Secondary Skin Grafting Research Articles

Extended Reverse Sural Artery Flap's Safety, Success and Efficacy - A Prospective Study.

One of the challenges in reconstructive surgeries, faced by a majority of surgeons, is the soft tissue defect management around the lower-third of the leg, plantar and dorsal feet. Due to the sensitive location and other related difficulties, only limited options are available in this region. A durable flap is the preferred option for coverage of such defects. To evaluate the safety, success and efficacy of the extended reverse sural artery flap which was harvested, with extension to proximal-third of the leg. This prospective study was conducted at Department of Plastic Surgery, on 18 consecutive patients with soft tissue defects and exposed bones, tendons and joints of distal-third of leg and foot. We harvested medium to large sized reverse sural artery flaps with extensions to the upper third of the calf, to cover the defects found in the distal tibia, ankle, heel, foot, and sole. A majority of flaps provided a good coverage for defects. Two cases developed marginal necrosis of flaps in the distal border, which was treated with use of secondary skin grafts. Four flaps developed venous congestions. In other patients, minor complications such as rupture of suture inset, development of ulcer over insensate flap, since only one patient developed ulcer and another one patient developed inset rupture and graft loss occurred. In 16 cases, the final outcome was unaffected by any complications. Extension of reverse sural artery flap to the proximal third of the leg was safe and reliable and it was efficiently used to treat patients with large and far wounds of distal leg, foot and sole.

Combined Co-Stimulatory Blockade and Donor Bone Marrow Cells Induce Robust Immune Tolerance in a Fully MHC-Mismatched Swine Hind Limb Transplant Model

INTRODUCTION: Vascularized Composite Allografts (VCA), such as hand and upper extremity transplants, contain vascularized bone marrow (BM) and a BM niche representing a constant source of donor-derived stem cells and hence can favor chimerism and tolerance induction.1,2 This study investigates the immunological effects of vascularized BM within VCA under co-stimulation blockade-based regimen and its impact on allograft survival and tolerance induction. METHODS: Fully MHC- and gender mismatched MGH miniature swine (n=3-5 per group) underwent heterotopic hind-limb transplantation containing intact vascularized BM component (Figure 1).Figure 1: Schematic diagram of swine heterotopic hind limb transplant. Osteomyocutaneous flap is transplanted to a subcutaneous pocket with externalized skin component.Recipient animals received a short course (30 days) of tacrolimus monotherapy with or without donor BM infusion (60x106 cells/kg), and CTLA4Ig. Short course tacrolimus only and untreated animals served as controls. Chimerism was assessed by SRY PCR analysis. Sequential skin and muscle biopsies were performed for histology. Alloreactivity against donor antigens was assessed in vitro using mixed lymphocyte reaction (MLR) assays. Challenge with secondary skin grafts was utilized to demonstrate robust immune tolerance in vivo. RESULTS: The co-stimulation blockade based immunomodulatory protocol resulted in indefinite graft survival (>150 days) in 3 out of 5 animals whereas control and tacrolimus only groups rejected allografts at days 7+/-1 and 29+/-2 respectively (Figure 2).Figure 2: Kaplan-Meier survival curve demonstrating rejection free survival of skin component of hind limb allograft.Combined costimulation blockade with augmented donor BM infusion resulted in indefinite graft survival in 2 out of 3 animals (>150 days). Long-term survivors demonstrated stable micro-chimerism in various graft and recipient tissues including skin, lymph node, bone marrow, and spleen. MLR data showed unresponsiveness to donor but not to third party allogeneic controls. Secondary skin grafting demonstrated advanced rejection of third party grafts on day 7 while donor-matched grafts were accepted indicating donor-specific immune tolerance. There was no evidence of donor specific antibody formation in long-term survivors. Donor unresponsiveness in MLR was lost five weeks post-graftectomy, which demonstrated that persistent antigenic stimulation was required for operational tolerance. CONCLUSION: Combined costimulation blockade and donor BM cell infusion can induce robust immune tolerance in a fully MHC mismatched hind limb transplant model. Such targeted immunomodulatory protocols might eliminate the need for long-term multi-drug immunosuppression after reconstructive transplantation.

