Mechanotransduction in Wound Healing: From the Cellular and Molecular Level to the Clinic.

GENERAL PURPOSE: To review the various mechanical forces that affect fibroblasts, keratinocytes, endothelial cells, and adipocytes at the cellular and molecular level as well as scar-reducing mechanical devices currently in clinical use. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Compare and contrast the responses of various types of cells to mechanical forces.2. Identify the mechanical devices and techniques that can help restore skin integrity.

Skin provides a critical protective barrier for humans that is often lost following burns, trauma, or resection. Traditionally, skin loss is treated with transfer of tissue from other areas of the body such as a skin graft or flap. Mechanical forces can provide powerful alternatives and adjuncts for skin replacement and scar modulation. This article first provides an overview of the various mechanical forces that affect fibroblasts, keratinocytes, endothelial cells, and adipocytes at the cellular and molecular level. This is followed by a review of the mechanical devices currently in clinical use that can substantially augment the restoration of skin integrity and reduce scarring. Methods described include tissue expanders, external volume expansion, negative-pressure wound therapy, and skin taping.

Functional outcome using early controlled active motion in rehabilitation of a replanted hand: A case report.

STUDY DESIGN: Case report. INTRODUCTION: This case report details the postsurgical rehabilitation and outcome of a young maintenance man who sustained a complete amputation of his dominant upper limb at the level of the distal forearm. The patient underwent replantation surgery with 2-centimeter bone shortening, followed by early controlled active motion commencing on day 6. PURPOSE OF THE STUDY: To illustrate the use of early motion after replantation. RESULTS: The patient achieved almost full active range of motion of the digits, intrinsic function, 30 seconds on Nine-Hole Peg Test and early return to work without any additional reconstructive procedures. DISCUSSION: Several fairly recently published protocols advocate initiating active range of motion at only 3 or 4 weeks after upper limb replantation. The following therapeutic interventions were considered important contributors to our favorable functional outcome; early controlled active motion, occupation-based therapy in combination with therapeutic exercises and many custom molded orthoses. CONCLUSION: Future research is required to determine if bone shortening, which is an integral part of replantation surgery, reduces tendon repair tension, allowing for early active motion and thereby contributing to a favorable outcome.

Free radial forearm flap lip reconstruction: a clinical series and case reports of technical refinements.

Lip reconstruction is best suited to the dictum of replacement of like tissue with like. The use of the remaining lip in the use of the lip reconstruction becomes more difficult as the size of the defect increases. The use of local tissue for subtotal lower lip loss problems like microstomia and facial and commissure distortion are real risks. The use of free tissue transfer becomes especially an attractive option when in addition to the lip there is associated loss of other aesthetic units and/or mandibular bone loss. The potential value of local perioral tissue is more likely to maintain dynamic and sensory function of the lip.Five patients were included in the clinical series during a period of 3 1/2 years since January 2002. All 5 patients were men. The age ranged from 15 to 67 years. Four patients underwent reconstruction by composite radial forearm flaps including both the cutaneous nerve of the forearm and the palmaris longus tendon. A single patient in this group had a partial brachioradialis muscle flap raised as chimeric component to the composite radial forearm flap. In the fifth patient, 2 simultaneous free radial forearm flaps were used for both upper and lower lip and bilateral buccal mucosal reconstruction. All patients achieved the goals of providing an adequate mouth opening with competence. The refinement of dynamic palmaris sling attachment to the perioral muscle provided for very good oral competence and support. In the single patient, adding bulk with the brachioradialis muscle to the neo lower lip most likely served to improve both aesthetics and lip function. With the use of free flaps an adequate labial sulcus, near dynamic sphincter control and sensation can be restored. The major drawback, however, is aesthetics of the lip. Further refinements like vermillion tattooing, fat injections or defatting by liposuction, and secondary mucosal flap surgery to provide the neolip with a vermillion are beneficial.

