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Background:. Microsurgical vascular anastomosis plays an important role in successful free-tissue transfer. The Microvascular Anastomotic Coupler Device (MACD) aims to simplify anastomosis and decrease the time spent on this step, thereby reducing surgeon stress and improving the overall quality of the surgery, especially when venous end-to-side anastomosis is required. Our comparative retrospective cohort study aimed to determine the effect of this widely used device on anastomosis times and complications in head and neck/esophageal reconstruction cases involving venous end-to-side anastomosis using the internal jugular vein as the recipient vessel. Methods:. All consecutive patients who underwent head and neck/esophageal reconstruction with hand-sewn or MACD-mediated venous end-to-side anastomosis using the internal jugular vein by three experienced microsurgeons in our tertiary-care hospital in 2012–2020 were identified. Venous anastomosis times and venous trouble cases were recorded. Results:. Of the 191 cases, 44 and 147 underwent hand-sewn and MACD-mediated anastomosis respectively. The average venous anastomosis times of these groups were 31 and 11 minutes, respectively. Venous trouble was observed in two hand-sewn (4.5%) and four MACD (2.7%) cases, respectively. Vein twisting and improper coupler placement were the causes in the latter four cases. Conclusions:. This study confirmed that MACD simplifies end-to-side venous anastomosis and reduces the time spent on this procedure. Also, for safer anastomosis, it is necessary to pay attention to preventing twisting and improper coupler placement when using MACD. We believe the MACD can improve the quality of reconstructive surgery.

Summary:. Isolated circumferential lining contraction of the midvault and nasal floor is a challenging reconstructive problem. In the cocaine nose, extensive loss of mucosal lining, with or without loss of columella, will result in collapse of the nose into the pyriform fossa. Various techniques have been used to provide nasal lining, but when the defect is extensive a free tissue transfer is advocated. The forehead flap is not able to reach the nasal vestibule when the nasal skin is intact. Transecting the ala creates a shortcut route for the forehead flap to provide lining for the nasal vault, nasal floor, and soft tissue cover for the columella. A bilateral trans alar forehead flap was used to reconstruct the nasal lining and columella in a patient with a severely contracted cocaine nose. An L strut cartilage graft was covered with the forehead flaps, which were divided and inset in the nasal vault separately 3 weeks apart. The bilateral trans alar forehead flap is an excellent alternative to microsurgical reconstruction of the nasal lining and columella in the cocaine nose. Secondary thinning of a wide columella may be indicated, but the forehead skin provides a good color match. The scars on the forehead and the alar scars on the border of subunits of the nose heal well and are minor tradeoffs.

Background:. Since 1994, we have used soft silicone blocks sculpted intraoperatively to correct pectus excavatum in male patients. This technique involves a horizontal access incision in the region of the lower edge of the sternum. During the dissection to expose the sternum, we observed a constant diastasis of the rectus abdominis muscle and changes of the anatomy at its superior insertion. There is no report on this association. Methods:. Male patients with untreated medial pectus excavatum with indication for silicone block correction were enrolled. Age, weight, height, and the presence of other associated conditions were noted. Ultrasound examination was performed. During the surgery, the width of the linea alba was evaluated and the anatomical positioning of the insertion of rectus abdominis muscle was noted. Results:. From 2017 to 2019, 10 patients were submitted to surgery. The mean age was 27 years. All patients presented diastasis at the preoperative physical examination. Imaging examination reports showed diastasis of the rectus abdominis muscle: seven partial epigastric separations and three total separations, two of which were associated with umbilical hernia. The intraoperative findings showed the line alba with a minimum of 23 mm and a maximum of 45 mm width at 4 cm from the xiphoid process edge. The muscle borders presented a curved lateral deviation up to the insertion in the costal arches with a distance ranging from 35 mm to 60 mm. Conclusions:. This study confirms the anatomical alterations of the superior portion of the rectus abdominis muscle. The authors discuss the surgical consequences and suggest that the semiology of rectus abdominis muscle is an important preoperative action in pectus excavatum patients.

Summary:. Paraffinoma of the penis is rare and caused by paraffin liquid injection. This condition can cause significant penile deformity, ulceration, pain, and sexual dysfunction. However, it can be managed with surgical procedures to obtain normal aesthetic and functional results. Herein, we reported a 42-year-old male with penile paraffinoma who underwent excessive surgical excision of the fibrotic tissue and one-stage reconstruction using a spiral stitch full-thickness skin graft. At one year of follow-up it showed a good aesthetic outcome with no hypertrophic scars, skin contractures, penile curvature, or penile shortening. The sexual evaluation using the International Index of Erectile Function instrument also showed a good result with normal erectile function and satisfaction with sexual sensation. This case is interesting because we used the spiral stitch full-thickness skin graft technique to cover the degloving area and long-term follow-up to evaluate the aesthetic and functional results.

Summary:. Treatment of an entero-atmospheric fistula (EAF) is challenging and associated with significant morbidity and mortality. For an EAF with protrusion of mucosa, chances for spontaneous closure are minimal. Standard surgical procedures may be associated with a high risk for complications in patients with a hostile abdomen. This article describes a new method for extraperitoneal closure of an EAF in a patient with a hostile abdomen. A free segmental latissimus dorsi musculocutaneous flap was harvested on its thoracodorsal pedicle, leaving the remaining muscle innervated. The flap was anastomosed to the internal mammary vessels. The muscle was sutured into the fistula opening using a parachute technique and temporarily immobilized with a negative wound pressure device. The skin of the flap was used for monitoring and later replaced by a skin graft. The postoperative course was uneventful. At 24 months follow-up, there were no signs of recurrences. The patient had no pain and had no defecation problems. Extraperitoneal closure of an EAF with a segmental free latissimus dorsi muscle flap sutured into the fistula opening with a parachute technique may be a new promising technique in patients where standard surgical procedures are associated with too high a risk for complications and where a local pedicled muscle flap is not available. The advantages of this method are that no laparotomy is required, the intestinal lumen is not reduced in diameter, and that no bowel resection is performed, which is a particular advantage in cases with a short bowel syndrome.