Suprafascial pre‐expansion of perforator flaps and the effect of pre‐expansion on perforator artery diameter

This study addresses the "pre-expanded perforator flap concept" by demonstrating a case series of relevant reconstructive procedures and evaluate the perforator vessel diameter changes that happen during the pre-expansion procedure. Fourteen patients were treated with 15 flaps. One patient was treated with two pre-expanded internal mammary artery perforator flaps. In other cases, thoracodorsal, circumflex scapular, lumbar, intercostal, lateral circumflex femoral, and deep inferior epigastric artery perforator flaps were used. Technical details and rate of complications were noted. Evaluations of the flap pedicles were done both by hand held Doppler and by color Doppler ultrasound (CDU). Flaps successfully served to resurface and release thick and rigid broad scar tissues and contractures in 11 of relevant 12 patients (in one patient with 50% flap loss, adequate contracture release could only be obtained with addition of a secondary split thickness skin graft to the residual flap) and provided a good source of tissue for anterior neck reconstruction of one patient and penis reconstruction of another patient. In six patients, perforator artery diameters were measured by CDU both before and after the expansion process and a significant increase secondary to the pre-expansion procedure was detected (Pre-expansion mean: 0.48 ± 0.08 mm; post-expansion mean: 0.65 ± 0.10 mm; P < 0.05). Flaps as large as 30 × 20 cm were harvested. Totally three partial flap necroses were experienced in 15 flap procedures. Suprafascial pre-expansion of the perforator flaps seems to provide a solution to achieve broader and thinner perforator flaps with larger perforator arteries.

Effect of nonmuscle myosin-derived peptide on cutaneous burn wound injury

3 out of 5 animals whereas control and tacrolimus only groups rejected allografts at days 7 1 and 29 2 respectively. Long-term survivors demonstrated durable micro-chimerism in various graft and recipient tissues including skin, lymph node, bone marrow, and spleen. CFSE-MLR data showed unresponsiveness to donor but not to third party allogeneic controls. Secondary skin grafting demonstrated advanced rejection of third party grafts while donormatched grafts were accepted indicating donor-specific immune tolerance.

Microsurgical reconstruction of soft-tissue defects in digits

Injuries that cause soft tissue defects could threaten the function and viability of the involved digit. Reconstruction of such defects can be challenging and requires careful consideration in restoring both the aesthetic and functional deficit. The purpose of this review is to describe appropriate reconstructive technique using various free tissue transfers. According to the location and the size of a defect, a proper reconstructive option is indicated. Owing to the specialized mechano-sensory property of its volar soft tissue, fingertip injury, when significant defects exist, are reconstructed using specialized free flaps with appropriate histological and functional similarities. Composite tissue including bone may be required in selected cases. Additional procedures, such as secondary skin graft or division of the flap, should be done after several weeks of the first operation. Refinements and improvements in free tissue transfer allow an expanse of reconstructive options for soft tissue defect in the digit.

Treatment of degloving injury of the finger with a pedicled split-thickness skin graft

