Plastic Surgical Intervention Research Articles

Alteration of the Circadian Network after Traumatic Brain Injury (TBI)

RESULTS: Sixty patients (83 procedures) were included in the study. Fifty-seven patients (95.0%) underwent previous craniotomy, craniectomy, or other trans-galeal procedure. Of the total 60 patients, 35 patients received preoperative radiation. Sixteen patients received bevacizumab prior to their index case, while 12 received bevacizumab postoperatively. Ten patients (16.7%) required additional plastic surgical intervention for wound complications after their index plastic surgery procedure. Plastic surgery was consulted prophylactically in 34 patients (38 procedures). When plastic surgery was consulted prophylactically, 4 patients (11.8%) required further wound revision. None of the 14 patients who underwent prophylactic plastic surgery closure for previous scalp incision, preoperative bevacizumab, and radiation administration required re-intervention.

The impact of the Major Trauma Network: will trauma units continue to treat complex foot and ankle injuries?

IntroductionApril 1st 2012 saw the introduction of National Trauma Networks in England. The aim to optimise the management of major trauma. Patients with an ISS≥16 would be transferred to the regional Major Trauma Centre (level 1). Our premise was that trauma units (level 2) would no longer manage complex foot and ankle injuries thereby obviating the need for a foot and ankle specialist service. MethodsRetrospective analysis of the epidemiology of foot and ankle injuries, using the Gloucestershire trauma database, from a trauma unit with a population of 750,000. Rates of open fractures, complex foot and ankle injuries and requirement for stabilisation with external fixation were reviewed before and after the introduction of the regional Trauma Network. Secondly, using the Trauma Audit & Research Network (TARN) database, all foot and ankle injuries triaged to the regional Major Trauma Centre (MTC) were reviewed. ResultsIncidence of open foot and ankle injuries was 2.9 per 100,000 per year. There were 5.1% open injuries before the network and 3.2% after (p>0.05). Frequency of complex foot and ankle injuries was 4.2% before and 7.5% after the network commenced, showing no significant change. There was no statistically significant change in the numbers of patients with complex foot and ankle injuries treated by application of external fixators. Analysis of TARN data revealed that only 18% of patients with foot and ankle injuries taken to the MTC had an ISS≥16. The majority of these patients were identified as requiring plastic surgical intervention for open fractures (69%) or were polytrauma patients (43%). Only 4.5% of patients had isolated, closed foot and ankle injuries. ConclusionWe found that at the trauma unit there was no decrease in the numbers of complex foot and ankle injuries, open fractures, or the applications of external fixators, following the introduction of the Trauma Network. These patients will continue to attend trauma units as they usually have an ISS<16. Our findings suggest that there is still a need for foot and ankle specialists at trauma units, in order to manage patients with complex foot and ankle injuries.

Prophylactic plastic surgery closure of neurosurgical scalp incisions reduces the incidence of wound complications in previously-operated patients treated with bevacizumab (Avastin®) and radiation.

Neurosurgical craniotomy, craniectomy, or other trans-galeal interventions are performed for a variety of indications, including the resection of benign or malignant tumors, hematoma evacuation, and for the management of intractable seizure disorders. Despite an overall low complication rate of intervention, wound healing complications such as dehiscence, surgical site infection, and cerebrospinal fluid leak are not uncommon. A retrospective review was performed of all patients who underwent scalp incision closure at a single institution by a single plastic surgeon between 2006 and 2013. Sixty patients (83 procedures) were included in the study. Fifty-seven patients (95.0 %) underwent previous craniotomy, craniectomy, or other trans-galeal procedure. Of the total 60 patients, 35 patients received preoperative radiation. Sixteen patients received bevacizumab prior to their index case, while 12 received bevacizumab postoperatively. Ten patients (16.7 %) required additional plastic surgical intervention for wound complications after their index plastic surgery procedure. Plastic surgery was consulted prophylactically in 34 patients (38 procedures). When plastic surgery was consulted prophylactically, 4 patients (11.8 %) required further wound revision. None of the 14 patients who underwent prophylactic plastic surgery closure for previous scalp incision, preoperative bevacizumab, and XRT administration required re-intervention. Plastic surgery closure of complex scalp incisions reduces the incidence of wound complications among patients who underwent previous neurosurgical intervention, XRT administration, and preoperative bevacizumab administration. This is particularly true when plastic surgery closure is performed "prophylactically." Further collaboration between the neurosurgical and plastic surgery teams is therefore warranted, particularly in the setting of these high-risk cases.

