The lower trapezius musculocutaneous flap for head and neck reconstruction: two decades of clinical experience.

BACKGROUND: Microsurgical free flap has gained the popularity over pedicle flap nowadays in the reconstruction of head and neck. However, pedicled flaps remain a promising alternative and have a remarkable position in selected patients. This review study aimed to determine the reliability and versatility of the lower trapezius musculocutaneous flap for reconstructing complex defects in the head and neck. METHODS: Between 1993 and 2012, 22 male and 10 female patients underwent a total of 32 lower trapezius flap reconstructions for complex defects that included neoplasm extirpation (n = 21), radionecrosis (n = 6), dehisced laminectomy (n = 2), pressure sore (n = 2), and necrotizing fasciitis (n = 1). The most common site of defect was the perioral region, followed by the neck, posterior skull, back, temporal region, shoulder, and the upper arm. Flap design was based on the defect size and location, as well as the ability to close the donor site primarily and to preserve muscle function. Outcome has been evaluated by the hospital course, postoperative morbidity, mortality, resultant cosmetics, and function at donor and recipient sites. RESULTS: Stable wound coverage with total flap survival was achieved in 30 (93.75%) patients, 2 patients had partial flap necrosis which required flap reinsertion and skin graft coverage. All donor sites were closed primarily. Seroma developed in 2 (6.25%) patients, which were solved by needle aspiration. All muscle function was preserved. Eight patients died of their primary disease. CONCLUSIONS: For selected patients who have advanced stage cancer, surgical sequelae after free flap surgery, unable to tolerate microsurgery, or special defect location, pedicled lower trapezius musculocutaneous flap provides efficient and effective reconstruction for complex defects especially in the head and neck.

Adipose-derived stem cells seeded on acellular dermal matrix grafts enhance wound healing in a murine model of a full-thickness defect.

INTRODUCTION: The promotion of wound healing using dermal substitutes has become increasingly widespread, but the outcomes of substitute-assisted healing remain functionally deficient. Adipose-derived stem cells (ASCs) have been investigated widely in regenerative medicine and tissue engineering, and they have the potential to enhance wound healing. In this study, we focused on investigating the effects and mechanism of ASCs combined with an acellular dermal matrix (ADM) to treat full-thickness cutaneous wounds in a murine model. METHODS: The ADM was prepared from the dorsal skin of nude mice by decellularization by treatment with trypsin followed by Triton X-100. The human ASCs were isolated and cultured from abdominal lipoaspirate. We created a rounded, 8-mm, full-thickness cutaneous wound in nude mice and divided the mice into the following 4 groups: silicon sheet cover only, silicon sheet with spreading ASCs, ADM only, and ASCs seeded on ADM. The granulation thickness was evaluated by histology after 7 days. Further comparisons between the ADM only and ASC-seeded ADM groups were undertaken by assessing the reepithelialization ratio and blood vessel density at postoperative days 9 and 14. Statistical analyses were conducted using Student 2-tailed t test. Immunofluorescent histology and ASC labeling were also performed to identify possible mechanisms. RESULTS: The ADM was successfully prepared, and the cytometry analysis and differentiation assay provided the characterization of the human ASCs. A marked improvement in granulation thickness was detected in the ADM-ASC group in comparison with other 3 groups. A significantly increased rate of reepithelialization in the ADM-ASC group (80 ± 6%) compared to the ADM only group (60 ± 7%) was noted on postoperative day 9. The blood vessel density was evidently increased in the ADM-ASC group (7.79 ± 0.40 vessels per field) compared to the ADM only group (5.66 ± 0.23 vessels) on day 14. Cell tracking experiments demonstrated that labeled ASCs were colocalized with staining for VEGF or endothelial cell maker vWF after the transplantation of ADM-ASCs on postoperative day 14. CONCLUSIONS: Adipose-derived stem cells seeded on an ADM can enhance wound healing, promote angiogenesis, and contribute to newly formed vasculature, and VEGF-expressing ASCs can be detected after transplantation. This model could be used to improve the other clinical applications of ASCs and to decipher the detailed mechanism by which ASCs interact with wound tissue.

Clinical experience using cadaveric skin for wound closure in taiwan.

UNLABELLED: Taiwan's skin banking program was initially set up to provide a ready source of cadaveric skin for patients with severe burns. However, human cadaveric skin may offer a useful alternative to conventional dressings in other wounds as well. METHODS: In this retrospective review, cadaveric skin transplantation was used as temporary coverage in 145 patients with chronic ulcers, diabetic foot ulcers (DFU), necrotizing fasciitis, and acute traumatic wounds. Sex, age, number of debridements, and number of cadaveric skin transplantations were analyzed using statistical methods. RESULTS: After clinical determination of engraftment 1 week after cadaveric skin allograft, skin samples harvested for histology in 15 cases revealed migration of epithelia from patient's skin to the surface of cadaver skin and the presence of granulation tissue in the base of the cadaver skin. All wounds exhibited good wound-bed preparation after cadaveric skin transplantation, and could eventually be resurfaced with a skin autograft. CONCLUSION: Human cadaveric skin, in addition to being the mainstay in burn therapy, is a good biological dressing for chronic ulcers, DFUs, necrotizing fasciitis, and acute traumatic wounds. .

