Flap Site Research Articles

Effect of concurrent mental nerve reconstruction at the same time as mandibular reconstruction using a fibula osteoseptocutaneous flap

The damage of inferior alveolar nerve causes some functional problem including numbness of lower lip and drooling. During segmental mandibulectomy, inferior alveolar nerve commonly resected, therefore, it is ideal to reconstruct the nerve to get better functional result. Sensory recovery was assessed after mandibular reconstruction using free fibula osteoseptocutaneous flap in thirteen cases. In six cases, the mental nerve reconstruction was performed simultaneously, and in seven cases, the mental nerve reconstruction was not performed. In the case that the mental nerve was reconstructed simultaneously, unilateral mental nerve reconstruction was performed in five cases, and bilateral mental nerve reconstruction was performed in one cases. More than one year after the reconstruction, sensory recovery was assessed and compared between the group that the mental nerve was reconstructed and the group that was not reconstructed. Our results showed almost a normal sensory recovery of the lips on the reconstructed side more than one year after the reconstruction in reconstructed group. In contrast, sensory recovery was poor in non-reconstructed group and non-reconstructed side. These results showed that mental nerve reconstruction at the same time as mandibular reconstruction affects the postoperative mandibular function. The sural nerve can be harvested from the same donor site of the free fibula osteoseptocutaneous flap and such mental nerve reconstruction with nerve grafting can be completed within an hour. Most cases of mandibular reconstruction using a free fibula osteoseptocutaneous flap transfer can therefore be candidates for mental nerve reconstruction at the time of mandibular reconstruction.

Antibiotic Prophylaxis in Patients Undergoing Head and Neck Free Flap Reconstruction.

Evidence supports short courses of perioperative antibiotics for patients receiving minor head and neck procedures. Few studies have addressed antibiotic prophylaxis for patients undergoing free flap reconstruction of head and neck defects. To determine ideal antibiotic prophylaxis in patients undergoing head and neck free flap reconstruction. Retrospective cohort study of 427 adults receiving free flap reconstruction of head and neck defects at 2 affiliated tertiary care academic hospitals between January 1, 2006, and January 28, 2013. Prophylactic antibiotic type and duration were recorded from patient records. Outcome data were abstracted from patients' medical records including infection at the surgical sites and distant nonsurgical sites and flap site complications including flap compromise, dehiscence, or fistula. Multivariate logistic regression was used to determine the association of risk factors with the primary outcome of any infection within 30 days of surgery. Ninety-six patients (22.5%) received prophylactic antibiotics for 24 hours or less, and 331 patients received prolonged courses of prophylactic antibiotics. The majority of patients received ampicillin-sulbactam alone for prophylaxis (53.2%), while 36.5% received clindamycin alone and 10.3% received an alternative regimen. Postoperative infections occurred in 46% of patients, and 22% of patients had an infection at the flap inset site or neck incision. The use of clindamycin (odds ratio [OR], 2.54; 95% CI, 1.25-5.14 [P = .01]) was associated with an increased risk of postoperative infection; extended duration of antibiotics (OR, 0.63; 95% CI, 0.34-1.19 [P = .18]) was not associated with increased risk of postoperative infection. By multivariate analysis, use of clindamycin (OR, 6.71; 95% CI, 1.83-24.60 [P = .004]) and oral tobacco use (OR, 1.20; 95% CI, 1.04-1.39 [P = .02]), but not extended course of prophylactic antibiotics (OR, 0.75; 95% CI, 0.30-1.86 [P = .53]), were associated with a higher risk of postoperative flap or neck infections. The choice of antibiotic appears to affect the rate of all postoperative infections and flap site infections more than the duration of antibiotics following head and neck free flap reconstruction. At our institutions, ampicillin-sulbactam is the preferred prophylactic antibiotic for major clean-contaminated head and neck procedures when possible.

Interdigitated craniotomy: a simple technique to fix a bone flap with only a single plate.

