Buried Skin Research Articles

Epidermal Inclusion Cyst after Breast Reconstruction with TRAM Flaps

Breast reconstruction with TRAM flaps has becomean increasingly common surgical procedure amongbreast cancer patients who undergo a mastectomy (1).TRAM flap reconstruction involves the transfer of lowerabdominal skin and subcutaneous fat to the chest defectat the mastectomy site (2). In this procedure, the epider-mal inclusion cyst can be developed at the surgical site ifthe de-epithelized portion of buried skin flaps retains theepithelial elements. This epidermal inclusion cyst,which can be mistaken for a recurrent cancer, may leadto a false positive finding on a mammogram.To our knowledge, reports on epidermal inclusioncysts after breast reconstruction surgery have not beenpreviously described in the literature. So, we report ourexperience of an epidermal inclusion cyst in a patientwho underwent a total mastectomy with breast recon-struction and TRAM flaps.Case ReportA 50-year-old woman was admitted to our hospital fora follow-up mammography. She underwent a left totalmastectomy and reconstruction with TRAM flaps fortreatment of the ductal carcinoma in situ, about 6-months prior. The mammography showed findings sug-gesting that the postoperative change and an oval-shaped, circumscribed partially indistinct marginal iso-dense mass at the 2 o’clock position of the left breast(Fig. 1A). The mass was believed to be benign, such asfat necrosis or benign granuloma, so the patient was rec-ommended to receive follow-up mammography 6-months later.The 6 month follow-up showed an increase in the sizeof the previously detected mass at the 2 o’clock positionfrom about 10 mm to 13 mm in diameter (Fig. 1B). Onultrasonography, the lesion was located in the peripher-al portion of reconstructed breast, adjacent to the inci-

Solving Acne Inversa (Hidradenitis Suppurativa) in Crohn Disease with Buried Chip Skin Grafts

Acne inversa is a progressive chronic inflammatory disease associated with abscess and fistula formation and subsequent scarring. In recent years, an increasing number of reports have been published about acne inversa and concomitantly occurring Crohn disease. Extensive anogenitoperineal soft tissue defects represent an enormous challenge to therapy. Common treatment strategies of reconstructive surgery such as local flaps, free flaps, or split-thickness skin grafts are frequently problematic and associated with poor outcomes. The aim of this case report is to demonstrate the clinical problem of extensive anogenitoperineal soft tissue defects and to present a surgical technique that can be successfully used in such difficult cases. In both cases, extensive excision of the affected areas was carried out down to the gluteal muscles followed by intramuscular grafting of buried skin chip grafts. In both cases, the final postoperative results after numerous surgeries were very good, with complete wound closure resulting in complete recovery and social reintegration. The technique of buried skin chip grafting has long been ignored since split-thickness skin grafting and different techniques of flap coverage evolved, but it may constitute a highly efficient treatment strategy in challenging reconstructive situations.

URETHROPLASTIES FOR STRICTURES1

SUMMARY The results of four years' experience with the Bengt Johanson type of operation for repair of urethral stricture in males have been reviewed, and the relative merits of modifications favoured by various surgeons compared. This study (involving fifty-one cases, forty-four of which were assessable), suggests that on the whole a strict adherence to the details of the technique described by Johanson is the best insurance of consistently favourable results in a variety of hands. Morbidity and complications increased with deviation from this technique. One exception to this rule was discussed and its success thought to be due to adherence to a fundamental principle of plastic surgery– a minimum of suture-line tension, with avoidance of ischaemia. The claims made for his operation by Johanson are substantiated, namely:– 1 That it can be applied to any urethral stricture or strictures. 2 That the principle of the buried skin strip (forming a tube by epithelialisation) is a satisfactory means of reconstructing a strictured urethra. 3 That post-operative dilatations are unnecessary. 4 That the patient is cured of his stricture–“immediately” in a satisfactory percentage of cases, and “eventually” in almost all cases.