Massive panniculectomy: a novel method of treatment of postlaparotomy wound dehiscence in morbid obesity

It was with interest that we read the article “High-concentration oxygen and surgical site infections in abdominal surgery: a meta-analysis.”1 Massive liposuction and body contouring procedures are no longer primary therapeutic options for the treatment of morbid obesity owing to their complications and suboptimal results. The obvious paradigm shift has been noted to favour bariatric procedures since the advent of laparoscopic approaches over last 2 decades. Panniculectomy is a cosmetic procedure that involves the removal of excess skin and fat from the affected organ. We performed massive panniculectomy for the treatment of postlaparotomy wound dehiscence in a morbidly obese patient. A 60-year-old woman with body mass index (BMI) of 41.7 underwent a total abdominal hysterectomy for dysfunctional uterine bleeding. A surgical site infection and dehiscence involving skin and subcutaneous layers across the complete length of incision developed in the immediate postoperative period. The initial treatment at the primary centre involved drainage, debridement and regular dressings. The patient was referred to our centre for further management in postoperative week 4. Upon clinical examination, we observed that the abdomen skin fold was thick and large, and it was difficult to examine the dehiscence suture line in the recumbent position (Fig. 1A). The bacteriological study of culture and sensitivity from the abdominal wound was unremarkable; blood work was essentially normal. After counselling the patient and her relatives, a decision was made to repair the wound with massive panniculectomy to remove excessive skin and subcutaneous tissue from the abdomen. The excessive abdominal skin complex incorporating the suture line and the umbilicus was removed (weighing 8.5 kg) and the procedure was completed. The duration of the surgery was 180 minutes; blood loss was minimal (100 mL). The postoperative period was uneventful and the wound healed well, with no excessive abdominal fold. The patient was able to resume her normal activities 14 days after the procedure (Fig. 1B). Fig. 1 (A) Clinical picture showing laparotomy wound dehiscence. (B) Postoperative picture of the suture line shows good healing after massive panniculectomy surgery. Management of morbid obesity involves a trial of strict diet and exercise, followed, if unsuccessful, by one of the various bariatric surgical procedures. Plastic surgical intervention usually comprises massive liposuction and body contouring with or without lumpectomies after achieving weight loss. Panniculectomy is a procedure that involves the removal of excess skin and fat from any part of the body. This procedure is different from abdominoplasty, which involves tightening of the muscles. Panniculectomy is done routinely after massive weight loss (e.g., after bariatric surgeries), where excessive skin and subcutaneous fat are removed to enhance appearance and improve confidence. When more than 10 lbs of tissue is removed, the procedure is known as massive panniculectomy.2,3 Abdominal wall hernia repair is treated with mesh repairs, component separation technique and pedicled fascia lata flap. In our case, excess bulk of the abdominal wall mass was dragging in multiple directions, thereby stretching the operative wound and preventing it from closing. During the procedure, the previous vertical wound was excised en masse with the excess abdominal apron and umbilicus using a supra pubic Pfannensteil incision; the postexcision wound was closed transversely corresponding to the relaxed skin tension lines. Therefore, a reduced abdominal wall mass and a new suture line along the relaxed skin tension lines enabled us to have good wound healing and increased patient satisfaction. We conclude that panniculectomy, which is primarily a cosmetic method of excess skin and fatty tissue removal, can be used to treat postsurgical wound dehiscence in morbidly obese patients.