Avulsion of fingers are common industrial incidents and small skin flap injuries of one or more fingers are emergency room problems encountered daily [1]. Avulsion of skin from the underlying structures is usually a result of trauma, and has a dramatic presentation. Besides the possibility of injury to other structures, there may be a problem with viability of the skin involved. The degloving injury is more significant in the hand injury. Reconstruction of a single degloved finger can be performed with local flaps and tubed pedicle flaps [2,3]. However, it is not easy to wrap the entire circumference of the finger by using a local flap. Avulsions of multiple fingers is a severe injury that is more difficult to reconstruct. Some authors use the Millard ‘crane principle’ and bury the digits in the abdominal fat for 2 weeks with secondary skin grafting [4]. A tubed groin flap can also be used to reconstruct the injury [5]. However, it requires the hand to be attached to the groin for least 2 weeks, which is awkward and makes hand therapy difficult. Another possibility for reconstruction is the radial forearm flap, which is a fascia-only flap with skin graft on the fascia [6]. A degloved finger can also be reconstructed with a toe wrap-around flap [7] or an innervated arterialised venous flap from the dorsum of the foot [8]. We present a reconstruction of a traumatic degloving injury of the finger using a pedicled split-thickness skin graft from the abdominal wall to treat five cases (11 fingers) between June 2010 and September 2010, and the results were satisfactory. The aim

The Treatment of Bone Exposure in Burns by Using Artificial Dermis

The treatment of bone-exposed wounds with artificial dermis is not widely accepted in burn patients because of uncertain clinical results. This article aimed to review our clinical experience with this technique. We implanted artificial dermis in 11 bone-exposed burns. Implantation was directly performed on bones with periosteum, whereas bones without periosteum were trephinated or burred before implantation. All wounds were closed by secondary skin grafting. The mean patient age was 49 years. Lower extremity is the most common site of bone exposure. The mean bone exposed area was 55.6 cm, whereas the mean Integra-implanted area was 86.7 cm. The overall implant take rate was 91%, and the skin grafting success rate was 80%. No secondary breakdown was noted after a 2-year follow-up. This study confirms that artificial dermis can be an alternative treatment tool for burns with exposed bones, especially in patients with limited donor sites.

Short-Term Treatment of VCAM-1-Targeting Antibody Induces Immunological Tolerance Against Allogeneic Islet Grafts

Background: Blocking adhesion domain of VCAM-1 prevents trafficking of immune cells into the inflammatory sites, and thereby prolongs longterm survival of allogeneic islet grafts in mice. In this study, we developed novel antibody targeting the sixth non-adhesive immunoglobulin-like domain of VCAM-1 and evaluated its efficacy with allogeneic-islet transplantation model. Methods: Chimeric rabbit/human VCAM-1 antibody (anti-VCAM-1-D6) targeting Ig-like domain six of VCAM-1 was generated using phage display technology. Balb/c islets were transplanted underneath of the kidney capsule of diabetic C57BL/6 mouse with the transient anti-VCAM-1-D6 (100ug/day on day -1, 0,1,2,3,4,5,6,7 after transplantation) treatment. Antigen-specific tolerance induction was confirmed by second-party transplantation of Balb/c islets or tail skin. Results: Short-term treatment of anti-VCAM-1-D6 antibody led to the long-term survival of islet allografts in 5 out of 5 mice. Donor-specific-IL-2, IFN-r, Granzyme B- secreting cell population significantly decreased in VACM-1-D6 treated-mouse in ELISPOT analysis. In the grafts, peri-islet infiltrates of leukocytes were observed with intact insulin-positive beta cells in long-term survived mice. Importantly, secondary-islet allograft, but not secondary-skin graft, was survived without evident graft rejection for more than 80 days, meaning tissue-specific tolerance was induced by the short-term treatment of anti-VCAM-1 antibody. Conclusion: Developing VCAM-1 targeting antibody may be a promising therapeutic modality in inducing antigen-specific tolerance in allogeneic islet transplantation.