Background:. Three-dimensional (3D) printing of implantable materials is a recent technological advance that is available for clinical application. The most common medical application of 3D printing in plastic surgery is in the field of craniomaxillofacial surgery. There have been few applications of this technology in other areas. Methods:. Here, we discuss a case of a large, symptomatic composite thoracic and abdominal defect resulting from the resection of a chondrosarcoma of the costal marginand sections of the abdominal wall, diaphragm, and sternum. The initial and second attempts at reconstruction failed, resulting in a massive hernia. Given the size of the defect, the contiguity with a large abdominal wall defect, and the high risk of recurrence, a rigid thoracic reconstruction was essential to durably repair the thoracic hernia and serve as a scaffold to which both the diaphragm and the abdominal mesh could be secured. A custom-made plate offered the most durable and anatomically accurate reconstruction in this particular clinical scenario. This technology was used in concert with a single section of coated mesh for reconstruction of the diaphragm, chest wall, and abdominal wall. Results:. There were no post-operative complications. The patient has improvement of his symptoms and increased functional capacity. There is no evidence of hernia recurrence 1.5 years after repair. Conclusions:. 3D printing technology proved to be a useful and effective application for reconstruction of this large thoracic defect involving the costal margin. It is an available technology that should be considered for reconstruction of rigid structures with defect-specific precision.

Summary:. We experienced a case of a sacral pressure ulcer complicated with Leriche syndrome, an aortoiliac artery occlusion that has not been previously reported. In this case, the abdominal aorta below the bifurcation of the renal arteries into the bilateral common iliac arteries was occluded, and wound healing was delayed. Therefore, endovascular treatment was used for managing this condition, and wound healing was accelerated. Then, reconstructive surgery with a local flap was performed, and wound healing was achieved. In the case of delayed healing of buttock pressure ulcers, it is important to evaluate the blood flow in the iliac artery as well as the infection and nutritional status of the wound. In addition, after endovascular treatment, blood flow in the local flap is a matter of concern. If the wound healing is good, and imaging confirms that there is no restenosis at the endovascular treatment site and the perforator of the flap, reconstructive surgery can be performed safely.

Summary:. Melkersson–Rosenthal syndrome (MRS) is a rare neuro-mucocutaneous granulomatous disorder that is likely underdiagnosed due to its variability on presentation. Few patients present with the characteristic triad of orofacial swelling, recurrent facial palsy, and lingua plicata; in fact, most patients present with only one or two of the symptoms. Additionally, patients are evaluated by a variety of specialists, including ophthalmologists, otolaryngologists, dermatologists, and plastic surgeons, depending on their particular symptom. There is no consensus standard of care for MRS due to a limited understanding of the disease. We describe a case of a patient with a 5-year history of persistent orofacial edema in the setting of Melkersson–Rosenthal syndrome refractory to medical management, who was treated with surgical debulking of the upper lip. We encourage increased clinical suspicion for Melkersson–Rosenthal syndrome when evaluating persistent orofacial edema in the plastic surgery clinic and highlight the importance of obtaining a full patient history. Surgical debulking can correct for aesthetic deformity while sparing oral function.

Background:. Oral tongue squamous cell carcinoma is the most common malignancy in the oral cavity. Overall survival varies across many countries, and poor prognosis is prevalent in developing countries, including Thailand. Our study aimed to identify prognostic factors that affected survival for oral tongue cancer in Thailand. Methods:. We performed a retrospective study of 183 patients diagnosed with oral tongue squamous cell carcinoma between January 2012 and December 2016 and who underwent multidisciplinary treatment. The disease stage was classified by tumor-nodes-metastasis (TNM) staging system. The survival outcome was calculated and represented in median survival time. Univariate and multivariate Cox proportional hazards models were used to identify factors that impacted survival outcomes. Results:. A clear margin was achieved in 88.8% of the 125 operated patients. Radiotherapy was given to 115 patients (62.84%). The survival shown in Kaplan-Meier curves was significantly lower according to advanced TNM stage, poor histologic grade, nonsurgical treatment, and patients treated with radical neck dissection. Radiotherapy was a good prognostic factor [hazard ratio (HR) 0.25, P = 0.022]. Poor prognostic factors were body mass index less than 18.5 kg per m2 (HR 3.03), vertical tumor dimension 20 mm or more (HR 5.84), non-well-differentiated grade tumor (HR 3.09), and operated cases with radical neck dissection (HR 4.29). Conclusions:. Surgical treatment can improve the survival outcome, whereas advanced stage and poor histological grading can worsen the overall survival. For oral tongue squamous cell carcinoma, radiotherapy was a good prognostic factor. On the contrary, a tumor with large vertical size, closed surgical margin, poor histologic grade, and radical neck dissection in the operated group were poor prognostic factors.

Summary:. An 18-year-old man presented with a fast-growing tumor of the right ala nasi. We excised the tumor and histology report revealed a keratoacanthoma with clear margins. After surgery, the patient was left with a composite defect of 3 × 2 cm. For reconstruction, we used an expanded prelaminated forehead flap with a durable cartilage graft from the ribcage and a turnover flap for inner lining. Our technique had a pleasing end result and excellent patient satisfaction.

Summary:. Some techniques to reconstruct the abdominal wall have been published, including the component separation procedure. The contribution of the rectus abdominis flap in the reconstruction of a giant incisional hernia is reported. The authors report three clinical cases in which the component separation technique was insufficient to reconstruct a giant midline incisional hernia. As a salvage technique, the rectus abdominis flap was dissected in the form of a hinge. The postoperative period was successful in all patients, combining both techniques. The rectus abdominis hinge flap could be used as a complementary technique to component separation to reconstruct a giant midline incisional hernia. There are several options to reconstruct the abdominal wall, such as anterior transposition of the posterior rectus sheath,1 or rotation of the anterior sheath toward the midline. This strategy is known as open book.2 The rectus turnover flap is also used.3 The anterior component separation technique closes defects less than 20 cm width.4 If it is wider, the reconstruction is more difficult. When the operative plan fails in the operating room, an additional technique should be considered. We report on the cases in which we use the rectus abdominis hinge flap.

Summary:. Axiality of lymphatic flow is possibly an important consideration for stimulating recanalization of flow between the transferred flap and the recipient site during wound healing. Antegrade lymphatic flow reconstruction has previously been reported. Here we report the first case where lymph stasis following groin lymph nodes dissection could be recanalized in a pedicled anterolateral thigh flap in which the collecting lymphatics were arranged retrograde. A 78-year-old male patient presented with bilateral lower extremity lymphedema and bilateral inguinal skin ulcers with lymphorrhea. He had been treated for rectal cancer by low-anterior resection, lymph nodes dissection, colostomy, and subsequent heavy particle radiotherapy for a local recurrence involving pelvic lymph nodes. We planned a reconstruction using a pedicled anterolateral thigh flap that included retrograde collecting lymphatic vessels, with the flap rotated as a propeller flap. The flap successfully survived and clinical symptoms of edema in both lower limbs improved during the short postoperative course. Although the collecting lymphatic vessels within the flap were arranged retrograde to the direction of the anatomical lymphatic flow at the recipient site, linear lymphatic flow consistent with the transferred flap was confirmed by lymphoscintigraphy. This case shows that the lymphatic flow may recanalize after tissue transplantation, even if the collecting lymphatic vessels in the flap are arranged retrograde to the direction of lymphatic flow.

