Subcutaneous Flap Research Articles

A prospective randomized comparative study on the use of ventral subcutaneous flap to prevent fistulas in the Snodgrass repair for distal hypospadias

We evaluated the importance of urethral coverage using vascularized subcutaneous ventral flaps for the prevention of fistulas in patients undergoing distal hypospadias repair. Our prospective study included 130 patients, aged 9 months to 12 years, who underwent distal hypospadias repair using tubularized incised plate urethroplasty (TIPU), from January 2001 through January 2006. Patients were assigned to one of two groups by a computer-generated random selection: 65 patients underwent non-covered urethroplasty (NCU group); another group of 65 patients underwent covered urethroplasty (CU group) with a vascularized subcutaneous ventral flap. The results were evaluated by two pediatric surgeons unaware of the type of treatment each patient had undergone. Successful results were achieved in 99/130 patients (76.2%). We recorded 31 (23.8%) post-operative complications: 20 patients presented with a urethrocutaneous fistula (15 patients in the NCU group and 5 in the CU group); five with urethral stenosis (3 in the NCU and 2 in the CU group); and six with skin dehiscence of the preputioplasty (3 patients in each group). We analyzed the results using the chi2 test and the only statistically significant difference between the two groups (p < 0.05) was in terms of incidence of fistulas. Urethrocutaneous fistulas seem to be the most frequent complication of distal hypospadias after TIPU repair. Urethral coverage should be part of the Snodgrass procedure because it significantly reduces the formation of fistulas. A well-vascularized subcutaneous ventral flap represents, in our experience, a simple and optimal choice for the prevention of fistulas.

Management of Soft-Tissue Complications of the Lateral Approach for Calcaneal Fractures

Soft-tissue complications after using the lateral approach for internal fixation of calcaneal fractures are relatively frequent, even in skilled hands. The global management of these wounds has never been standardized. The authors present a series of 24 patients with wound edge necrosis of lateral approaches for displaced intra-articular calcaneal fractures. Follow-up ranged from 5 to 52 months. The wound was covered with a local subcutaneous transverse flap in six cases, a sural subcutaneous flap in 12 cases, and a distal vastus lateralis free flap in six cases. Hardware was removed only if gross malalignment of the fracture was present. A treatment algorithm is proposed. All the transverse local flaps were successful. Two sural flaps had complications that were salvaged with a free flap. All free flaps were successful, and all fractures healed. No chronic infections developed. The authors' algorithm proved useful. For minor necroses (<1.5 cm wide) with supple tissues and no infection, the transverse local subcutaneous flap was effective. For moderate-sized wounds (1.5 to 5 cm) with no infection, a sural subcutaneous flap was used. In infected wounds with good fracture reconstruction, a free flap was used without hardware removal. If unsatisfactory bone reconstruction and infection were present, hardware removal and a sural flap were appropriate. For extensive defects (>5 cm) or when regional flaps failed, a free flap was useful.

Safe Treatment of Post Thoracotomy Seroma

Postoperative seroma is a common complication after muscle-sparing lateral thoracotomy. The main cause is considered to be the result of subcutaneous flap mobilization. We present a case of seroma which occurred following a pneumonectomy owing to subcutaneous flooding with pleural fluid, which was successfully treated by subclavian catheter insertion. The technical aspect of the procedure is described.

Tipu repair for distal hypospadias. to cover or not to cover the urethroplasty? a prospective randomized comparative study

Purpose We evaluated the importance of urethral coverage using a vascularized ventral subcutaneous flap for fistula prevention in patients who underwent a distal hypospadias repair. Material and methods Our prospective study included 130 patients, aged 9 months to 12 years, who underwent distal hypospadias repair using tubularized incised plate urethroplasty (TIPU) from January 2001 to January 2006. Using a computer-generated random choice the patients were enrolled in 2 groups: 65 patients received a no covered urethroplasty (NCU group); the other 65 patients received a covered urethroplasty (CU group) using a vascularised ventral subcutaneous flap. Results The results were evaluated by 2 pediatric surgeons unaware of the type of the treatment the patients had undergone. Median follow-up was of 24 months (6 – 60). A successful result was achieved in 99/130 patients (76.2%). We recorded 31 (23.8%) postoperative complications: 20 patients presented a urethrocutaneous fistula (15 patients were in NCU group and 5 in the CU group); 5 urethral stenoses (3 in NCU group and 2 in CU group); 6 skin dehiscence of the preputioplasty (3 pts for each group). We have analysed the results using test χ2 and the only statistically significant difference between the 2 groups (p Conclusions Urethrocutaneous fistulae seem to be the most frequent complication of distal hypospadias after a TIPU repair. Urethral coverage should be performed as part of the Snodgrass procedure because it significantly reduces the formation of fistulae. A ventral well vascularized subcutaneous flap represents in our experience a good and easy choice for fistulae prevention.