Amniotic band syndrome with persistent sciatic artery: a case report.

Amniotic band syndrome (ABS) has an incidence of 1/15,000. Deformities vary from rare but bizarre craniofacial defects or truncal defects to the commoner limb defects. The pathogenesis of ABS remains controversial. The following is a case of a 3-month-old infant with amniotic band syndrome with the typical limb reduction defects, a constriction band on the thigh associated with a persistent sciatic artery and bifurcation of the femur and the duplication of the knee and tibia on the contra lateral side. The anatomy of the persistent sciatic artery is demonstrated in magnetic resonance angiography and digital subtraction angiography. The vascular anomaly was unilateral. The patient underwent surgical correction of the constriction band by excision and multiple Z plasty. This case is the first description of the coexistence of ABS and persistent sciatic artery. Persistent sciatic artery has angiographic incidence of 0.05%. Is this purely a coincidence? Or perhaps their coexistence may serve to further the understanding of the mechanism of ABS.

Treatment of Constriction Bands of Limbs by Fat Injection: An Additional Modality.

BACKGROUND: Constriction bands in the majority of cases presents as a contour deformity. The gold standard of treatment is a single-stage constriction ring excision and serial Z-plasty. The expense is unsightly scarring. We present case reports of deformity correction by serial fat injections. METHODS AND PARTICIPANTS: Three case studies of children in whom this modality was used in limbs to correct the deformity are presented. RESULTS: Two participants showed a good correction of the deformity and in a single-case treatment failed requiring excision and serial Z-plasty for correction. CONCLUSION: Fat injection in combination with Khouri's technique of aponeurotomies is an attractive modality of managing superficial constriction bands of limbs.

HISTORIQUE: La majorité des brides amniotiques sont responsables d'une malformation des contours. Le traitement de référence est une intervention unique pour exciser les brides amniotiques, suivie de plasties en Z sérielles, au prix de cicatrices disgracieuses. Les auteurs présentent un rapport de cas de malformations corrigées par l'injection sérielle de graisse. MÉTHODOLOGIE ET SUJETS: Les auteurs présentent l'étude du cas de trois enfants chez qui ils ont utilisé cette modalité pour corriger la malformation. RÉSULTATS: Chez deux sujets, la malformation a bien été corrigée, mais dans un seul cas, le traitement a échoué et il a fallu procéder à une excision et à des plasties en Z sérielles. CONCLUSION: L'injection de graisse alliée à la technique d'aponévrotomie de Khouri est une modalité intéressante pour traiter des brides amniotiques superficielles des membres.

Buttock Reconstruction in Sarcoma Surgery: An Esthetic Sigmoidplasty Closure for Large Circular Defects Using Double Opposing Skin Flaps.

BACKGROUND: Large defects arising from extirpation surgery of buttock sarcomas requiring adjuvant radiotherapy are best closed with flap surgery. The traditional solutions are derived from an approach to pressure sores, which were designed for the ischial, sacral, or trochanteric areas, and have now been adapted for true buttock defects. This invariably destroys the esthetics of the buttock. We describe a novel technique of sigmoidplasty, which preserves most of the esthetic features. METHODS: We report on a retrospective review of 11 consecutive buttock sarcomas managed at our institution between 2009 and 2014, focusing on those for which the described reconstruction method was used (N = 5). RESULTS: The immediate outcome was very good. In 1 patient, partial loss of 1 of the flaps and the management thereof resulted in a minor contour deformity. In general, the buttock volume was significantly decreased but the shape was preserved. This was obtained without secondary donor defect and with minimal contour irregularity. Long-term follow-up remained pleasing, and all patients were satisfied with the outcomes. CONCLUSIONS: The described technique of buttock defect closure satisfies the oncoplastic principles of tumor surgery with the added benefit of superior esthetics. We suggest that it is a versatile adjunct to the reconstructive surgeon's armamentarium for buttock reconstruction after sarcoma excision, particularly when the gluteal artery perforator systems are unavailable.

