Advancement Flap Closure Research Articles

P29 The use of adjunct oral methotrexate as primary prevention for keloid scarring following syndactyly release surgery

Abstract A 12-month-old Asian female underwent syndactyly release surgery with advancement flap closure of the first web space of the right hand. The procedure was complicated by enlarging keloids over the surgical site and dactylitis, a rare complication with only a few previously reported cases [Muzaffar AR, Rafols F, Masson J et al. Keloid formation after syndactyly reconstruction: associated conditions, prevalence, and preliminary report of a treatment method. J Hand Surg Am 2004; 29: 201–8. https://doi.org/10.1016/j.jhsa.2003.10.017]. Initial treatment of the keloid scarring with intralesional triamcinolone under general anaesthetic was unsuccessful. Subsequently, we elected to surgically excise the keloids closing with a full-thickness skin graft from the groin, with adjunct oral methotrexate (0.4 mg kg–1 weekly) for 9 months post-surgery. The use of oral methotrexate for this indication is rarely reported: one series included two cases of successful keloid suppression with 4 years of follow-up [Muzaffar et al.] and another series of four patients with successful keloid suppression after surgery for syndactyly with dactylitis [Tolerton SK, Tonkin MA. Keloid formation after syndactyly release in patients with associated macrodactyly: management with methotrexate therapy. J Hand Surg Eur 2011; 36: 490–7]. Low-dose methotrexate exerts anti-inflammatory effects by stimulating adenosine A2 receptors and increasing adenosine release at sites of inflammation, such as surgical sites [Muzaffar et al.]. In our patient, methotrexate was well-tolerated, keloid recurrence and dactylitis were avoided, and range of movement and functioning of the digits was maintained. Keloid formation after syndactyly release poses a complex management challenge and we propose methotrexate should be considered as an adjunct to reduce recurrence risk.

TH3.9 Cleft closure is an effective procedure for the treatment of pilonidal disease with low recurrence rate

Abstract Aims The surgical treatment of pilonidal sinus disease has evolved over time, with reported time to healing, post-operative complications and disease recurrence rates still significant. The modified Karydakis procedure such as the Bascom's cleft lift operation or “cleft closure” flattens the cleft and has shown promising results. The purpose of this single-centre study is to analyse outcomes of this technique. Method This is a retrospective study of 192 patients undergoing cleft closure as a day case over 10 years. The technique involves an off-midline cleft closure with an advancement flap and primary closure. Outcome measures were postoperative complications, time to healing and recurrence requiring surgery. Results The median age at surgery was 25 years (IQR 21–33), with males representing 76%. Overall, 91 (47%) were smokers. 141(73%) patients had previous emergency treatment. The median numbers of pits/sinuses were 3 and in 71% of patients were localized in the midline. The median time to wound healing was 3 weeks (IQR 2–6). Twenty-five (13%) patients had postoperative complications including infection (n=21) and hematoma (n=4). Disease recurrence requiring surgery occurred in 7 (3.6%) patients. Median time to recurrence was 9 months (IQR 5–15). Conclusion Cleft closure is an effective procedure for the treatment of pilonidal disease, with a low rate of postoperative complications and recurrence.

Anticipating local flaps closed-form solution on 3D face models using finite element method.

A realistic three-dimensional (3D) computational model of skin flap closures using Asian-like head templates from two different genders, male and female, has been developed. The current study aimed to understand the biomechanics of the local flap designs along with the effect of wound closures on the respective genders. Two Asian head templates from opposite genders were obtained to use as base models. A third-order Yeoh hyperelastic model was adapted to characterize as skin material properties. A single layer composed of combined epidermis and dermis was considered, and the models were thickened according to respective anatomical positions. Each model gender was excised with a fixed defect size which was consequently covered by three different local flap designs, namely advancement, rotation, and rhomboid flaps. Post-operative simulation presented various scenarios of skin flap closures. Rotation and rhomboid flaps demonstrated maximal tension at the apex of the flap for both genders as well as advancement flap in the female face model. However, advancement flap closure in the male face model was presented otherwise. Yet, the deformation patterns and the peak tension of the discussed flaps were consistent with conventional local flap surgery. Moreover, male face models generated higher stresses compared to the female face models with a 70.34% mean difference. Overall, the skin flap operations were executed manually, and the designed surgery model met the objectives successfully while acknowledging the study limitations. NOVELTY FILE: 3D head templates were considered to address the gap as 3D face models were uncommonly employed in understanding the biomechanics of the local flaps realistically. Most of the existing studies focus on the 2D and 3D planar geometry in their models. As gender comparison has yet to be addressed, we intended to fill this gap by exploring the stress contours of the local flap designs in different genders. Create a 3D face model from two opposite genders which is capable of simulating closure of wounds using local flaps with a focus on advancement, rotation, and rhomboid flaps.