Interdisziplinäres Management von komplexen chronischen Ulzera mittels V.A.C.®-Therapie und „Buried Chip Skin Grafts”

We report the case of a 68-year-old female patient who was admitted to the hospital with deranged blood sugar levels in a septic condition. Due to complex chronic ulcerations of both feet she was intended for major amputation of both limbs. Clinical findings on admission were a diabetic foot syndrome with stage D IV ulcerations according to the Wagner and Armstrong classification, partially visible tendons and phlegmon of the lower leg. Vascular diagnostic revealed arterial occlusive disease in the lower legs without chance of reconstruction. Enterococcus faecalis and Staphylococcus aureus were extracted in swabs from ulcers. After correction of metabolic status and antibiotic treatment radical débridement of all ulcers was carried out and vacuum assisted closure therapy (V.A.C.) was initiated. All wounds showed good granulation tissue after four cycles of V.A.C.-therapy. Interdisciplinary treatment with a plastic surgeon was initiated to accelerate epithelial closure. Using the "Buried Skin Chip" technique in combination with V.A.C.-therapy epithelialisation was completed within four weeks. The patient recovered well and was fully independent on discharge. A goal-oriented interdisciplinary setting can achieve preservation of extremities even in septic patients. The combination of buried skin chip grafts and V.A.C.-therapy may be a feasible and promising procedure to achieve accelerated wound closure in those patients.

Indication and clinical results of buried skin grafting to treat problematic wounds

In 1920 Braun described a technique of skin grafting particularly designed for areas where shearing forces, high pressure and extensive secretion cause repetitive loss of conventionally transplanted skin. During the last 10 years we successfully used this technique when impaired wound healing was encountered due to various reasons. Clinical examples of application and results are presented. By combining this technique with vacuum therapy, formation of granulation tissue can be accelerated, thereby resulting in successful transplantation of problematic and therapy resistant wounds.

The history of hypospadias

The dictum, "There is nothing new in surgery not previously described", is particularly true of hypospadias. The major significance of chordee was fully appreciated by Galen in the second century A. D. and then almost forgotten until Mettauer in 1842, all previous surgeons overstressing the position of the orifice. Mettauer recognised skin shortening as a cause of chordee, a fact not re-discovered until 1967. Urethroplasty from penile skin in situ was well described by Thiersch in 1869 and Duplay in 1874; additional covering skin flaps were developed in 1892 by Lauenstein. The modern enthusiasm for pedicle tubes from prepuce was first employed by Van Hook in 1896, Rochet in 1899, Hamilton Russell in 1900, and Mayo in 1901; the "buried skin" technique of Denis Browne was described by Duplay in 1880, although attributed by Browne to Hamilton Russell in 1915. Even scrotal tissues were incorporated in repairs in 1860 (Bouisson). Beck, in 1898, practised a repair for balanitic hypospadias very similar to the modern MAGPI repair, and free grafts, so popularised in the last 20 years, were performed by Nové-Josserand in 1897. We have certainly advanced from the era of the first millenium A. D., in which the treatment was amputation beyond the orifice, but almost all present-day techniques are well-founded in ideas developed by enterprising surgeons of the last century.

The history of hypospadias

The dictum, "There is nothing new in surgery not previously described", is particularly true of hypospadias. The major significance of chordee was fully appreciated by Galen in the second century A. D. and then almost forgotten until Mettauer in 1842, all previous surgeons overstressing the position of the orifice. Mettauer recognised skin shortening as a cause of chordee, a fact not re-discovered until 1967. Urethroplasty from penile skin in situ was well described by Thiersch in 1869 and Duplay in 1874; additional covering skin flaps were developed in 1892 by Lauenstein. The modern enthusiasm for pedicle tubes from prepuce was first employed by Van Hook in 1896, Rochet in 1899, Hamilton Russell in 1900, and Mayo in 1901; the "buried skin" technique of Denis Browne was described by Duplay in 1880, although attributed by Browne to Hamilton Russell in 1915. Even scrotal tissues were incorporated in repairs in 1860 (Bouisson). Beck, in 1898, practised a repair for balanitic hypospadias very similar to the modern MAGPI repair, and free grafts, so popularised in the last 20 years, were performed by Nove-Josserand in 1897. We have certainly advanced from the era of the first millenium A. D., in which the treatment was amputation beyond the orifice, but almost all present-day techniques are well-founded in ideas developed by enterprising surgeons of the last century.