In pterional craniotomy, fixation plates cause artifacts on postoperative radiological images; furthermore, they often disfigure the scalp in hairless areas. The authors describe a simple technique to fix a cranial bone flap with only a single plate underneath the temporalis muscle in an area with hair, rather than using a plate in a hairless area. The key to this technique is to cut the anterior site of the bone flap at alternate angles on the cut surface. Interdigitation between the bone flap and skull enables single-plate fixation in the area with hair, which reduces artifacts on postoperative radiological images and provides excellent postoperative cosmetic results.

Cutaneous T-cell lymphoma with nasal necrosis.

Mycosis fungoides is a rare T-cell cutaneous lymphoma that poses a unique diagnostic challenge given its heterogeneous presentation. The refractory case presented here highlights the need for advances in early diagnostic technologies. A 73-year-old diabetic man presented with erythema and necrosis of the nose. He initially had a 7 mm squamous cell carcinoma on the nose which was excised with Mohs surgery. The wound rapidly progressed to full thickness necrosis of the left nasal ala without pain or fever. During subsequent reconstruction with a nasolabial flap and cartilage graft, biopsies of the nasal margin showed severe inflammation without malignancy. The reconstructed area failed to heal and serial cultures grew multiple species of bacteria which were treated with several courses of antibiotics. Erythema of the nose and face continued to progress over 7 months and new lesions appeared, including skin necrosis at the site of previous left ala flap, right dorsum of nose and right cheek (Fig. 1). Computed tomography (CT) scan showed no involvement of sinuses or facial bones. Repeat biopsy showed acute and chronic inflammation with no malignancy and no organisms. A few weeks later a new erythematous plaque developed on the back (Fig. 2) and biopsy showed lymphocytic infiltrate with a monoclonal T-cell population (Figs. 3, ​,4).4). Repeat assay of previous nasal biopsy showed the same T-cell receptor gene rearrangement leading to the diagnosis of cutaneous T-cell lymphoma, consistent with mycosis fungoides (MF). The patient was staged with positron emission tomography-CT scan showing no visceral disease despite developing new lesions in his groin in addition to new lesions on his back and face. He was treated with a combination of systemic chemotherapy, radiation and phototherapy. At 16 month follow up he has persistent skin lesions, with progression of tumor burden. Fig. 1 Facial involvement of mycosis fungoides with significant nasal necrosis at site of previous nasolabial flap. Fig. 2 Erythematous plaque distant to original lesion with biopsy results demonstrating cutaneous T cell lymphoma. Fig. 3 Diffuse lymphocytic infiltrate through the dermis with inconspicuous epidermotropism (H&E, ×6.3). Fig. 4 Immunohistochemical study demonstrates a predominance of lymphocytic cells labeling with CD4 with some extension into the epidermis (×12.6). This case highlights the diagnostic difficulty seen in many cases of cutaneous T-cell lymphoma described in the literature. The diagnosis of cutaneous T-cell lymphomas, the majority of which are classified as Mycosis fungoides or Sezary syndrome, requires integration of both clinical and histopathological information [1]. The diagnosis of early MF is often difficult given its heterogeneous clinical and pathologic presentations [2,3]. Histopathologically, early MF may resemble chronic inflammatory dermatoses with reactive T cells and other immune cells [2,4]. Adjuvant techniques such as immunophenotyping and T cell receptor gene rearrangement studies can help make the diagnosis in some difficult cases [3]. The classic histopathology of MF is characterized by lymphocytes with cerebriform nuclei and a haloed appearance that display epidermotropism or populate the dermoepidermal junction [2,4]. Histological diagnosis of early disease typically requires several follow up skin biopsies [3]. Given the difficulty of diagnosis, clinic-pathologic correlation is crucial for early MF diagnosis [3], though the use of novel immunohistochemical and molecular biology techniques has been discussed as a method of helping with diagnosis [4]. Classic presentation of MF includes patches and plaques on non-sun exposed areas that may slowly evolve [2]. The patient's atypical clinical presentation likely contributed to the difficulty with diagnosis. Treatment goals are typically determined by extent of disease, prognostic factors, quality of life, and patient comorbidities [5]. Staging is determined by skin, lymph node, viscera and blood involvement; in early disease, prognosis is generally favorable [5]. Therapy for early disease often includes topical corticosteroids, topical nitrogen mustard and phototherapy, total skin electron beam therapy and/or low-dose local radiation [5]. Systemic therapy is used in advanced cases or cases refractory to topical therapy. Interferons and retinoids are commonly used first-line, with histone deacetylase inhibitors, alemtuzumab also possible therapeutic agents. Chemotherapy is generally reserved for treatment refractory or rapidly progressive disease [5]. In this patient, chemotherapy was appropriate given his treatment refractory disease, with appropriate alterations in treatment after toxicities developed.

