Myocutaneous Flap Coverage Research Articles

Odontogenic cervical necrotizing fasciitis with descending mediastinitis: a case report and discussion

<p class="abstract">Mr KE is a 46 years old gentleman with a background of type 2 diabetes mellitus who was referred to our department for severe polymicrobial cervical necrotising fasciitis with descending mediastinitis after mandibular dental extraction. He was managed with endotracheal intubation, cervicotomy and video assisted thorascopic surgery (VATS), antibiotic and antifungal therapy and myocutaneous flap coverage. This case describes a classical presentation of an uncommon pathology and discusses options for airway management, surgical debridement, antimicrobial therapy and definitive defect coverage. </p>

Management of open tibial fractures type IIIB by segment transfer using limb reconstruction system fixator

Purpose To evaluate the effectiveness of bone transport using limb reconstruction system (LRS) fixator and early coverage in open-type IIIB tibial fractures with massive bone and soft tissue loss. Patients and methods In this study, eight patients with type IIIB open tibial fractures were managed by initial debridement and fixation by LRS uniplanar external fixator. A second-stage rotational myocutaneous flap coverage and osteotomy for segment transfer was done within 14 days. All patients were followed up till full union. Results Full union was achieved in all patients. A total of five patients needed iliac bone graft at the docking site. Union occurred in an average external fixator index of 45.3 days/cm. No flap coverage infection occurred, and there was no significant limb malalignment. Significant limb shortening occurred only in one patient. Conclusion LRS fixator is an effective definitive method for management of open tibial fractures with massive bone loss and soft tissue defects. It is easy to apply, allows early intervention by plastic surgeons to obtain soft tissue coverage, and also allows early patient rehabilitation and joint mobilization.

Couverture d’une escarre ischiatique et trochantérienne récidivante par un lambeau fasciocutané antérolatéral de cuisse pédiculée

Ischial pressure sores, common in paraplegic patient, are the most difficult to treat, and poor prognosis associated with a high rate of postoperative recurrence. Many surgical techniques by muscular or myocutaneous flap coverage have been described. We report an original use of a fasciocutaneous pedicled anterolateral thigh (ALTp) flap for coverage of an ischial pressure sore combined with a trochanteric pressure sore, exceeded beyond any conventional therapeutic solution. A 45-year-old paraplegic patient suffered from a trochanteric and ischial pressure sore, which had already received coverage by a muscular flap of biceps femoris and gluteus maximus. At 1 year, the result is satisfactory, with good coverage without recurrence. The fasciocutaneous ALTp flap can be a solution to cover recurrent ischial pressure sores beyond conventional methods.

Adductor Myocutaneous Flap Coverage for Hip and Pelvic Disarticulations of Sarcomas with Buttock Contamination

Hip disarticulation and hemipelvectomy are alternatives to limb-salvage procedures for patients with extensive tumors of the upper thigh and buttocks. In cases when neither the conventional posterior gluteus maximus flap nor the anterior quadriceps flap can be used because of the location of the tumor, a medial adductor myocutaneous flap may be an alternative. The flap is outlined over the anteromedial thigh. The distal extent is at the level of the adductor hiatus. The common femoral vessels and nerve are traced, preserved, and protected. The adductor muscles then are divided above their insertions on the femur and preserved with the flap. En bloc removal of the tumor is performed by either hip disarticulation or hemipelvectomy. The long adductor myocutaneous flap is brought up laterally and proximally to close the wound. We reviewed four patients who underwent a medial adductor myocutaneous flap after either hip disarticulation or hemipelvectomy. The medical records and radiographs were analyzed. These patients were followed up for at least a year or until death. Wide surgical margins were achieved in all four patients and the flap remained viable, with no skin necrosis or flap breakdown. The patients were able to sit on the flap, and one patient was able to wear a prosthesis. In patients undergoing hip disarticulation or hemipelvectomy where tumor infiltration or inadvertent contamination by previous surgery will not allow the traditional posterior gluteus maximus or anterior quadriceps flap, this unconventional medial adductor myocutaneous flap is a feasible, technically simple option. Level IV therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Experience with the Mentor Contour Profile Becker-35 expandable implants in reconstructive breast surgery

