Inferior Gluteal Artery Perforator Flap for Sacral Pressure Ulcer Reconstruction: A Retrospective Case Study of 11 Patients.

Despite advances in reconstruction techniques, sacral pressure ulcers continue to present a challenge to the plastic surgeon. The flap from the gluteal crease derives blood supply from the inferior gluteal artery perforator (IGAP) and reliably preserves the entire contralateral side as a donor site. To incorporate the IGAP in the reconstruction of sacral pressure ulcers, a skin paddle over the gluteal crease was created and implemented by the authors. Data from 11 patients (8 men, 3 women; mean age 67 [range 44-85] years old) whose sacral ulcers were closed with an IGAP flap between June 2006 and May 2012 were retrieved and reviewed. All patients were bedridden; 1 patient in a vegetative state with a diagnosis of carbon monoxide intoxication was referred from a local clinic, 2 patients had Parkinson's disease, and 8 patients had a history of stroke. The average defect size was 120 cm(2) (range 88-144 cm(2)). The average flap size was 85.8 cm(2) (range 56-121 cm(2)). Only 1 flap failure occurred during surgery and was converted into V-Y advancement flap; 10 of the 11 flaps survived. After surgery, the patients' position was changed every 2 hours; patients remained prone or on their side for approximately 2 weeks until the flap was healed. After healing was confirmed, patients were discharged. Complications were relatively minor and included 1 donor site wound dehiscence that required wound reapproximation. No surgery-related mortality was noted; the longest follow-up period was 24 months. In this case series, flaps from the gluteal crease were successfully used for surgical closure of sacral pressure ulcers. This flap design should be used with caution in patients with hip contractures. Studies with larger sample sizes are needed to ascertain which type of flap is best suited to surgically manage extensive pressure ulcers in a variety of patient populations.

Bilateral breast reconstruction with a pedicled transverse rectus abdominis myocutaneous flap after subcutaneous mastectomy for symptomatic injected breasts.

Breast deformities after augmentation with injectable materials carried out by uncertified medical personnel present challenging problems. Materials include liquid silicone, paraffin, polyacrylamide hydrogels, and unknown gels. They usually cause granulomatous reactions, erythema, pain, and even skin necrosis. Tender masses that cannot be differentiated from breast cancers are the major concern. This retrospective study presents the authors' experience in managing 10 symptomatic injected breasts in five patients during the past 8 years. Subcutaneous mastectomies were carried out using periareolar, inverted "T", or inframammary approaches combined with breast reconstruction using bilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flaps. All flaps survived well and gave a satisfactory cosmetic appearance. There was no major complication or late occurrence of breast cancers over the following 8 years. Injectable materials used for breast augmentation should be prohibited until more scientific data are available about the long-term effect of these materials in breast tissues. Once the injected breasts become symptomatic, subcutaneous mastectomy and reconstruction with bilateral pedicled TRAM flaps is a reasonable option for the patient.

Comparison of surgical result of anterolateral thigh flap in reconstruction of through-and-through cheek defect with/without CT angiography guidance.

OBJECTIVES: Anterolateral thigh flap (ALT) is an useful flap for head and neck reconstruction, but the variable perforators may limit its applications. Our goal was to clarify the benefits of preoperative CT angiography (CTA) in mapping of free ALT perforators for reconstruction of cheek through-and-through defects. METHOD: We retrospectively reviewed 32 patients undergoing reconstruction of through-and-through cheek defects with a free ALT flap between February 2005 and July 2009. These patients were divided into two groups. Group I (N=17): the ALT flap was designed based on the traditional handheld Doppler probe. Group II (N=15): preoperative imaging with CTA was used to map the perforator's number, size and variations. Surgical results were evaluated for both major and minor complications, as with the operation time, length of hospital stay and donor-site morbidity. RESULTS: Overall flap survival was 96.88% (31 of 32 flaps). The use of preoperative CTA was associated with a significant reduction in major surgical complications, length of surgery and the need for a secondary debulking procedure (p<0.05). There was no difference in minor complication and donor-site morbidity. CONCLUSIONS: The use of CTA for preoperative navigation of ALT flap for cheek reconstruction is associated with improved operative outcomes. Detailed data from images allow the surgeon to interpret any anatomical variations, choosing the exact suitable thigh, facilitate flap design, and greatly reduce major postoperative complications.

Computed tomography angiography imaging for the chimeric anterolateral thigh flap in reconstruction of full thickness buccal defect.

BACKGROUND: Microvascular free flap transplantation is the current most common choice for reconstruction of difficult through-and-through buccal defect after cancer extirpation. The chimeric anterolateral thigh (ALT) flap is an ideal flap to cover this full thickness defect, but variation in the location of perforators is a major concern. Herein, we introduce computed tomographic angiography (CTA)-guided mathematical perforators mapping for chimeric ALT flap design and harvest. METHODS: Between September 2008 and March 2009, nine patients with head and neck tumour underwent preoperative CTA perforator mapping before free ALT flap reconstruction of full thickness buccal defects. The perforators were marked on a 64-section multi-detector CT image for each patient, and the actual perforator locations were correlated with the intra-operative dissection. The donor limb of choice, either right or left, was also selected based on the dominant vascularity. Flap success rates, any associated morbidity and complications were recorded. RESULTS: A total of 23 perforators were identified on CTA image preoperatively. Twenty-two of these perforators were chosen for chimeric flap design, and all were located as the CTA predicted, with the rate of utilization being 95.7% (22/23). There were two post-operative complications, including one partial flap necrosis and one microstomia. All of the ALT flaps survived, and there was no donor site morbidity. CONCLUSIONS: Preoperative CTA allows accurate perforator mapping and evaluation of the dominant vascularity. It helps the surgeon to get an ideal designing of the chimeric ALT flap with two skin paddles based on individual perforators, but only one vascular anastomosis in reconstruction of full thickness buccal defects.