“Two stages at one time” procedure: a single stage urethroplasty for severe hypospadias

Purpose To present a video showing a procedure for severe scrotoperineal hypospadias repair that attempts to combine the advantages of a single-stage reconstruction with the safety of a two-stage procedure. Material and methods The operation originates from the Koyanagi-Nonomura technique. Its modification by Emir and the “Yoke” procedure described by Snow starts with the degloving of the penis and straightening of the shaft. A buttonhole is created in the dorsal penile skin through which glans is passed, transposing the entire foreskin ventrally. Glanular wings are created. The transposed foreskin is separated vertically in the midline. The two flaps are longitudinally sutured together in the midline and secured to the glans and to the corpora creating the tissue for the future urethral plate. A “U”shaped incision including the native urethral meatus is performed, defining the urethral plate, that is minimally detached from the lateral skin, keeping the blood supply intact, rolled into a tube and sutured in the midline. Glansplasty and coverage of the neourethra with subcutaneous tissue or vaginal flaps are next steps. Skin is approximated in the midline in a “pants over vest” fashion. Urine drainage is secured by a dripping stent.

Comparison of Elongations Provided by Subcutaneous Pedicle Rhomboid Flap and Z-Plasty in Rat Inguinal Skin

Comparison of Elongations Provided by Subcutaneous Pedicle Rhomboid Flap and Z-Plasty in Rat Inguinal Skin

Laser Surface Scanning Analysis in Reconstructive Rhytidectomy

The implementation of laser surface scanning to assess facial symmetry after unilateral face-lift procedures used to reconstruct defects after skin tumor resection is presented. Six patients who had undergone defect reconstruction with a flap raised from the subcutaneous plane were included in the study. Immediate postoperative photographic evaluation confirmed facial asymmetry because of unilateral skin tension. After a minimum follow-up period of 1 year, photographic and laser surface scanning analysis showed restored facial symmetry. In conclusion, laser surface scanning is a promising technology for objectifying results obtained and could be implemented for evaluation of the immediate and long-term effects from rhytidectomy procedures. Subcutaneous flaps without duplication or resection of the superficial musculoaponeurotic system are ideal for unilateral procedures because facial symmetry is restored after 1 year.

Open, Intraperitoneal, Ventral Hernia Repair

Recent literature suggests that laparoscopic repair of ventral hernias may have very low recurrence rates. However, laparoscopy may not be feasible in certain situations. We describe an open technique that uses the tension-free retrofascial principles of laparoscopic repair without the need for subcutaneous flaps. Through an incision in the hernia, the peritoneum is entered and adhesions are taken down. A piece of DualMesh (W.L. Gore & Associates, Inc, Newark, Del) is trimmed to fit with a 5-cm circumferential overlap. A vertical incision is made in the mid portion of the mesh. The mesh is fixed in an intraperitoneal retrofascial position using GORE-TEX sutures (W.L. Gore & Associates, Inc). The sutures are brought through the abdominal wall using a laparoscopic suture passer and tied into place on one side of the mesh. That side is then tacked to the posterior fascia with a spiral tacking device. The other side is sutured into place in a similar fashion and then tacked to the fascia by passing the spiral tacking device through the incision in the mesh. The mesh incision is closed with a running GORE-TEX suture. The overlying tissues are closed in layers.