Combined use of a petal flap and V-Y advancement flap for reconstruction of presacral defects following rectal resection.

The aim of this study was to evaluate the efficacy of a combination of flaps for the reconstruction of presacral defects following abdominoperineal resections: a paramedian vertically oriented caudally based lotus petal flap for presacral defects combined with a horizontal V-Y advancement flap for closure of the superficial donor site defect. A retrospective study was conducted on patients with a residual defect following an abdominoperineal resection between 2010 and 2017 in the Noordwest Ziekenhuisgroep. The primary endpoint was complications related to the reconstruction. Twelve patients were included, all reconstructions healed well. Three patients had a grade I or II complication (Clavien Dindo classification). Use of a petal flap and V-Y advancement flap for reconstruction of presacral defects was found to be safe and simple, and should, therefore, be considered in the management of such problems.

Simultaneous Septal Perforation Repair with Septorhinoplasty: A 31-Year Experience.

Septal perforation repair and septorhinoplasty (SRP) each present unique surgical challenges. However, in many instances, these procedures may be performed together successfully. In this study, the authors aim to determine the safety and effectiveness of combining primary or revision SRP and septal perforation repair via an open approach. A retrospective review was carried out of all consecutive patients who had SRP and septal perforation repair via an open approach between 1986 and 2017 in the senior author's practice. Perforation closure in surgery and at the patient's last follow-up, resolution of presenting symptoms, cosmetic results, and complications were analyzed. Records for 141 patients who had simultaneous septal perforation repair and SRP via an open approach, with a mean follow-up of 3.24 years, were reviewed. The mean anterior-posterior perforation dimension was 1.41 ± 0.89 cm, and the mean vertical perforation dimension was 1.16 ± 0.59 cm. The most common etiologies for septal perforation were previous SRP (35.4%) and septoplasty (24.1%). An overall 93.6%, perforation closure, 91.1% symptom relief, and 91.2% patient satisfaction with cosmetic results were achieved. Septal perforations under 1.5 cm in height were closed in 96.7% of patients as opposed to 71.4% of patients with perforations 1.5 cm or taller. Minor revision rhinoplasties were performed in 7.0% of patients. Postoperative infections were rare and noted in only two (1.4%) patients. In the largest study of its kind to date, the authors have shown that in experienced hands septal perforation repair may be performed simultaneously with primary or revision SRP via an open approach without compromising the perforation repair outcome. The vertical dimension of a septal perforation and presence of mucosa above and below a perforation are important considerations for the difficulty of a perforation closure, as septal mucosa is recruited from these locations in our technique of four-quadrant intranasal bipedicled mucosal advancement flap closure.

A New Option for the Reconstruction of Primary or Recurrent Ischial Pressure Sores: Hamstring-Adductor Magnus Muscle Advancement Flap and Direct Closure.

Owing to the high recurrence rates of ischial pressure sores, surgeons should consider the possibility of future secondary flap surgery during flap selection. The purpose of this article is to present a new surgical option for the reconstruction of primary or recurrent ischial pressure sores using a simple hamstring-adductor magnus advancement flap and direct closure. After horizontal fusiform skin excision, complete bursa excision and ischiectomy were performed. The tenomuscular origin of the adductor magnus and the conjoined tenomuscular origin of the biceps femoris long head and semitendinosus were isolated and completely detached from the inferior border of the ischial tuberosity. They were then advanced in a cephalad direction without detachment of the distal tendon or muscle and securely affixed to the sacrotuberous ligament. The wound was directly closed without further incision or dissection. Twelve ischial pressure sores (6 primary and 6 recurrent; 12 patients) were surgically corrected. The follow-up period was 12 to 65 months. All patients healed successfully without early postoperative complications, such as hematoma, seroma, infection, wound dehiscence, or partial necrosis. Late complications included wound disruption 5 weeks after surgery that spontaneously healed in 1 case and recurrence 3 years later in another case. The new surgical option presented herein, which involves hamstring-adductor magnus advancement flap and direct closure, is a simple and reliable method for providing sufficient muscle bulk to fill the dead space and proper padding to the bone stump while preserving the main vascular perforators and pedicles as well as future surgical options.

