Local Flap Coverage Research Articles

Abstract: Flaps and Lower Extremity Trauma: Differences in Flap Rates Across the United States

INTRODUCTION: Open fractures with large soft tissue defects represent a challenging reconstructive problem. Successful attempts at limb salvage require a multi-disciplinary approach including early access to reconstructive plastic surgery. However, given the only recent rise in microsurgery, it is not yet known if this demand is being met. MATERIALS AND METHODS: Using ICD-9CM codes, all adult patients presenting with open tibia fractures in the 2003–2012 Nationwide Inpatient Sample (NIS) were included in the analysis. Flap rates during the index hospitalization were evaluated over time and against demographics, comorbidities, rates of amputation, and patient and hospital factors regarding access to care. NIS data was multiplied to its United States (US) population estimate. RESULTS: We identified 29,717 patients over 10 years, a predicted 14,859 open tibia fractures in the US per year, with a mean age of 41.24 ± 16.68 years. Yearly, 5.92% (n=879) of open tibia fractures receive local or free flap coverage on the index hospitalization. Younger age and peripheral vascular disease were significantly associated with increased rates of flaps (p<0.01). Other medical co-morbidities, including diabetes, and race were not associated. Medicare (p<0.01), patient zip code with a mean household income in the lower 25% (p<0.05), city less than 1 million people (p<0.05), small (p<0.01) or medium (p<0.05) hospitals, and rural or urban non-teaching hospitals (p<0.01) were all associated with significantly lower rates of flaps. Mean income greater than 50% (p<0.05), large hospitals (p=0.05), urban teaching hospitals (p<0.01), and metropolitan areas with at least 1 million people (p<0.01) were associated with significantly higher rates of flaps than the mean. East South Central had significantly lower flap rates (p<0.001) and higher amputation rates (p<0.01), and geographic regions with higher flap rates were New England (p<0.05), Mid Atlantic (p<0.001), and Mountain (p<0.01). CONCLUSION: Rates of flap coverage for open tibia fractures differ primarily based on factors related to access to care, and are not explained by differences in medical co-morbidities. Specifically, medically underserved areas of the country, as well as individuals without financial resources received flaps at lower rates and amputations at higher rates. These findings suggest that skilled lower extremity reconstruction is not universally applied to all Americans. Hospital administrators, insurance providers and the plastic surgery community must work together to support lower extremity reconstructive surgeons. DISCLOSURE/FINANCIAL SUPPORT:None of the authors have commercial associations or financial disclosures with a conflict of interest to the information presented here.

A prospective randomized cost billing comparison of local fasciocutaneous perforator versus free Gracilis flap reconstruction for lower limb in a developing economy

Distal half leg complex wounds are usually a formidable problem that necessitates either local or free flap coverage. The aim of this study was to compare cost billing charges in free Gracilis flap (fGF) and local fasciocutaneous perforator flap (lFPF) in reconstructing complex soft tissue leg and foot defects. Thirty consecutive adult (>15-year-old) patients with soft tissue defects in the leg and/or foot requiring tissue coverage with a flap in the period between 2012 and 2015 were randomly assigned (block randomization) to either an fGF or lFPF procedure. The outcome measures addressed were total billed charges costs, perioperative billed charges cost, partial or complete flap loss, length of hospital stay, inpatient postsurgical care duration, complications, operating time and number of operative scrub staff. One patient suffered from complete flap loss in each group. Reconstruction with lFPF showed total lower billed charges costs by 62% (2509 USD) (p<0.001) and perioperative billed charges cost by 54% (779 USD) (p<0.001), and shorter total hospital stay (36.5 days; p<0.001), inpatient postsurgical care duration (6.4 days; p<0.001), operating time (4.3h; p<0.001) and fewer scrub staff (2.2 persons; p<0.001). These results suggest that neither flap is totally superior to the other; the choice should instead be based on the outcome sought and logistics. lFPF requires lower billed charges cost and resource use and saves operative time and personnel and reduces length of hospital stay. Our approach changed towards using perforator flaps in medium-sized defects, keeping the free flap option for larger defects.

