Use of a versatile transpositional flap in the surgical treatment of axillary hidradenitis suppurativa.

Axillary hidradenitis suppurativa is a chronic recurrent disorder characterized by abscessing inflammation, fistulating sinus tracts, and scarring. This is not only a medical disease, but also a complicated problem necessitating surgical intervention. While various management strategies have been reported, the results are frequently unsatisfactory. Primary closure of the defect after radical excision is often impossible and results in poor wound healing. Skin graft on the soft tissue defect often results in obvious scar contracture and limitation of movement. Local muscle flap can fill in the defect but the range of adduction of the arm will be limited by its muscle bulk. Free flap transfer is a choice of management but this technique calls for a trained team, laborious execution, expensive instruments and plenty of time. We describe the use of transpositional fasciocutaneous flap, which can provide a reliable flap of variable size of skin and soft tissue coverage with good elastic properties. The technique is easily adapted to the reconstruction of resultant defects. This technique was used to transfer 8 transpositional fasciocutaneous flaps in 7 patients for the closure of axillary defects resulting from radical excision of chronic hidradenitis suppurativa. No flap complication or disease recurrence was observed during 2 years of follow-up. The technique had satisfactory esthetic and functional results as well as low donor site morbidity.

Free medial sural artery perforator flap for ankle and foot reconstruction.

Resurfacing shallow defects over the ankle and foot with an appropriately thin flap is a common but difficult task. This can be accomplished by harvesting the medial sural artery perforator flap from the medial aspect of the upper calf. Based on the musculocutaneous perforator of the medial sural artery, this flap preserves the medial gastrocnemius muscle and avoids unnecessary flap bulkiness. Between January 2002 and February 2004, we used 2 variants of the free medial sural artery perforator flap for ankle and foot reconstruction in 13 patients (10 fasciocutaneous flaps and 3 adipofascial flaps). In these patients, skin defects were combined with bone, joint, or tendon exposure. The main advantage of this flap is that it provides a thin and pliable coverage to achieve better accuracy in the reconstructive site. Other advantages include maintaining the function of the medial gastrocnemius muscle, providing a long vascular pedicle, and avoiding the need to sacrifice major arteries of the leg. The main disadvantages are the tedious process of intramuscular retrograde dissection of the perforator and the unsightly skin graft over the medial calf.

Sensate first dorsal metacarpal artery flap for resurfacing extensive pulp defects of the thumb.

Finding an appropriate soft-tissue grafting material to close a wound located over the distal phalanx of the thumb, especially the pulp region, can be a difficult task. A sensate first dorsal metacarpal artery flap, mobilized from the dorsum of the adjacent index finger and used as an island pedicle skin flap, can be useful for this purpose. The pedicle includes the ulnar branch of the first dorsal metacarpal artery, the dorsal veins, and the cutaneous branch of the radial nerve. Although this tiny artery is anatomically variable, safe dissection can be achieved by including the radial shaft periosteum of the secondary metacarpal bone and the ulnar head fascia of the first interosseous muscle. This approach has been used for 8 individuals with extensive pulp defects of the thumb over the past 3 years. Skin defects in all patients were combined with bone, joint, or tendon exposure. All flaps survived completely. This 1-stage procedure is reliable and technically simple. It provides sensate coverage to the pulp of the thumb but also avoids nerve repair or more complicated microsurgery.

Unusual epithelium in a subpubic sinus.

A 5-year-old male presented with the history of whitish discharge from a midline sinus opening just above the pubis for 2 months. Attempted radiography of the sinus revealed a blind fistula and voiding cystourethrography was normal. The fistula was excised deep to the subpubic space without any evidence of connection to the lower urinary tract. Pathologic evaluation of the lesion revealed a ciliated-columnar lining with stratified-squamous and transitional epithelium. To our knowledge, a subpubic sinus with this unique presentation of epithelium has not been reported previously.