Postauricular Advancement Flap for Closure of Persistent Mastoid Cutaneous Fistula

Postauricular Advancement Flap for Closure of Persistent Mastoid Cutaneous Fistula

Management of Recurrent Ischemic Fasciitis, a Rare Soft Tissue Pseudosarcoma

Ischemic fasciitis, also termed atypical decubital fibroplasia, is considered a pseudosarcoma that usually presents as a painless mass in areas overlying bony prominences [1]. Historically, ischemic fasciitis is thought to be a condition that occurs only in the elderly and debilitated because of direct pressure on bony prominences. However, recently, ischemic fasciitis has also been detected in mobile young individuals [1,2]. Epidemiological studies have revealed a predominance of this condition in patients in their 70s and 80s [1]. Common sites of occurrence are the limb girdles, sacrum, greater trochanter, and shoulders. The other locations described include the buttocks and the posterior chest wall. Isolated lesions have also been reported in skeletal muscle [3]. Upon histological analysis, ischemic fasciitis is noted to involve the entire depth of the subcutis, including the deep dermis, muscle, and tendon. Ischemic fasciitis is characterized by a pseudosarcomatous proliferation of fibroblasts and myofibroblasts with a central area of fibrinoid degeneration surrounded by granulation [1]. The granulation tissue is characterized by capillary growth and plump endothelium. Further, the fibroblasts are enlarged mimicking ganglion cells [3]. Similar entities include nodular fasciitis and proliferative fasciitis. In the case of nodular fasciitis, also known as infiltrative fasciitis, lesions grow rapidly and are located typically on the volar aspect of the forearm, chest, and back. These lesions have dense cellularity with immature fibroblasts and are generally less than 3 cm in diameter [3]. In proliferative fasciitis, lesions affect the upper and lower extremities, including most commonly, the forearm, thigh, and shoulder girdle. Upon histological analysis, lesions demonstrate a mixture of proliferating cells including spindle and stellate fibroblasts, as well as ganglion-like cells. However, proliferative fasciitis lacks the central area of fibrinoid deposition and capillary growth [3]. Primary therapy for ischemic fasciitis is surgical resection, and recurrence has been reported to be limited in most studies [1,4]. We report a case of recurrent ischemic fasciitis treated successfully with bony debridement and myofascial advancement flap closure. The patient presented with pain and a firm mass in the region of the coccyx. Her history was significant for immobility resulting from transverse myelitis, a disease process leading to spinal cord inflammation from a viral or autoimmune etiology. One year prior to her initial visit, the patient had fallen and developed a sacral mass that enlarged over time causing discomfort. It is uncertain, as with many soft tissue tumors, whether trauma had any relation to the formation of the mass or whether it was noticed because of the attention paid to the area of injury. Magnetic resonance imaging demonstrated a soft tissue mass isodense to muscle on T1-weighted images in the region of the coccyx. Examination revealed a firm but mobile mass palpable at the base of the coccyx near the gluteal cleft. During the initial operation, a wide excision was performed including the involved fascia overlying the coccyx. A layered closure was then performed. The patient's immediate recovery was uneventful. Three months following the excision, the patient had what appeared to be a recurrence on physical exam. This was confirmed on reoperation. After extirpation of the mass, the surrounding tissue that was grossly clear of the tumor was further debrided. This included using a rongeur on the coccyx to create a smooth contour. The medial aspect of the gluteal muscle was undermined at the level of the fascia and advanced across the operative bed to provide additional soft tissue coverage. A histopathologic evaluation showed areas of fibrinoid necrosis surrounded by zones of granulation tissue and ganglion-like myofibroblasts consistent with ischemic fasciitis. This lesion was typical of the ischemic fasciitis described above. Further, polygonal cells with prominent nuclei are usually present as described in our specimen by ganglion-like cells [1]. The presence of granulation tissue also differentiates the lesion from that of proliferative fasciitis. This case is presented because of its uncommon pathology and its rare incidence of recurrence. Physicians should be aware of this suspicious but benign entity and the rare potential for recurrence. Careful consideration should be taken not to confuse this lesion with a sarcoma, which it closely resembles. There was no recurrence after the second operation. Debridement of the coccyx during the second operation may have eliminated the point of pressure. Moreover, the rearrangement of local tissue provided relatively bulky soft tissue coverage.