Surgical reconstructive procedures of the chest wall after mediastinitis

Sternal osteomyelitis as adirect consequence of advanced mediastinitis or as in most cases after median sternotomy is still associated with a prolonged hospital stay, increased morbidity and postoperative mortality. Early diagnosis and an adequate surgical treatment are decisive for the prognosis. Prerequisites for asecondary stabilization of the chest wall using wires or plates are sterile wound conditions. Diverse reconstructive techniques are available for anterior chest wall reconstruction depending on the defect size and localization. The various reconstructive methods including local and free flap coverage are described in this review article.

The Effect of Positive Post-Debridement Cultures on Local Muscle Flap Reconstruction of the Lower Extremity

Background Local muscle flaps are a reconstructive option for wound coverage in the distal lower extremity, particularly in high-risk patients who are poor candidates for free tissue transfer. At our institution, chronic and infected wounds are managed with serial debridement before definitive reconstruction. There is a paucity of data on optimal timing for reconstruction in this patient population. This study investigates the relationship of positive postdebridement cultures (PDC) and wound closure rates at 90 days. Methods A retrospective review of patients undergoing local muscle flap coverage of chronic distal lower extremity wounds between 2006 and 2012 was performed. All patients were managed with serial debridement until negative PDC were obtained. In some cases, PDC remained positive or exhibit delayed culture growth in the day(s) following closure. Data recorded include demographics, flap type/location, culture data, and wound closure at 90-day follow-up. Results Of 76 patients, 60 met inclusion criteria with minimum 90-day follow-up. Despite 100% flap survival, 17 patients (28.3%) had failure of wound closure at 90 days and 22 patients (36%) had positive PDC. Multivariate analysis identified positive PDC (odds ratio, 29.6; 95% CI, 3.6-246.4; P = 0.002) and smoking (odds ratio, 8.9; 95% CI, 1.4-57.6; P = 0.02) as independent predictors of nonclosure at 90 days. Conclusions In this series of local muscle flap coverage of distal lower extremity wounds, positive PDC were a strong independent predictor of failure of wound closure at 90 days. This study demonstrates the importance of serial debridement to negative cultures before definitive coverage in this patient population.

Pediatric lower extremity sarcoma reconstruction: A review of limb salvage procedures and outcomes

In recent years, dramatic advances in the multidisciplinary treatment of pediatric sarcoma have resulted in significant improvement in the long-term survival of the patient. Thus, following tumor resection, significant effort has gone into limb salvage and improving functional outcomes. Plastic surgeons, in conjunction with orthopedic surgeons, are using techniques in microvascular free-tissue transfer and rotational flap surgery to preserve limb length. This study presents a review of the current reconstructive strategies and the oncologic, surgical, and functional outcomes in this population. Using the Pubmed and Cochrane Library databases, studies describing lower extremity plastic surgical reconstruction were identified following pediatric lower extremity sarcoma resection. This study included those studies which described reconstructive techniques, oncologic and functional outcomes, and surgical complications. A total of nine articles were identified, yielding 96 pediatric patients. The most common procedures performed were free fibular flaps (53 patients) followed by pedicled muscle flaps (31 patients). A total of 72 of 96 patients (75%) achieved independent ambulation, and an additional 19 patients (20%) ambulated with assistance. There were only three (3%) amputations. A total of 13 patients died from metastatic disease (14%). Plastic surgery procedures play an increasingly important role in pediatric lower extremity sarcoma reconstruction and functional limb salvage. Published series are limited in number and case volume; to date, no systematic review has been published. The existing data emphasize the role of microvascular free-fibula transfer as well as local muscle flap coverage in preserving limb length and function, with minimal risk of local recurrence and need for amputation.

Solitary Gluteus Maximus Muscle Metastasis in a Breast Cancer Patient.

