity have been described, but to date no studies describe a review of complications and how to manage them. Complications are dependent not only on the technique used and the patient's age, but also on the experience of the treating surgeon. The authors present their 15 years' experience with surgical correction of pectus carinatum and the complications that have occurred. A literature review regarding complications with pectus carinatum surgery is performed., Methods: A retrospective review of 95 patients (mean age, 19 years) was performed. One hundred four surgical procedures for repair of pectus carinatum were performed from July of 2000 to July of 2015 using a modified Ravitch technique, bioabsorbable material, postoperative bracing, and in some cases a diced rib cartilage graft technique. Intraoperative and postoperative complications were evaluated., Results: The mean patient follow-up was 13.6 months (range, 4 months to 9.75 years). Intraoperative complications were pleura lesion and laceration of the internal mammary vein. Postoperative complications were recurrent mild protrusion, persistent protrusion of one or two costal cartilages, minor wound healing delay, skin ulcer, hypertrophic scar, transient intercostal dysesthesia, marginal pneumothorax, seroma, meningitis, and epidural hematoma., Conclusions: In our reported series of pectus carinatum repair, increasing experience and progressively less extensive techniques have resulted in fewer complications, low morbidity, and early return to activity. Complications were observed in the early period of application, predominantly because of a lack of experience, and usually subsided with increasing numbers of patients and frequency of surgery., Clinical Question/level of Evidence: Therapeutic, IV.

Background: The minimally invasive repair of pectus excavatum (MIRPE) procedure as a standard procedure in children is rarely described in adolescents, adults, or in patients with asymmetric deformities. For these challenging cases, the authors have adopted a semiopen approach (minor open videoendoscopically assisted repair of pectus excavatum, or MOVARPE) with additional skin incisions and osteochondrotomies. This descriptive application study was set to assess whether both procedures are effective and safe in adolescents and adults, to determine whether they have similar complication and recurrence rates, and to analyze the overall outcome in nonpediatric patients., Methods: A retrospective review of 69 patients (45 male and 24 female patients; mean age, 20.8 years) who underwent either technique from August of 2002 to June of 2012 was performed. Intraoperative and postoperative complications, clinical outcome, and patient satisfaction were evaluated., Results: The mean patient follow-up after bar removal in 55 patients was 27.3 months (p = 0.624). In the MIRPE group, two bar dislocations, one rupture of the internal mammary artery, and one case of pneumonia were observed. Mild recurrence of deformity after bar removal was present in four cases. Satisfaction outcomes were excellent in 70 percent in the MOVARPE group and 55.1 percent in the MIRPE group (p = 0.0182)., Conclusion: The MOVARPE technique is a hybridized, semiopen modification of the MIRPE procedure that seems to be advantageous, particularly in adolescents, adults, and those with asymmetric pectus excavatum deformities, for overcoming resistant skeletal rigidity with low complication rates, high patient satisfaction, and superior aesthetic results., Clinical Question/ Level of Evidence: Therapeutic, III.

Background: Adults are increasingly seeking surgical correction of pectus excavatum deformity, and the alternative custom-made silicone implant is not always desired or suitable. The paramount concern of female patients is the apparent strabism of their breasts. In some cases, the standard minimally invasive reconstruction of pectus excavatum procedure or a modified approach with a semiopen technique can help remodel the anterior thoracic wall and simultaneously reposition the female breasts to a desired and aesthetically acceptable position., Methods: Between November of 2000 and March of 2011, 35 female adolescent and adult patients underwent surgical funnel chest repair with different approaches. In seven of these patients, a pectus bar was implanted using minimally invasive reconstruction of pectus excavatum, whereas 15 underwent a combined semiopen approach. The pectus bar was removed after a period of 14 to 39 months (mean, 31 months) in the minimally invasive reconstruction group and 12 to 25 months (mean, 13.5 months) in the other group. Preoperative and postoperative photographs were examined, and the results were assessed by independent surgeons., Results: During the follow-up period of 1 month to 3.9 years (mean, 12 months), no major complications occurred. The aesthetic appearance of the anterior thoracic wall was distinctly improved, and breast strabism and breast tissue projection were eliminated., Conclusions: Pectus bar implantation appears to be an excellent method for the correction of breast malposition in female adults with a funnel chest deformity. Although invasive, it allows permanent remodeling of the anterior thoracic wall and the décolleté, and a repositioning of the female breast to achieve a natural appearance., Clinical Question/level of Evidence: Therapeutic, IV.