The benefits of preincision ropivacaine infiltration for reducing postoperative pain after robotic bilateral axillo-breast approach thyroidectomy: a prospective, randomized, double-blind, placebo-controlled study.

PurposeThe aim of this study was to evaluate the effects of preoperative ropivacaine infiltration in patients undergoing robotic thyroidectomy using the bilateral axillary breast approach method.MethodsUsing a randomized, double-blind study design, 34 consecutive female patients who underwent robotic thyroidectomy were randomly assigned to receive local infiltration to the skin flap site using either only 0.9% saline solution, 3 mL/kg (group C, n = 17) or 0.1% ropivacaine with saline, 3 mg/kg (group L, n = 17). Local anesthetic was administered prior to skin incision after the induction of general anesthesia. Postoperative pain was rated at 2, 6, 18, 30, 42, and 66 hours postoperatively by visual analogue scale (VAS) score. The bottom hit counts (BHC) from patient controlled analgesia and fentanyl consumption were evaluated. CRP levels, mean blood pressure (BP), and heart rate (HR) were also evaluated.ResultsVAS pain scores were significantly lower in group L than in group C from 2 to 42 hours (P < 0.05). Fentanyl use for analgesia and BHC were also significantly lower in group L compared with group C during the first postoperative 6 and 2 hours, respectively (P < 0.05). The total consumption of fentanyl was significantly lower in group L than in group C (P = 0.009). No significant differences were noted for baseline, postoperative mean BP, or HR.ConclusionPreoperative infiltration using ropivacaine with saline to all flap sites is a safe and effective method for reducing postoperative pain and postoperative fentanyl consumption in patients with robotic thyroidectomy.

Risk factors of recipient site infection in head and neck cancer patients undergoing pectoralis major myocutaneous flap reconstruction.

The aim of this study was to investigate the factors associated with infection at the recipient site of pectoralis major myocutaneous flap (PMMF) of head and neck cancer patients. We retrospectively reviewed head and neck cancer patients who underwent PMMF reconstruction and identified those with recipient site infection. Variables of patients with and without infection were compared and associated factors were investigated by logistic regression model. A total of 478 patients were included in the final analysis and 183 patients (38.3%) developed recipient site infection. Lower margin of skin island, concurrent tracheotomy, diabetes mellitus, mandibular plate reconstruction, prior radiation, and peri-operative blood transfusion were independent factors associated with recipient site infection of PMMF. Skin island of PMMF beyond the eighth intercostal space markedly increased the risk of recipient site infection after major head and neck cancer surgery. Recognition of relevant factors associated with infection may help surgeons to identify those at risk.