Hinged Forearm Split-Thickness Skin Graft for Radial Artery Fasciocutaneous Flap Donor Site Repair

To present a modified technique in the harvest and application of split-thickness skin graft (STSG) from the primary flap donor site in forearm fasciocutaneous free flaps. A prospective review was performed on 16 consecutive patients who had undergone a radial forearm free flap procedure for reconstruction of head and neck defects with a hinged forearm STSG used to reconstruct the flap donor site defect. Sixteen patients with a mean (SD) defect size of 53.7 (29.9) cm(2) underwent the hinged STSG procedure. A hinged STSG was successfully harvested from all patients without disruption. Graft take was greater than 90% in all patients by postoperative day 7. A secondary skin graft donor site was avoided in all but 2 patients. Good color match of the deepithelialized flap with surrounding oral and pharyngeal mucosa was observed. Visible scarring along the graft hinge margin was absent. No bridging scars resulted from the deepithelialized flaps. The hinged STSG from the forearm is a reliable method of repairing radial forearm free flap donor site defects and offers the advantages of reduced suture line scarring, minimal STSG disruption, low or no secondary donor site morbidity, and good color match at the donor and recipient flap sites.

Freestyle Pedicled Perforator Flaps

Despite the widespread use of free perforator flaps, pedicled perforator flaps seem not to be as widely accepted, probably because of the fear of vascular complications caused by transfer of a flap attached only by its vascular pedicle, prone to shearing, kinking, and trauma. In this article, the authors report on their experience with 85 consecutive cases, focusing on incidence, prevention, and management of complications. Eighty-five consecutive cases were treated over 6 years at the Plastic and Reconstructive Surgery Department of the University of Palermo for defects of different causes that were reconstructed with a freestyle pedicled perforator flap, in every region of the body, including the head and neck (41.2 percent), trunk (20 percent), upper limb (7.1 percent), and lower limb (31.8 percent). The majority of flaps (67.1 percent) were 180-degree propeller perforator flaps. Complete flap survival was observed in 93 percent of cases. Six flaps (7 percent) had vascular complications that were managed with venous supercharging (two cases), derotation (one case), conservative management (two cases), or secondary skin grafting (one case). The authors provide their approach to each situation to prevent or manage complications. The 93 percent success rate in this series seems to be acceptable and demonstrates that these flaps might be safely included in the authors' routine. If the flaps are appropriately planned and executed, with the suggestions provided in this article, some mistakes can be avoided to make these flaps even safer. Therapeutic, IV.

Basal Cell Carcinoma and Rhinophyma: A Novel Treatment Option

Objective: Resection of basal cell carcinoma (BCCA) from a background of advanced rhinophyma can present a reconstructive challenge, thus a novel surgical treatment option is presented. Report a case of concurrent rhinophyma and BCCA, review the literature, and discuss surgical options available. Method: A review of the literature reveals only 12 reported cases of concurrent BCCA and rhinophyma since 1955, all describing occult discovery of BCCA. This is the first reported case of known BCCA complicated by rhinophyma. Results: The traditional repair options after excision of BCCA from the nasal tip include healing by secondary intention, skin grafting, and local flap rotation. In patients with rhinophyma, these options are less than ideal. As a novel alternative, wide local excision of the lesion with intra-operative frozen section margin control was carried out, followed by single-stage tangential excision and dermabrasion of the nasal skin involved with rhinophyma. Negative margins were obtained, symmetry and homogeneity of the nasal skin was achieved, and the patient was very pleased with the results. Before and after photo documentation and representative histologic sections will be presented. Conclusion: The reported synchronous presence of known BCCA and rhinophyma is exceedingly rare. This case demonstrates that both cancer cure and an optimal aesthetic result can be achieved by this novel treatment option.