HIV-associated lipodystrophy in South Africa: The impact on the patient and the impact on the plastic surgeon

With 67% of the world's human immunodeficiency virus (HIV)-infected population existing in sub-Saharan Africa and recent access to highly active antiretroviral therapy (HAART), the demand for plastic surgical intervention in addressing lipodystrophy has expanded dramatically. We assessed the rate of lipodystrophy in a random clinic cohort, the demand for surgical correction and risk of treatment non-compliance. Questionnaire and database cross-sectional review of 554 patients over a 3-month period at the Themba Lethu Clinic, Johannesburg, South Africa. A total of 479 patients completed the questionnaire, 83% were female. Nearly 90% of patients were on, or had been on, stavudine (d4T). The prevalence of lipodystrophy was 11.7%. Nearly 5.9% of patients had considered stopping treatment due to the development of lipodystrophy; 47% would consider surgery to correct unwanted physical changes. Male patients were satisfied by the changes they noted in their physical features following treatment (pre-treatment satisfaction 38% vs. post-treatment satisfaction of 94%). Female patients had6.5 times more breast hypertrophy-related symptoms than in their pre-treatment state. We identify a prevalence of 11.7% of patients with HIV-associated lipodystrophy, of whom 5.9% would consider non-compliance on the basis of this side effect alone. The demand for surgical correction is significant and needs to be addressed.

Early Escharectomy and Concurrent Composite Skin Grafting over Human Acellular Dermal Matrix Scaffold for Covering Deep Facial Burns

Although escharectomy and full-thickness skin autografting have been widely used to treat deep facial burns, the clinical outcomes remain unacceptable. Composite razor-thin skin grafting over acellular dermal matrix scaffold has been used successfully in repairing burns of the trunk and limbs, but its use in covering deep facial burns has rarely been reported. In this study, the authors investigated the clinical outcomes of early escharectomy and concurrent composite razor-thin skin autografting and acellular dermal matrix scaffold for treating deep facial burns. Patients with deep facial burns (n = 16) involving 8 to 30 percent of the total body surface area received early escharectomy by postburn day 3 and concurrent, one-stage, large, razor-thin skin autografting on top of human acellular dermal matrix scaffold. Wound dressings were changed on postoperative days 7, 9, and 12 to examine the survival of skin autografts. Patients were followed up for 12 months to evaluate their facial profiles. The take rate of composite skin autografts was 97.3 percent at postoperative day 12. At the follow-up visit, the skin autografts appeared normal in color, with soft texture and good elasticity. The skin junctures showed little scarring. The patients exhibited a chubby facial appearance and abundant expression, except for one patient with microstomia and two patients with ectropion who required further plastic surgical interventions. Early escharectomy and concurrent composite razor-thin skin autografting on top of acellular dermal matrix scaffold constitute an effective and favorable option for covering deep facial burns, especially for patients with limited donor sites.

Simulating plastic surgery: From human skin tensile tests, through hyperelastic finite element models to real-time haptics

In this paper, we provide a summary of a number of experiments we conducted to arrive at a prototype real-time simulator for plastic surgical interventions such as skin flap repair and inguinal herniotomy. We started our research with a series of in-vitro tensile stress tests on human skin, harvested from female patients undergoing plastic reconstructive surgery. We then used the acquired stress–strain data to fit hyperelastic models. Three models were considered: General Polynomial, Reduced Polynomial and Ogden. Only Reduced Polynomial models were found to be stable, hence they progressed to the next stage to be used in an explicit finite element model aimed at real-time performance in conjunction with a haptic feedback device. A total Lagrangian formulation with the half-step central difference method was employed to integrate the dynamic equation of motion of the mesh. The mesh was integrated into two versions of a real-time skin simulator: a single-threaded version running on a computer’s main central processing unit and a multi-threaded version running on the computer’s graphics card. The latter was achieved by exploiting recent advances in programmable graphics technology.