Background:. Animal bites are common worldwide. Due to the plethora of animals, there are diverse pathogens with specific associated risks and treatment algorithms. It is crucial to understand these to develop and execute appropriate management plans. This practical review was designed to amalgamate the most common bites worldwide and synthesize data to help guide treatment plans. Methods:. A PubMed literature search was performed focusing on the major animal bites. High-level studies were preferred and analyzed but lower-level studies were also used if high-level studies did not exist. Results:. The tables presented in this article cover the pertinent information regarding the incidence, common presentation, initial treatment, and potential complications associated with bites from dogs, cats, horses, rodents, snakes, marine life, and spiders. Many of the pathogens associated with the bites are treatable with various and somewhat common antimicrobials, though some are less easy to access. Basic irrigation, debridement, and wound culture are common to almost every animal and should be the first step in treatment. Conclusions:. Based on the current studies, the most important factor in treating animal bites is timely presentation to a medical facility and/or physician. It is critical that the offending animal be accurately identified to help guide medical and surgical algorithms, including specific antimicrobial treatment guided by the most commonly presenting pathogens specific to certain animals.

Summary:. Bullous pemphigoid is an autoimmune blistering disease where patients suffer from painful bullae, often covering large portions of the skin and requiring management with immune-suppression. Our case report of recurring bullous pemphigoid illustrates the importance of considering immunosuppressive perioperative management in patients with a history of autoimmune blistering even when the disease has been quiescent for some time. With multidisciplinary care and immune suppressive therapies in the perioperative period, a free flap complicated by recurrent bullous pemphigoid can be salvaged.

Summary:. We present the interesting case of an 87-year-old woman who underwent debridement of chest wall osteoradionecrosis (ORN) that arose following radiotherapy for breast cancer. Debridement left a complex defect with exposed myocardium and parietal pleura. An extensive surgical history, compromised physiological reserve, and the patient’s desire not to undergo major reconstructive surgery limited the reconstructive options. Ultimately, a split skin graft (SSG) was applied directly to the heart and pleura to obtain wound closure. We believe this is the first report of an SSG being applied directly onto the myocardium to achieve stable soft tissue cover

Summary:. Negative pressure wound therapy (NPWT) is widely used in skin defects, active infection, and surgical reconstruction; lately, it is being used after skin graft to improve the adhesion on the receptor area. During the last decade, another indication has been identified: the use of NPTW to avoid complications after free flaps such as venous congestion and the risk of necrosis. NPWT can be used in the initial complication of a free flap, and the venous congestions can be treated with this technique, with very good outcomes. NPWT can be established as a part of a postoperative protocol in microsurgical procedures to avoid major complications.

Background:. Lymphovenous anastomosis (LVA) is an accepted microsurgical treatment for lymphedema of the upper extremity (UE). This study summarizes and analyzes recent data on the outcomes associated with LVA for UE lymphedema at varying degrees of severity. Methods:. A literature search was conducted in the PubMed database to extract articles published through June 19, 2020. Studies reporting data on postoperative improvement in limb circumference/volume or subjective improvement in quality of life for patients with primary or secondary lymphedema of the UE were included. Extracted data consisted of demographic data, number of patients and upper limbs, duration of symptoms before LVA, surgical technique, follow-up, and objective and subjective outcomes. Results:. A total of 92 articles were identified, of which 16 studies were eligible for final inclusion comprising a total of 349 patients and 244 upper limbs. The average age of patients ranged from 38.4 to 64 years. The duration of lymphedema before LVA ranged from 9 months to 7 years. The mean length of follow-up ranged from 6 months to 8 years. Fourteen studies reported an objective improvement in limb circumference or volume measurements following LVA, ranging from 0% to 100%. Patients included had varying severity of lymphedema, ranging from Campisi stage I to IV. The maximal improvement in objective measurements was found in patients with lower stage lymphedema. Conclusion:. LVA is a safe, effective technique for the treatment of UE lymphedema refractory to decompressive treatment. Results of LVA indicate greater efficacy in earlier stages of lymphedema before advanced lymphatic sclerosis.

Summary:. From early on in the development of plastic surgery, it was quickly realized that utilizing locally adjacent tissue, or “matching like with like,” yielded superior aesthetic reconstructions to those in which the tissue was derived from a distant location. In many cases, the use of a local perforator flap is a simpler procedure with less patient morbidity and a quicker recovery from surgery. The difficulty with local perforator flaps has been locating the supplying perforators, ensuring that the flap has a robust and reliable blood supply, and that sufficient tissue is able to be transferred. The recent reappraisal of our understanding of the blood supply of the integument has allowed, for the first time, the capacity to accurately and inexpensively, without the need for “high tech equipment,” locate perforators, as they emerge from the deep fascia into the overlying integument, and through a better understanding of the interconnecting anastomotic vessels between perforators reliably predict how much tissue can be safely raised on a single perforator, before surgery. Further, through the use of strategic “delay,” it is possible to manipulate the interconnecting vessels between the selected perforator and its surrounding neighbors to design a flap of tissue of any dimension, composed of whatever tissue we require, and safely transfer that tissue locally, or if required, distantly, as a free flap. This article will highlight these advances, explain their relevance in raising reliable local perforator flaps, and will, where possible, call attention to any pearls and pitfalls, and how to avoid complications.

Summary:. Replacing an infected prosthetic thoracic aorta graft carries a high re-infection risk. We previously reported two clinical cases successfully treated with a new muscular wrapping technique: latissimus dorsi (LD) muscle flap with a distally based serratus anterior (SA) extension; however, a cadaveric study to prove the regular existence of the distal attachment area was lacking. We tried to establish an appropriate way of elevating the combined muscle flap safely. All of the cadavers were preserved using the Thiel embalming technique to retain flexibility. We checked for the existence of the distal attachment area between the LD and SA. Combined muscle flaps were elevated proximally while identifying the thoracodorsal artery, including the LD and SA branches. After the SA branch was ligated and cut, the SA muscle was manually peeled from the LD muscle with only the distal tight attachment area remaining. Contrast-enhanced computed tomography was performed using a multislice computed tomography system. Six human cadavers (three men, three women: 91 years old, on average) were examined. All six LD and SA combined muscle flaps showed a distal tight attachment area at the level from the seventh rib to the ninth rib. The tip of the SA muscle easily reached the sternum. Contrast-enhanced computed tomography failed to reconfirm the distal vascular flow from the LD to the reverse SA muscle, which we had visualized in a clinical case. We demonstrated the anatomical reliability of the new Y-shaped muscular flaps, which are suitable for preventing re-infection of aortic graft replacement.

