Pyoderma gangrenosum of the eyelid: report of two cases and review of the literature.

Pyoderma gangrenosum (PG) of the eyelid is extremely rare, and its proper management is essential for the preservation of visual function. Here, we report 2 cases of PG of the eyelid with intraorbital involvement. In both cases, the skin and intraorbital lesions improved after systemic immunosuppressive therapies; however, corneal perforation occurred in 1 case. In order to assess the clinical features of PG of the eyelid and to obtain clues for optimal treatment, we reviewed 15 well-documented cases in the literature, including the present cases. Corneal perforation occurred in 4 cases and defective ocular motility in 1 case. Three patients eventually underwent enucleation of the affected eye. Our cases and the literature review clearly indicate that MRI is a powerful tool for evaluating the extent of extracutaneous PG lesions around the eye and that early diagnosis and immediate immunosuppressive therapy are crucial for the preservation of visual acuity.

Variation of microvascular blood flow augmentation--supercharge in esophageal and pharyngeal reconstruction.

AIM OF THE STUDY: A gastric tube is commonly used in thoracic esophageal reconstruction. When a gastric tube is not available, pedicled jejunum transfer and colonic interposition are alternative methods. Oral end of the reconstructed esophagus occasionally has poor blood flow and may result in partial necrosis of the oral segment. We performed additional microvascular blood flow augmentation, the "supercharge" technique, to improve a blood flow circulation in the oral segment of the reconstructed esophagus. METHODS: A series of 86 esophageal reconstructions with microvascular blood flow augmentation using the "supercharge" technique were performed. Reconstructive methods included a gastric tube in five patients, a gastric tube combined with a free jejunual graft in one, an elongated gastric tube in eight, a pedicled colonic interposition in 22, and a pedicled jejunum in 50. Recipient vessels were used in neck or chest region. RESULTS: The color and blood flow of the transferred intestine appeared greatly improved after microvascular blood flow augmentation. Thrombosis was noticed in three patients during the surgery, and all thrombosies were salvaged by re-anastomosis. There were only three patients with partial graft necrosis of oral segment, two patients with anastomotic leakage, one anastomotic stricture. CONCLUSIONS: Augmentation of microvascular blood flow by this "supercharge" technique can be expected to reduce the risk of leakage and partial necrosis of the transferred intestine. This technique contributes to the successful reconstruction of esophageal defect.

Clear cell sarcoma associated with multiple pulmonary metastases with structural and numerical karyotypic changes.

Cytogenetic analysis was performed on a specimen from a pulmonary metastasis of clear cell sarcoma originated on the right ankle of a 53-year-old Japanese woman. It revealed near-triploid with several numerical changes including abnormalities in the copy number of chromosomes 7, 8, and 22, and structural abnormalities of chromosome 22 and others. This is a minor case which showed the multiple abnormalities of chromosomes in the absence of a t (12;22) translocation.

Experience with 24 cases of reconstructive anterior skull base surgery: classification and evaluation of postoperative facial appearance.

This article details our experience with 24 cases of anterior skull base reconstruction after tumor resection. They were classified into four types according to the resected region. In 11 cases of type I resection, the orbital part of frontal bone and/or cribriform plate of ethmoid bone were resected. In two cases of type II resection, the orbital contents and partial orbital bone were resected with the addition of type I. In five cases of type III resection, the maxillary bone was resected with the addition of type II. In six cases of type IV resection, the zygomatic bone and/or facial skin were resected with the addition of type III. The tumor originating from intracranial region was 25% of this series and all of them belonged to type I. The tumor originating from extracranial region tumor was 75% and its resected region was more extensive. In type I and II resections, the cranial flap, radial forearm free flap, or a combination of the two was used for reconstruction. The rectus abdominis myocutaneous/muscle free flap was used for reconstruction of massive defects in type III and IV defects. Total incidence of postoperative complications was 16.7%. Donor site deformity of the cranial flap at the frontal and temporal region in types I and II resections and facial contour deformity in zygomatic region and defect of upper and/or lower palpebra in type IV resection were major problems with postoperative facial appearance. Although use of the rectus abdominis myocutaneous free flap combined with costal cartilages improved the midfacial contour, palpebral reconstruction remained an unsolved problem in reconstructive skull base surgery. The reconstructive goals in skull base surgery are not only to obtain safe and reliable skull base reconstruction but also to restore the facial appearance postoperatively.