Tumor metastasis into skeletal muscle is uncommon, and is rarely noticeable clinically. Lung cancer and gastrointestinal tumors are the most frequent primary malignancies that metastasize to the skeletal musculature, but some reports have described muscle metastases from breast cancer [1]. The authors present a case of gluteal muscle metastasis in a patient with a known primary breast cancer. A 53-year-old woman presented with a mass on her right buttock with pain that was aggravated by walking. She had previously undergone modified radical mastectomy due to left breast cancer. A histopathological examination at the time had shown invasive ductal carcinoma without axillary lymph node metastasis. She had received five cycles of adjunctive chemoradiotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil, followed by tamoxifen. Seven years after surgery, a slowly growing mass developed on her right buttock with mild throbbing pain. On physical examination, tenderness was observed, but no palpable mass was found in the right buttock. A computed tomography (CT) examination of the pelvis found a poorly defined, mildly enhanced intramuscular mass measuring 3 cm in the patient's right gluteal maximus muscle (Fig. 1), and a subsequent needle biopsy of the lesion confirmed a metastatic, poorly differentiated invasive ductal carcinoma. In order to address suspicion of systemic metastasis, the patient underwent CT scans of the breast, positron emission tomography-CT, and bone scans. No other metastatic sites were found (Fig. 2). A wide excision and local flap coverage were performed to remove the metastatic mass along with tissue from the gluteus muscle (Fig. 3). Histological findings showed metastatic invasive ductal carcinoma (Fig. 4). She received adjunctive chemotherapy with capecitabine and no local recurrence was observed 12 months after surgery. Fig. 1 (A, B) Preoperative computed tomography views. An enhancing mass is visible in the right gluteus maximus muscle, suggesting an intramuscular metastasis. Fig. 2 Preoperative positron emission tomography-computed tomography (PET-CT) view. PET-CT revealed a significant hypermetabolic lesion in the right gluteal muscle. No other suspected metastatic sites were found. Fig. 3 Gross photo of the resected intramuscular mass. Fig. 4 Histological findings of the surgical specimen. Metastatic invasive ductal carcinoma had infiltrated into the surrounding muscle (H&E, ×100). Skeletal muscle metastasis of a primary malignancy is relatively rare and can be misdiagnosed as a primary soft tissue sarcoma; however, distinguishing between the two diagnostic possibilities is critical, because the treatment and prognosis may differ markedly [1]. Metastases of breast cancer may appear in any organ, and although different relapse sites may be observed depending on the subtype of breast cancer, the most frequent metastasis sites are bone, the liver, the lungs, and the brain [2]. Skeletal muscle metastasis of breast cancer is very rare. The following sites have been reported for skeletal muscle metastasis: the abdominal wall muscle, the iliopsoas muscle, the gluteus medius muscle, the triceps muscle, the scalene muscle, the extraocular muscle, the cervical muscle, and the paraspinal muscle [3]. The gluteus maximus muscle has not been reported as a site of skeletal muscle metastasis. It has not been clearly established why tumor metastasis is so rare in skeletal muscle, despite its abundant vascular supply. However, one possible reason is that muscle contractions, in combination with variable but abundant vascular flow, may mechanically prevent tumor cells from stopping and proliferating. It also appears that the settlement and growth of tumors are not favored in muscle tissue due to its pH value and a chemical environment driving the degradation of lactic acid, an angiogenesis-promoting agent [3]. The most common symptom is pain at the metastatic site, although skeletal muscle metastasis is manifested as the formation of a tumor mass and muscle weakness [3]. If a patient presents with mild pain without clear evidence of a mass upon physical examination, as occurred with the patient in this case, the metastatic tumor may be easily missed. Therefore, careful diagnosis is required. The prognosis and appropriate treatment of skeletal muscle metastasis are uncertain. A previous report recommended that skeletal muscle metastases be treated palliatively if they occur together with systemic metastasis, but an isolated metastatic neoplasm can be resected operatively with or without radiotherapy [3,4]. Although some authors have proposed performing contralateral prophylactic mastectomy, randomized controlled trials to assess the overall survival benefit of this procedure in breast cancer patients have never been carried out, and its efficacy is therefore unclear [5]. This report presented a rare case of a breast cancer metastasis into the gluteal muscle that was completely resected operatively after confirming the diagnosis with a preoperative needle biopsy. In patients with an intramuscular mass, it is necessary to proceed with a suspicion of metastatic cancer, even though metastasis to muscle tissue is rare.

Salvage of Exposed Groin Vascular Grafts with Early Intervention Using Local Muscle Flaps.