Summary:. Negative pressure therapy has been utilized in the treatment of open and closed wounds to increase blood flow and improve wound healing. More recently, external negative pressure has been shown to induce a noninvasive delay phenomenon in animal models by increasing vessel size and density within a planned flap, leading to improvement in flap survival. Although successful in animal models, this new method of delay has not been demonstrated in clinical practice. We present our initial experience with preoperative external negative pressure delay of free anterolateral thigh flaps in upper extremity reconstruction to detail the technique and safety profile of this innovative new technique. External negative pressure delay has the potential to provide results similar to those of traditional surgical delay, while being cost effective, safer, and more convenient for patients. More research is needed to investigate the clinical benefit and cost effectiveness of external negative pressure delay.

Background:. Prosthetic vascular graft infection is a serious complication associated with significant morbidity and mortality often requiring graft excision and numerous additional operations. Pedicled flaps are often used for the coverage of exposed deep tissue or hardware for graft salvage. In the absence of pedicled options, the properties of omentum make it an excellent choice for free flap tissue coverage, particularly in cases involving implanted prostheses. Methods:. A 63-year-old woman developed a mycotic right subclavian arterial aneurysm requiring ligation and extra-anatomic bypass grafting to restore right-sided intracranial and right upper extremity arterial perfusion. Subsequent wound breakdown and poor healing left the grafts exposed, resulting in contamination. Given the profound risks associated with graft excision in this patient, salvage was attempted with IV antibiotics, serial wound/graft washouts, and graft coverage with an omental free flap. Results:. The patient tolerated the procedure well. The remainder of her hospital course was uneventful, and she was discharged home in good clinical condition. She will remain on long-term suppressive antibiotics per Infectious Disease recommendations. Conclusions:. Contemporary literature reporting novel and effective applications of omental free flap coverage is rare. This report demonstrates that omental free flap coverage is safe and can provide healthy tissue to protect implanted grafts and even aid in the salvage of infected extra-anatomic bypass grafts.

Summary. We report our positive experience on the treatment of a patient with a composite facial maxillary defect. The stoma was formed following the removal of the adenoid cystic carcinoma of the maxillary sinus. We propose reconstruction repair of the postoperative facial maxillary defect using an inverted cutaneous flap and a split-thickness skin graft.

Summary. Small-to-medium cutaneous defects of the distal nose pose a significant challenge to reconstructive surgeons, and commonly described reconstructive techniques have their limitations. As the skin of this region is characteristically rigid and sebaceous, care must be taken to avoid introducing unfavorable tension vectors that can result in functional or anatomic distortion of the nasal free margins. With this in mind, the authors discuss 3 alternative reconstructive options, the East-West, nasalis sling, and trilobed flaps, which have wide utility in the repair of distal nasal cutaneous defects and can result in excellent cosmesis. The indications, surgical technique, and limitations of each are discussed in detail, and are compared with several of the more commonly described options in the context of distal nasal reconstruction.

Summary. The paramedian forehead flap is a historic cornerstone of plastic surgery and a mainstay of complex nasal reconstruction. Although initially described as a 2-stage procedure, several procedural advancements and modifications have been proposed, with the most notable being the addition of a third, intermediate stage. Proponents of this 3-stage approach argue that the addition of an intermediate stage improves flap perfusion, expands lining and structural support options, and provides superior aesthetic outcomes. Although this technique has grown in popularity, studies comparing the 2- versus 3-stage approach are relatively scarce in the literature. Existing comparative studies seem to suggest that the 3-stage paramedian forehead flap may have advantages in large, complex nasal defects and patients at high risk for vascular compromise. Additionally, comparative analyses with respect to aesthetic outcome were found to be largely equivocal, suggesting that surgeon comfort and preference should guide flap selection.

Background:. Although abdominally based flaps continue to be the gold standard for autologous breast reconstruction, alternative donor sites are necessary when the abdominal region is unavailable or inadequate for flap harvest. In this case, thigh-based flaps, such as the profunda artery perforator (PAP), transverse upper gracilis (TUG), or newly described TUGPAP, are thought to be reliable with low morbidity and satisfactory cosmesis. The objective of this study was to perform a systematic review of breast reconstruction with PAP, TUG, or TUGPAP, and present anatomy and surgical techniques through illustrative examples. Methods:. A systematic review of the literature was conducted using PubMed, Embase, and Cochrane Library. Articles were included if they used a PAP, TUG, or TUGPAP flap for oncologic, traumatic, or congenital breast reconstruction in patients 18 years or older. Results:. Forty-nine studies met inclusion criteria. Seven hundred five patients underwent 906 breast reconstructions with 1037 flaps (755 TUG, 230 PAP, and 52 TUGPAP). Mean patient age was 45.9 years. The mean flap weight for TUG, PAP, and TUGPAP flaps were 323.4, 346.9, and 437.0 g, respectively. The most common recipient vessel was the internal mammary artery in 821 flaps. The overall flap survival rate was 97.2% (1008/1037). TUG flaps had a significantly higher recipient and donor complication rate compared with both PAP (recipient: 18.1% versus 7.8%, P = 0.0001; donor: 25.8% versus 7.0%, P < 0.00001) and TUGPAP flaps (recipient: 18.1% versus 2.0%, P < 0.001; donor: 25.8% versus 7.7%, P < 0.01). Conclusion:. The TUGPAP flap is a safe and effective alternative for autologous breast reconstruction when the abdominal donor site is unavailable.

Background:. Although a local flap repair is optimal for facial defects, an extra flap or split-thickness skin graft may be needed if a sufficient local flap area is not available. In this study, we developed a distant axial pedicle flap procedure based on the inner transverse perforator of the ascending frontal branch of the superficial temporal artery to repair facial defects while meeting patients’ requirements for a like-for-like tissue reconstructive outcome. Methods:. For defect repair after facial tumor removal, we designed upper frontal facial pedicle flaps based on the inner transverse perforator of the ascending frontal branch of the superficial temporal artery. Facelift procedures were applied concomitantly for donor site repair. Results:. We applied the procedure to 12 patients who underwent curative lesion resection. Notably, all flaps survived. Venous congestion developed in only 1 case, in which the wound was covered with heparin sodium gauze to inhibit wound coagulation until the congestion gradually resolved. In all cases, the frontal donor site scars were adjacent to the hairline and were concealed very well by hair growth. During postoperative follow-ups of 8–43 months, the patients experienced only minor complications. Conclusions:. The flap based on the inner transverse perforator of the ascending frontal branch of the superficial temporal artery is a useful alternative for facial defect repair surgery. The low incidence of complications and easy concealment of the donor site underscore the safe and aesthetically acceptable nature of the procedure.

