Covering small defects on the weight bearing surfaces of the foot: the free temporal fasciocutaneous flap.

Although defects in the weight bearing area of the heel can be covered by local flaps, radiodermatitis is a contraindication to these flaps. Thin free flaps, as grafted fascial or muscles flaps and thin fasciocutaneous flaps, are usually the option of choice in these particular defects. These reconstructions are prone to shearing strains resulting in ulceration, hypertrophic scars and hyperkeratosis. The authors present a retrospective study of the reconstruction of six small heel defects with the fasciocutaneous temporal free flap performed between 1996 and 2001. The mean size of the defect was 20 cm(2). All arterial anastomoses were performed end to side on the posterior tibial artery. Despite the flap thinness, swelling was present during 12-25 months and one debulking had to be performed. With a mean follow-up of 32 months, all flaps regained protective sensibility after 7 months. No sliding of the flaps could be noted but there was one transient hyperkeratosis. Although the amount of hair on the transferred flaps decreased spontaneously with time, laser hair removal was performed in two patients for psychological reasons. In conclusion, it seems that in selected cases where local flaps are contraindicated, the fasciocutaneous temporal free flap can offer an excellent alternative for heel reconstruction. Due to its particular architecture, it resembles the complex tissue of the sole of the foot resulting in fewer complications and maintenance of flap durability.

Combined reconstruction of the diabetic foot including revascularization and free-tissue transfer.

Diabetic patients, presenting with both peripheral vascular disease and large soft-tissue defects, are too often treated by primary amputation. A combined revascularization and free-tissue transfer procedure can extend limb salvage in these patients. The authors report their experience over 4 years with 19 diabetic patients with peripheral vascular disease and large soft-tissue defects of the foot requiring free-tissue transfer. Although there was a 100 percent flap survival, early local wound problems occurred in three patients (16.6 percent). The recurrence rate was about 18.7 percent, but no complementary flap procedures were mandatory. With a mean follow-up of 38 months (range: 23 to 55 months), the limb salvage rate was 94.4 percent. Although there was one limb loss and one patient with ambulation difficulties, 16 patients (84.2 percent) were fully rehabilitated and were able to function independently. Despite a rather small series, this study confirms that in selected diabetic patients, a combined approach of vascular and reconstructive surgeons can reduce the limb amputation rate with acceptable complication rates. This combined approach offers major benefits to these patients, especially stable coverage and preservation of ambulation, and should always be considered before amputation.

Abdominal aplasia cutis congenita: case report and review of the literature.

A case of bilateral abdominal aplasia cutis congenita without skull defect is reported and was treated successfully by a combination of allografts and growth factors delivered by allogenic cultured keratinocytes.

[Free flap pedicle loss: clinical study on 8 cases]. / Perte du pédicule nourricier d'un lambeau libre : étude clinique sur 8 cas.

The authors report on 8 cases of free flaps with vascular pedicle disruption that were encountered between postoperative days 8 to 18. In one case, the inflow disappeared 18 months after the transfer without any trouble. This resulted in 2 partial and one complete flap losses. The 4 other flaps survived completely. This complete survival is related to the angiogenesis process coming from the surrounding tissues. The most obvious causal factor responsible for the 2 partial losses was the coverage of large, non viable areas, such as a prosthetic material and bone deprived of periosteum. The only causal factor that could be assessed in the case of total necrosis was the presence of an immunosuppressive treatment. Variables participating in the installation of an adequate angiogenic response are then discussed in accordance to this experience and to the literature. Limited contact with viable tissue, ischemia-reperfusion or drugs limiting the angiogenesis seems to promote failure when the pedicle is quickly disrupted. Hypoxia seems to be the most important cellular mechanism promoting the angiogenesis in this context.

[Coverage of defects: principles]. / La couverture des pertes de substance: les principes.

The coverage of defects is a broad field with which the plastic surgeon is confronted daily within traumatic, tumoral or other context. The various techniques used are skin graft and flaps, forming both heterogeneous groups. Indeed, there are various types of skin graft although a common denominator is the need for a good recipient site in order to allows an adequate "take". On the other hand, flaps carry their own vascularization. Thus, they are not dependent of the recipient site for their survival. Those are divided into three groups: local flaps, pedicled flaps and free flaps. The choice of the adequate technique with respect to the defect to be covered depends on the characteristics of the defect, its localization, the functional requirements of the area, the exposed structures, the medical status of the patient. The possible morbidity left on the donor site the aesthetic and functional goals are taken into consideration. For each case, there are often several good options as well as others less optimal solutions. The existing solutions are often so numerous that the plastic surgeon is frequently able to solve all the types of defects.

[Deep vein thrombosis in a burn patient]. / Thrombose veineuse profonde chez le patient brûlé.

Association between deep venous thrombosis (DVT) and pulmonary embolism is probably an underestimated problem in the thermally injured patients. However, those patients display important risk factors according to Virchow's triad. This article reports on three unrecognised DVT's accompanying burns which were characterized by absence of healing or edema. The pathophysiology of this issue is then discussed with respect to the specific area of the thermally injured patient. It is our belief that local inflammatory phenomenon play a major part in the genesis of DVT associated with chronic non-healing burns.

Use of the medial adipofascial flap of the leg for coverage of full-thickness burns exposing the tibial crest.

Bone exposure constitutes a frequent and difficult problem in burn patients. Where free flaps remain indicated in tibial osteomyelitis, a pedicled fascial or adipofascial flap provides an excellent alternative for coverage of simple tibial crest exposure. In fact, the adipofascial tissue of the anteromedial aspect of the leg can be mobilized over the whole length of the tibia. It is vascularized by the saphenous artery and the posterior tibial artery perforators. This pattern of blood supply allows a wide range of use for any size of burn defect in this area. Therefore, this local pedicled flap provides an excellent solution for coverage of the exposed tibia after severe burns.

[Arterial revascularization with free tissue transfer for salvage of ischemic limbs with extensive tissue loss: an alternative to amputation]. / Revascularisation artérielle et transfert de lambeau libre pour le sauvetage des membres ischémiques avec perte de tissus mous: une alternative à l'amputation.

Severe limb ischemia is a common problem encountered in medical practice. Aggressive attempts at revascularization have extended the limits of limb salvage. However, in certain cases, extended tissue loss compromises the healing process. It often results in amputation despite bypass graft patency. Microvascular free tissue transfer combined with arterial revascularization allows healing of these wounds and limb preservation. This combined approach is the ultimate alternative to amputation.

[Chronic ulcer and wound dehiscence..when the origin is unknown and therapy is ineffective!]. / Un ulcère chronique ou une déhiscence cicatricielle.... Quand l'origine est inconnue et les thérapeutiques infructueuses!

The authors report on two cases of factitious disorders in the field of surgery. The discussion is focused on the different aspects of this pathology that are encountered by a plastic surgeon, in order to provide him with more confidence when dealing with this too-often ignored disease.

[Hypothenar hammer syndrome]. / Le syndrome du marteau.

The hypothenar hammer syndrome is an uncommon but underestimated lesion of the cubital artery caused by repetitive trauma at the level of the hamate bone. It characteristically occurs in patients with a history of manual work as metal workers, carpenters and motor mechanics. We present a case of a patient who developed this syndrome following intensive use of a dig. Clinical finding, diagnosis and treatment are discussed.