Functional alveolar ridge reconstruction with prefabricated iliac crest free flap and osseointegrated implants after hemimaxillectomy.

We achieved functional alveolar ridge reconstruction after hemimaxillectomy using a prefabricated iliac crest flap. The iliac crest was vascularized secondarily by a long rectus abdominis muscle flap with its inferior epigastric vessels intact to obtain an ideal anatomic location between the maxillary defect and microvascular anastomosis site. The iliac crest was tightly resurfaced with a split-thickness skin graft as well. After a bony surgical delay, the prefabricated iliac crest flap was microsurgically transferred to the face. Three osseointegrated implants were placed in the prefabricated iliac crest, and a dental prosthesis was worn with immobilization and stability. Our procedure enabled recovery of a satisfactory facial appearance and excellent masticatory function.

Quantification of third-body damage and its effect on UHMWPE wear with different types of femoral head.

We examined stainless-steel, cobalt-chrome, titanium and alumina and zirconia ceramic femoral heads retrieved at revision surgery. All the heads had articulated against ultra-high-molecular-weight-polyethylene (UHMWPE) acetabular cups. We studied the simulation of third-body damage and the wear of UHMWPE against the various materials used for the heads. The surfaces of the retrieved heads were analysed using a two-dimensional contacting profilometer. Third-body damage was characterised by the mean height of the scratches above the mean line (Rpm). The alumina ceramic and zirconia ceramic retrieved heads were found to have significantly less damage. In laboratory studies the ceramics were also more resistant to simulated third-body damage than the metal alloys. We studied the wear of UHMWPE against the damaged counterfaces in simple configuration tests. The damaged ceramics produced less polyethylene wear than the damaged metal counterfaces. The wear factor of UHMWPE against the damaged materials was dependent on the amount of damage to the counterface (Rp). Our study has shown the benefit of using the harder and more damage-resistant ceramic materials for femoral heads.

Use of intraperitoneal vessels in reconstructive microsurgery: an account of 117 cases.

The purpose of this study was to evaluate our experience of microvascular anastomosis of intraperitoneal vessels. Between 1985 and 1994, 117 microsurgical reconstructions were done using intraperitoneal vessels. These included oesophageal reconstruction (n = 106), reconstruction of the hepatic arterial, superior mesenteric arterial, or portal venous system (n = 8), and reconstruction of the chest or abdominal wall (n = 3). We used 129 intraperitoneal arteries and 117 intraperitoneal veins. Of a total of 246 intraperitoneal vessels, five hepatic arteries, seven splenic, 14 gastroepiploic, six superior mesenteric, 178 jejunal, 30 ileocolic, four middle colic arteries or veins, and two portal veins were used for microvascular anastomosis. The overall successful rate for these reconstructive cases was 97% (114/117). Microsurgical use of intraperitoneal vessels is a safe and developing procedure in plastic and reconstructive surgery.

Role of buttress reconstruction in zygomaticomaxillary skeletal defects.

The purpose of this study was to review eight patients undergoing midfacial skeletal reconstruction following extensive resection of tumors based on the principles of restoration of three maxillary buttresses, the nasomaxillary, zygomaticomaxillary, and pterygomaxillary. The zygomaticomaxillary skeletal defects were reconstructed with a three-dimensionally contoured piece of titanium mesh, vascularized costal cartilage, or vascularized bone flap of scapula and rib. Restoration of the zygomaticomaxillary buttress prevented the inferior deviation of the orbit and provided good zygomatic contour. Restoration of the nasomaxillary buttress prevented the superior and posterior deviation of the alar base of the nose, and restoration of the pterygomaxillary buttress prevented the superior and posterior deviation of the upper lip. Combination of the V-shaped scapular bone and the rib flap based on the thoracodorsal vascular system, which provides simultaneous reconstruction of all three buttresses, is a very versatile technique for reconstruction of extended midfacial skeletal defects. In this series, both of the patients reconstructed with titanium mesh presented with late persistent cutaneous fistulas. We now recommend a vascularized autologous soft and bony tissue reconstruction for midfacial composite defects.