Supplemental Digital Content is available in the text., Background: Vaginoplasty aims to create a functional feminine vagina, sensate clitoris, and labia minora and majora with acceptable cosmesis. The upward trend in the number of transfemale vaginoplasties has impacted the number of published articles on this topic. Herein, we conducted an updated systematic review on complications and patient-reported outcomes. Methods: A update on our previous systematic review was conducted. Several databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were assessed. Random effects meta-analysis and subgroup analyses were performed. Results: After compiling the results of the update with the previous systematic review, a total of 57 studies pooling 4680 cases were included in the systematic review, and 52 studies were used in the meta-analysis. Overall pooled data including any surgical technique showed rates of 1% [95% confidence interval (CI)

Background:. Cannabis use is increasingly prevalent. Cannabinoid receptors regulate pro-inflammatory cytokines, and compounds in marijuana exert diverse physiologic effects. As more patients use cannabis, clinicians should recognize implications of perioperative cannabis use. Although the role of cannabis use in perioperative pain control has been explored, little is known about its effect on perioperative wound healing or on hematologic, pulmonary, and cardiovascular physiology. Methods:. We searched PubMed for English-language articles related to cannabis (ie, marijuana, cannabidiol oil, and tetrahydrocannabinol) and wound healing, cardiovascular, pulmonary, or hematologic outcomes, and surgery. Titles and abstracts were reviewed, and relevant articles were analyzed. Human, animal, and pathology studies were included. Editorials, case reports, and review articles were excluded. Results:. In total, 2549 wound healing articles were identified; 5 human studies and 8 animal/pathology studies were included. Results were conflicting. An estimated 2900 articles related to cardiovascular effects were identified, of which 2 human studies were included, which showed tetrahydrocannabinol and marijuana caused tachycardia. A total of 142 studies regarding pulmonary effects were identified. Three human studies were included, which found no difference in respiratory complications. In total, 114 studies regarding hematologic effects were identified. The 3 included human studies found conflicting venous thromboembolism risks. The overall study quality was poor. Information about dose/duration, administration route, and follow-up was reported with variable completeness. Conclusions:. Surgeons should consider effects of cannabis in the perioperative setting. Little is known about its perioperative effects on wound healing, or on cardiovascular, pulmonary, and hematologic physiology. Further research should elucidate the effects of administration route, dose, and timing of cannabis use among surgical patients.

Summary:. The coronavirus disease 2019 posed an unprecedented strain to plastic surgery services. The scarcity of validated guidelines—at the beginning of this healthcare crisis—to direct clinical, ethical, transparent decision-making for head and neck cancer patients requiring palliative reconstructive surgery was a difficult situation. We report a 15-year-old girl with an advanced chemoresistant rare radiotherapy-induced mandibular osteosarcoma during the early phase of the pandemic in the United States in mid-March 2020, when official recommendations for triage were still developing. Local guidelines suggested canceling all elective procedures, and allowed operating emergency and/or nonelective cases only. Many surgeons declined surgery due to patient’s poor prognosis and high perioperative risk, but her mother pursued different professional opinions elsewhere. However, upon Beaumont hospital approval, the patient underwent radical en bloc resection of the tumor, hemimandibulectomy, zygomatic resection, maxillectomy, and hemipalate resection followed by reconstruction with free fibula osteocutaneous and anterolateral thigh flaps. The challenging decision to proceed with surgery was based on evidence-based and objective risk-stratifying scores, available at the time, and ethical recommendations from emerging reliable published literature. Despite a favorable postoperative outcome, the patient expired due to cardiac complications of the disease. Our patient taught us that ethical decision-making, sound clinical judgment, and a patient-centered individualized approach remain pivotal aspects of the medical profession. Although the surgery will not provide a cure for the disease, we have found that palliative reconstructive surgery can greatly improve patient’s quality of life, and help family cope with the advancing stages of disease.

Background:. Every day, we see more patients present to hospitals and clinics seeking gender-affirmation care to ameliorate the symptoms of gender dysphoria. However, to provide a multidisciplinary approach, it is important to offer an integrated clinical program that provides mental health assessment, endocrine therapy, physical therapy, research, and the full spectrum of surgical services devoted to transgender patients. This article describes our experience on building a specialized, multidisciplinary, academic state-of-the-art gender-affirmation program. Methods:. Herein, we describe the main and critical components on how to build a multidisciplinary academic gender-affirmation program. We share our lessons learned from this experience and describe how to overcome some of the obstacles during the process. Results:. Building a multidisciplinary academic gender-affirmation program requires an invested team, as each and every member is essential for feedback, referrals, and to improve patient’s experience. Institutional support is essential and by far the most important component to overcome some of the obstacles during the process. Having all team members working under the same institution provides all the critical components needed to improve outcomes and patient satisfaction. In addition, the collection of prospective data with a well-structured research team will provide information needed to improve clinical services and standardize clinical protocols, while leaving space for innovation. Conclusions:. This article describes the steps and experience needed to build a multidisciplinary holistic academic gender-affirmation program. We provide our lessons learned during the process that will help guide those who intend to start an academic gender-affirmation program.

Background:. Closed incision negative pressure therapy (ciNPT) has been shown to improve wound healing for patients at high risk for wound complications. Current devices consist of opaque interface dressings that do not allow ongoing visual evaluation of the surgical incision and utilize a negative pressure of −80 mm Hg to −125 mm Hg. The Negative Pressure Platform Wound Dressing (NP-PWD) was developed to address these aspects. This case series is the first evaluation of the NP-PWD in a clinical setting. Methods:. Patients aged 18–85 undergoing an operation with an anticipated incision and primary closure were screened. Demographics, comorbidities, and operation performed were recorded. Following closure, the incision was measured and photographed before NP-PWD placement. The NP-PWD was removed at the first postoperative check (POC) between postoperative days (PODs) 3–5. Subjects were followed until PODs 9–14. POCs consisted of incision assessment, measurement, photography, and adverse event monitoring. Results:. A total of 8 patients with 10 incisions were included in the study. Five patients were men. Median age was 56 years (IQR 53–74 years). All incisions were intact and without inflammation or infection at all POCs. Three adverse events, including small blisters and interruption of therapy, were noted. Conclusions:. This case series reports that patients tolerated the NP-PWD on closed surgical incisions well and that all incisions were intact without evidence of inflammation or infection after 2 weeks of follow-up. Future controlled, clinical studies should further examine the safety and efficacy of the use of the NP-PWD.