Perforator-based propeller flaps treating loss of substance in the lower limb

BackgroundLocal flaps based on perforator vessels are raising interest in reconstructive surgery of the limbs. These flaps allow efficient coverage of large wounds without the need to sacrifice a major vascular axis. The operative technique does not require microvascular anastomosis and allows reconstruction of soft tissue defects using nearby similar tissues. The aim of this study was to evaluate the clinical results of local perforator flaps in the treatment of complex lower-limb defects.Materials and methodsTwenty-two local perforator flaps were retrospectively studied. Loss of substance was due to postsurgical complications in seven cases, oncological resection in six, posttraumatic defect in five, pressure sores in three, and osteomyelitis in one.ResultsPostoperatively, two patients showed partial flap necrosis. In five patients, a superficial epidermolysis occurred. Minor complications were seen in three patients who showed transient venous congestion of the flap. Furthermore, transient leg edema was sometimes observed in patients with large propeller flaps. All but one patient healed without further major surgical procedures. In three cases, secondary skin grafts were performed. In most cases, the aesthetic result was optimal and patients were fully satisfied.ConclusionsWhen characteristics of the defect are suitable for treatment with a propeller-based local flap, this technique should be considered as one of reasonable options for surgical reconstruction. Microsurgical techniques facilitate the management of complex trauma in emergency and may allow planning reconstructive procedures and limb salvage in elective orthopedic surgery.

Ursolic acid promotes robust tolerance to cardiac allografts in mice

Nuclear factor (NF)-κB is an important molecule in T cell activation. Our previous work has found that T cell-restricted NF-κB super-repressor (IκBαΔN-Tg) mice, expressing an inhibitor of NF-κB restricted to the T cell compartment, can permanently accept fully allogeneic cardiac grafts and secondary donor skin grafts. In this study, we explore if transient NF-κB inhibition by a small molecular inhibitor could induce permanent graft survival. Ursolic acid, a small molecular compound, dose-dependently inhibited T cell receptor (TCR)-triggered NF-κB nuclear translocation and T cell activation in vitro. In vivo, ursolic acid monotherapy prolonged significantly the survival of cardiac allograft in mice. Assisted with donor-specific transfusion (DST) on day 0, ursolic acid promoted 84·6% of first cardiac grafts to survive for more than 150 days. While the mice with long-term surviving grafts (LTS) did not reject the second donor strain hearts for more than 100 days without any treatment, they all promptly rejected the third-party strain hearts within 14 days. Interestingly, this protocol did not result in an increased proportion of CD4(+) CD25(+) forkhead box P3(+) regulatory T cells in splenocytes. That adoptive transfer experiments also did not support regulation was the main mechanism in this model. Splenocytes from LTS showed reduced alloreactivity to donor antigen. However, depletion of CD4(+) CD25(+) regulatory T cells did not alter the donor-reactivity of LTS splenocytes. These data suggest that depletion of donor-reactive T cells may play an important role in this protocol.

Experience of using local flaps to cover open lower limb injuries at an Indian trauma center

Background:Optimal care of open, high-velocity, lower limb injury requires surgical skills in debridement, skeletal stabilization, and in providing appropriate soft tissue cover. Timely coordination between orthopedic and plastic surgeons, though ideal, is often difficult. In our center, orthopedic surgeons undertake comprehensive treatment of open fractures including soft tissue cover. We reviewed the results of the local flaps of lower limb, done by orthopedic surgeons.Materials and Methods:We retrospectively reviewed the results of the lower limb flaps done between January 2005 and December 2006. All flaps done at and below the level of knee were included.Results:There were 105 patients with 120 flaps during this period. Two patients with two flaps were lost to follow-up. The average age was 32 years. Sixty-four patients had Type IIIB Gustilo and Anderson injuries. Thirty-nine patients had isolated soft tissue injuries. The indications for flaps were exposed bone, tendon, and joint in 45, 11, and 12, respectively, or a combination in 35 patients. The flaps done were 51 reverse sural artery, 35 gastrocnemius, 25 local fasciocutaneous, and seven foot flaps. The flap dimensions ranged from 2 × 2 to 30 × 15 cm. Ninety-three flaps (79%) healed primarily. Among 25 flaps (21%) with necrosis, 14 flaps required secondary split skin graft for healing, while the other nine flaps healed without further surgery.Conclusion:Appropriate soft tissue cover provided by orthopedic surgeons can help in providing independent, composite care of lower limb injuries.