The rectus abdominis myocutaneous flap combined with vascularized costal cartilages in reconstructive craniofacial surgery.

The efficacy of osteocutaneous or vascularized bone flaps for reconstruction of massive skeletal and soft-tissue defects has been supported by recent descriptions in the literature. In this article we presented an alternative technique, which is the rectus abdominis myocutaneous flap combined with vascularized eighth and ninth costal cartilages, for reconstruction of midfacial composite defects. The vascular pedicle of the composite flap is the deep inferior epigastric artery and vein. The costal cartilages are supplied by the perichondrial vascular network through the anterior intercostal vessels connecting with the deep epigastric vascular system. Vascularized costal cartilages are considered to reduce the incidence of postoperative complications and resorption of this material. This technique is a useful tool for restoration of craniofacial contour in reconstructive head and neck surgery.

Surgical salvage of failed esophageal reconstruction attempted with gastric pedicle.

Use of the gastric pedicle is an established method for esophageal reconstruction. However, fistula or necrosis of the pedicle occasionally occur due to vascular insufficiency or the severity of the surgery. During the past 4 years, the authors encountered six patients with necrosis of the gastric pedicle, who required reconstruction of circumferential defects of the cervical and thoracic esophagus. In such secondary reconstructive cases, primary closure of the wound is very difficult because the surrounding soft tissue becomes fibrous from infectious and fistulous complications of the first operation. Free jejunal transfers were utilized for restoring continuity of the alimentary tract, a platysma myocutaneous and pectoral fasciocutaneous flap for covering the intestinal anastomoses, and a mesenteric flap connected with the jejunal graft for covering the remaining skin defects in these cases. In follow-up periods from 3 to 21 months, satisfactory results were obtained in all but one patient. Five patients could eat a normal diet without difficulty. This reconstructive method is advocated as safe and well-tolerated physiologically in the salvage of necrosis of the gastric pedicle.

Pelvic reconstruction with a free fillet lower leg flap.

The free fillet lower leg flap was applied for immediate reconstruction after hemipelvectomy including the overlying soft tissue and the internal and external iliac vessels. The flap, harvested from the amputated lower extremity, is a versatile reconstructive technique for such a large pelvic defect.

Reconstruction following total laryngopharyngoesophagectomy and extensive resection of the superior mediastinum.

Our experience with four patients who underwent immediate reconstruction following total laryngopharyngoesophagectomy and extensive resection of the superior mediastinum is presented. The reconstructive procedures included free jejunal graft or microvascularly augmented gastric pedicle for esophageal reconstruction, pectoral fasciocutaneous or myocutaneous flap for tracheal reconstruction, and mesenteric flap connected with jejunal graft omental flap, or pectoral flap for protection of the great vessels and obliteration of the dead space in the cervical and superior mediastinal region. The reconstructive procedures were successful, and no pharyngocutaneous fistula, mediastinitis, or great vessel rupture was noted in any patient. There was one patient who developed lung edema and liver dysfunction postoperatively. Combinations of reconstructive procedures using well-vascularized soft tissues can be expected to provide well-tolerated reconstruction following extensive cervical and superior mediastinal resection.

Use of the expanded skin flap in esthetic reconstruction of postburn deformity.

Tissue expansion is very useful in the restoration of postburn deformities. We describe two esthetic reconstructions of postburn deformity with expanded skin flaps. In case No. 1, the patient was plagued with the pigmented skin graft used for coverage of a burn ulcer on the lateral chest. The graft was completely replaced by expanded skin flaps and esthetic improvement was obtained. In case No. 2, the patient had postburn alopecia including the right hairline and sideburn. The expanded scalp free flap harvested from the contralateral side was used and an excellent result was obtained. We submit that tissue expansion is the technique of choice for esthetic reconstruction of postburn deformities.

Application of a suture anchor technique for flap fixation to bone.

The authors have developed a technique for fixation of a flap to underlying bone. Their technique involves an anchor system which has been used for tenodesis and ligament repair in orthopedic bone and joint surgery. The anchor technique provides reliable fixation with simplicity of application. A wider use of this technique in reconstructive flap surgery is expected.

The combined flap based on a single vascular source: a clinical experience with 32 cases.