Background: Lymphedema is defined as a chronic condition, caused by lymphostasis. A major part in the Western world consists of iatrogenic lymphedema caused by surgery to the lymph nodes of the axilla or groin. Prophylactic lymphovenous anastomosis (LVA) could be beneficial in the prevention of lymphedema of the extremities. These procedures require experienced supramicrosurgeons and can be time consuming, which might be the reasons why prophylactic LVA has not yet been widely implemented in the treatment of cancer. Due to the small diameter of lymphatic vessels, it remains challenging to identify the lumen, and therefore, anastomoses are prone to back wall stitching. Different inventive procedures have been described making use of stents or monofilament sutures. Methods: In this article, we describe a newly developed and straightforward technique for LVA in 4 patients who underwent an axilla dissection and 1 patient who underwent a dissection of the groin lymph nodes. This latter approach makes use of clipping of the lymphatic vessel during lymph node dissection, and remains ligated during anastomosis. The candidate vein was the V. thoracodorsalis for the axilla and the V. circumflexa superficialis for the groin. We describe the feasibility, average duration, and complications. Results: Performing an end-to-side anastomosis on a clipped lymphatic vessel minimizes the problem of back wall stitching as well as the trouble of finding the lumen due to collapsing of the vessel. The turgor of the lymphatic vessel is maintained and makes anastomosing easy. Average time for LVA was 33.4 minutes and 1 minor complication was seen. Conclusion: We believe that this approach might be of value in popularizing LVA in the treatment or prevention of different conditions such as breast cancer-related lymphedema.

Summary:. Soft tissue defect reconstruction at joint regions is a challenging problem due to the sparse excessive tissue and late complication of constrigent scar formation. Priorly irradiated tissue, often the case in sarcoma patients, is especially problematic. The keystone design perforator island flap is safe and reliable. We now present a new keystone flap design, which is particularly suitable for the reconstruction of large soft tissue defects at joint regions. It provides a cutaneous component without the need for a skin graft and therefore minimizes the risk of contracture. Donor site morbidity is negligible. Furthermore, it offers a favorable aesthetic result compared to other flaps, eg, a muscular flap. We propose a new keystone flap design as an extension of Behan's classification, the Keystone flap type IIIb.

Trichiasis is an acquired condition in which eyelashes are misdirected toward the ocular surface, resulting in eye irritation and ocular morbidities. Different treatment modalities have been described, including surgical and non-surgical methods. The goal of this article is to present a novel technique for treatment of trichiasis, with a brief review of treatment options. Through a supratarsal incision, each misdirected eyelash follicle root was reached and freed from surrounding tissues by meticulous dissection. Then, hair shafts on the lid margin were redirected upward and glued to 2 bars extending horizontally across the upper eyelid. Two years after operation, the corrected eyelashes maintained their normal upward direction. To the best of our knowledge, this is the first reported case of chronic trichiasis treated by this technique. The main advantage of the technique, unlike most of the other treatment methods, is that follicles of the affected eyelashes are not removed or destroyed, which is appreciated from the aesthetic point of view, especially in female patients. We believe that any plastic surgeon with basic knowledge of blepharoplasty and hair transplantation can perform this technique without much difficulty. So far, there is no recurrence; however, long-term follow-up with a large series of patients is required for drawing better conclusions., NA

Background:. Chronic facial paralysis can lead to significant functional and psychosocial impairment. Treatment often involves free muscle flap-based facial reanimation surgery. Although surgical techniques have advanced considerably over the years, consensus has yet to be reached for postoperative outcome evaluation. To facilitate outcome comparison between the various techniques for free muscle-flap-based reanimation, a standardized, widely accepted functional outcomes assessment tool must be adopted. Methods:. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review of the PubMed, Cochrane, and Embase databases to identify the reported functional outcome measurement tools used in the free muscle flap-based reanimation literature. Results:. The search yielded 219 articles, 43 of which met our inclusion and exclusion criteria. We noted an increase in publications reporting the utilization of objective measures over time, particularly software-based tools, as well as increased utilization of patient reported outcomes measures. Conclusions:. Based on the trends identified in the literature, we suggest standardization of outcome measures following facial reanimation surgery with free muscle-flap using a combination of the Facial Assessment by Computer Evaluation (FACEgram) software and the Facial Clinimetric Evaluation (FaCE) Scale.

Background:. The clinical assessment of indeterminate burn wounds has relatively poor accuracy. Indocyanine green angiography (ICGA) has high accuracy and can be used to mark wounds precisely so as to guide burn excision. This study aimed to assess the differences between ICGA and clinical assessment marking and compare the marking result with the long-term wound outcome. Methods:. This was a prospective, multicentered, triple-blinded, experimental study. Indeterminate burn wounds were clinically assessed, and the area to be excised was firstly marked by the attending surgeon. ICGA marking was then performed by a second surgeon. Measurement of the marked area was conducted by a third surgeon. Three surgeons were each blinded to the others' processes. The wounds were followed up to assess complete wound closures on day 21. Results:. There were 20 burn sites included in the study. There was a significant difference in the marked areas between clinical assessment and ICGA (mean, 57.3 ± 44.1%; P = 0.001). The maximum difference found was as high as 160.9%. The correction rate of ICGA marking to complete wound closure on day 21 was 95.0%. Over 90% of the decreased areas of excision—which were assessed by ICGA to be superficial burns but evaluated by clinical assessment to be deep burns—were completely healed on day 21. Conclusions:. ICGA contributes to a significant difference versus clinical assessment in the marking for excision of indeterminate burns and strongly associates with long-term wound outcomes. The burn wounds can be assessed precisely to reduce unnecessary excision and prevent inadequate excision.

Background:. Injuries to the long thoracic nerve, which directly branches off of the C6, C7, and C8 brachial plexus nerve roots, can cause scapular winging and affect shoulder movements. Long thoracic nerve injuries resulting from accidents, violence, or overuse can be severe lesions requiring challenging surgeries. We evaluated the long-term functional outcomes of neuroplasty and the scalene muscle resection procedures in patients with long thoracic nerve injury and winging scapula. Methods:. All 15 patients who underwent scalene muscle resection with decompression and neurolysis of the long thoracic nerve in a single institution to treat winged scapula and limited shoulder movements between March 2007 and May 2020 with follow-up over 2 years were included in the study. Results:. Shoulder abduction and arm flexion improved significantly to 158 ± 52 degrees and 165 ± 53 degrees from a mean of 108 ± 54 degrees and 104 ± 52 degrees (P < 0.02) over 2 years after surgery (mean 3.4 years). Overall, there was a significant reduction in the scapular winging, as assessed by estimating the decrease in the angle between the scapular plane and the posterior chest wall. The extent of the score greatly improved post-surgically from a mean of 1.2 ± 0.4 to 3.5 ± 0.9 (range 1–4; 1—severe, 2—moderate, 3—mild, and 4—minimal) (P < 0.01). Conclusion:. The improvement in shoulder movements and reduced scapular winging was significant and stable over 2 years of surgery in 81% of our study patients.