Flap Survival After Previous Vascular Pedicle Division and Preexisting Scar Formation at the Pedicle Site

We conducted an experimental study to investigate if it would be possible to re-elevate a flap at a standard flap site if its vascular pedicle was mutilated previously and there was a preexisting scar formation at the pedicle site. Thirty-five male Sprague-Dawley rats were divided into 3 groups. In the control group (n = 5), animals received a procedure in which unilateral axial pattern abdominal flap was elevated, and then sutured to its original place. The remaining 2 groups underwent 2-stage procedures. In the first stage, scar tissue was created with either a skin incision (group 2, n = 15) or excision (group 3, n = 15) at the prospective pedicle site of the abdominal flap. In the second stage, abdominal flap was raised in 5 rats as a scar-pedicled flap at day 7, day 21, and day 42. Flaps were sutured in their places. Seven days later, flap survival was evaluated. Control flaps had complete survival (day 7, 95.5%; day 21, 94.8%; and day 42, 94.5%). Group 2 and group 3 flaps raised on day 7 (group 2, 65.4%; group 3, 63.9%) and on day 21 (group 2, 65.7%; group 3, 66.7%) showed decreased survival compared to control group flaps (P < 0.05). On day 42, group 1 flaps had better survival when compared to group 2 flaps (82.6% vs 70.0%, P < 0.05). Group 1 flaps showed progressive vascular network formation as evidenced by contrast medium first in the proximal two thirds of the flaps on day 7, and later via visualization of the axial pattern vascular tree on day 42. In group 3, approximately half of the flap was filled with barium contrast and no single pedicle was identified on day 42. Preexisting scar tissue and pedicle division in the pedicle site of a standard flap diminished dimensions of surviving flap when compared to control flaps. Incision-scar-pedicled flaps achieved better survival compared to excision-group flaps, particularly in the late postoperative period. The study findings showed that it may be possible to raise a flap from previously mutilated site secondary to scar formation and pedicle injury.

Distinguishing binders from false positives by free energy calculations: fragment screening against the flap site of HIV protease.

Molecular docking is a powerful tool used in drug discovery and structural biology for predicting the structures of ligand–receptor complexes. However, the accuracy of docking calculations can be limited by factors such as the neglect of protein reorganization in the scoring function; as a result, ligand screening can produce a high rate of false positive hits. Although absolute binding free energy methods still have difficulty in accurately rank-ordering binders, we believe that they can be fruitfully employed to distinguish binders from nonbinders and reduce the false positive rate. Here we study a set of ligands that dock favorably to a newly discovered, potentially allosteric site on the flap of HIV-1 protease. Fragment binding to this site stabilizes a closed form of protease, which could be exploited for the design of allosteric inhibitors. Twenty-three top-ranked protein–ligand complexes from AutoDock were subject to the free energy screening using two methods, the recently developed binding energy analysis method (BEDAM) and the standard double decoupling method (DDM). Free energy calculations correctly identified most of the false positives (≥83%) and recovered all the confirmed binders. The results show a gap averaging ≥3.7 kcal/mol, separating the binders and the false positives. We present a formula that decomposes the binding free energy into contributions from the receptor conformational macrostates, which provides insights into the roles of different binding modes. Our binding free energy component analysis further suggests that improving the treatment for the desolvation penalty associated with the unfulfilled polar groups could reduce the rate of false positive hits in docking. The current study demonstrates that the combination of docking with free energy methods can be very useful for more accurate ligand screening against valuable drug targets.

Seroma and Quilting Suture at the Donor Site of the TRAM Flap in Breast Reconstruction

Seroma formation at the donor site of the transverse rectus abdominis myocutaneous flap was evaluated in 48 patients who underwent breast reconstruction with either quilting sutures and suction drains (QS+DN group) or quilting sutures alone (QS group) or suction drains alone (DN group). Clinical and ultrasound examinations were performed to assess seroma formation in 5 regions of the abdominal wall on postoperative days 7 and 14. The incidence of seroma detected by ultrasound examination was significantly higher in the DN group (P = 0.008) than that in the other 2 groups. No difference in seroma volume (puncture) was found between the QS+DN and QS groups (P = 1.00). Seroma formation was observed in the iliac region in the DN group but not in the QS+DN and QS groups (P = 0.028). Quilting sutures at the transverse rectus abdominis myocutaneous flap donor site were efficient in reducing seroma formation.