Enhancing upper lid aesthetics with the lateral subcutaneous brow lift

Surgical techniques for improving the upper eyelid aesthetic unit have recently focused on the management of eyebrow position. In our practice, we noticed that in some patients the lateral brow was low preoperatively, whereas in others it was well positioned but overly mobile. We describe our experience using the lateral subcutaneous brow lift (LSBL) to elevate and stabilize the lateral brow. An incision was marked at the junction of the hair-bearing scalp and forehead, beginning on a line extending superiorly from the mid-pupillary line, and carried down to the subcutaneous plane, just superficial to the frontalis muscle. The subcutaneous tissues were dissected from the frontalis muscle, and the skin and subcutaneous flap were retracted superiorly. The flap was divided vertically, a skin staple was placed, and after assessment of brow position and stability, the medial and lateral excess skin was excised. Tisseel (Baxter Hyland Immuno, Glendale, CA) was found to facilitate hemostasis and, to a lesser extent, flap adherence. At the end of the procedure, the brow was slightly overcorrected to compensate for some postoperative descent. If planned, an upper blepharoplasty was performed in the standard fashion. The LSBL was performed in 117 patients during a 2-year period; in 82 of these cases the brow lift was performed in conjunction with upper lid blepharoplasty, and in 31 cases it was performed as part of a facial rejuvenation procedure that did not include upper eyelids. All patients reported their scars as imperceptible. Complications included 2 hematomas and 6 cases of hypesthesia confined to the region just posterior to the incision; all resolved within 8 weeks. In 1 case, the flap was inadvertently torn during its elevation; it was repaired and did not affect the outcome. The LSBL is a safe and technically simple technique that allowed us to achieve optimal aesthetic results in the upper periorbita with few complications and a high patient acceptance rate.

Parotidectomy: Assessment of a surgical technique including facelift incision and SMAS advancement

Despite its proven safety and its relevance regarding the cosmetic outcome, the SMAS-lifting technique is not a routine procedure for many surgeons. To compare the classical (subcutaneous flap and neck incision) with the SMAS-lifting techniques for parotidectomies from the patient's perspective. Both procedures are described, tricks are pointed out. In both procedures the posterior branch of the great auricular nerve was not preserved, hence the two procedures were not evaluated regarding sensitivity of the auricle and preauricular area. Forty consecutive patients were asked to classify their concerns before (1-4 months) and 1 year after surgery (10 classical technique and 30 SMAS-lifting technique). Before parotidectomy, patients were concerned in a decreasing order with the facial nerve function, the scar, the soft-tissue defect in the dorsal part of the cheek and Frey's syndrome. Following use of the classical technique, patients were concerned in decreasing order with the soft-tissue defect, the scar and Frey's syndrome. Following the SMAS technique, no one was concerned with the scar, Frey's syndrome, or the soft tissue defect although a slight asymmetry could still be noticed. The SMAS-lifting technique might possibly appear to offer a new standard procedure for parotidectomy, except for malignant tumours or in obese patients.

Comparison of Karydakis versus midline excision for treatment of pilonidal sinus disease

Pilonidal sinus disease is associated with a high rate of recurrence and complications. The Karydakis (KAR) method, whereby an asymmetric subcutaneous flap obliterates the anal crease, has been shown to be effective in adults. The goal of this study is to assess the efficacy of the KAR procedure in the operative treatment of children with pilonidal sinus disease compared to those treated via a midline excision (ME). Sixty-eight cases of pediatric pilonidal sinus excision were reviewed over the past 10 years. Data abstracted included surgical approach, complication rate and recurrence rate. Student's t-test or the Chi square test was used for statistical analysis, with P < 0.05 being considered significant. An ME was performed in 44 patients; the KAR method was used in 24 patients. Mean age at diagnosis was 14.4 +/- 4.2 years for the ME group compared to 15.7 +/- 4.3 years for the KAR patients (P = 0.18). Mean operative time was significantly longer with the KAR method (58.7 +/- 25.6 min) compared to 46.3 +/- 18.6 for the primary ME (P = 0.04). Despite the increased operative dissection, there was no difference (P = 0.42) in early post-operative complication rates between groups (25% in the KAR group compared to 34.8% in the ME group). Initial drainage of an abscess had no significant effect upon the recurrence/complication rate in either group. Recurrence rate alone was lower in patients operated on via the KAR approach 0% versus 11.0% using the ME (P = 0.153). Recurrence and complication rates were lower for those patients with a pilonidal sinus treated by the KAR method compared to the ME, but the results did not reach significance. In conclusion, this study does show a potential benefit for children treated with the KAR method for pilonidal sinus. This study mimics the data obtained in adult patients and suggests that a larger study is likely to achieve significance.

