Medial Flap Research Articles

Experiences in the Clinical Use of the Medial Genicular Flap

Four cases with defects at varying sites were reconstructed with the medial genicular flap. Three cases utilized free microvascular skin flaps based on the saphenous artery and one case a pedicled flap based on the same artery. All flaps survived well with satisfactory functional and cosmetic results. Regional anatomy is briefly reviewed, dissection of the flap is described in detail, and some special technical points are mentioned.

Symmastia

This paper presents the problem of medial confluence of the breasts producing a web across the midline. Significant references in the literature dealing with uncommon clinical problems are virtually nonexistent. The purpose of this paper is to stimulate discussion of this entity and its surgical management and to propose the term symmastia to facilitate retrieval of information about this entity in the future. Two cases that highlight the central problem but which differ in the specifics of the surgical approach are presented. In the first case, the medial web was corrected by elevating an inferiorly based triangular skin flap that was advanced superiorly in an inverted Y-V manner after the excess medial soft tissue was divided and sutured superiorly to the medial pectoralis fascia to create a brassiere-band sling effect. In the second case, a superiorly based medial flap containing both skin and soft tissue was elevated. The excess skin and soft tissue were then excised. The remaining flap was tailored to fit into a V-shaped defect in the inferior incision to place the scar in a less viable place inferior to the sternum. The relative advantages of the two surgical approaches are discussed and a third approach based on the strengths of the two approaches is suggested. This approach would consist of the vertical division and superior rotation of the excess subcutaneous tissue flaps and the elevation of a superiorly based skin flap inserted into a V-shaped defect in the inferior incision.

Soft-tissue reconstruction of the leg associated with the use of the Hoffmann external fixator.

Soft-tissue injuries and defects associated with severe fractures of the tibia treated with the Hoffmann external fixator were reviewed. Of 84 cases of open tibia fractures (classified as Gustilo's Type II and III), 54 patients with 55 injured limbs required soft-tissue reconstruction other than skin grafts or small rotational flaps. These 55 cases were constructed with 37 local musculocutaneous flaps (20 gastrocnemius, 17 soleus and other smaller muscle flaps), 15 free musculocutaneous flaps (14 latissimus dorsi, and one tensor fascia lata), and three medial gastrocnemius cross leg flaps. In all cases the soft-tissue reconstruction was done with the external fixator in place. All but three of the musculocutaneous flaps healed with no problems (94%). Bony healing was found in 30 cases (69.09%) at 18-month followup. There was one amputation after two failed local flaps and three late amputations due to patient's request (infected nonunion). There was a nonunion rate of 25.45% (14 cases) at 18 months postinjury. The Hoffmann external fixator has allowed bony stabilization and has not precluded the subsequent soft-tissue reconstruction or bone grafting. Muscle and musculocutaneous flaps, both local and free, have been employed in the reconstruction of the leg with minimal interference from the Hoffmann device.

Modification of “Periwinkleshell operation” for involution and ptosis of the breasts

Involution and ptosis of the breast may follow gestation or dietary weight loss. Whenever possible the breast tissue is reshaped by resecting the skin over its inferior part, detaching the fixation of the glandular tissue medially and laterally, and dividing it centrally to create two mammary gland flaps. The lateral flap is fixed medially to the base of the medial flap and vice versa. In this way the breast tissue assumes a conical form with only minimal to moderate recurrence of ptosis and flatness. If necessary, an augmentation mammoplasty with a prosthesis can be carried out in a second operation 3 to 4 months later.

The use of a medial upper arm flap to cover axillary structures after radical mastectomy

The use of a medial upper arm flap to cover axillary structures after radical mastectomy

Modification of ?Periwinkleshell operation? for involution and ptosis of the breasts

Involution and ptosis of the breast may follow gestation or dietary weight loss. Whenever possible the breast tissue is reshaped by resecting the skin over its inferior part, detaching the fixation of the glandular tissue medially and laterally, and dividing it centrally to create two mammary gland flaps. The lateral flap is fixed medially to the base of the medial flap and vice versa. In this way the breast tissue assumes a conical form with only minimal to moderate recurrence of ptosis and flatness. If necessary, an augmentation mammoplasty with a prosthesis can be carried out in a second operation 3 to 4 months later.

REDUCTION MAMMAPLASTY BY THE INFERIOR PEDICLE TECHNIQUE

Patients with massive macromastia, or severe ptosis, should be candidates for a reduction mammaplasty by the inferior pedicle transposition technique, instead of by free nipple and areola grafting. With the inferior pedicle technique the blood supply to the nipple and areola remains generous, coming from the entire width of the inframammary fold. By using a keyhole skin flap pattern, a conical breast shape is achieved when the medial and lateral skin flaps are brought together as a skin brassiere. The methods seems safe and simple, and the results have been satisfactory. An unexpected benefit has been the excellent postoperative sensation of the nipple, areola, and the skin of the breasts.