Fournier gangrene: a review of 41 patients and strategies for reconstruction.

Fournier gangrene is an acute and potentially fatal infection of the scrotum, perineum, and abdominal wall. It is characterized by necrotizing fasciitis with loss of subcutaneous tissue and skin. The aim of this study was to analyze the prognosis and treatment effectiveness of this fulminant infectious disease. Forty-one patients were admitted to our hospital with the diagnosis of Fournier gangrene between January 1998 and December 2006. The patients' age, sex, predisposing factors, duration of symptoms and hospital stay, time to operation, size of the skin defect, bacteria isolated, treatment modalities, and outcomes were reviewed. The data were analyzed by chi2 analysis and Student t test. A P-value <0.05 was considered significant. The mean age of the patients was 57.2 years. The most common predisposing factor was diabetes mellitus in 21 patients (51.2%), followed by cirrhosis of the liver, uremia, alcoholism, and underlying malignancy. The most common symptoms were fever (87.8%) and pain or swelling over the genital region (85.4%). The initial treatment included extensive debridement and open drainage. Time to operation ranged from 1 to 10 days. Reconstructive surgery was performed for 22 patients. The mortality rate was 19.5%. Delayed debridement was a significant factor affecting the survival rate. Our study is a retrospective study of patients with Fournier gangrene undergoing debridement and reconstructive procedure. Because of the fulminant course of Fournier gangrene, it may be difficult to design a prospective study. Fournier gangrene is a severe infectious disease with a high mortality rate. Early and aggressive debridement is a significant prognostic factor in the management of Fournier gangrene. Several reconstructive modalities are useful to correct the tissue defect. Early debridement and reconstructive surgery for wound coverage improve the quality of life.

Free flap from the superficial palmar branch of the radial artery (SPBRA flap) for finger reconstruction.

BACKGROUND: Functional reconstruction after a severe hand injury is best achieved by obtaining primary, stable soft tissue coverage to avoid delayed wound healing, prolonged immobilization, and joint stiffness. A wide range of procedures from spontaneous healing to local flaps has been proposed to treat soft tissue defects in appropriate circumstances. However, these pedicled flaps are insufficient in covering larger finger defects, so we used flaps from the free superficial palmar branch of the radial artery (SPBRA) for such cases. MATERIALS: Between June 2003 and May 2007, 11 people with traumatic finger injury were treated with SPBRA flaps. The blood supply of the flap is derived from the SPBRA, which can be palpated and confirmed by Doppler flowmetry 18 mm proximal to the palmar wrist crease. Anastomoses of vessels were performed under a microscope, linking the SPBRA to the digital artery and the concomitant vein to the digital dorsal vein. The defects were located at the fingertip in seven patients, in the dorsum of the proximal phalanx in two, and at the interphalangeal joint in two. The average flap size was 8.4 cm with the largest flap being 12.5 cm2 (50 mm x 25 mm). RESULTS: All the flaps survived completely and the wound healed satisfactorily, except for one partial necrosis. All the donor sites were closed primarily without complications or obvious scarring. Most of the fingers involved achieved a full range of motion and showed a good contour. Two-point spatial sensory discrimination was recorded for six patients and adequate protective sensation was attained. CONCLUSION: The SPBRA flap provides a thin, pliable, reliable, and good glabrous skin flap for covering medium to large finger defects. Only one operative field is required and the major vessels are preserved. This approach can add to the armamentarium of the plastic surgeon for covering large defects of the finger.

Use of two-dimensional projection for estimating hand surface area of Chinese adults.

Accurate estimates of the surface area of burns are important for initial fluid resuscitation and prognosis of burn victims. The area of the surface of the open hand is often used to estimate the area of a burn. Although it is accepted that hand surface area is generally equal to 1% of total body surface area among Caucasians, this ratio has not been verified for Chinese people. We used two-dimensional projection to estimate the hand surface areas of Chinese adults. The area of the palm was 0.44% of total body surface area among men and 0.42% among women. The area of the hand, including that of the thumb and fingers, was 0.76% of total body surface area among men and 0.73% among women. We conclude that the ratio between hand and total body surface area among Chinese adults differs from the ratio among Caucasians, and suggest an adjustment of the ratio for use with Chinese people.

Isolated endobronchial metastasis of Wilms' tumor.

Isolated endobronchial metastasis from extrapulmonary solid organ was rarely reported in previous literature. We report an isolated endobronchial metastasis of Wilms' tumor in a 4-year-old boy. He underwent right nephrectomy on account of Wilms' tumor at the age of 3 years. We performed a wedge resection of a metastasis to the right lower lobe of the lung a year later, followed by chemotherapy and irradiation of the involved lung over a period of 30 weeks. One and a half years later, he developed obstructive pneumonitis of the left lung. Fiberoptic bronchoscopy identified a tumor at the left main bronchus with near total bronchial obstruction, compatible with findings on a computed tomographic scan. Rigid bronchoscopy was performed to core out the obstructing tumor. It was reported as a metastatic Wilms' tumor. Successful reexpansion of the left upper lobe was achieved and he was discharged uneventfully, followed by adjuvant chemotherapy.