Background:Peripheral vascular surgery may be complicated by wound infection and potential graft exposure in the groin area. Muscle flap coverage of the graft has been promoted to address these wound complications. The authors present their findings regarding graft salvage rates and patient outcomes using local muscle flaps to address vascular graft complications of the groin.Methods:Data were obtained by retrospective cohort study of patients who underwent a local muscle flap procedure by a single surgeon following vascular graft complication in the groin.Results:Seventeen patients undergoing local muscle flap coverage of a vascular graft were reviewed. Six men and 9 women, 51–80 years old, were included in the study. Wound complications in the groin occurred anywhere from 3 days to 3.5 years following graft placement. Graft exposure was the most common presenting complication (14 of 17 patients). Muscle flap coverage occurred within 15 days of complication presentation in all patients (average, 6.4 days). Seven of the 15 patients experienced postoperative complications within 6 months of the procedure, most commonly wound dehiscence. However, analysis demonstrated that vascular grafts were successfully salvaged in 10 of the 17 patients (59%) over the course of follow-up (range, 104–1748 days). Average time to muscle flap coverage was 4.2 days in patients who retained the graft and 9.6 days in patients who ultimately lost their vascular graft.Conclusion:The authors demonstrate improved vascular graft salvage rate when local muscle flap procedure is performed early after initial wound complication presentation.

Evolving paradigm in treatment of Merkel cell carcinoma of the digit from ray resection to wide local excision and flap coverage.

Merkel cell carcinoma is a rare cutaneous neuroendocrine neoplasm that typically presents on the head and neck. Merkel cell carcinoma (MCC) of the digits is rare, and thus limited treatment options have been presented. In contrast to the current treatment recommendation of ray resection of the affected digit, two patients were treated by sentinel node biopsy, wide local excision, and flap coverage of the defect. No local recurrences or metastases have been seen 24months postoperatively. We suggest that the paradigm of ray amputation of a digit affected by MCC should evolve to initial treatment with a sentinel lymph node biopsy (SLNB) with subsequent local excision with wide margins and local flap coverage.

Extravasation of a percutaneous femoral hepatic infusion device.

Extravasation of a percutaneous femoral hepatic infusion device.

Local Flap Surgical Scar Management Caused by Skin Cancer Using Fractional CO2Laser Treatment

Background Despite careful and atraumatic surgical techniques, surgical treatment and reconstruction can result in scarring. Scar from skin cancer on the face may continue for a long time. This current report demonstrates the utility of a fractional CO2 laser to treat facial scar resulting from local flap coverage to remove skin cancer. Methods Five patients underwent local flap coverage after removing facial skin cancer tumors. The resulting scars after reconstruction of these skin cancer defects are on face. Each received 6 treatments with a fractional CO2 laser device (LineXel ® ; UTI Co. Ltd, Seoul, Korea). Treatments were spaced about 1 month apart. Results were evaluated before the initial treatment, and at 1 month after the last treatment session. Results The fractional CO2 laser device is effective for treating surgical scars especially on scar texture and thickness without significant adverse effects. Prior to the laser session, these scars concerned different pigmentation, pliability, height, vascularity compared to the surrounding skin. Patients also expressed a 4-point subjective scale of satisfaction. Patients were satisfied with the treated scars. Conclusions The fractional CO2 laser device of the present report is an effective treatment modality for facial scars after reconstruction of skin cancer defects. Besides this laser also does not show any serious adverse effect