Congenital vascular anomalies in amniotic band syndrome of the limbs.

INTRODUCTION: Bone abnormalities and nerve compression are sparsely reported features of amniotic band syndrome. No studies of the vascular architecture of limbs affected by this syndrome have been published. MATERIAL AND METHODS: Patients with amniotic band syndrome affecting the limbs were evaluated in the period between 1997 and 2007. The arterial blood supply was studied using magnetic resonance angiography or computed tomographic angiography. The subjects comprised 8 patients with bilateral and 2 with unilateral limb involvement. The patients' ages ranged from 2 months to 8 years. The male-to-female ratio was 4:6. A total of 20 limbs was investigated, comprising 18 lower limbs and 2 upper limbs. The amniotic bands were divided into superficial or deep. RESULTS: The patients were divided into 4 groups: group 1, thigh bands; group 2, below-knee amputations; group 3, leg bands; and group 4, upper limb bands. A single patient in group 1 with a deep band had a persistent sciatic artery. In group 2, three limbs demonstrated attenuated segments in the superficial femoral artery and/or abnormalities arising at the popliteal artery division. In group 3 (14 legs), 7 with deep bands showed some anomaly either in the popliteal artery division or its branches or both. In the other 7, and in group 4, all with superficial bands, no vascular abnormalities were seen except in one. CONCLUSION: Our findings show that amniotic band syndrome is definitely associated with vascular abnormalities and the depth of the band is an important contributory factor.

Peroneal artery perforator chimeric flap: changing the perspective in free fibula flap use in complex oromandibular reconstruction.

The fibula osteoseptocutaneous flap has undergone multiple refinements since its first description in oromandibular reconstruction. There is now a better understanding of the blood supply to the skin of the lateral aspect of the leg. Multiple free skin paddles can be harvested freestyle from the lateral aspect of the leg. The size of the flaps that can be harvested has not been clearly defined. A case report of a complex oromandibular reconstruction following a shotgun injury to the face demonstrates a way of maximizing the skin harvest. An osteoseptocutaneous fibula flap was used for the replacement of the mandible and the internal lining of the oral cavity. A larger lateral leg flap based on a musculocutaneous perforator of the peroneal artery was used for the external and full-thickness lower-lip defect. The latter flap by definition is a peroneal artery perforator flap, which to the best of my knowledge is terminology that has not been used in the English literature. The main purpose of this article is to review the blood supply of the lateral leg and how this can be utilized to reach the goals of a complex oromandibular and total lower-lip reconstruction.

Traction-assisted dermatogenesis by serial intermittent skin tape application.

BACKGROUND: The use of both tissue expanders and skin-stretching devices is commonplace in reconstructive surgery. The authors describe a noninvasive technique of tissue expansion. METHODS: This article describes a prospective study in which 26 consecutive patients consisting of eight male patients and 18 female patients were recruited for expanding the skin by the authors' devised technique of intermittent serial traction Micropore taping of skin at weekly intervals. Once the skin was expanded, the scar revision was performed in one or two stages by excision and flap advancement. The age range of the patients was 8 to 48 years. The anatomical regions that underwent scar revision were scalp (n = 6), face (n = 9), upper limb (n = 6), and lower limb (n = 9). RESULTS: The size of the scars to be resurfaced ranged from 35 x 50 mm on the temple to 280 x 130 mm on the scalp. The average follow-up after surgical correction was 11 months. The number of taping sessions ranged from two to 15, with an average of 6.9. Fourteen patients had successfully completed the surgical management, and four patients are in the midst of treatment. Four patients defaulted on treatment, and in four patients, the expansion failed to progress. Illustrative examples of some of the cases are described. CONCLUSION: Traction-assisted dermatogenesis is an additional method of tissue expansion that is easy and cost effective for reconstruction.