Die Arthrodese des Sprunggelenks in Infektsituationen: Ergebnisse mit dem Ilizarov-Ringfixateur

The treatment of severe bacterial infections of the ankle joint is difficult and complex. In the case of a chronic infection with destruction of the ankle joint, a tibiotalar arthrodesis with external fixation is the treatment of choice. In this study the results of ankle arthrodesis due to bacterial infection using the Ilizarov external fixator are presented. Between 2001 and 2004 37 patients (10 female, 27 male, mean age 58 years) were treated with a tibiotalar arthrodesis using the Ilizarov fixator. All patients had a confirmed infection in the course of their disease. Active infection was present in 20 patients at the time of the operation. Most secondary ankle arthritides (81 %) were caused post-traumatically after various internal fixation procedures. Previous ankle arthrodeses were tried in 14 cases (12 cases with internal fixation, two cases with external monolateral fixation). Patients were treated with a four-ring Ilizarov frame (in two cases with a five-ring frame) and stainless steel wires. All patients could be included at a mean follow-up of 46 (12-49) months. A modified AOFAS score was used for the functional outcome. The operation took 141 minutes at an average ranging from 90 to 252 minutes. The inpatient treatment lasted between 10 and 63 days (mean 26 days). The time spent in the fixator was 116.7 (69-245) days. All patients were mobilised under full weight bearing with the external fixator. Surgical revision was necessary in 13 patients: four patients needed wound revisions due to ongoing infection, six patients needed wire exchange due to deep infection in three cases and wire breakage in three cases, one patient needed additional wires because of an initially instable frame configuration and two patients needed secondary skin grafting. Bony consolidation was achieved in 32 patients (86.5 %). With a re-arthrodesis performed in four patients using the Ilizarov fixator, the overall fusion rate was 94.6 %. Infection was persistent in two cases with one solid ankle fusion and one ankle pseudarthrosis. At the time of follow-up 35 patients were able to walk under full weight loading with orthopaedic shoe modifications, four patients needed support of a cane and three patients wore an ankle-foot orthesis. The two patients with persistent pseudarthrosis were mobilised in a lower-leg orthesis after declining another surgical revision. The positioning of the hindfoot showed in seven cases an equinus of 10°, in one case a varus of 10° and in two cases a valgus positioning of 10°. A plantigrade foot positioning or with minimal degrees of deviation could be achieved in all other cases. The modified AOFAS score at the time of the follow-up examination ranged from 19 to 86 with an average score of 67.9 points. All patients except three were satisfied or rather satisfied with the treatment procedure and its results. The Ilizarov external fixator is a safe method for ankle fusion in cases of infection. The advances are a possible application at acute infection and immediate mobilisation at full weight bearing. However, it remains a time-consuming and stressful procedure for the patient.

The surgical effect of applying reverse sural neuro-fasciomusculocutaneous flap to rehabilitate limb parenchyma wound

Objective To evaluate the surgical effect of applying reverse sural neurofasciomusculocutaneous flap to rehabilitate limb parenchyma wound.Methods Assess the size of wound on limb,cut incisor flap from posterior crus,then use sural nerve and nutrient vessel as pedicel.The flag was reversely transfened to rehabilitate limb wound.There are 31 cases with parenchyma wounds,include in lower 1/3 crus wound,ankle wound,heel wound,and foot wound.The size of flap is range from 5cm×6cm to 12cm×17cm.Observe survival rate of surgical flap.Results 26 cases(83.9%)of surgical flag are alive,while 5 cases occurred necrosis on distal superficial flag or part of the flag.The five cases finally healing through secondary suture and skin-grafting.Conclusion As a new surgery therapy,applying reverse sural neuro-fasciomusculocutaneous flap to rehabilitate limb parenchyma wound is effective.It is character with simple,available,do not need to anastomose vessel,reserve main vessel and high survival rate.So it is worth recommend to widely use in clinical practice. Key words: Sural nerve; Surgical flaps; Rehabilitate

Vascularized Bone Grafts within Composite Tissue Allotransplants Can Autocreate Tolerance through Mixed Chimerism with Partial Myeloablative Conditioning: An Experimental Study in Rats