Use of a Double-Opposing Advancement Flap for Closure of a Basosquamous Carcinoma on the Forehead: A Technique Designed to Optimize the Esthetic Outcome in a Young Patient

Use of a Double-Opposing Advancement Flap for Closure of a Basosquamous Carcinoma on the Forehead: A Technique Designed to Optimize the Esthetic Outcome in a Young Patient

Outcomes of anal fistula surgery in patients with inflammatory bowel disease

Background Anal fistulas in patients with Crohn's disease are especially difficult to manage because of nonhealing and incontinence. We reviewed our outcomes for the newer sphincter-preserving techniques of anal fistula plug and fibrin glue compared with standard treatments of advancement flap closure and seton drain insertion. Methods This was a retrospective study of patients with inflammatory bowel disease treated for high transsphincteric anal fistulas. The primary outcome was healing and continence at 12 weeks postoperatively. Results Between 1997 and 2009, 51 patients with anal fistulas and inflammatory bowel disease were identified in the St Paul's Hospital Anal Fistula Database. Postoperative healing rates at 12 weeks for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 75%, 0%, 20%, and 28%, respectively. Continence scores were not altered by these procedures. Conclusions Closure of the primary fistula opening in patients with inflammatory bowel disease using a biologic anal fistula plug had improved healing compared with fibrin glue, seton drain, and flap advancement. Given its low morbidity and relative simplicity, the anal fistula plug should be considered for treating high transsphincteric anal fistulas in patients with inflammatory bowel disease.

Anal fistula plug and fibrin glue versus conventional treatment in repair of complex anal fistulas

Introduction High transsphincteric fistulas are difficult to treat because fistulotomy of involved sphincter muscle results in incontinence. We compare our outcomes for anal fistula plug, fibrin glue, advancement flap closure, and seton drain insertion. Methods This is a retrospective study of patients treated for high transsphincteric anal fistulas. The primary outcome was full healing at 12 weeks postoperatively. Results Between 1997 and 2008, 232 patients with anal fistula were identified in the St. Paul's Hospital Anal Fistula Database. Postoperative healing rates at the 12-week follow-up for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 59.3%, 39.1%, 60.4%, and 32.6%, respectively ( P < .0001). Conclusions Closure of the primary fistula opening using a biological anal fistula plug and anal flap advancement result in similar fistula healing rates in patients with high transsphincteric fistulae. These 2 strategies are superior to seton placement and fibrin glue. Given the low morbidity and relative simplicity of the procedure, the anal fistula plug is a viable alternative treatment for patients with high transsphincteric anal fistulas.

A Case Report of a Double Advancement Flap Closure Combined With an Ilizarov Technique for the Chronic Plantar Forefoot Ulceration

Soft tissue closure of defects on the plantar surface of the foot continues to be a challenge for the reconstructive surgeon secondarily to the limited number of surgical options and often difficulty of replacing durable and similar soft tissue coverage. Primary closure and skin grafting may not be suitable for the weight-bearing surfaces of the plantar forefoot area, and closure may then be obtained by other means of plastic surgery techniques.

Management of Urethral Fistulas and Strictures after Hypospadias Repair

Purpose: Urethrocutaneous fistulas and urethral strictures are the most frequent complications after hypospadias repair. We reviewed outcomes after surgical repair of these complications to evaluate the factors determining successful outcome. Materials and Methods: In 60 patients with fistula or stricture after hypospadias repair performed between September 1993 and January 2008, we reviewed incidences, clinical features, and outcome after repair with respect to initial hypospadias types. Results: Fistulas were observed in 42 patients and were surgically repaired in 39 (92.8%). In 8 (19.0%) and 3 (7.1%) patients, concurrent meatal and urethral strictures were noted, respectively. The number of fistulas was single in 38 (90.5%) and 2 in 4 (9.5%) patients. Fistulas occurred most frequently from the penoscrotal type hypospadias (22/65, 33.8%) and had initially undergone transverse preputial island flap repair (13/26, 50%). Complete excision of the fistulous tract and multilayer advancement flap closure was the most common method for fistula repair (24), followed by cross-suture in 9 and repeat urethroplasty in 6. Initial management was successful in 35 (89.7%) patients. Urethral strictures were observed in 16 patients with equal incidences at the meatus and the other portion of the urethra. Successful outcome was achieved in all metal stenosis after repeat meatoplasty, whereas for urethral strictures, 4 (20%) patients who underwent visual urethrotomy experienced recurrent strictures. Conclusions: Urethrocutaneous fistulas can be successfully repaired by complete excision and cross-suture closure and multiple coverage with healthy tissues. In urethral strictures, reconstruction of ample neo-meatus is the key to achieving sufficient stream regardless of the stricture site. (Korean J Urol 2009;50:46-50)