Use of buried skin implants after recurrent failure of conventional skin grafting in a massive burn: the renewal of an old technique

The technique of burying small pieces of skin under old granulation tissue after recurrent failure of conventional skin grafting is described in a patient with 95 per cent full skin thickness burns. This method of treatment, which was described in the past and neglected, is of value for massive burns or grafting in difficult areas. The technique is described again and the relevant literature reviewed.

実験的骨破壊における皮膚のうの役割 中耳真珠しゅとの関係について

In the present study, we used animal models to induce chronic inflammatory bone resorption which was associated with or without development of skin cysts in order to understand the pricise role of the skin to born resorption in middle ear cholesteatomas. The following tissues were implanted subcutaneously in the back of a total of 60 rats.Group 1: Fresh cortical cochlea wall bone alone.Group 2: Fresh cortical cochlea wall covered with full thickness skin obtained from the external ear canal.Group 3: Fresh cochlea wall wrapped with carrageenan granuloma.Group 4: Fresh cochlea wall combined with full thickness canal skin and carrageenan granuloma.All the animals were sacrificed between 45 to 57 days after the implantation. After each specimen was removed, the size of the bone fragment was determined by the longest diameter with calipers under the operative microscope. Then, the specimen was fixed in formalin and used for histological study.In our stndy, the buried skin made a complete epidermal cyst subcutaneously in 70% of the 42 specimens. Microscopically, most of the bones implanted in various graft combinations indicated that the graft was the seat of a dual process, destruction and reconstruction. The inflammatory connective tissue, pyogenic or foreign body reaction produced by the skin cyst, was the common finding in bone resorption margins. The presence of the skin cyst with carrageenan was associated with the highest incidence of bone resorption in our series. On the other hand, the fact in our series that the skin cyst lied in a shallow or deep depression on the surface of a bone indicated that there might be a certain type of mechanical bone destruction in interaction of the skin cyst and bone. Therefore, it is suggested that the skin cyst adjacent to the bone or conective tissue may play an enhancing role in the localized bone destruction by:a. Promoting a persistent chronic inflammatory response in the underlying connective tissue, andb. Influencing bone cells by the physical presence as a space occupying structure.

Treatment of temporo-mandibular ankylosis with particular reference to the interposition of full-thickness skin autotransplant

In the treatment of the temporo-mandibular ankylosis, the maintainance of separation between the temporal and mandibular raw surfaces, after osteotomy of the bony fusion, constitutes the key to the prevention of recurrence; the great potential of bone to reform is acknowledged by all those who are experienced in this problem. Analysing 168 temporo-mandibular arthoplasties in which different methods have been used in order to maintain the newly created joint space, the causes of failures have been brought out and the difficulties studied. The conclusion is reached that the best results were obtained by the interposition of autogenous full thickness skin. The surgical technique is briefly presented as well as the records regarding the cases followed-up for a period of 2 to 19 years, illustrating the anatomical and functional conservation of the new joints. The experimental investigations concerning the behaviour and fate of the buried skin autotransplants complete the clinical studies, proving the qualities and the value of full thickness skin as an interposition material in arthroplasties.

Construction of epithelialised tubes

The construction of an epithelialised tube from a buried split skin strip and the free transfer of the constructed tube are described in animal experiments.

Two-stage urethroplasty for stricture: results and technical considerations.

SUMMARY Forty-four patients who underwent the two-stage urethroplasty employing the buried skin strip principle are reviewed. Follow-up extended from one to five years. Urinary drainage was by urethral catheter in all cases. Good results were obtained in 81 per cent. overall, and in 92 per cent. of the last 27 cases. The causes of failure are analysed and the technique necessary to obtain “good” results outlined: 1 Recurrences of stricture are primarily due to incomplete division of the original stricture. Panendoscopy at operation is essential in defining the extent of the stricture. 2 Diverticula are due to improper cutting of the urethral flaps at the second stage and can be avoided if a No. 20 sound is used as a guide. 3 Stitches in the urethra or in the urethral skin flaps are completely unnecessary and probably harmful.