Free-flap resurfacing of tissue defects in the foot due to large gouty tophi.

BACKGROUND: Large or extensive gouty tophi on the feet can cause functional impairment, drainage sinus, and infected necrosis, finally resulting in complex soft-tissue defects with tendon, joint, bone, nerve, and vessel exposure. Reconstruction of complex soft-tissue defects of the foot is still challenging. The purpose of this report was to review the outcomes of free-flap reconstructive surgery for treating the metatarsal joint defects of the feet caused by chronic tophaceous gout. METHODS: Ten patients who had large tophus masses (>5 cm) and ulceration on the feet were admitted to our hospital between September 2006 and September 2010. Six patients underwent free-flap reconstruction after debridement to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for exposed tendons. The patients' age, sex, comorbidities, location and size of the defects, reconstructive procedures, surgical outcomes, complications, follow-ups, and recurrence of tophaceous gout were reviewed and recorded. RESULTS: The mean patient age was 49.8 years (range, 36-72 years). The average skin defect size was 92.2 cm(2) . Five patients were treated using free anterolateral thigh flaps, and 1, using a free medial sural flap. These free flaps were safely raised and showed excellent functional and cosmetic results, with a mean follow-up of 31.7 months (range, 7-50 months). CONCLUSION: Chronic tophaceous gout can cause severe skin infection and necrosis, even resulting in deformity or sepsis if left untreated. Surgical debridement is inevitable in patients with extensive wounds. We reconstructed the large, ulcerative skin and soft-tissue defects on the dorsum of the foot by performing free-flap reconstruction after adequate debridement and achieved good functional and cosmetic results.

Medial sural artery perforator flap for intraoral reconstruction following cancer ablation.

In oral cavity reconstruction, the fasciocutaneous flaps of the distal extremities have always been preferred to any other kind of flap because of their thinness and pliability, which makes them adaptable to different areas in the oral cavity. The radial forearm flap is frequently considered the first choice for intraoral reconstruction, but the disadvantages of donor site morbidity include sacrificing a major artery to the hand and leaving a conspicuous donor site scar. The search for another primarily thinned skin flap as an alternative has led to the application of the medial sural artery perforator flap, which is harvested from the medial aspect of the upper calf. Between June 2003 and March 2007, 22 free medial sural artery perforator flaps were transferred for intraoral defects after cancer ablation, including tongue and floor of mouth (15 cases), buccal mucosa (5 cases), retromolar trigone (1 case), and anterior floor of mouth (1 case). We paid attention to the major perforator (vein > or =1 mm), which was confirmed by the endoscope, as the vascular relay for the skin flap. The size of the skin paddle varied from 7.5 x 4 cm to 17 x 8 cm. The main advantage of this flap is that it provides thin and pliable coverage to achieve better accuracy in the oral cavity. Other advantages of minimizing donor site morbidity include maintaining the function of the medial gastrocnemius muscle, avoiding the need to sacrifice major arteries of the leg, and possible primary closure of the donor defect.

Treatment of nonhealing diabetic lower extremity ulcers with skin graft and autologous platelet gel: a case series.

Lower extremity ulcers in diabetic patients are difficult to treat. Recently, the use of human blood platelet-derived components in this indication has been raising interest. In this study, we have evaluated the safety and efficacy of the combination of autologous platelet gel (PG) and skin graft for treating large size recalcitrant ulcers. Eight consecutive diabetic patients aged 25 to 82 with nine nonhealing lower extremity ulcers (median size of 50 cm(2); range 15-150 cm(2)) were treated. Skin ulcer was debrided, and the wound was sprayed after 7 to 10 days with autologous platelet-rich plasma and thrombin. Thin split-thickness skin graft with multiple slits was then applied on the wound bed and fixed with staples or cat-gut sutures. There were no adverse reactions observed during the study. Eight out of 9 skin grafts took well. The interval between skin graft and complete wound healing ranged from 2 to 3 weeks in the 8 successful cases. No ulcer recurrence was noted in those patients during the follow-up period of 2 to 19 months. In this study, the combination of autologous platelet gel and skin grafting has proven beneficial to heal large-size recalcitrant ulcers.

Three abdominal defects, three pedicled flaps.

The reconstruction of complex defects in the abdominal wall after wound infection or trauma can be challenging. In this article, a superficial inferior epigastric artery flap, a tensor fascia lata flap, and an anterolateral thigh flap used for 3 different abdominal wall reconstructions are described. The authors conclude that different specific abdominal wall defects can be successfully reconstructed using different pedicled flaps in simple and effective single-stage reconstructions.