Certain composite tissue allotransplants contain vascularized bone grafts (e.g., hand/forearm composite tissue allotransplants). The authors investigated the role of the vascularized bone graft within the hind-limb osteomyocutaneous flap in inducing tolerance. Brown Norway and Lewis rats were used as composite tissue allotransplant donors and recipients, respectively. Experimental groups were as follows: group I, syngeneic controls (Lewis to Lewis); group II, allogeneic controls (both received no pretransplantation total body irradiation); and groups III, IV, and V, which received 5 mg of antilymphocyte globulin administered intraperitoneally (on days -1 and 10), 1 mg/kg of tacrolimus administered intraperitoneally (on days 0 to 10), and total body irradiation (600, 400, and 200 cGy, respectively, 1 day before composite tissue allotransplantation). Each Lewis rat in groups II, III, IV, and V received a composite tissue allotransplant on day 0 in the form of a Brown Norway hind-limb osteomyocutaneous flap. Different donor hematopoietic cell lineages in recipients' peripheral blood were assessed by flow cytometry on posttransplantation days 15, 30, 60, 90, 120, and 150. Secondary Brown Norway skin grafts in recipients with composite tissue allotransplant acceptance were performed at 150 days after transplantation. Allotransplanted hind-limb osteomyocutaneous flaps produced chimerism and donor multilineage hematopoietic cells in groups III, IV, and V; composite tissue allotransplant acceptance rates in these groups were 37.5, 16.7, and 0 percent, respectively. Graft-versus-host disease occurred in 62.5 percent of group III recipients. Recipients with acute graft-versus-host disease produced a higher percentage of donor T cells compared with composite tissue allotransplant-accepting recipients (p < 0.05). Secondary Brown Norway skin graft acceptance in composite tissue allotransplant-accepting recipients confirmed durable tolerance. Vascularized bone grafts contained within composite tissue allotransplants can autocreate chimerism and tolerance in rats with partial myeloablative tacrolimus-based conditioning.

Acellular Dermal Regeneration Template for Soft Tissue Reconstruction of the Digits

Trauma to the digits often leaves soft tissue defects with exposed bone, joint, and/or tendon that require soft tissue replacement. The objective of this study was to evaluate the effectiveness of acellular dermal regeneration template combined with full-thickness skin grafting for soft tissue reconstruction in digital injuries with soft tissue defects. Acellular dermal regeneration template was used to reconstruct digital injuries with exposed bone, joint, tendon, and/or hardware not amenable to treatment with healing by secondary intention, rotation flaps, or primary skin grafts. Acellular dermal regeneration template was applied to 21 digits in 17 patients. Nineteen digits had exposed bone, 8 digits had exposed tendon, 6 digits had exposed joints, and 2 digits had exposed hardware. The acellular dermal regeneration template was sutured over the soft tissue defect. Over 3 weeks, a neodermis formed. The superficial silicone layer of the acellular dermal regeneration template was removed, and the digits received full-thickness epidermal autografting with cotton bolster. The duration of postoperative follow-up extended to a minimum of 12 months. For the injury sites where acellular dermal regeneration template was applied, the total area of application ranged from 1 cm(2) to 24 cm(2), with the largest individual site measuring 12 cm(2). Twenty of 21 digits demonstrated 100% incorporation of the acellular dermal regeneration template skin substitute. One digit that had sustained multilevel trauma developed necrosis requiring revision amputation. Full-thickness epidermal autografting was performed an average of 24 days after acellular dermal regeneration template skin substitute application and demonstrated a 100% take in 16 of 20 digits and partial graft loss of 15% to 25% in 4 of 20 digits that did not require further treatment. Acellular dermal regeneration template combined with secondary full-thickness skin grafting is an effective method of skin reconstruction in complex digital injuries with soft tissue defects involving exposed bone, tendon, and joint. The neodermis increases tissue bulk and facilitates epidermal autografting with digital injuries that otherwise would require flap coverage or skeletal shortening of the digit. Therapeutic IV.