Summary:. Celiac artery (CA) occlusion, or stenosis, is not uncommon, and most cases are asymptomatic. If the CA is occluded, collateral circulation from the superior mesenteric artery (SMA) is maintained through the pancreaticoduodenal arcade. However, the pancreaticoduodenal arcade is removed if pancreaticoduodenectomy (PD) is performed, which results in ischemia of the liver, stomach, and residual pancreas. Thus, these patients require CA revascularization, which can include antegrade endovascular reconstruction and retrograde reconstruction using vascular anastomosis from the SMA system to the CA system. Both methods carry risks of restenosis or anastomotic thrombosis. We report a technique that involves a combination of both revascularization methods in an 89-year-old man who underwent PD for lower bile duct cancer. Preoperative endovascular stent placement in the CA preserved antegrade blood flow to the liver, and intraoperative vascular anastomosis of the jejunal artery and right gastroepiploic artery achieved retrograde blood flow. Although we confirmed both stent and anastomosis patency and blood circulation in our case, obstruction of 1 of these revascularization pathways would not likely lead to ischemia of the liver. Thus, our 2-way revascularization technique for managing celiac artery stenosis during PD may reduce the risk of organ ischemia.

Summary:. Recent studies have provided evidence that lymphovenous bypass—microsurgical re-routing of divided lymphatics to an adjacent vein—performed at the time of lymph node dissection decreases the rate of lymphedema development. Immediate lymphatic reconstruction in this setting is technically demanding, and there is a paucity of literature describing the details of the surgical procedure. In this report, we review the literature supporting immediate lymphatic reconstruction and provide technical details to demystify the operation for surgeons who wish to provide this option to their patients.

Summary:. Vascularized omentum lymphatic transplant is frequently used for the treatment of lymphedema due to demonstrated efficacy, a reduced complication profile, and, in particular, negligible risk of donor site lymphedema. Historically harvested by open laparotomy, more recent techniques involve laparoscopic omental harvest. Although effective and reproducible, laparoscopy may be limited by reduced visualization, minimal tactile feedback, multiple port sites, and imprecise instrumentation. Therefore, we employed the da Vinci Single-Port (SP) surgical robot system for vascularized omentum lymphatic transplant. A 52-year-old man with a 3-year history of progressive left lower extremity swelling and lymphoscintigraphy and magnetic resonance lymphangiogram consistent with lymphedema of unknown etiology underwent vascularized omentum lymphatic transplant to the left groin. A 2.5-cm infraumbilical incision was used for placement of the primary trocar, through which the camera and operating instruments were passed. Following robotic harvest, the omental lymph node flap was transferred to the left groin for microsurgical anastomosis. The procedure was uneventful, and the patient was discharged on postoperative day 1. At 6 weeks, there were no complications. Here, we show for the first time the safety and feasibility of robotic omental lymph node flap harvest for extremity lymphedema using the da Vinci Single-Port robotic system. The benefits of this technology include a minimally-invasive approach that allows for flap dissection and removal through a single 2.5-cm incision. Further investigation is necessary to characterize the indications and limitations of this technique in plastic surgery.

Background:. The COVID-19 pandemic has brought seismic shifts in healthcare delivery. The objective of this study was to examine the impact of telemedicine in the disadvantaged population. Methods:. All consecutive patients with outpatient appointments amongst 5 providers in the Plastic and Reconstructive Surgery Department between March 2, 2020, and April 10, 2020, were retrospectively reviewed. Appointment and patient characteristics collected include visit modality, reason for visit, new or established patient, history of recorded procedure, age, sex, race, insurance provider, urban/rural designation of residence, Social Vulnerability Index, and income. The primary outcome of interest was whether or not a patient missed their appointment (show versus no-show). Results:. During the study period, there were a total of 784 patient appointments. Before the COVID-19 pandemic, patients with a higher Social Vulnerability Index were more likely to have a no-show appointment (0.49 versus 0.39, P = 0.007). Multivariate regression modeling showed that every 0.1 increase in Social Vulnerability Index results in 1.32 greater odds of loss to follow-up (P = 0.045). These associations no longer held true after the lockdown. Conclusions:. This study indicates a reduction in disparity and an increase in access following the dramatically increased use of telemedicine in the wake of the COVID-19 pandemic. Although drawbacks to telemedicine exist and remain to be addressed, the vast majority of literature points to an overwhelming benefit—both for patient experience and outcomes—of utilizing telemedicine. Future studies should focus on improving access, reducing technological barriers, and policy reform to improve the spread of telemedicine.

Background:. Facial transplantation (FT) is recognized as the ultimate reconstruction for severely disfigured patients. The substantial cost of these procedures in a nationalized health system has not been extensively published. The first Canadian FT performed in May 2018 was a great opportunity to address this subject and evaluate the viability of such a program. Methods:. A detailed patient chart review was performed and a cost per unit approach was used to estimate the procedure cost. The preoperative, operative, and the postoperative periods up to 1-year after the surgery were analyzed. Financial support from private sponsors and Hospital Fund donations were considered. The literature on international FT and national solid organ transplantation was reviewed. Results:. The overall 1-year cost was estimated at $440,224 (2018 CAD). The costs are explained by a long hospital length of stay, costly immunosuppressive therapy, and high immunosuppression-related complications. Those findings are consistent with international FT literature. The societal impact of the surgery was minimized with a $36,921 (2018 CAD) grant obtained from an external contributor. Interestingly, the hospital foundation sustained a 794% increase in donations ($1,787,148; 2019 CAD) the year following the surgery. Conclusion:. Our experience confirmed that the combination of private funding, with positive goodwill and hospital donations, is a workable model for innovative surgery in the setting of a nationalized health system with financial restrictions.