Quality-Adjusted Life-Year as a Surgical Outcome Measure: A Primer for Plastic Surgeons

Historically, surgical outcomes have been measured by rates of mortality and morbidity. Fortunately, in plastic surgery, mortality is rarely an issue unless one is practicing in high-risk settings such as burn units or war zones. The improvement of presurgical morbidity, however, is very relevant to our specialty, and great effort should be made to measure it as precisely as possible. The success of plastic surgery interventions has traditionally been measured by beforeand-after photographs in cosmetic surgery, pinch and grip strength and range of motion in hand surgery, percentage of successful flaps or replanted digits in microsurgery, and so forth. Although such outcomes are important, they serve only as proxies for the ultimate goal of optimal physical, mental, and social well-being of the patient. Would one seriously consider a face-lift result satisfactory if the patient required psychiatric support after her operation despite a much improved postoperative photograph? Likewise, would an improvement of 0.5 kg in grip strength after a novel hand procedure be considered successful if the patient was still unable to return to work? What about a meticulously executed flap to reconstruct a through-and-through defect of the mandible in a head and neck cancer where the patient died 6 months later from cancer recurrence?1 Plastic surgeons have recognized for some time now that there can be a discrepancy between their interpretation of a successful surgical outcome and the patient’s expectation. A rapid expansion of outcomes research has occurred over the past two decades in many medical specialties. This has been fueled, at least in part, by the practice of evidence-based medicine. Evidence-based medicine integrates individual clinical expertise with the best available clinical evidence from systematic research.2,3 Outcomes research sets out to measure a patient’s quality of life. The broader term “quality of life” can be defined as “the adequacy of people’s material circumstances and their feelings about these circumstances.”4,5 This encompasses indicators of life satisfaction; personal wealth and possessions; level of safety; level of freedom; spirituality; health perceptions; and physical, psychological, social, and cognitive well-being.4,5 Health-related quality of life, a subcomponent of quality of life, includes all areas specific to health, that is, physical, emotional, psychological, social, cognitive, and role functioning, in addition to abilities, relationships, perceptions, life satisfaction, and well-being. It refers to patients’ appraisals of their current level of functioning and satisfaction with it, compared with what they perceive to be ideal.6,7 There are several different methods available to measure a patient’s health-related quality of life. In the past two decades, a number of validated and reliable scales have been introduced to measure improvement in quality of life of plastic surgical interventions. One particular health-related quality-of-life outcome measure, although infrequently used in plastic surgery, is the quality-adjusted life-year. The quality-adjusted life-year was originally introduced as a measure of health effectiveness for cost-effectiveness analysis to assist decision makers in allocating scarce resources across competing health care programs.8–10 Health care spending in the United States is the highest in the world, averaging $7026 per person per year.11 However, the U.S. health care system ranks 37th among the 191 countries.12 Although nationwide efforts to decrease this unsustainable growth have had limited success so far, this issue will be dealt with sooner From the Department of Clinical Epidemiology and Biostatistics and the Surgical Outcomes Research Center, McMaster University, and the Department of Surgery, Division of Plastic and Reconstructive Surgery, St. Joseph’s Healthcare. Received for publication July 23, 2009; accepted October 29, 2009. Copyright ©2010 by the American Society of Plastic Surgeons

Dealing with the non-healing; donor site defect following latissimus dorsi myocutaneous flap in breast reconstruction

We present two cases of donor site morbidity following immediate breast reconstruction using the extended latissimus dorsi myocutaneous flap. Early post operative dehiscence occurred in both cases, followed by a prolonged period of expectant and conservative management. Plastic surgical intervention involved exploration and removal of significant epithelial lined cavities and reconstruction using local flaps to solve this complication.