This article provides a retrospective review of 32 combined flap transfers. It consists of two or more flaps based on independent vascular branches from a single vascular source. This series included the combined flap based on the subscapular-circumflex scapular-thoracodorsal vascular system in 24 patients and the profunda femorislateral circumflex femoral vascular system in 8 patients. Twenty-four combined flaps were transferred as free flaps and eight as pedicled flaps. The combined flap based on the subscapular system has very good indications for massive and three-dimensional composite defects in the head and neck region. The combined flap based on the lateral circumflex femoral-profunda femoris system is useful for reconstruction of large defects in the groin, perineal, and lower abdominal regions.

Facial contouring surgery with the scapular osteo-adipo-fascial flap.

Recently, deepithelialized scapular or parascapular flaps have been used for reconstruction of facial contour. The authors used a scapular osteo-adipo-fascial flap, based on the subscapular vascular system, accompanied with scapular bone on the angular branch, for surgical correction of facial contour in two cases. At follow-up, both patients showed aesthetic improvements, and were pleased with the results. The scapular osteo-adipo-fascial flap provides a technique to reconstruct facial contour, including the bony structure as well as the soft tissue.

Cheek reconstruction with an expanded prefabricated musculocutaneous free flap: case report.

We present a case of reconstruction of the left cheek with a prefabricated musculocutaneous flap. A pedicled serratus anterior muscle flap was transferred to the left chest, deep to skin. The muscle flap and overlying skin were expanded. The expanded, prefabricated musculocutaneous flap was then transferred as a free flap to the left cheek defect.

Mesenteric flap in free jejunal transfers: a versatile technique for head and neck reconstruction.

BACKGROUND: The technique of free jejunal transfers has been widely used for pharyngoesophageal reconstruction. However, secondary infectious and fistulous complications may develop in extensive and preoperatively high-dose irradiated cases. METHODS: A generous jejunomesenteric composite graft was harvested and the mesenterium was effectively applied for head and neck reconstruction. RESULTS: The mesenteric flap connected with the revascularized jejunum was used as means for obliterating dead space in the head and neck region, as a cover for the cover for the cervical vessels, as a vascularized bolstering for the vascular and enteral anastomoses, or as a vascularized bed for skin grafting when the skin flaps are deficient. Only one small fistula occurred in 10 patients who underwent the mesenteric flap. CONCLUSIONS: This versatile technique is expected to reduce the incidence of postoperative complications in pharyngoesophageal reconstruction using free jejunal transfers.

"Boomerang" rectus abdominis musculocutaneous free flap in head and neck reconstruction.

Immediate head and neck reconstruction after cancer resection using the "boomerang" rectus abdominis musculocutaneous (RAM) free flap was performed in 13 patients over the past 2 years. The skin paddle of the flap is designed as a boomerang shape based on the anatomical construction of the dominant perforators from the inferior epigastric vascular system. A versatile technique of the boomerang RAM flap provides effective use for reconstruction of the complex defects at the skull base, orbital, nasal cavity, paranasal sinuses, oropharynx, palate, buccal mucosa, tongue, floor of mouth, and neck. It also allows a reconstructive surgical team to elevate the flap simultaneously with a head and neck surgical team before the size and location of the defect are exactly determined and greatly reduces operating time. This flap will be a routine technique for immediate head and neck reconstruction after cancer resection.

Experience with arteriovenous malformations treated with flap coverage.

Fourteen patients with arteriovenous malformations were treated with surgical resection followed by well-vascularized tissue transfer. Free-tissue transfers were used in 12 of the patients and axial local flaps in 2 patients to reconstruct the region with arteriovenous malformations. The feeding arteries of the arteriovenous malformations were used as recipient vessels in all cases of free-tissue transfers without any trouble in microvascular anastomosis. With an average follow-up of 3 years and 2 months, 12 patients showed no clinical recurrence (86 percent). Follow-up angiography in seven patients showed complete disappearance of malformations in two patients and residual malformations not enlarged in three patients. Two patients had residual malformations that were noted to be increasing in follow-up angiograms, and they also had clinical evidence of recurrence. In these patients an intramaxillary recurrence in one and intraorbital in the other appeared at about 1 and 3 years, respectively, after surgery. This therapeutic concept can be expected to provide great remission in the treatment of arteriovenous malformations.