Background: Various methods of corrective thoracoplasty for congenital anterior chest wall deformities have been described. To date, no studies have described the use of diced cartilage as a surgical procedure in thoracoplasty. The authors present their experience with 23 patients for whom diced cartilage grafts were used as an innovative approach for thoracoplasty., Methods: A retrospective review of 23 patients was performed. From January of 2004 to September of 2010, 18 patients underwent repair of pectus excavatum, three patients underwent repair of pectus arcuatum, and two patients underwent repair of pectus carinatum using diced rib cartilage grafts. Intraoperative and postoperative complications, patient satisfaction, and clinical outcome were evaluated. Preoperative and postoperative photographs were examined, and the results were assessed by independent surgeons., Results: The mean patient follow-up was 18.1 months. No major complications were observed in the perioperative period. Postoperative complications were mild recurrence of deformity (n = 2). No graft extrusion, infection, or contour irregularities occurred. The patients rated their cosmetic results as very good. All 25 of the wrapped diced cartilage grafts appear to have survived completely, with only one partial graft absorption. One patient had palpable diced cartilage., Conclusions: The diced cartilage graft technique is a novel and safe procedure in thoracoplastic refinement procedures with clear advantages, including limited surgical trauma, autogenous material, easy preparation, absence of significant donor-site morbidity, absence of additional costs, high patient satisfaction, and good aesthetic results. The authors advocate using this technique for augmentation and contouring of minor anterior wall deformities in selected patients., Clinical Question/level of Evidence: : Therapeutic, IV.(Figure is included in full-text article.).

Soft tissue coverage of the medial ankle and foot remains a difficult, challenging, and often frustrating problem to patients as well as surgeons. To our knowledge, the abductor hallucis muscle flap is not frequently used and only a few well documented cases were found in literature. The purpose of this paper is to report and to present the long-term results of a series of four patients who underwent reconstruction of foot and ankle defects with the abductor hallucis muscle flap. In two cases, the abductor hallucis muscle flap was transposed in combination with a medialis pedis flap to cover a medial ankle defect, whereas in another case it was combined with a medial plantar flap. In this latter case, the muscle flap served to fill up a calcaneal dead space after osteomyelitis debridement, whereas the cutaneous flap was used to replace debrided skin at the heel. The abductor hallucis flap was used as a distally-based turnover flap to cover a large forefoot defect in a fourth case. Follow-up period ranged between 18 and 64 months (mean 43.3). In the early postoperative period, two flaps healed completely In two patients marginal flap necrosis occurred which was subsequently skin grafted. No donor-site complication occurred in any of the patients. In all cases, protective sensation of the skin was satisfactory as early as 6 months. In two cases mild hyperkeratosis at the skin graft border to the sole skin (non-weight bearing area of medial plantar and medialis pedis flap donor site) was present, but probably related to poor foot care. All patients were fully mobile as early as 3 months after treatment. In the long-term follow-up (43.3 months), all flaps provided with durable coverage. Functional gait deficit due to consumtion of the abductor hallucis muscle was not apparent. Our long-term results demonstrated that the abductor hallucis muscle flap is a versatile, and reliable flap suitable for the reconstruction of foot and ankle defects. Utilizing the abductor hallucis muscle as a pedicled flap (distally or proximally-based) with or without conjoined regional fasciocutaneous flaps offers a successful and durable alternative to microsurgical tree flaps for small to moderate defects over the calcaneus region, medial ankle, medial foot, and forefoot with exposed bone, tendon, or joint.

Recurrent palatal fistulae present a particularly vexing problem for patients with cleft lips and palates and their surgeons. When primary closure fails, conventional wisdom and the standard of care suggest local flap techniques for defect closure. For the large majority of patients, this approach is successful. There is, however, a small subset of patients who undergo multiple surgical procedures in unsuccessful attempts to close recalcitrant fistulae, particularly at the anterior, densely scarred, hard palate. In this setting, repair calls for the introduction of well-vascularized pliable tissue to close the defect and to avoid hampering further palatal growth. Local muscle flaps and oral axial pattern flaps have been advocated and used successfully. However, those approaches have their own drawbacks, such as multiple surgical interventions, patient compliance, and intraoral scarring. In an effort to avoid the problems associated with local flaps, distant microvascular tissue transfers were investigated. During a 6-year period, six free-tissue transfers were performed as a primary means of treating recalcitrant palatal fistulae. Three dorsalis pedis flaps and three osseous angular scapular flaps were used. The conditions of all patients improved, with five patients achieving complete long-term closure of the palatal defect. This experience indicates that modern microvascular techniques have reached a level of success commensurate with that of other flap techniques; therefore, it is concluded that free-tissue transfer should be considered as a primary means of addressing these difficult cleft problems.