Round expander-implants (Beckers 25 and 50) and anatomical expander-prostheses filled with firm cohesive gel (McGhan Style 150) are established choices for single-stage expander breast reconstruction. Because of their drawbacks we selectively adopted the anatomical Becker-35 expander-implant filled with soft cohesive gel from January 2005. All patients undergoing reconstructive breast surgery using the Contour Profile Becker-35 expandable implant over a two-year period were retrospectively reviewed with respect to indication, implant sizes, inflation details, complications and outcomes. 36 patients, mean age 48.9 years (r=14-69), received 39 anatomical Becker-35 expanders (three bilaterally). Three quarters of these implants (29) were used for immediate breast reconstruction while the remainder were equally divided between delayed postmastectomy reconstruction (5) and correction of congenital breast asymmetry (5). Half of the patients had simultaneous latissimus dorsi myocutaneous flap coverage of the implants. The median numbers of inflations and deflations needed to achieve the target expansion size and shape were 3 (r=0-7) and 0 (r=0-4), respectively. The mean time from expander insertion to completion of reconstruction was 4.6 months (r=0-13 months). Four patients required surgical intervention for haematoma, implant infection, severe capsular contracture, and palpable rippling. Additionally there were three injection port adjustments, giving a 20% overall revisional surgery rate (8/39 breasts) after a median follow-up of 20 months (r=6-38 months). Four implants (10%) developed significant but asymptomatic rippling. The significant capsular contracture rate was 21% (8/39 breasts), which was related to chest wall radiotherapy. In this short-term study, the Becker-35 expander was successfully used for single-stage prosthetic breast reconstruction with an incidence of early complications comparable to alternative prostheses. Although it has expanded the range of implants available to the breast surgeon, its exact role in reconstructive breast surgery has yet to be established.

Full-Thickness Resection With Myocutaneous Flap Reconstruction for Locally Recurrent Breast Cancer

Despite available recommendations, therapeutic procedures of locally recurrent breast cancer are very different. This retrospective study presents the possibilities and results of complete, full-thickness chest wall resection. Between 1985 and 2006, 63 women (mean age, 58 years) with local recurrence of breast cancer invading the chest wall underwent chest wall resection with myocutaneous flap coverage and are included in this study. Adequate lung, cardiovascular, renal, and hepatic functions were additional eligibility requirements for inclusion. Preoperative known extrapulmonary metastases, pleural dissemination, and Eastern Cooperative Oncology Group (ECOG) status 3 or 4 were exclusion criteria. Survival rates were calculated by the Kaplan-Meier method. Univariable and multivariable Cox regression analysis was used for relative risk factors. The median interval between operation for the primary tumor and of the local recurrence was 89 months, with median follow-up at 28 months. In the total collective, cumulative 5-, 10- and 15-year survival rates were 46%, 29%, and 22%, respectively, with a median survival of 56 months. R0 resection was associated with a 5-year survival of 50.4%. Prognostic factors were patient age at the time of the primary operation and tumor invasion of bony structures. Mortality was 1.6% and morbidity was 25%. Full-thickness chest wall resection of locally recurrent breast cancer performed by a team of thoracic and plastic surgeons provides the best survival rates, with low mortality and morbidity. An earlier application of this method may lead to further improvement of these results.

Carotid Artery Reconstruction Combined with Myocutaneous Flap Coverage: A Complex and Durable Rescue Operation

Carotid reconstruction combined with myocutaneous flap coverage is a rare and challenging operation. We reviewed our experience to define the indications and outcome of this complex procedure. Clinical data and neurologic, wound, and vascular complications of all patients who underwent carotid artery reconstruction combined with myocutaneous flap coverage over a 17-year period were retrospectively reviewed. Results from this procedure indicate that pectoralis major myocutaneous flap is a safe and durable option for wound coverage in patients who undergo carotid endarterectomy, resection, and/or reconstruction for neck malignancy, previous irradiation or graft infection. Late outcome is favorable with low neurologic, vascular, and wound complication rates.

External Oblique Myocutaneous Flap Coverage of Large Chest-Wall Defects Following Resection of Breast Tumors

Defects resulting from resection of advanced breast tumors can be quite large, posing a difficult reconstructive challenge. A significant number of such patients present with local recurrences after receiving external beam radiation and/or chemotherapy treatments. Pectoralis major, latissimus dorsi, rectus abdominis, and omental flaps with split-thickness skin grafts have been recommended for closure of chest-wall defects. What is often excluded from the list of reconstructive options is the external oblique myocutaneous flap. In our series of 20 consecutive patients treated at Memorial Sloan-Kettering Cancer Center, an external oblique myocutaneous flap was used to cover these large chest-wall defects successfully. The median age of our patient population was 54.5 years, and 68 percent of them presented with local recurrence. Fifty percent had external beam radiation, and fifty percent had received chemotherapy. Twenty-five percent of our study group had had both treatments. The mean chest-wall defect measured 326 cm2, corresponding to a 20 x 16 cm area. We believe that the external oblique myocutaneous flap should be considered a safe and reliable option when reconstruction of large chest-wall defects is contemplated.