Perspectives on Plastic Surgery and Global Health

Of the many factors affecting the health of the human race, those amenable to correction by plastic surgical intervention comprise a significant number. The interface between the global health community and the plastic surgery community historically has been quite diminutive, but this is changing with globalization. This overview provides a primer of global health for the plastic surgeon, and a discussion of the global burden of disease as it relates to plastic surgery. The article then briefly discusses the disparity between the global plastic surgery needs and the supply of expertise, and the difficulties presented by policy, finances, and implied societal preferences for care.

Wound Infection Rates in Elective Plastic Surgery for HIV-Positive Patients

Human immunodeficiency virus (HIV)-positive patients suffer from a unique set of aesthetic challenges, frequently requiring plastic and reconstructive surgical intervention. This study was designed to evaluate the overall wound infection rates for elective surgery in this patient population, focusing specifically on differences between transdermal (both open and minimally invasive) and transoral procedures. Charts were reviewed for all patients with an International Classification of Diseases, Ninth Edition code of V08 (asymptomatic HIV infection, CD4 count >200 cells/microl) who underwent surgery by the senior author (S.P.D.) at this tertiary care hospital between January 1, 2000, and October 1, 2007 (39 patients, 98 procedures). Indication for surgery, type of procedure performed, wound infection rates, length of follow-up, status of HIV infection, and HIV treatment status were all documented. Data were collected according to internal review board protocol. Infection rates were compared between study groups and with the existing surgical literature. Statistical analysis revealed no significant difference in wound infection rate between open and minimally invasive procedures when a transdermal approach is used (10 percent and 0 percent, respectively; p > 0.05). However, there was a significantly increased infection rate in transoral surgery when compared with these two groups (71 percent; p < 0.001). These findings indicate that there is a greatly increased risk of wound infections for HIV-positive patients undergoing transoral surgery when compared with transdermal surgery and historical norms.

Successful treatment of a chronically infected and necrotic tendo Achillis in a diabetic with excision, flexor hallucis longus transfer and split-skin grafting

Chronic infections and ulceration around the tendo Achillis are difficult to manage. Split-skin grafts do not survive even on healthy exposed tendon. Refractory cases may require plastic surgical intervention with the use of free flaps. Patients with significant vascular disease are not suitable for such techniques. Flexor hallucis longus tendon transfer is an established treatment for chronic ruptures of the tendo Achillis. We report the successful treatment of an infected tendo Achillis with excision and reconstruction with flexor hallucis longus transfer. The muscle belly of this tendon allowed later skin grafting while the tendon transfer provided good functional recovery.

Pediatric Upper Extremity Burns: Outcomes of Emergency Department Triage and Outpatient Management

Pediatric upper extremity burns are common. Though current American Burn Association guidelines recommend burn unit referral for burns involving the hands or major joints, many minor injuries are treated in the emergency department (ED) or outpatient setting. Despite the large number of burn patients managed by primary care providers, no large studies have been performed to assess effectiveness. A retrospective 5-year review of the epidemiology and outcomes associated with pediatric upper extremity burns treated at an urban ED was performed. Two hundred sixty-nine patients were identified. The mechanism of burn, percentage of total body surface area (%TBSA) affected, plastic surgery consultations (for wound management recommendations and additional treatment), complications, and surgical interventions were examined. Mechanisms of burn included direct contact (47%), scald (29%), flame (12%), electrical (10%), and friction or chemical (1.5%). Fifty percent of patients suffered from burns over less than 1% TBSA; close to 95% had burns on less than 5% TBSA. Seventy-five percent of patients had second-degree burns, 21% had first-degree burns, and 2% had third-degree burns. Forty patients (15%) had a plastic surgery consult. Seven patients (3%) required skin grafting. Complications occurred in five (2%) patients and included two cases of hypertrophic scarring; two patients with flexor contractures, one case of compartment syndrome requiring fasciotomy, and one late infection. These results suggest that although significant burns are usually cared for in specialized burn centers, the majority of childhood burns to the upper extremity are relatively minor and often treated in the primary care setting. Most patients had small areas of injury and healed without complications. Contact burns are an ever-increasing proportion of childhood burns and should be seemingly preventable. Education to parents and primary care physicians should be reemphasized. It appears that minor upper extremity burns treated by our urban ED staff are handled appropriately and result in favorable outcomes.