A rare involvement of Romberg’s disease: frontal region

Progressive hemifacial atrophy is characterized by slow progressive atrophy of the subcutaneous tissue. Although, in the majority of sufferers, half of the face and the chin are the most severely-affected areas, we present the case of a patient with a 2-year history of local atrophy in the forehead, a very rare involvement. Reconstruction was done using bilateral subcutaneous flaps. There was no recurrence of the atrophy at the 12th-month postoperative check.

The Changes of Peripheral Nerve Microstructure After Surgical Manipulation – Experiment on Rat Model

The aim of our study was to describe histopathology of the peripheral nerve after its circular release followed by embedding in different environs. We operated on 18 male rats divided into 3 groups. In the first group right femoral nerve was surgically released. In the second group the nerve was enveloped by the subcutaneous fat flap. In the third one the nerve was wrapped up by the skeletal muscle. Six weeks later the animals were killed by exsanguination. The femoral nerve, in the first group, did not show any pathological changes. In the second group 3 animals appeared normal or nearly normal, nevertheless in 3 of them perineural fibrosis and axonal degeneration were observed. Histological reaction in the third group disclosed dispersed axonal injury. Our experiments using rat model imitate situation in humans. The results obtained will help us in making meaningful decision when performing peripheral nerve injury.

Anterolateral Thigh Flap Technique in Hand and Upper Extremity Reconstruction

The anterolateral thigh flap is an extremely versatile flap first described in 1984. The flap is based on either a septocutaneous or musculocutaneous perforator of the descending branch of the lateral circumflex femoral system. It can be designed as a skin and subcutaneous flap, fasciocutaneous, or musculocutaneous flap. Furthermore, it can be harvested as a sensate flap by taking the lateral cutaneous nerve of the thigh. Technique for harvesting the flap is described in detail. Complications include flap failure and donor site morbidity. Due to its versatility, the anterolateral thigh flap is particularly useful for upper extremity reconstruction.

Minimally invasive approach and fixation of cochlear and middle ear implants

One of the conventional surgical approaches for cochlear implantation is a retro-auricular incision with a posterior-inferiorly based skin and subcutaneous tissue flap and a superiorly based periosteal flap. The obvious advantage is an open operating field but the disadvantages are a large wound and a lengthy operating time. It may also result in more wound-related complications. To overcome these disadvantages, we have developed a minimally invasive technique that includes a small retro-auricular single layer incision. We have used a metal bridge beneath the posterior flap to increase accessibility when creating a recess for the implant. A novel technique is used to place the securing suture deep to the flap. This technique has been used in 49 paediatric and adult patients, and there have been no wound-related complications. Although this technique was initially designed for the CLARION CII implant, it has been used to place and secure the new CLARION HiRes 90 K, the Nucleus device, the MEDEL device and the Vibrant Soundbridge.

Comprehensive analysis of tubularized incised‐plate urethroplasty in primary and re‐operative hypospadias

To retrospectively review our experience of the tubularized incised-plate (TIP) urethroplasty over the last 4 years. From 1998 to December 2001, 133 patients (mean age 7 years, sd 4, range 1-22), had a TIP urethroplasty by one surgeon for primary (103) and re-operative (30) hypospadias; the defects included 106 (79%) distal and mid-shaft, and 27 (21%) posterior shaft. The neourethra was covered by a subcutaneous flap in 66 (50%) patients or by corpus spongiosa (spongioplasty) in 31 (23%), with no cover in the remaining 36 (27%). In the last 20 patients (15%) a modified meatoplasty was used; the site and size of the new meatus was predetermined on the glans around a suitable catheter before any incision. Urethral stents were not used after repair in 39 (29%) patients, and regular meatal dilation was used only in patients with voiding difficulty and obvious tendency to stenosis. The presence of complications requiring re-operation and overall general appearance were recorded. The mean (sd) follow-up was 10 (5) months; there were 24 complications in 20 patients (15%), including a small fistula in 12 (9%), complete disruption of the repair in 4 (3%), meatal stenosis in seven (5%) and neourethral stricture in one (0.8%). Complications were not significantly different between primary and re-operative cases, and unaffected by the use of the stents. On univariate analysis complications were significantly higher with running than interrupted sutures, in repairs in the first 2 years of the study, in patients with posterior hypospadias, and in those with no neourethral coverage. However, the last two factors were the only significant independent risk factors in a multivariate analysis. Regular urethral dilatation was indicated in 43 patients (32%). Modified meatoplasty was associated with a significantly lower requirement for regular dilatation (P < 0.05) and no meatal stenosis. In the 113 complication-free patients the operation gave an excellent cosmetic appearance with a vertical slit meatus on the tip of conical glans in 110 (97%); there was slight meatal retraction in the remaining three patients. The TIP repair is a reliable method for treating both distal and proximal penile shaft hypospadias, is suitable for both primary and re-operative cases, and is more versatile than other repairs. Covering the neourethra with a flap or spongioplasty significantly improves the results. Regular urethral dilatation is required in a third of patients but modified meatoplasty obviates the need for regular dilatation and eliminates the risk of meatal stenosis.