Polypropylene mesh closure of the complicated abdominal wound

Background: Closure of the abdominal wall in the face of fascial necrosis or massive intestinal edema remains a difficult problem with frequent complications. Prior studies have addressed both the utility and the pitfalls of placing polypropylene mesh in this setting. Methods: We performed a retrospective evaluation of our experience with polypropylene mesh in traumatic and nontraumatic difficult abdominal closures. Timing of mesh placement and removal relative to the initial operation were recorded, as were abdominal complications, number of operative procedures, and type of ultimate abdominal closure. Results: Between 1988 and 1993, polypropylene mesh was placed in 26 critically ill or injured patients requiring celiotomy, of whom 23 survived more than 3 weeks. Ultimate wound management was delayed mesh removal and primary closure (17%), myocutaneous flap coverage over mesh (4%), split-thickness skin grafting to the granulating wound (35%), or closure by secondary intention over mesh (43%). Split-thickness skin grafting and closure by secondary intention resulted in enterocutaneous fistulas in 50% and 40% of cases, respectively. Full-thickness closure with or without mesh removal resulted in no fistulas. Conclusion: Mesh provided adequate fascial closure, even with gross wound contamination. Coverage of polypropylene mesh by secondary intention or split-thickness skin grafting resulted in unacceptably high rates of fistulous complications, and this procedure should be replaced by either mesh removal or full-thickness coverage.

Mandibular reconstruction using a titanium plate: The impact of radiation therapy on plate preservation

To evaluate the soft tissue and bone tolerance of radiation therapy (RT) in patients undergoing radical composite resection and mandibular reconstruction using a bridging titanium plate with myocutaneous flap closure. From 1990 to 1994, 47 patients with primary or recurrent oral cavity or oropharyngeal carcinomas were treated with radical composite resection and mandibular reconstruction using a bridging titanium plate with myocutaneous flap closure. Eleven patients received no RT (no RT), 10 patients received RT greater than 10 months from the time of surgery (remote RT), and 26 patients received RT within 12 weeks of surgery (perioperative RT). The radiation dose to the reconstructed mandible ranged from 45 to 75 Gy (median 63 Gy). The effect of the titanium plate on the radiation dose was measured using film dosimetry and soft tissue and bone-equivalent materials. The median follow-up was 17 months (range: 3-50 months). Late complications included four patients with osteomyelitis or necrosis, two plate exposures requiring flap revision, one chronic infection, two cases of chronic pain, two fistulae, and one case of trismus and malocclusion. The crude incidence of late complications by treatment was: (a) no RT: 3 of 11 patients (27%); (b) remote RT: 2 of 10 patients (20%); and (c) perioperative RT: 9 of 26 patients (35%). One patient in the no-RT group lost the plate due to chronic pain. Five patients in the perioperative RT group also had plate loss, four due to osteomyelitis and/or necrosis, and one due to pain related to a recurrent tumor. No patients in the remote RT group had plate loss. The actuarial prosthesis preservation rate at 2 years was 88% for the no RT, 100% for the remote RT, and 57% for the perioperative RT groups (p = 0.05). Phantom dose measurements showed that for parallel opposed 6 MV photon beams, there was no significant increase in the dose proximal or distal to the plate in either a soft tissue- or bone-equivalent phantom. The impact of radiation therapy on plate preservation after mandibular reconstructive surgery using a titanium plate may be dependent on the timing of RT relative to surgery. Significantly more mandibular reconstruction plates were lost when the involved mandible received RT in the perioperative period than when RT was delivered beyond 10 months from surgery or when no RT was given. The use of alloplastic implants such as titanium plates in conjunction with myocutaneous flap coverage for mandibular reconstruction is attractive because it allows immediate reconstruction of the defect and promotes a good functional and cosmetic result; however, administration of perioperative RT may result in a higher plate failure rate.

Approaches to Repair of Ventral Hernia and Full-Thickness Losses of the Abdominal Wall

This article describes the causes, course, and treatment options for surgical repair of umbilical epigastric and incisional hernias. Special attention is paid to the full-thickness abdominal wall defects, which are particularly difficult wounds to close. A method of closure with Marlex mesh, followed by myocutaneous flap coverage, is discussed.

Use of inferior rectus myocutaneous flap for coverage of bladder exstrophy defect

Use of inferior rectus myocutaneous flap for coverage of bladder exstrophy defect

Use of Inferior Rectus Myocutaneous Flap for Coverage of Bladder Exstrophy Defect

This report details the closure of a large suprapubic abdominal wall defect with the use of inferior rectus abdominis and tensor fascia lata myocutaneous flaps in a 14-mo-old child with exstrophy of the bladder.

Gluteal plication closure of sacral pressure ulcers.

A technique for closure of gluteal pressure sores is described. It has been successfully used on 19 of 21 patients during the last 58 months. Median follow-up time is 23 months. Muscular and vascular integrity are preserved for future myocutaneous flap coverage if required. It is recommended as a relatively conservative method of early repair of sacral pressure defects not in excess of 8 cm in diameter.