In this report, the authors describe the application of a muscle-sparing technique to harvest a myocutaneous latissimus dorsi muscle flap, including only a tiny lateral muscle segment but carrying a large skin paddle, with the advantage of leaving intact innervation and function of the remaining latissimus dorsi muscle. According to the experiences and complications associated with the pure thoracodorsal artery perforator harvest at the authors' institution, the necessity of increasing the reliability of the vascular pedicle demands that a small muscle strip be left embedding the perforator vessels attached to the skin paddle. This procedure was applied in eight cases with only one minor complication, which was a distal flap tip necrosis in the largest flap used. The muscle function and aesthetic contour of the posterior axillary fold were preserved in every case. Harvesting a large skin paddle flap that is carried by a diminutive longitudinal segment of latissimus dorsi muscle circumvents thoracodorsal nerve damage and maintains muscle function. In contrast to a thoracodorsal artery perforator flap without muscle, the harvesting of which is a delicate procedure, this procedure is regarded as easier and safer.

The aim of this interdisciplinary study was to evaluate power Doppler imaging as a method of collecting reliable preoperative data concerning the diameters and topography of exemplary internal mammary vessels as recipient vessels in reconstructive microsurgery. Thirteen female patients (range, 37 to 58 years; mean, 45.6 years) were examined preoperatively with power Doppler imaging from the first to the fifth intercostal space parasternally and bilaterally. These data are compared with measurements obtained intraoperatively in each individual. Mean velocity in the artery in the second intercostal space on the right side is 47.11 cm/sec (range, 15 to 90 cm/sec) and on the left side is 42.25 cm/sec (range, 18 to 95 cm/sec). Mean velocity in the vein in the second intercostal space on the right side is 17.80 cm/sec (range, 10 to 30 cm/sec) and on the left side is 13.06 cm/sec (range, 5.3 to 32 cm/sec). The topographic results are in close agreement with intraoperative measurements and previous anatomical studies. Sonographic preoperative data of arteries (mean, 1.88 mm) show slightly smaller diameters than intraoperative measurements (mean, 2.08 mm), whereas veins show slightly larger diameters in sonography (mean, 2.33 mm) than intraoperatively (mean, 2.12 mm). Mean sonographic diameter of artery ranges from 2.14 mm (second intercostal space) to 1.46 mm (fifth intercostal space), of the vein from 2.76 (second intercostal space) to 1.25 mm (fifth intercostal space). In one case, a vein was not detectable. This noninvasive method leads to confirmation of the preoperative choice of the optimal recipient vessels for free tissue transfer and does not harm the patient.

The free "serratus fascia" flap as a free flap was first described by Wintsch and named a free fascia flap of gliding tissue; however, it has not yet been given a distinct name. The particular advantages of this flap consist of an easy access and a low donor-site morbidity without functional deficit. Additionally, it may be designed very variably and molded even three-dimensionally as a tendon wraparound flap or folded to fill up cavities. In our clinic, we used this flap in 21 patients for distinct indications and in 7 patients as a vascular graft in fingers or great toe with a minimal adjacent layer of gliding tissue around the vessels for the treatment of cold intolerance after finger replantation or severe finger or toe trauma. In the other cases, this versatile flap served for the coverage of traumatically exposed tendons or bones at the extremities, covered with a skin graft. Eighteen flaps survived completely, whereas 3 flaps developed partial or superficial necrosis. Only once did a major complication by unintentional sacrification of the long thoracic nerve during flap harvesting occur, resulting in a wing scapula. We recommend this flap for defect cover at sites where a thin vascularized gliding layer for defect cover is needed, especially in distal extremities with exposed tendons or nerves, and present the current indications in discussing our experiences.