Vijayasekaran, Aparna

ABSTRACT The deep inferior epigastric perforator (DIEP) flap remains the preferred flap option for autologous breast reconstruction following mastectomy. This case report presents the novel use of the cephalic vein (CV) as an interposition graft to alleviate venous congestion in a patient undergoing DIEP flap reconstruction. A 42‐year‐old woman experienced venous congestion following her initial autologous reconstruction, attributed to thrombus formation from kinking of the vascular pedicle. Despite initial attempts to resolve the congestion, the condition persisted. Since the flap was based on a single perforator, we decided to attempt a CV turndown. The CV was noted to be attenuated and not feasible for use in turndown; therefore, venous salvage was completed by using the CV as an interposition graft to bypass the affected flap vena comitans. The procedure successfully restored venous flow, allowing for flap salvage and subsequent healing. This case underscores the potential of CV as an interposition graft in autologous breast reconstruction, particularly when traditional CV turndown is not possible due to vessel attenuation.

AbstractIntroductionReconstruction of abdominal wall defects with enterocutaneous fistulas (ECF) remains challenging. The purpose of this report is to describe a single‐stage approach using combined microscopic enterolysis, pedicle seromuscular bowel flaps, mesh, fasciocutaneous, and myocutaneous flaps.MethodsBetween 1990 and 2016 a retrospective review identified a total of 18 patients with an average age of 39 years (ranging 26–59 years). Thirteen cases were associated with trauma, four were complication of previous mesh repair, and one was after an aortic dissection. Average diameter of defect size was 22 cm (ranging 20–24 cm). Surgical technique involved enterolysis using microscope magnification, a pedicle seromuscular bowel flap to reinforce the bowel anastomosis, mesh, musculocutaneous, and fasciocutaneous flaps to reconstruct the abdominal wall.ResultsFifteen patients required rotational flaps with an average skin paddle area of 442.7 cm2 (ranging 440 cm2–260 cm2) and 10 patients required a serosal patch with an average length of 5 cm (ranging 4–6 cm). Complications included three wound dehiscence and one abdominal wall bulging. Flap survival was 100%. The majority of patients (12 out of 18) were able to resume normal activities, and the remaining (n = 6) were able to resume most activities. Functional outcome as assessed by 36‐Item Short Form Survey (SF‐36) physical function component questionnaire at 18–24 months follow up was 67.8% (ranging from 59 to 72%). Mean length of hospital stay was 2.2 weeks (ranging 1.4–2.7 weeks). Mean follow‐up was 24 months (ranging 22–26 months) with clinical examination.ConclusionMicroscopically assisted intra‐abdominal dissection with resection of diseased bowel, replacement with well‐vascularized tissue at the anastomosis site in, and reinforcement with mesh combined with pedicle musculocutaneous and fasciocutaneous flaps may be an alternative when other local reconstructive options have failed.

Early soft‐tissue coverage is critical for treating traumatic open lower‐extremity wounds. As free‐flap reconstruction evolves, injuries once thought to be nonreconstructable are being salvaged. Free‐tissue transfer is imperative when there is extensive dead space or exposure of vital structures such as bone, tendon, nerves, or blood vessels. We describe 2 cases of lower‐extremity crush injuries salvaged with the quad flap. This novel flap consists of parascapular, scapular, serratus, and latissimus dorsi free flaps in combination on one pedicle. This flap provides the large amount of soft‐tissue coverage necessary to cover substantial defects from skin degloving, tibia and fibula fractures, and soft‐tissue loss. In case 1, a 51‐year‐old woman was struck by an automobile and sustained bilateral tibia and fibula fractures, a crush degloving injury of the left leg, and a right forefoot traumatic amputation. She underwent reconstruction with a contralateral quad free flap. In case 2, a 53‐year‐old man sustained a right tibia plateau fracture with large soft‐tissue defects from a motorcycle accident. He had a crush degloving injury of the entire anterolateral compartment over the distal and lower third of the right leg. The large soft‐tissue defect was reconstructed with a contralateral quad flap. In both cases, the donor site was closed primarily and without early flap failures. There was one surgical complication, an abscess in case 2; the patient was taken back to the operating room for débridement of necrotic tissue. There have been no long‐term complications in either case. Both patients achieved adequate soft‐tissue coverage, avoided amputation, and had satisfactory aesthetic and functional outcomes. With appropriate surgical technique and patient selection, the quad‐flap technique is promising for reconstructing the lower extremity.