Combined ipsilateral and contralateral second toe flaps for repair of finger degloving injury

The purpose of this report was to retrospectively review the results of treatment of degloving injury of the finger by use of combined ipsilateral second dorsal nail-skin flap and contralateral medial second toe flap. From 2010 to 2012, seven fingers in seven patients with complete degloving injuries from the level of middle or distal phalanx were reconstructed with combined ipsilateral second dorsal nail-skin flap and contralateral medial second toe flap. The injured fingers included the index finger in four cases, and middle finger in three cases. The nerves of both the flaps were sutured to the bilateral common digital nerves. The donor site of second toe flap was covered with a full-thickness skin graft. All transferred flaps survived after surgery, and all postoperative courses were uneventful. During the follow-up period (mean of 15 months; ranging 6-20 months), the appearance of the reconstructed fingers was comparable with normal ones. The range of motion of the distal interphalangeal joint averaged 55 ± 5.8 degrees. The two point discrimination of the pulp ranged from 8 to > 15 mm (average, 11.3 mm). All the patients were able to walk without difficulty. The MHQ score averaged 59 ± 4.2 points and Maryland foot rating score averaged 92 ± 4.2 points. The ipsilateral second toe dorsal nail-skin flap combined with contralateral medial second toe flap may provide an alternative for the reconstruction of completely degloved fingers at the middle and the distal phalangeal level, with satisfactory functional and cosmetic results.

Free-Style Dual Plane Recycling Tensor Fascia Lata Musculocutaneous Perforator Flap for Reconstruction of Recurrent Trochanteric Defects

Sequential flap coverage might be required for recurrent defects, but reusing a flap as a donor site has seldom been reported. The concept of a "free-style flap" has been developed, and it allows reconstructive surgeons to raise flaps with various designs reliably, even at sites of previous flap surgery. This article presents the concept of free-style recycling of a tensor fascia lata flap into a perforator-based flap separated in 2 planes in a patient with a recurrent bilateral trochanteric defect. If a reliable perforator is preserved and identified within the tissues by computed tomography angiography or a Doppler device, a new perforator flap can be designed and raised at the previous flap site.

Pedicled latissimus dorsi flap for arm defects: A report of twenty-three cases

Background: The latissimusdorsi muscle or myocutaneous flap is one of the most reliable and versatile flaps used in reconstructive surgery. It is known for its use in chest wall and post mastectomy reconstruction and has also been used effectively for coverage of large soft tissue defects in the head and neck and upper limb either as a pedicled flap or as a free flap. It has been described for reconstruction of hand and foot defects as microvascular flap and functional reconstruction of elbow in brachial plexus injuries. Aim: Evaluate its role in reconstruction of arm defects. Patient and Methods: Twenty three cases of pedicled Latissimus dorsi flaps for arm defects are enrolled into the study. The cause of the defect, the site and size of the defect, associated injuries and timing of flap cover are also noted. Observaion and Result: Out of 23 cases majority of defects are from trauma (19 cases) and rest from neoplastic resection (4 cases) all belonging to the age group of 15-45 years with defect size ranging from 10 × 15 cm 2 to 15 × 25 cm 2 . The average duration of follow up was 6 months to 1 year. All the flaps survived without partial loss. Six patients developed seroma at flap donor site which settled with multiple aspirations. Two patient developed hyper trophy at the borders at the donor site scar. Three patients had stretching of the scar. There were no other donor site complications at the flap or skin graft sites. All patients have cosmetically satisfactory result. Conclusion: Pedicled Latissimus dorsi muscle and musculocutaneous flap with a split thickness skin graft is the primary choice for reconstruction of large complex arm defects.

Post burn contracture neck: clinical profile and management.