The aesthetic wrap-around flap technique for thumb reconstruction

Objective In addition to restoring thuntb function in wrap-around flap transfer for thumb reconstruction, modification was done to improve the appearance of the reconstructed thumb and minimize donor site morbidity. Methods Thirty-nine thumb defects were reconstructed using Morrison＇ s procedure and modified great toe wrap-arotmd flap. The donor site was covered with free skin graft in 30 cases, with flap and skin graft in 8 eases and with flap in 1 case. Results Of the 39 transferred wrap-around flaps, 38 survived. One case failed. Postoperative follow up ranged from 3 months to 2 years. The reconstructed thumbs presented various degrees of reduction in diameters, thin skin and shallow fingerprint. Atrophy was most prominent in the nails. The mean static 2-point discrimination was 10 mm in the pulps. In 4 cases secondary skin graft or closure after partial phalanx resection was required to heal the wound of the donor great toe site. Wound healing was achieved in donor sites of the other cases. Most patients experienced mild pain of the donor foot during ambulation within the first 3 months after the surgery. Pain gradually disappeared when follow up interval exceeded 6 months. Standing, walking and nmning were near normal. Conclusion Attention should be paid to the design of bone construct, nail harvest and multiple nerve coaptations in wrap-around flap transfer. Modified flap harvest procedure reduces damage to the donor site and improves appearance of the reconstructed thumb. Key words: Transplantation ; Thumb; Microsurgery

Management of Extensive and Complex Scalp Defects in Patients of Neoplasm

Background: Reconstruction of extensive and complex scalp defects in patients of neoplasm remains a significant challenge because of cerebrospinal fluid leak, bacterial contamination from sinus exposure, effect of radiation therapy, neoadjuvant or postoperative chemotherapy, and functional and cosmetic deformity from the size and location of the defect. In this series, we present our experience in the management of extensive defects Materials and Methods: Between 1993 and 2008, ten patients with scalp defects received reconstruction with a variety of free flaps: four free vastus lateralis muscle flaps, three anterolateral thigh flaps, three latissimus dorsi flaps with fasciocutaneous extension and one radial forearm flap. These defects had a wide spectrum of complexities including extensive multilaminar defects with exposed brain and dura, irradiation damage, infection of the wounds and central nervous systems. The flaps were used to cover the defects resulting from the radical debridement or tumor ablation with or without radiation in patients ranging from 35 to 61 years of age. Follow-up ranged from one to ten years. The patients' demographics, surgical indications, type of flaps and exposed structures, comorbidity, complications and outcomes were assessed. Fisher's exact test was used to evaluate the correlation between CSF leakage and postoperative complications and mortality. Results: All patients were referred from our neurologic surgeons after ablative surgery with or without adjuvant radiotherapy. Among the ten patients, six had a cerebrospinal fluid leak at the time of the reconstruction. Of the six patients, one had total flap loss requiring another free flap reconstruction and two had partial flap necrosis, demanding debridement and split-thickness skin grafting. Four flaps totally survived and the cerebrospinal fluid leak all resolved in the six patients. In comparison, of the four patients without a cerebrospinal fluid leak, all flaps survived. The perioperative mortality is 10% and the overall mortality is 20%. One patient died of sepsis 1.5 months later and the other one died of primary cancer 1.5 years after reconstruction. Conclusion: Although our case number is very small, our results support that free flap reconstruction is a life-saving procedure in this high-risk population and that success is possible. Comparing to fasciocutaneous flaps, muscle flaps with primary or secondary split-thickness skin grafting can provide better cosmetic result. Difficult problems, such as severe central nervous system infection, recurrent cerebrospinal fluid leaks and large irradiated wounds including osteoradionecrosis, can be managed and resolved successfully using this technique.