Epidermoid Cyst in the Phalanx

A 47-year-old man had been sufferring from the pain and swelling in his left thumb for a month.Roentgenograms revealed the enlarged terminal phalanx with distended and thinned cortex.By the surgical operation, the radial portion of the cortex was perforated. The content of this cyst was a semisolid, cheesy one as seen in the atheroma. The inner surface of the cyst-wall was lined by the thinn and soft membrane, which was consist of the stratified squamous epithelium and sud surrounding connective tissue without hair, sebaceous gland and sweat duct.For these reason this cyst was diagnosed as epidermoid cyst.Although a small portion of the attenuated cortex seemed to be destroyed roentogenologically, judging from surgical finding, the cyst was not suposed to occure outside the phalangeal bone, but inside the bone.Therefore, if the epidermoid cyst is originated from the deeply buried skin, the trauma should be serious one in this case. In spite of this, the patient remembers no traumatic lesion in his thumb.

Buried skin-strip urethra in a tube pedicle phalloplasty

Summary o 1. A patient who had undergone a tube pedicle phalloplasty lost a large part of the reconstructed organ as the result of a hot-water bottle burn seven years later. 2. During a second reconstruction the inturned urethra was lost owing to too short an interval between stages. 3. A new urethra was constructed on the tube pedicle by the buried skin strip principle. Junction of the new urethra with that of the penile stump was also effected by using the same principle.

Immediate and secondary reconstruction of the floor of the mouth and mobilization of the tongue by a new technic

Abstract Some of the previous methods for reconstruction of the floor of the mouth following radical surgery are discussed. A newer technic utilizing a buried skin graft with a rubber stent is described. Its advantages provide for improved speech, better control of saliva and the use of dentures.

Buried skin-strip urethra in a tube pedicle phalloplasty

Summary o 1. A patient who had undergone a tube pedicle phalloplasty lost a large part of the reconstructed organ as the result of a hot-water bottle burn seven years later. 2. During a second reconstruction the inturned urethra was lost owing to too short an interval between stages. 3. A new urethra was constructed on the tube pedicle by the buried skin strip principle. Junction of the new urethra with that of the penile stump was also effected by using the same principle.

Immediate and secondary reconstruction of the floor of the mouth and mobilization of the tongue by a new technic

Some of the previous methods for reconstruction of the floor of the mouth following radical surgery are discussed. A newer technic utilizing a buried skin graft with a rubber stent is described. Its advantages provide for improved speech, better control of saliva and the use of dentures.

Hypospadias: A simple modification in the technique of urethral reconstruction by the buried skin strip method

Hypospadias: A simple modification in the technique of urethral reconstruction by the buried skin strip method

Urethroplasties for strictures.

SUMMARY The results of four years' experience with the Bengt Johanson type of operation for repair of urethral stricture in males have been reviewed, and the relative merits of modifications favoured by various surgeons compared. This study (involving fifty-one cases, forty-four of which were assessable), suggests that on the whole a strict adherence to the details of the technique described by Johanson is the best insurance of consistently favourable results in a variety of hands. Morbidity and complications increased with deviation from this technique. One exception to this rule was discussed and its success thought to be due to adherence to a fundamental principle of plastic surgery– a minimum of suture-line tension, with avoidance of ischaemia. The claims made for his operation by Johanson are substantiated, namely:– 1 That it can be applied to any urethral stricture or strictures. 2 That the principle of the buried skin strip (forming a tube by epithelialisation) is a satisfactory means of reconstructing a strictured urethra. 3 That post-operative dilatations are unnecessary. 4 That the patient is cured of his stricture–“immediately” in a satisfactory percentage of cases, and “eventually” in almost all cases.

A SURGICAL PROCEDURE CLOSING AN ESOPHGOSTOME AND A TRACHEOSTOME

The purpose of this report is to describe a new surgical procedure closing an esophagostome following laryngo-esophagectomy and a tracheostome.This method is of great value to close the stoma when it is large or the tissue adjacent to the stoma is highly damaged following irradiation.The operative procedure was as follows;First operation: A large tubed abdominal flap with buried skin graft was made. The buried skin graft is to provide the internal skin lining of newly reconstructed esophagus or trachea when the stoma is closed.Second operation: Two weeks after the first operation, one end of the tubed abdominal flap was cut off and transplanted to the wrist, Third operation; Three weeks after the second operation, the other end of the tubed abdominal flap was cut off, the skin lined tube was opend, and the stoma was closed with this pedicleflap which has the internal skin lining.Fourth operation: Four weeks after the third operation, the pedicle was cut off, and the repair of the stoma was completed.