Background:Local propeller flaps preserve the main vascular arteries of the lower extremity and muscle function, avoiding the need for a microsurgical anastomosis and the benefit of providing a “like with like” coverage. Our goal in this study was to demonstrate the versatility, safety, and complications of the local propeller flaps for lower extremity reconstruction.Methods:We present a series of 28 patients in whom we used local propeller flaps to restore small-to-medium soft-tissue defects of the lower limb in different hospitals of Managua, Nicaragua.Results:Flap average dimensions were of 48 cm2. Flap rotation was performed in 180 degrees in 85% of the cases. The propeller flaps were based on a single perforator, from the posterior tibial artery in 50%, anterior tibial artery in 39.3%, and peroneal artery in 10.7% of the cases. Complications occurred in 14% of the propeller flaps performed, with 3 partial necrosis of less than 15% of the flap transposed. Complications of the patients occurred in both sex groups; however, for the female group, there was a 75% of complications with a tendency toward statistical significance of P = 0.038. Donor site of the flap was closed primarily in 85.7% (24) of the cases.Conclusions:In our opinion, the availability and safety of local propeller flaps, justifies its use in cases where microsurgical techniques are not an option for the reconstruction of the middle and distal extremity, in small-to-medium defects of soft-tissue coverage of the lower limb.

BackgroundThe unmet burden of surgical disease represents a major global health concern, and a lack of trained providers is a critical component of the inadequacy of surgical care worldwide. Competency-based training has been advanced in high-income countries, improving technical skills and decreasing training time, but it is poorly understood how this model might be applied to low- and middle-income countries. We describe the development of a competency-based program to accelerate specialty training of in-country providers in cleft surgery techniques.MethodsThe program was designed and piloted among eight trainees at five international cleft lip and palate surgical mission sites in Latin America and Africa. A competency-based evaluation form, designed for the program, was utilized to grade general technical and procedure-specific competencies, and pre- and post-training scores were analyzed using a paired t test.ResultsTrainees demonstrated improvement in average procedure-specific competency scores for both lip repairs (60.4–71.0%, p < 0.01) and palate (50.6–66.0%, p < 0.01). General technical competency scores also improved (63.6–72.0%, p < 0.01). Among the procedural competencies assessed, surgical markings showed the greatest improvement (19.0 and 22.8% for lip and palate, respectively), followed by nasal floor/mucosal approximation (15.0%) and hard palate dissection (17.1%).ConclusionSurgical delivery models in LMICs are varied, and trade-offs often exist between goals of case throughput, quality and training. Pilot program results show that procedure-specific and general technical competencies can be improved over a relatively short time and demonstrate the feasibility of incorporating such a training program into surgical outreach missions.

Summary: Large oronasal palatal fistulas can be challenging to reconstruct. The authors present a modified buccal myomucosal flap repair technique and review intermediate-term outcomes. In this technique, large anterior palatal fistulas are closed in two layers. First, apposing nasal turnover flaps of vomer mucosa medially and nasal wall mucosa laterally are approximated. Second, a posteriorly based buccal flap incorporating full-thickness buccinator muscle and overlying mucosa is transposed with interposition of the flap in the retromolar trigone and lateral palate to preserve dental occlusion. Consecutive patient cases performed in low-resource settings were reviewed and outcomes reported. Among eight subjects aged 3 to 22 years, with average defect size of 2.5 cm2 (range, 0.8 to 3.5 cm2), the flap was viable in all cases and required revision or pedicle division in only two patients (25 percent); all patients showed symptom improvement. The modified buccal myomucosal flap shows promising intermediate-term results as a single-stage reconstruction suitable to a wide patient age range, low airway/anesthetic risk, reliable functional outcomes, and low comorbidity.

Background Access to surgical care is a pressing challenge, particularly for vulnerable populations. Informal and formal community health workers (CHWs), including lay people, increasingly function in pivotal roles in primary care, however, remain disconnected from surgical care in most environments. This study examined the degree to which CHW understanding of surgical conditions could be improved through the use of a pictorially based manual. Methods A manual and associated situational problem-solving questionnaire instrument were developed and contextualized through focus groups in Central America. A baseline assessment was obtained. In the program implementation, cohorts of formal and informal CHWs were introduced and trained to use the manual through a short curriculum. Assessment was repeated in program implementation, first with access to relevant manual content only, and then after the teaching session. Participants were also surveyed about manual scheme, usability, and utility. Results A total of 100 subjects (67% female) participated in baseline assessment, and 403 subjects (68% female) were assessed through the program implementation. Baseline problem-solving averaged 11.8 (SD 2.46) out of a possible 20 points. Mean score increased to 15.4 (SD 3.10) when participants had access to relevant surgical manual content and again to 15.9 (SD 3.09, p \ 0.0001) following participation with an instructive curriculum. Participant score while utilizing the manual correlated with amount of education completed (r = 0.26), but baseline score did not. High readability 389 (96%) and high self-reported willingness for use 398 (96%) were noted. Conclusion Baseline familiarity with surgically treatable conditions appears modest among rural Central American populations, and improves with access to a contextualized, pictorial manual focused on recognizing and appropriately referring surgical conditions.Please note that this study has eight authors. The international, multisite nature of this study, with core involvement of surgeons, statisticians, and global health researchers from several sites were included in all key phases of the study. Each meets WJS criteria as an author.