Background: Our objective was to analyze whether a correlation could be observed between preoperative factors and microvascular lymph node transfer outcome after long-term follow-up. Methods: We included 67 patients in this retrospective case series. The incidence of cellulitis, the difference of arm circumference, the use of the compression garments both preoperatively and postoperatively, and subjective symptoms, such as pain, were analyzed. Volumetry and lymphoscintigraphy results were also analyzed in a subgroup of patients. We correlated preoperative factors with postoperative results. Results: After 70 +/- 17 months of follow-up, 42% of the patients were able to discontinue the use of compression garments. The subjective pain symptoms were reduced in 75% of the patients. The incidence of cellulitis was reduced from preoperative 0.20 +/- 0.55/y to postoperative 0.02 +/- 0.08/y. As a novel finding, the patients with preoperative cellulitis were more likely to continue the use of the compression garments. Conclusions: The surgery is beneficial to most studied lymphedema patients, although it is not the cure for all patients. The incidence of cellulitis was reduced, and further, the presence of preoperative cellulitis seems to affect the outcome of the operation.

Summary:. Few studies have evaluated vascularized nerve grafts (VNGs) for facial nerve (CNVII) reconstruction. We sought to evaluate long-term outcomes for CNVII recovery following reconstruction with VNGs. A retrospective review of all patients at a tertiary centre who underwent radical parotidectomy and immediate CNVII reconstruction with VNGs was performed (January 2009–December 2019). Preoperative demographics, perioperative factors (flap type, source of VNGs), and postoperative factors [complications, adjuvant therapy, revisionary procedures, length of follow-up, and CNVII function via the House-Brackmann scale (HB)] were collected. Data were summarized qualitatively. Twelve patients (Mage = 53 ± 18 years) with a mean follow-up of 33 (± 23) months were included. Six patients underwent reconstruction with a radial forearm flap and dorsal sensory branches of the radial nerve. Six patients underwent reconstruction with an anterolateral thigh flap and only deep motor branches of the femoral nerve to the vastus lateralis (n = 4) or combined with the lateral femoral cutaneous nerve (n = 2). Two patients regained nearly normal function (HB = 2). Eight patients regained at least resting symmetry (HB = 3 for n = 7; HB = 4 for n = 1). One patient regained a flicker of movement (HB = 5). One patient did not regain function (HB = 6). Six patients had static revision procedures to improve symmetry. Five patients had disease recurrence; 3 died from their disease. VNGs offer a practical and viable addition to the CNVII reconstruction strategy, and result in good functional recovery with acceptable donor site deficits. The associated adipofascial component of these flaps can also augment the soft tissue defect left after tumor ablation.

Summary:. Patients with end-stage temporomandibular joint (TMJ) pathology present with loss of vertical ramus height with resulting retrognathia, anterior open bite, and restricted jaw function requiring joint reconstruction. Costochondral grafts, long considered the gold standard for TMJ reconstruction, carry risks of bony ankylosis and resorption. Custom-made alloplastic TMJ prostheses show excellent objective and subjective outcomes but are also associated with complications such as infection or metal sensitivity, and necessitate hardware explantation in some cases. Revision surgeries are rare but present a real challenge. We present the case of a 50-year-old woman with longstanding TMJ arthritis, having undergone many surgical procedures to her TMJ, including explantation of failed alloplastic replacement, who presented with bilateral facial weakness as well as difficulty chewing and swallowing food. She had class II malocclusion with retrodisplacement of her mandible and anterior open bite, and moderate trismus with an inter-incisal opening of only 15 mm, consistent with fibrous ankylosis. After weighing all the reconstructive options, bilateral mandibular condyle and ramus reconstruction with a single fibula free flap (FFF) was planned with the use of preoperative virtual surgical planning (VSP) and 3D-printing of osteotomy and repositioning guides. A 2-team approach increases efficiency of the procedure and decreases operative time. The procedure and postoperative recovery were uncomplicated, and at her 2-month follow-up, she had increased range of motion and maintained the planned position of her mandible. Her masticatory function and deglutition were also improved due to the correction of her malocclusion and repair of her anterior open bite.

Background:. Within the past decade, poly-4-hydroxybutyrate (P4HB) biosynthetic mesh has been introduced as a potential alternative to traditional biologic and synthetic mesh in ventral hernia repair (VHR). The aim of this study was to systematically assess clinical outcomes with the P4HB in VHR. Methods:. A literature search identified all articles published in 2000 involving the use of P4HB in VHR. Descriptive statistics were used to synthesize collective data points, including postoperative outcomes. A pooled analysis of postoperative outcomes was performed using chi-square test and Fisher exact test. Results:. Across 7 studies, the P4HB was used in 453 patients. The mean rate of surgical site infection (SSI) was 6.8% (31/453), reoperation 10.7% (30/281), and recurrence 9.1% (41/453). At an average follow-up of 26.8 months, the incidence of recurrence was 10.4% (28/270). Onlay was significantly associated with increased recurrence (14.2% versus 4.4%, P = 0.001). Among sublay placements, there was no difference in recurrence in clean (Center for Disease Control [CDC] 1) or contaminated (CDC >1) wounds (2.7% versus 6.1%, P = 0.585), but contaminated wounds were associated with increased SSI (2.7% versus 15.2%, P = 0.028). Ventral Hernia Working Group grade 2 and 3 did not have different incidences of recurrence (8.0% versus 5.1%, P = 0.526) nor SSI (5.1% versus 14.6%, P = 0.265). Conclusions:. Overall, clinical outcomes of the P4HB mesh in VHR are acceptable. The P4HB mesh serves as a reliable alternative to traditional synthetic and biologic mesh across a range of defect characteristics and patient health conditions. Further research is needed to better understand the conditions in which it may provide a clinical benefit over traditional mesh types.

Background:. Pilonidal sinus is a chronic recurrent medical disease. The exact etiology of the disease is still unknown, but the most accepted theory is an acquired condition characterized by infected sinus in the natal cleft area containing a lifeless hair tuft. Multiple techniques were prescribed for its treatment; however, the ideal method is not yet defined. Methods:. The study population includes 58 male patients who underwent excision of their recurrent pilonidal sinus, and the resulting defects were reconstructed using combined horizontal split gluteus maximus flaps and rhomboid flaps. Outcomes were revised from patient case files and followed up in our outpatient clinic and via questionnaires. Results:. The mean hospital stay was 3 days. The mean time to return to work was 16 days. Partial wound dehiscences occurred in 2 patients. Distal end flap necrosis occurred in 1 patient. There were no flap losses, no recurrences, no infections, no loss of function, and no seromas during a mean follow-up period of 24 months. All patients were satisfied with the results. Conclusions:. This technique has an operative time and hospital stays comparable to those of other techniques. It has minimal and acceptable complication rates and no recurrences. We can conclude that this procedure of combined split gluteus maximus muscle flap and rhomboid flap provides an excellent, effective, easy, and feasible method of choice for reconstructing defects of recurrent pilonidal sinus disease.