The Case Files

A 63-year-old woman presented to the ED via ambulance with complaint of a draining abscess from her groin that had worsened over the past day. She also reported subjective fever and chills. The patient said she first noticed the abscess two days earlier. The patient had had an appendectomy in 1994 and a hysterectomy in 2000, and she had type II diabetes, hypercholesterolemia, and hypertension. The patient was not compliant with her medications, and was not sure what they were. Her body mass index was 33.2, respiration rate was 18 bpm, oral temperature was 100.5°F, pulse was 108 bpm, blood pressure was 173/94 mm Hg, and pulse oximetry was 97% on room air. Physical examination was significant for a foul-smelling draining abscess in the perineal region that was tender, erythematous, and edematous with crepitus surrounding the site of drainage and copious amounts of pus that were expressed with light pressure during palpation. Laboratory results were significant for a blood glucose level of 395 mg/dL and a white blood count of 20.3 cells/ml. A CT scan of the abdomen and pelvis with contrast showed multiple foci of air in the right lower anterior pubic region that was suspicious for a gas producing infection. (Photo.) The diagnosis of Fournier's gangrene was confirmed, and the patient was immediately started on broad-spectrum IV antibiotics, insulin, and IV fluids.Figure: CT of the abdomen and pelvis.The patient was transferred to surgery where, after consulting with urology, a decision was made to perform a radical debridement of necrotic tissue and to drain the area surgically. The patient was stabilized after debridement and released from the ICU. The patient underwent reconstructive surgery, and was released three weeks after admission. The patient also received education on managing her chronic conditions. Because of immediate identification and intervention, the patient recovered. Fournier's gangrene is a rare form of necrotizing fasciitis with rapid onset and progression. Venereologist Jean Alfred Fournier was the first to describe a rapidly progressing case of necrotizing fasciitis in 1883. (AJR Am J Roentgenol 1998;170[1]:163.) This form of necrotizing fasciitis is caused by anaerobic and aerobic microorganisms. The infection often begins as a simple cellulitis from a defect or break in the skin of the perineal or genital region, providing entry for bacteria. Because of the aggressive nature of the bacteria, even with early intervention, mortality rates remain high. Multiple organisms can be present in the infection and may act synergistically, encouraging growth. The most common bacteria present are Escherichia coli, Bacteroides, Proteus, Staphylococcus, Enterococcus, Streptococcus, Pseudomonas, Klebsiella, and Clostridium species. (EMN 2005;27[5]:24.) The byproducts of an anaerobic metabolism lead to soft tissue gas formation that is composed of hydrogen, hydrogen sulfide, and nitrous oxide. (AJR Am J Roentgenol 1998;170[1]:163.) It is important that surgical debridement be performed as soon as possible once Fournier's gangrene is identified. Diagnosis can be made through physical examination, blood tests such as a CBC, imaging such as sonograms and CT scans that can provide evidence of the extent of subcutaneous infection, and a thorough history to help establish comorbidities such as diabetes, alcohol abuse, or immunodeficiency. Treatment consists of broad-spectrum antibiotics, surgical debridement of necrotic tissue, and surgical drainage. Hyperbaric oxygen therapy is not a mainstay of treatment, but it can be beneficial and reduce mortality. (J Urol 1997;158[3 Pt 1]:837.) Primary closure of the skin is done once granulation tissue begins to form after surgical debridement. Depending on the amount of debridement, local skin flap coverage or skin grafts can be used for closure of surgical site. Differential diagnosis of Fournier's gangrene includes cellulitis, abscess, hernia, hydrocele, orchitis, testicular torsion, balanitis, fungal infections, and vulvovaginitis. Patients should have appropriate surgical and urological follow-up.

Pediatric Lower Extremity Sarcoma Reconstruction

INTRODUCTION: Dramatic advances in the multidisciplinary treatment of pediatric sarcoma have been made in recent years resulting in significantly improved long-term survival. As survival has increased, greater effort has been made towards limb salvage and improving functional outcomes following tumor resection. Plastic surgeons in conjunction with orthopedic surgeons are applying techniques in microvascular free tissue transfer and rotational flaps to preserve limb length. METHODS: Studies describing lower extremity reconstruction following pediatric lower extremity sarcoma resection were identified by PubMed literature search. Those studies which described reconstructive techniques, oncologic and functional outcomes, and surgical complications were included. RESULTS: A total of 10 articles were identified, yielding 119 total patients. Two articles presented a wider scope of inquiry but sufficient sub-group detail to permit inclusion and three articles were single patient case reports. The average patient age ranged 9 to 14 years and overall age range was 15 weeks to 19 years. The average follow-up ranged 27 to 63 months and overall follow-up range was 0 to 168 months. The most common procedures performed were pedicled gastrocnemius +/- soleus flap (58 patients) and free fibular flap (40 patients). Eighty eight out of 116 patients (76%) achieved independent ambulation, and an additional ten patients (9%) were ambulatory with assistance. There were only three (2.5%) amputations. Seven patients died from metastatic disease (5.9%). CONCLUSIONS: Plastic surgery procedures play an increasingly important role in pediatric lower extremity sarcoma reconstruction and functional limb salvage. Published series are limited in number and case volume, and no systematic review has been published to date. However, the existing data emphasizes the role for local muscle flap coverage as well as microvascular free fibula transfer in preserving limb length and function, with a minimal risk of local recurrence and need for amputation.