Psychosocial Impact of Abdominoplasty

The number of patients desiring reconstructive surgery after a huge weight loss achieved with gastric banding is increasing. This study was undertaken to determine whether plastic surgical removal of an overlap flap has a psychosocial effect on patients. Thirty-women and four men who underwent overlap flap surgery were interviewed 1 day before, and again 3 and approximately 12 months after the procedure using a series of instruments: Strauss and Appelt's Questionnaire for assessing one's body, the Body Perception Questionnaire by Paulus, the questionnaire for satisfaction of life by Fahrenberg, Myrtek, Schumacher, and Brähler, the Hospital Anxiety and Depression Scale (German version) by Herrmann, Buss, and Snaith, and the authors' general questionnaire after surgery. The same clinical parameters were also investigated in a control group of persons who did not undergo plastic surgery. Comparisons were made before and after surgery between and in both groups. In contrast to the control group, surgical patients reported a highly significant increase in self-confidence and the feeling of being attractive (p <or= 0.001); 75% of the surgical patients stated that their expectations were met by the plastic surgical intervention. Plastic surgery after weight loss improves body image and subjective quality of life. These results will influence the indication for a reconstructive operation in future.

Sternal closure with titanium plate fixation - a paradigm shift in preventing mediastinitis

Sternal instability predisposes to post-operative mediastinitis. Biomechanical studies have shown the superiority of rigid plate fixation over wire circlage in sternal healing. We studied rigid plate fixation for sternotomies in high-risk patients. High-risk patients were identified as those having three or more historically established risk factors for post-operative mediastinitis, such as COPD, re-operative surgery, renal failure, diabetes, steroid use, obesity, existing infection, and immunosuppression. Three hundred and twenty high-risk patients had prophylactic rigid plate fixation (Group S) between July 2000 and Jan 2005. The control group (Group C) comprised 215 patients with similar risk profiles that were not plated during 2000 and 2001. Average age, male-female ratio, risk factors and type of procedures were similar in both groups. Follow up ranged from 4 to 200 weeks. There were 12 peri-operative deaths (3.75%) in group S and 8.6% (18 patients) in group C. There were no instances of deep mediastinitis in group S. Group C had mediastinitis in 28 (13%, P<0.05), requiring high dose antibiotics and plastic surgical intervention. Sternal fixation with titanium plates is an effective way of ensuring sternal immobility thereby reducing the substrate for bony infections. Application of this technique in high-risk patients prevents mediastinitis.

Perforator based flap coverage from the anterior and lateral compartment of the leg for medium sized traumatic pretibial soft tissue defects—a simple solution for a complex problem

Compound fractures involving the leg, exposing the tibia or other poorly vascularised tissues such as tendons still pose a big problem for a reconstructive surgeon and they need early plastic surgical intervention. A prospective study of 10 cases of moderate sized defects in the leg exposing the tibia due to trauma was undertaken between January 2003 and August 2004 with an average follow up of 12 months. Pre-operative identification of the perforator around the wound was meticulously performed using hand held Doppler equipment. Most of the wounds were covered within the first 3-5 days of the injury. All the flaps were raised from the anterior or the lateral compartment of the leg to cover the adjacent tibial bone. Five flaps were raised as proximally based and five flaps were raised as distally based flaps. No flap was raised and advanced in a V-Y fashion. Split skin grafting was required in all cases to cover the secondary raw area created following the flap elevation. All flaps survived and served the purpose. In one case we encountered a deep seated infection resulting in sinus formation needing further debridement in the form of sequestrectomy. In conclusion, the authors believe that the perforator based flap cover described here is simple, safe and a versatile procedure for a trauma surgeon to cover the moderate sized traumatic pre-tibial wounds exposing the bone and the tendons.