Morbidity related to hypertrophic scars and contractures which are well known sequel after burns remains high and in fact has increased as more severely burned patients are surviving. This study was undertaken in order to assess the varied clinical presentation, precipitating factors, preventive measures, treatment modalities of neck contractures and evaluate the results after surgical procedures. This hospital based study was conducted on patients admitted in our institution with proven cases of Post burn neck contracture from 1st August 2009 to 31st July 2011. Twenty two patients of post burn neck contracture who underwent operative treatment were included. 10 of 22 cases were in the middle age group i.e. between 21-30 years. There were 5 males and 17 females. Accidental flame burn was the commonest aetiology. Fourteen patients were treated within 1 year of burns for functional disability. Excisional release was performed in 13 and incisional release in 9 of our patients. Resurfacing with STSG (split thickness skin graft) was carried out in 19 cases and a local or regional flap with or without a graft in 3 patients. Hypertrophy and recontracture were the commonest late complications and occurred in 3 cases. Good to fair results were obtained in 19 patients Local flaps have many advantages and are to be used whenever possible. It is preferable to place the grafts if used in the area surrounding the neck (donor site of flap) or at least in the non-visible area of the neck (submental area). When a combination of flap & graft is used, it's preferable to place the flap in a horizontal intersecting fashion in between the two patches of the graft. A follow up program for reasonable period is highly desired.

Recurrent endophthalmitis following a scleral fixated intraocular lens in a glaucoma patient

Dear Editor, We would like to highlight the possibility of recurrent endophthalmitis in a patient with a scleral-fixated intraocular lens (IOL) and glaucoma. A 65-year-old patient with a history of primary angle closure glaucoma in both eyes, on topical anti-glaucoma medications, presented with redness, pain, and watering in his left eye for 5 days. The patient had undergone a scleral-fixated IOL implantation in his left eye 1 year ago, after his IOL had got dislocated subsequent to an episode of trauma. He developed endophthalmitis in that eye after 6 months and was treated with intravitreal antibiotics. No causative organism was isolated then. His anti-glaucoma medications had been neglected after the IOL placement. Scleromalacia was not noted in the surgical records of the patient. The axial lengths of the right and left eye were 22.3 and 22.4 mm, respectively. He underwent trabeculectomy with mitomycin C (0.2 mg/ml sub-conjunctivally for 2 min) in the left eye after resolution of endophthalmitis, for uncontrolled intraocular pressure (IOP; 44 mmHg) and pain. Visual acuity was perception of light with inaccurate projection of rays. On follow-up, the bleb remained vascularized and minimally raised. The current episode of redness and pain occurred 4 months after trabeculectomy. The left eye had a visual acuity of no light perception, circumciliary congestion with fixed hypopyon [Fig. 1a]. There was uveal tissue prolapse through scleral flap site constructed for scleral-fixated IOL [Fig. 1b]. The bleb was low and there was vascularization over the bleb. The IOP in the Left eye (LE) was 34 mmHg. Ultrasound of the LE revealed moderate amplitude spikes in the vitreous cavity suggestive of exudates. He was started on topical timolol and brimonidine, and was given anterior chamber vancomycin wash, followed by intensive topical antibiotics (concentrated cefazolin 50 mg/ml and tobramycin 14 mg/ml). On culture of the anterior chamber aspirate, Staphylococcus aureus was isolated. Four weeks later, the hypopyon had resolved. However, there was hypotony and a choroidal detachment was noted on ultrasound. The uveal prolapse had settled and the overlying conjunctiva showed vascularization. Figure 1 (a) Fixed hypopyon with circumciliary congestion. (b) Uveal tissue prolapse through scleral flap site for scleral-fixated intraocular lens Increase in IOP after scleral fixation of IOL has been reported in literature. Yan et al.,[1] in a retrospective review of 65 eye, of scleral-fixated posterior chamber IOL implantation, reported elevated IOP requiring intervention in 16% of eyes with pre-existing glaucoma and 13% of eyes that did not have pre-existing glaucoma Our patient had high IOP, which led to uveal tissue prolapse at scleral flap site for scleral-fixated IOL. This exposed uveal tissue probably acted as a conduit for the entry of microorganisms into the eye, resulting in endophthalmitis. Even though he underwent trabeculectomy, the surgery failed. The possibility of bleb related endophthalmitis was ruled out in the absence of a thin avascular bleb. Scleral-fixated IOLs should be used in glaucoma patients with additional care. They have to be very carefully monitored both for IOP control and scleral flap site integrity in case of high IOP. In case of glaucoma poorly responsive to topical medications, simultaneous trabeculectomy at the time of scleral fixation of IOL has also been described.[2] A glaucoma drainage device could have been considered for IOP control in cases with high risk of failure of trabeculectomy.