Diagnosis and management of ecthyma gangrenosum in chronic renal failure patient.

Diagnosis and management of ecthyma gangrenosum in chronic renal failure patient.

Surgical Management of Genitoperineal Hidradenitis Suppurativa in Men

To report our successful experience in treating genital and perineal hidradenitis suppurativa (HS) and its sequelae including localized chronic lymphedema. We describe our method of diseased tissue resection and wound defect coverage with local flaps and split-thickness skin grafts (STSG). From 2004 to 2012, we treated 6 patients with genital and perineal HS with radical resection of diseased tissue. Wound coverage was performed with skin flaps and/or STSGs. Two patients had enough normal neighboring skin for local flap coverage of their wound defect. Four others had more extensive disease requiring STSG coverage. Two patients with secondary penile skin lymphedema required STSG for penile shaft reconstruction. All patients achieved excellent cosmetic results. There was one recurrence that required repeat resection and wound coverage. No wound complications occurred at the STSG donor site. Successful STSG "take" on the scrotum and penis ranged from 90% to 100% (mean 98%). Wound complications from local flap closure were clinically insignificant and include small (≤2cm) areas of wound breakdown with no evidence of infection in 3 patients (50%). Genitoperineal HS is a debilitating and disfiguring disease that results in the need for repeated abscess drainage operations, chronically painful skin boils, and chronic foul-smelling infectious discharge. It can be associated with lymphedema of surrounding tissues, requiring removal of tissues not originally affected by the disease. The use of complete resection and reconstruction with skin flaps and grafts provides a viable treatment option for these patients.

98 SURGICAL MANAGEMENT OF GENITOPERINEAL HIDRADENITIS SUPPURATIVA IN MEN

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery (II)1 Apr 201398 SURGICAL MANAGEMENT OF GENITOPERINEAL HIDRADENITIS SUPPURATIVA IN MEN Mang Chen and Richard Santucci Mang ChenMang Chen Pittsburgh, PA More articles by this author and Richard SantucciRichard Santucci Detroit, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1476AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To report our successful experience in treating genital and perineal hidradenitis suppurativa. We describe our method of diseased tissue resection and wound defect coverage with local flaps and split-thickness skin grafts (STSG). METHODS From 2004 thru 2012, we treated 6 patients with genital and perineal hidradenitis suppurativa with radical resection of diseased tissue. Three patients underwent local flap coverage of their wound defect. Three others had more extensive disease requiring STSG coverage. Two patients with penile skin involvement required STSG for penile shaft reconstruction. RESULTS All patients achieved good cosmetic results. Operative variables such as disease severity, blood loss, and length of hospital stay was dependent on severity of disease and patient comorbidities. No wound complications occurred at the STSG donor site. STSG take on the scrotum and penis ranged from 60-100%. Wound complications from local flap closure were clinically insignificant and includes small (2cm or less) areas of wound breakdown with no evidence of infection. CONCLUSIONS Genital and perineal hidradenitis suppurativa is a debilitating and disfiguring disease. The use of radical resection and reconstruction with skin flaps and grafts provides a viable treatment option for these patients. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e39-e40 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mang Chen Pittsburgh, PA More articles by this author Richard Santucci Detroit, MI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Protection of the Reconstructed Nipple by Using a Breathing Bag Connection Tube

Nowadays, local flap coverage methods, including the C-V breast flap compose the majority of nipple reconstruction procedures [1]. As the projection of new nipple from the C-V breast flap is basically subcutaneous fat, the reconstructed nipple tends to be flattened over the long term, especially if submitted to pressure. In addition, necrosis or abrasion may result in flap failure. For this reason, it has been a principle to overcorrect the nipple height and to provide prudent dressings using various protective devices as a physical support against pressure on the reconstructed nipple [1]. The authors propose the use of a breathing bag connecting tube as a protective device in nipple reconstruction.