Clinical experience with linezolid in conjunction with wound coverage techniques for skin and soft-tissue infections and postoperative osteomyelitis.

Gram-positive organisms are emerging as possibly the most important nosocomial pathogens during the past decade. Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of infection in the postoperative patient. Burn victims are at high risk for developing vancomycin-resistant Enterococcus (VRE) and other multidrug-resistant microbial infections as a result of the immunocompromising effects of burn injury, prolonged intensive care unit stays, and broad-spectrum antibiotic therapy. To prevent serious and dreaded complications such as skin graft breakdown, delayed wound healing, loss of a limb, and even death, these infections require a combination of extensive antibiotic therapy and plastic surgical intervention. The objectives of this study were to report clinical experience with linezolid in addition to wound care, debridement, and wound coverage techniques for the treatment of S. aureus (including MRSA) and VRE infections. Forty patients received linezolid for infections of wound coverage such as an infected graft or flap, or received linezolid in conjunction with wound coverage techniques for a S. aureus or VRE infection. The median patient age was 53 years (range, 14-85 years), 55% were female, 28% of patients received intravenous (i.v.) linezolid only, 45% received i.v. with a switch to the oral formulation, and 28% received the oral formulation only. The clinical success rate of linezolid with adjuvant wound coverage techniques was 90.0% for osteomyelitis and was 100% for skin and soft-tissue infections. For infections of wound coverage, the clinical success rate was 83.3%. In conclusion, linezolid was an effective antibiotic for the treatment of S. aureus (including MRSA) and VRE infections in conjunction with wound coverage techniques. In addition, linezolid offers the option of treating these infections with an oral agent that is 100% bioavailable.

Plastic solutions for orthopaedic problems.

Infection and exposure of the implant may occur in 1-12% of patients operated on for arthroplasty or osteosynthesis. Variables such as tissue viability, presence of infection, exposure of osteosynthesis material and patient-related factors contribute to the lack of general consensus regarding the management of these defects. Between January 1999 and January 2001, six patients were treated for complex soft-tissue defects following various orthopaedic procedures at the Department of Plastic Surgery in the Slotervaartziekenhuis in Amsterdam, a rheuma-orthopaedic orientated hospital. All patients were initially treated by radical debridement and vacuum-assisted closure (VAC) system of the wound. After 1 week, this was followed by transplantation of a pedicled or free flap to cover the defect. We studied the medical history, initial orthopaedic procedure, wound treatment, transplanted flap and outcome of plastic surgery in this group. Plastic surgical intervention led to wound closure in all cases. In only one case was the osteosynthesis material removed because of osteomyelitis. We conclude that the earlier coverage with vital tissue is obtained, the lower the incidence of infection. Early consultation by a plastic surgeon will increase a positive outcome of treatment of complex tissue defects.

Management of Soft-Tissue Problems in Leg Trauma in Conjunction with Application of the Ilizarov Fixator Assembly

Forty-five patients presenting with high-energy open grade III tibial diaphyseal fractures were treated with the Ilizarov technique. Of these patients, 28 required plastic surgical intervention for achieving wound closure. Most of the injuries were complicated by initial neglect and inadequate primary soft-tissue coverage resulting in osteitis, sequestration, and segmental diaphyseal tibial defects, often in combination with skin-envelope deficits of various types in and around the fracture perimeter. The unique soft-tissue problems encountered while using the Ilizarov fixator have not been focused on in previous reports on the management of segmental bone defects. Four basic local flap procedures: the transposition flap, rotation flap, adipofascial turnover flap, and Z-plasty are useful and versatile for managing most types and grades of soft-tissue defects associated with a segmental bone loss with the Ilizarov technique.

Assessing Adolescents and Young Adults for Plastic Surgical Intervention

Assessing Adolescents and Young Adults for Plastic Surgical Intervention