The Extended Brow Lift: The Toucan Technique

Brow ptosis is the main consequence of aging in the upper third of the face. Many methods have been described to correct it: skin excisions of the brow hairline, skin excisions of the forehead natural creases, skin trimmings of the temporal, coronal, or forehead hairline flaps, and endoscopic methods [1,15,17,18,24,26,27]. The authors created a procedure which is based on a forehead-temporal subcutaneous flap and a muscular relocation. It treats the brow ptosis and its surrounding area-temporal ptosis, upper and lower lateral eyelid ptosis, crow's feet-and at the same time improves the sclera show or ectropion. The method preserves the sideburn and the temporal hairline and can reduce the width between the temporal hairline and the lateral end of the eyebrow. The method produces maximum improvement, with high-quality scars and minimal evidence of surgery. The procedure is called "The Toucan Technique," due to the shape of the skin resection which looks like a toucan bird [11,13,14].

The partial-thickness cross-lip flap for correction of postoncologic surgical defects

Purpose: Abbe and Estlander cross-lip flaps have been described and designed as a full-thickness flap to reconstruct a full-thickness excisional defect. Some Mohs surgical excisions and other serial excisions leave partial-thickness defects. This article reviews a series of partial-thickess cross-lip flaps, which included some orbicularis oris muscle in the vermilion region but otherwise was a subcutaneous flap. Patients and Methods: In the last 7 years, 110 patients with lip cancer had their postsurgical defects reconstructed 24 to 72 hours after the resection. In all cases, negative margins were established by histologic evaluation or Mohs micrographic surgery. Twenty of 29 patients had Abbe- and Estlander- (lip-switch) type flaps, which were composed of a musculomucosal pedicle of 1.25 to 1.50 cm and an attached skin/subcutaneous flap trimmed to fit the defect. The remainder had full-thickness lip-switch flaps. Results: There were no vascular complications in either group. Four patients had notching or trapdoor- type bulking, which were revised after 3 to 6 months. Conclusion: The partial-thickness cross-lip flap has the same viability as the full-thickness flap within 1 cm from the inferior border of the mandible. © 2001 American Association of Oral and Maxillofacial Surgeons

Mycobacterium ulcerans skin ulcers: review of surgical management

Mycobacterium ulcerans infection causes debilitating ulceration of the skin and subcutaneous tissue. Until 1993, this infection was not a major health problem in Ghana. In 1993, there was a major outbreak in the Ashanti Region of Ghana, in the Amansie West District in the village communities of Tontonkrom [1, 2]. Unfortunately, pharmacological treatment of this disease is not effective. Traditional methods of wound care such as the use of Eusol or Acriflavine lotion do not promote healing. Surgical management involves radical excision of the ulcer with meticulous haemostasis and coverage with a split-thickness skin graft (STSG) or local skin subcutaneous flap. Successful covering of the ulcers, proper splinting and physiotherapeutic exercises in the affected limbs prevented the contracture deformities other associated with the disease. This report reviews the management of 240 patients surgically treated at the Komfo Anokye Teaching Hospital (KATH) and at two nearby hospitals from 1994 to 1997 with a 2- to 5-year follow-up.

Subcutaneous tissue flaps: theoretical principles and clinical applications

The paper examines the anatomical principles and clinical applications of subcutaneous tissue flaps. This tissue, located between the dermis and muscular aponeurosis, is an anatomical entity supplied by a well-developed vascular network. Two examples of the application of the principles of the de-epithelialized ”turn-over” flaps in the hand and leg are presented. The reasons for their use and their advantages are briefly discussed.