Surgical management of limb prosthetic vascular graft exposure

To investigate the risk factors and surgical management of limb prosthetic vascular graft exposure. The clinical data of 17 patients suffering from limb prosthetic vascular graft exposure in Peking Union Medical College Hospital from August 2006 to December 2011 were retrospectively analyzed. Among 17 cases, 5 suffered from prosthetic vascular graft exposure after vascular bypass for the lower limb ischemia, whereas 12 were affected after the artificial graft arteriovenous fistula construction in the upper limbs for hemodialysis. The surgical procedures mainly included the local debridement as well as the local flap and transferred muscle-cutaneous flap reconstruction to preserve the prosthetic vascular graft. All 17 patients underwent local flap or muscle-cutaneous flap coverage procedure. After the surgery, the prosthetic vascular graft was successfully salvaged in 14 cases. The total successful rate was 82.4%. The surgery failed in three patients, in whom the prosthetic vascular grafts were finally removed. Local flap and transferred muscle-cutaneous flap reconstruction is an effective surgical management to salvage the exposed grafts.

LOCAL FLAPS AND SPLIT;

Background: Two point discrimination (TPD).is the minimum distance between two stimulus points on the skin, which areperceived as distinct points, Among the two types of TPD i.e., static and dynamic, static two-point discrimination (STPD) is commonly used todetermine digital nerve integrity. Local flaps usually do well in maintaining sensibility of the covered area in terms of two point discrimination incontrast to s-plit thickness skin grafts (STSG). Objective: The objective of this study was to determine the frequency of sensory deficit in termsof TPD in STSG and local flaps for soft tissue defects of fingers after three months. Study design: It was a Quasi experimental study. Settings:Patients admitted in the indoor of Plastic surgery department, Services Hospital Lahore. Period: February 2009 to January 2010. Material andMethods: Thirty five patients underwent local flap coverage and other thirty five underwent split thickness skin grafting for soft tissue defects offingers depending upon nature of defect. Patients were followed up at 2, 4, 8 and 12 weeks. Results: The sensory deficit observed at the end of12th week post operatively was in 8.6% of the patients with local flap coverage (3 patients) and 45.7% of those with STSG (16 patients).Patients with no sensory deficit were 91.4% (32 patients) in the local flap coverage and 54.3% (19 patients) in the STSG at 12th week of followup. The relative ratio of sensory deficit in local flaps and STSG was 5 (&gt;2). Conclusions: The results of this study show that Local flaps arebetter options in terms of TPD preservation as opposed to STSG for soft tissue defects of fingers.

Flexor Digitorum Sublimis Flap for Recalcitrant Carpal Tunnel Surgery

Carpal tunnel release is commonly performed to treat paresthesias, pain, and hand or wrist dysfunction. Despite it being a highly successful procedure, on occasion some patients may continue to suffer from persistent or recurrent symptoms after surgery. Techniques to manage recurrent symptoms range from nonoperative care including injections, splinting, and medications to revision surgery that may include a number of options such as local or distant flap coverage of the median nerve, nerve conduit placement, and/or utilization of vascularized tissues. This paper describes the technique of using a vascularized rotational muscle flap harvested from the flexor digitorum sublimis as a viable option to envelop the median nerve and promote healing during carpal tunnel revision surgery.

Couverture d’une exposition cérébrale post-traumatique par un lambeau temporal total : à propos d’un cas

Major defect of the scalp associated with penetrating brain injury is one of the most challenging issues in acute craniofacial trauma. Depressed skull fractures associated with injuries of the skin and periosteal tissue can be easily covered using various locoregional scalp flap techniques. However, if the skin is damaged around the wound, the surgical possibilities are reduced, allowing only local transposition flap or free flap coverage with many disadvantages for the latter such as vascular micro-anastomosis issues, unsuitable underlying vascular status, and a “patch” effect which is often unsightly. The authors describe, using a clinical case, the steps to provide a total temporal flap to cover a defect of both skin and bone. This can be performed in three separated stages: the first is the empowerment of both middle temporal pedicles; the second stage, 15 days later, is the section, transposition and coverage of the wound; the third stage, 30 days later, is the flap separation.