A Comparison Between Proximal Lateral Leg Flap and Radial Forearm Flap for Intraoral Reconstruction

Free flaps have become a popular option for the reconstruction of intraoral defects. The radial forearm flap used to be the workhorse flap for small and thin defects, but was associated with numerous donor-site morbidities. The proximal lateral leg flap can provide a thin and pliable tissue similar to the radial forearm flap but without the related donor-site morbidities. We compared the differences between these 2 flaps. Thirty-four patients with intraoral defects from September 2005 to October 2011 were reconstructed, using the radial forearm flap in 23 cases, and the proximal lateral leg flap in 11 cases. The radial forearm flap group had a success rate of 95.6%. The flap survival rate was 100% in the proximal lateral leg flap group. However, the difference was statistically insignificant. Skin graft was required in 22 of the 23 cases for the donor site of the radial forearm flap. Partial loss of the skin graft occurred in 5/22 (23%) of the patients, with exposure of tendons in 3/22 (14%). Delay in healing of the donor sites occurred in 6/23 (26%) of the patients. The donor sites of the proximal lateral leg flap were all closed primarily. One case developed wound dehiscence and this healed by conservative treatment. Long-term follow-up showed functional impairment of the donor forearm (reduced extension or grip strength) in 17% of the patients. Thirty percent of the patients developed sensory disturbance and 48% complained of poor outcome of the donor forearms. In the proximal lateral leg flap group, no motor or sensory functional deficits were seen. No patients complained of poor outcome of the donor legs. Primary closure of the donor site of the proximal lateral leg flap could be performed if the flap width was less than 6 cm. This flap is useful for patients with small and thin intraoral defects and is associated with minimal donor-site morbidity when compared to the radial forearm flap.

Crystallographic Fragment‐Based Drug Discovery: Use of a Brominated Fragment Library Targeting HIV Protease

A library of 68 brominated fragments was screened against a new crystal form of inhibited HIV-1 protease in order to probe surface sites in soaking experiments. Often, fragments are weak binders with partial occupancy, resulting in weak, difficult-to-fit electron density. The use of a brominated fragment library addresses this challenge, as bromine can be located unequivocally via anomalous scattering. Data collection was carried out in an automated fashion using AutoDrug at SSRL. Novel hits were identified in the known surface sites: 3-bromo-2,6-dimethoxybenzoic acid (Br6) in the flap site and 1-bromo-2-naphthoic acid (Br27) in the exosite, expanding the chemistry of known fragments for development of higher affinity potential allosteric inhibitors. At the same time, mapping the binding sites of a number of weaker binding Br-fragments provides further insight into the nature of these surface pockets.

Impact of obesity in microsurgical breast reconstruction: flap and donor site complications

Impact of obesity in microsurgical breast reconstruction: flap and donor site complications

The sensate fibular osteoneurocutaneous flap in oromandibular reconstruction: Clinical outcomes in 31 cases