Surgery for a Complex Anal Fistula

Purpose: Because of the complexity and un-expectation of the courses and clinical features for the complex anal fistula, the management of it presents a difficult surgical challenge. Various techniques have been used, such as seton placement, advancement flap closure, muscle filling procedure, and fibrin glue injection. The classic lay-open and seton placement may distort the anal anatomy and result in poor functional outcomes, such as incontinence. Also, advancement flap techniques are associated with relatively high recurrence rates. This study assesses the results of surgery for a complex anal fistula, as performed in Hangun Hospital, Busan. Operative procedures were comprised of two or more separate procedures, including 1) a total fistulectomy, 2) muscle reconstruction, sometimes muscle transposition, 3) direct closure of the primary opening without making a mucosal advancement flap, and 4) a drainage procedure and/or other minor procedure. Methods: Surgical procedures were performed on 22 patients (18 males) with a complex anal fistula between July 2004 and December 2004. The clinical and the manometric results were analyzed with respect to postoperative recurrence, delayed wound healing, and postoperative fecal incontinence. Results: Nineteen of the 22 patients were completely healed without any sequelae. Treatment failure was encountered in one patient two months postoperatively, when an additional fistulotomy was performed to achieve a cure. There were two patients displaying delayed healing, who were successfully treated by curettage. No patient complained of postoperative fecal incontinence in either the clinical examination on the manometric study (mean resting pressure, 75.5±3.5 mmHg; maximal squeeze pressure, 175.7±10.3 mmHg). Conclusions: This shortterm study suggests that a direct closure of the internal opening after a total fistulectomy can be an alternative surgical option for the treatment of a complex anal fistula. J Korean Soc Coloproctol 2008;24:77-82

V–Y advancement flap closures for complicated pilonidal sinus disease

Hair entry into the midline is the generally accepted theory in pilonidal sinus formation. This theory is also involved in the pathogenesis of the recurrence after different types of operations for pilonidal sinus disease. The relationship of the suture lines and the midline was evaluated in this study. Thirty-four patients with stage 4 or recurrent pilonidal sinus disease who underwent V--Y advancement flap closure were randomized into two groups: vertical suture line unrelated to midline (VLUM, n=18) and vertical suture line related to midline (VLRM, n=16). None of the patients with or without a suction drain developed flap necrosis, local haematomas or seromas. The median length of the postoperative hospital stay was 3 days for theVLRM group and the VLUM group (p>0.05). The median follow-up period was 32 months. During the follow-up period, two recurrences were determined 22 and 15 months after operation in the VLRM group. Recurrences were situated in the scar tissue over the midline. Routine application of suction drains is not recommended after V--Y advancement flap closure. Avoidance of the relationship of the postoperative suture line and the midline, if possible, offers a safe method of definitive reconstruction.

Management of sternal wounds with pectoralis major musculocutaneous advancement flaps in patients with a history of chest wall irradiation.

Although debridement and pectoralis major musculocutaneous advancement flap closure has proved to be an effective treatment of sternal wounds in the general population, the purpose of this study was to examine the use of these flaps in patients with previously irradiated chest walls. The authors examined 5 patients with a history of breast cancer and chest wall radiation therapy who developed poststernotomy wound complications that were treated with debridement and pectoralis major musculocutaneous advancement flaps. The average patient age was 76 years. Three patients had previously undergone a radical mastectomy and had only 1 pectoralis major muscle remaining. There were no intraoperative deaths. One patient died during the 30-day postoperative period. There were no hematomas, seromas, or dehiscences. One woman developed a postoperative wound infection. Functional and aesthetic results were excellent. This study demonstrates that early, aggressive sternal debridement and closure with pectoralis major musculocutaneous advancement flaps is effective in patients with a history of chest wall irradiation, including those who have had 1 pectoralis major muscle previously resected.

