Total Urethra and Penile Shaft Reconstruction with Combined Pedicled Anterolateral Thigh Flap and Radial Forearm Free Flap after Total Penectomy

Pietro Giovanni di Summa,Gianluca Sapino,Olivier Bauquis 대한성형외과학회 2022 Archives of Plastic Surgery Vol.49 No.3

Total reconstruction of the penis (TPR) represents a challenge for urologists and plastic surgeons, especially when urethral length is severely reduced.We here describe, for the first time in an oncologic scenario, a double flap phalloplasty using a pedicled anterolateral thigh (ALT) flap for penile reconstruction and a radial forearm free flap (RFFF) for complete neourethra and glans reconstruction following penile amputation. A 48-year-old patient came to our department following a total penectomy with inferior urethral derivation. The indication for a double flap phalloplasty was posed as only way to fully reconstruct the urethra on its length avoiding possible complications of single flap reconstruction using tube-into-tube technique. Both flaps healed uneventfully with no neourethral strictures or fistulas described. At 18 months follow-up, the patient was extremely satisfied with the aesthetic result and was able to void in standing position. We think that a double free tissue transfer for TPR should be considered, particularly when a urethral length>14 cm needs to be reconstructed. While the pedicled ALT can be used to reconstruct a proper penile shaft with an easily concealed scar, the RFFF can provide adequate neourethra length with satisfactory sensory recovery at the neoglans.

Late avulsion of a free flap in a patient with severe psychiatric illness: Establishing a successful salvage strategy

Clara Schaffer,Andrew Hart,William Watfa,Wassim Raffoul,Pietro Giovanni di Summa 대한성형외과학회 2019 Archives of Plastic Surgery Vol.46 No.6

Post-traumatic defects of the distal third of the leg often require skipping a few steps of thewell-established reconstructive ladder, due to the limited local reliable reconstructive options. In rare cases, the reconstructive plan and flap choice may encounter challenges when the patienthas psychiatric illness affecting compliance with postoperative care. We describe a caseof a patient with severe intellectual disability and an open fracture of the distal lower limb. After fracture management and debridement of devitalized tissues, the resultant soft tissuedefect was covered with a free gracilis flap. On postoperative day 7, the patient ripped outthe newly transplanted flap. The flap was too traumatized for salvage, so a contralateral freegracilis muscle flap was used. The patient showed good aesthetic and functional outcomes ata 1-year follow-up. When planning the postoperative management of patients with psychiatricillness, less complex and more robust procedures may be preferred over a long and complexsurgical reconstruction requiring good compliance with postoperative care. The medicalteam should be aware of the risk of postoperative collapse, focus on the prevention of pain,and be wary of drug interactions. Whenever necessary, free tissue transfer should be performeddespite potential compliance issues.

Late avulsion of a free flap in a patient with severe psychiatric illness: Establishing a successful salvage strategy

Schaffer, Clara,Hart, Andrew,Watfa, William,Raffoul, Wassim,Summa, Pietro Giovanni di Korean Society of Plastic and Reconstructive Surge 2019 Archives of Plastic Surgery Vol.46 No.6

Post-traumatic defects of the distal third of the leg often require skipping a few steps of the well-established reconstructive ladder, due to the limited local reliable reconstructive options. In rare cases, the reconstructive plan and flap choice may encounter challenges when the patient has psychiatric illness affecting compliance with postoperative care. We describe a case of a patient with severe intellectual disability and an open fracture of the distal lower limb. After fracture management and debridement of devitalized tissues, the resultant soft tissue defect was covered with a free gracilis flap. On postoperative day 7, the patient ripped out the newly transplanted flap. The flap was too traumatized for salvage, so a contralateral free gracilis muscle flap was used. The patient showed good aesthetic and functional outcomes at a 1-year follow-up. When planning the postoperative management of patients with psychiatric illness, less complex and more robust procedures may be preferred over a long and complex surgical reconstruction requiring good compliance with postoperative care. The medical team should be aware of the risk of postoperative collapse, focus on the prevention of pain, and be wary of drug interactions. Whenever necessary, free tissue transfer should be performed despite potential compliance issues.

Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery

Schiraldi, Luigi,Jabbour, Gaby,Centofanti, Paolo,Giordano, Salvatore,Abdelnour, Etienne,Gonzalez, Michel,Raffoul, Wassim,di Summa, Pietro Giovanni Korean Society of Plastic and Reconstructive Surge 2019 Archives of Plastic Surgery Vol.46 No.4

Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.

Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery

Luigi Schiraldi,Gaby Jabbou,Paolo Centofanti,Salvatore Giordano,Etienne Abdelnour,Michel Gonzalez,Wassim Raffoul,Pietro Giovanni di Summa 대한성형외과학회 2019 Archives of Plastic Surgery Vol.46 No.4

Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.

Role of the Gastrocnemius Musculocutaneous with a Propeller Style Skin Flap in Knee Region Reconstruction: Indications and Pitfalls

Sapino Gianluca,Osinga Rik,Maruccia Michele,Guiotto Martino,Clauss Martin,Borens Olivier,Guillier David,di Summa Pietro Giovanni 대한성형외과학회 2023 Archives of Plastic Surgery Vol.50 No.6

Background Soft tissue reconstruction around the knee area is still an open question, particularly in persistent infections and multiple reoperations scenario. Flap coverage should guarantee joint mobility and protection, even when foreign materials are implanted. The chimeric harvesting of the musculocutaneous gastrocnemius flap, based on the sural artery perforators, can extend its applicability in soft tissue reconstruction of the upper leg, overcoming the drawbacks of the alternative pedicled flaps.Methods A multicenter retrospective study was conducted enrolling patients who underwent to a pedicled, chimeric gastrocnemius musculocutaneous–medial sural artery perforator (GM-MSAP) or lateral sural artery perforator (GM-LSAP) flap for knee coverage in total knee arthroplasty (TKA) recurrent infections and oncological or traumatic defects of the upper leg from 2018 to 2021. Outcomes evaluated were the successful soft tissue reconstruction and flap complications. Surgical timing, reconstruction planning, technique, and rehabilitation protocols were discussed.Results Twenty-one patients were included in the study. Nineteen GM-MSAPs and 2 GM-LSAPs were performed (soft tissue reconstruction in infected TKA [12], in infected hardware [4], and in oncological patients [5]). Donor site was closed primarily in 9 cases, whereas a skin graft was required in 12. Flap wound dehiscence (1), distal flap necrosis (1), distal necrosis of the skin paddle (1), and donor site infection (1) were the encountered complications. Flap reraise associated to implant exchange or extensive debridement was successful without requiring any further flap surgery.Conclusion The propeller–perforator GM-MSAP offers qualitative defect coverage and easiness of multiple flap reraise due to skin availability and its laxity.