Thirty-one patients requiring composite mandibular resection were reconstructed with sensate fibula osteocutaneous flaps. Preoperatively, all patients underwent lower extremity sensory testing at the location of the proposed flap site. Intraoperatively, either the Lateral Sural Cutaneous Nerve (LSCN) or the Recurrent Superficial Peroneal Nerve (RSPN) was chosen as donor. It was then joined to either the lingual or the greater auricular nerve. Both end-to-end and end-to-side neurorrhaphies were used. At least six months postoperatively, the intraoral flaps were tested for sensory function. Twenty-eight patients achieved sensory return, including hot/cold and pinprick sensation. Both the LSCN and RSPN groups demonstrated improved two-point discrimination in static and moving studies. Better results were obtained when the lingual rather than the greater auricular nerve was the recipient. Only three patients underwent end-to-side repair, with improved two-point discrimination in two patients. The average follow-up for all patients was 11.7 months. The most dramatic return of sensory function was seen in the end-to-end lingual nerve neurorrhaphies, followed by end-to-side lingual nerve neurorrhaphies. Of the five repairs using the greater auricular nerve, only three demonstrated any measurable postoperative sensory return. Functional outcomes of postoperative patients were measured via analysis of speech, type of food consumption, and oral continence. The majority of patients exhibited normal or easily intelligible speech, was able to consume a soft food or normal diet, and could maintain normal to manageable oral continence. A subset of patients enrolled in the study went on to pursue dental rehabilitation.

Modified deep iliac circumflex osteocutaneous flap for extremity reconstruction: Anatomical study and clinical application

The classic deep iliac circumflex osteocutaneous flap with iliac crest has been one of the most commonly used flaps for mandibular reconstruction since its advent. However, the unnecessary bulk of the 'obligatory muscle cuff' limited its widespread use. The authors describe in this article the use of a modified deep iliac circumflex osteocutaneous flap with reduced bulk and great mobility between the skin and the bone components. This study was divided into two parts: anatomical study and clinical application. In the anatomical study, 40 sides of adult cadaveric specimens perfused with red gelatin in the arteries were dissected with the anterior superior iliac spine and the inguinal ligament serving as the anatomical landmarks to observe the course and the branches of the deep circumflex artery, with its terminal part being given priority. Clinically, five patients received modified deep iliac circumflex osteocutaneous flaps for extremity reconstruction. The anatomical study showed that the terminal part of the deep circumflex iliac artery ended as a musculocutaneous perforator with a diameter of 1.0±0.1mm, which could be located 6.2±1.2cm posterior and 1.5±0.6cm lateral to the anterior superior iliac spine. As for clinical application, in four cases osteocutaneous flaps survived completely, while that in one case suffered partial loss of the skin component. The modified deep iliac circumflex osteocutaneous flap enjoys a great degree of mobility between the skin and the bone components; it has greater manoeuvrability compared to the conventional one for the reconstruction of complex three-dimensional defects. The donor site of the skin flap is confined to the lower abdominal region, facilitating direct closure.

Unilateral and Bilateral Breast Reconstruction with Pedicled TRAM Flaps: An Outcomes Analysis of 188 Consecutive Patients.

Background:The abdomen remains a popular donor site for autologous tissue breast reconstruction. Recently, however, some authors have questioned whether the pedicled transverse rectus abdominis myocutaneous (TRAM) flap should remain a first-line reconstruction option.Methods:Between 1998 and 2009, 188 women underwent breast reconstruction with pedicled TRAM flaps by the senior author (J.A.A.). All TRAM flaps involved reinforcement of the abdominal wall repair with polypropylene mesh. Reconstruction was unilateral in 164 patients and bilateral in 24 patients, yielding a total of 212 flaps.Results:The mean follow-up period was 36 months. There were no complete flap losses. Overall hernia rate for the series was 1.6%, and overall abdominal bulge rate was 0.5%. When combining all types of morbidity, 38 unilateral (23.2%) and zero bilateral TRAM flap patients experienced flap site complications (P = 0.005), and 16 unilateral (9.8%) and 5 bilateral patients (20.8%) experienced donor site complications (P = 0.155). For morbidity that required a return to the operating room, the overall rate was 4.3% for unilateral TRAM flap patients and 4.2% for bilateral TRAM flap patients. Flap site morbidity was significantly associated with obesity, former or active smoking, and receiving 2 or more adjuvant therapies. Donor site morbidity was significantly associated with obesity.Conclusions:The pedicled TRAM flap continues to be an excellent option for breast reconstruction. Complication rates for both unilateral and bilateral TRAM flaps were low in this series, with no complete flap losses and just 4.3% of patients requiring a return to the operating room secondary to morbidity.