Inguinal hernia repair: A comparison of the shouldice and cooper ligament repair of the posterior inguinal wall

The basic principle of the Cooper ligament repair is the closure of the deficiency in the posterior inguinal wall effected by suturing the upper margin of the defect, represented by the aponeurosis of the transversus plus its investing fascia, downwards to its insertion on to Cooper's ligament along the superior ramus of the pubis lateral to the pubic tubercle. Because of tension, a relaxing incision in the anterior rectus sheath is frequently necessary. The basic principle of the Shouldice repair of the posterior inguinal wall is an overlapping repair utilizing the transversalis fascia, previously divided from internal ring to pubic tubercle. The lateral (or lower) transversalis flap is anchored upwards, underneath the medial (or upper) flap, being attached medially to the edge of the rectus and laterally to the arching fibers of transversus and internal oblique. The medial flap is then attached to the deepest part of the shelving surface of the inguinal ligament. Tension is a less significant factor and a relaxing incision is not used. In two large well-documented series, each using one of these technics exclusively, the recurrence rates are used to compare these two methods of repair. In Halverson and McVay's twenty-two year series of 263 repairs for primary direct inguinal hernia, using the Cooper ligament method throughout, this rate was 4.9 per cent. In my personal twenty-one year series of 4,812 primary direct inguinal hernia repairs using the Shouldice method exclusively, a recurrence rate of 0.7 per cent was achieved. These results suggest that the Shouldice repair is superior.

Voluminous Aneurysmal Bone Cyst in Proximal Part of The Femur

A male, aged 31 years, was admitted with complaint of swelling on outer aspect of his for two years.On physical examination, the swelling was remarkable, rounded and hard, and ulceration was found on its top. The gluteal and adjacent muscles became thin and atrophic. Radiograph revealed a voluminous cystic mass in proximal part of the femur which expanded eccentricall, showing thin layer of the cortex and coarse trabeculae in it. The femoral head and neck were completely destroyed.Under clinical diagnosis of aneurysmal bone cyst, disarticulation of the hip was performed and the stump was covered with the medial flap containing the adductor muscles.The excised tumor was measured about 24×13×12cm oval in size. The appearance of the cut surfaces of it was darkish red, encapsulated with the thin bony shell, and had many cavities of various sizes Histologically, fibrous tissues infiltrated with lymphocytes were found which were dotted with multinucleated giant cells and hemosiderine deposits. In another areas of the same specimens, many irregular cavities separated by fissues and lined with endothelial on their inner surfaces, so called benign vascular channels, were found.Three months after the operation, the patient is in good clinical conditions.

MIDCALF AMPUTATION IN THE ISCHEMIC EXTREMITY. USE OF LATERAL AND MEDIAL FLAP.

WHEN AN amputation is necessary, rehabilitation can be more frequent and successful with a midcalf than with a supracondylar amputation. Many advantages are available to the patient with a below-theknee amputation. 5 He can more readily turn in bed, support himself on the knee, and control his prosthesis. The older patient will frequently use a below-knee prosthesis, whereas an above-knee prosthesis is often impractical and is discarded. Blood supply is better and healing is more certain with the thick medial and lateral flap. Careful selection 4,8 of the patient for the midcalf amputation and utilization of methods to increase the chances of primary healing would seem to minimize failure. 1,6 Fifteen patients out of 20 requiring leg amputations were selected for amputation in the midcalf. Medial and lateral flaps were used in all amputations at this level. A 100% healing was obtained including delayed healing in three cases. No deaths

A Postoperative Mastectomy Dressing

No extract is available for articles shorter than 400 words.

THE USE OF LIVING FASCIA TRANSPLANT TO REPAIR A HERNIA OF THE TIBIALIS ANTICUS MUSCLE

It was over thirty years ago that McArthur 1 first brought out the use of fascia as a suture in the repair of hernia. After incising the external oblique aponeurosis he cut a small strip off the free border of the medial and lateral flaps. He left these attached at their inferior ends. After ligating the sac he used the strip from the medial border to suture the internal oblique muscle to Poupart's ligament under the cord. He then used the strip from the lateral border to suture together over the cord the flaps of the aponeurosis of the external oblique. Three years later he reported ninety-three consecutive cases in which fascia had been used as a suture without recurrence of the hernia. One of his patients died a year after the operation had been performed and he secured the scar. Microscopic sections showed the graft passing through

"PLASTIC REPAIR OF INGUINAL HERNIA"

To the Editor: —The Journalfor Nov. 15, 1930, contains an article by Joseph A. Pettit, M.D., Portland, Ore., in which the author states: About the time this technic was brought out Skillern presented a plastic flap technic lacking in the essential advantages presented by mine. And on the next page Pettit writes further: I find three distinct disadvantages in the Skillern operation, in which the lower or lateral flap is plicated beneath the upper or medial flap: (1) It is not possible to make so extensive a plication; (2) it is not possible to construct a new fascial canal for the structures of the cord without producing an additional curve having a sharp and disadvantageous angulation, and (3) the general reconstruction is anatomically incorrect. The article describing the operation referred to was published in 1922 (Skillern, P. G.: The Choice of Operation in Inguinal Hernia, Surg. Gynec. Obst