Simple pectoralis major myocutaneous advancement flaps for closure after sternal wound dehiscence

Between October 1994 and March 1996, 14 consecutive patients with a wound dehiscence after median sternotomy for cardiac surgery were treated with pectoralis major myocutaneous advancement flaps. After thorough sternal wound debridement, the sternal edges were contoured to create a shallow defect. This was to enable the obliteration of dead space between the mediastinum and the flaps. The pectoralis muscle was then elevated off the chest wall, its humeral attachment, the thoraco-acromial pedicle and the connection with the skin were left intact. Next, the bilateral myocutaneous flaps were advanced medially and approximated to each other in the midline. The mean operation time was 140 min and the mean follow-up time was 10 months. Four patients developed minor complications. The advantage of this technique is its simplicity and the reduction in mean operation time.

Closure of infected sternal wounds with a unilateral rectus abdominis muscle flap in addition to bilateral pectoralis major myocutaneous advancement flaps

We have recently added to our regimen a unilateral rectus abdominis muscle flap to cover the lower sternum and adjacent soft tissues, in addition to bilateral pectoralis major myocutaneous advancement flaps for closure of infected sternal wounds. Twenty patients underwent this procedure for closure of infected sternal wounds after initial debridement at our institutions. There were no intraoperative deaths in this series, but three patients died of other medical conditions. Two patients developed hematomas and one developed recurrent sternal wound infection after surgery; two had superficial wound infections and five had minor wound problems (i.e., skin edge necrosis). All surviving patients (17/20, 85%) had healed sternal wounds with normal chest contour and there were no instances of flap necrosis, sternal wound dehiscence, or abdominal wall hernia during the follow-up (18–60 months). Based upon our experience, we recommend a unilateral rectus abdominis muscle flap in addition to bilateral pectoralis major myocutaneous advancement flaps for selected patients with infected sternal wounds. This approach provides reliable soft tissue coverage with acceptable morbidity and mortality in this high-risk patient population.

Anocutaneous advancement flap closure of high anal fistulas.

Fistula-in-ano may be treated by closing the internal fistulous opening. An anocutaneous flap was developed to facilitate this closure. From October 1995 to April 1997, 40 patients with high trans-sphincteric or suprasphincteric anal fistulas were treated. The important components of the procedure are excision of the internal opening, excision or curettage of the tract, closure of the internal opening by an anocutaneous flap, and external drainage. In two patients (5 per cent) the flap separated and the sutured internal opening was exposed. One of the two was healed 4 weeks later. In the remaining 38 patients, complete healing occurred 2-3 weeks after operation. No patient was incontinent of gas or stool. This procedure is technically simple, heals rapidly with minimal scarring, and cures anal fistulas while preserving the anal sphincter.

Cutaneous advancement flap closure: alternative method for treatment of complicated anal fistulas.

A retrospective chart review of 20 consecutive patients with 23 anal fistulas treated with cutaneous advancement flap closure was undertaken to ascertain the efficacy of this previously unreported technique. The so-called "diamond" and "house" flaps are commonly used to treat anal stenosis, and mucosal advancement flaps are successfully used to close fistulas. The authors began, in 1994, to close selected fistulas with skin advancement flaps after suture closure of the internal opening and adequate drainage of the external opening. Fourteen patients (4 females; average age, 42 years; a total of 14 fistulas) without inflammatory bowel disease and 6 patients (3 females; average age, 35 years) with inflammatory bowel disease (5 with Crohn's disease; 1 with chronic ulcerative colitis; a total of 8 fistulas) were treated. Indications were low internal opening with transsphincteric fistula in both groups. Mucosal advancement was relatively contraindicated, either because of fear of ectropion or, in the inflammatory bowel disease patients, diseased mucosa. No one in the noninflammatory bowel disease group was diverted or kept without anything by mouth, and all were treated as outpatients or with overnight observation. The inflammatory bowel disease group was either diverted (1 patient) or kept on home total parenteral nutrition (5 patients) for three to six weeks. Cyclosporine, antibiotics, 5-acetylsalicylic acid, and other medications were used judiciously in the inflammatory bowel disease group. In the noninflammatory bowel disease group, complete healing of all wounds occurred in 11 patients in an average of 6.5 weeks (average follow-up, 18 months). Complications included donor site separation in two patients and minor incontinence of flatus in one patient. In the inflammatory bowel disease group, five fistulas healed, two failed, and one patient developed a new fistula during an average follow-up of 16 months. Deep venous thrombosis and catheter sepsis occurred in one patient in this group. There were no fatalities in either group. Although the numbers, especially in the inflammatory bowel disease group, are very small, the results are encouraging. This technique appears to have a place in the armamentarium of the surgeon repairing anal fistulas.