An Algorithmic Anatomical Subunit Approach to Pelvic Wound Reconstruction.

BACKGROUND: Prior radiation therapy, pelvic dead space, and a dependent location contribute to perineal dehiscence rates as high as 66 percent after primary closure of pelvic wounds. Various regional flaps have been described to reconstruct pelvic defects, but an algorithmic pairing of individual flaps to specific anatomical regions has not been described. METHODS: A retrospective review of a prospectively maintained database was performed to identify consecutive pelvic reconstructions from 2010 to 2013 with at least 6 months' follow-up. Pelvic defects and resulting flaps were described by anatomical subunits involved: anterolateral thigh flap for mons, gracilis flap for labia majora and introitus, vertical rectus abdominis myocutaneous flap for vagina and/or perineal raphe, and gluteus musculocutaneous flap for isolated perianal defects. RESULTS: Twenty-seven women and three men underwent consecutive pelvic reconstruction with a mean age of 60 years (range, 26 to 83 years) and a mean body mass index of 28 kg/m(2) (range, 17 to 40 kg/m(2)). Twenty-one patients (70 percent) had prior radiation therapy. In total, 45 flaps were performed according to the subunit principle. Three patients had a minor dehiscence (<5 cm), one patient had a major dehiscence, and one required reoperation for abscess. There were two partial flap losses necessitating débridement and readvancement of the flap. Twenty-five percent of female patients were sexually active after vaginal reconstruction. CONCLUSIONS: The pelvic subunit principle provides an effective algorithm for choosing the ideal pedicled flap for each region involved in acquired pelvic defects. This algorithm is based on individual attributes that make each flap most appropriate for each subunit. Complications were minimal and patient satisfaction with appearance and function was excellent.

Use of tranexamic acid in craniosynostosis surgery.

BACKGROUND: Intraoperative tranexamic acid (TXA) administration has been used to abate blood loss in a variety of surgical procedures. Several recent studies have supported its efficacy in reducing transfusion requirements in pediatric cranial vault reconstruction (CVR). OBJECTIVE: To conduct a retrospective chart review to determine whether a significant reduction in packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusions exists when TXA is used. METHODS: A retrospective cohort study of 28 patients who underwent CVR for sagittal craniosynostosis was performed. Transfusion requirements for 14 patients who did not receive TXA were compared with 14 patients who did. Predictors of increased blood product transfusion were also studied. RESULTS: Total volume of PRBC transfusion was reduced by 50% with the use of TXA (P=0.004) with a 34% reduction in intraoperative PRBC transfusion (P=0.017) and a 67% reduction in postoperative PRBC transfusion (P<0.001). Total volume of FFP transfusion was reduced by 46% (P=0.002) and postoperative FFP transfusion was reduced by 100% (P=0.001). The use of TXA was associated with a lower total volume of PRBC (P=0.003) and FFP (P=0.003) transfusions. Older patient age was associated with lower total volume of PRBC transfused (P=0.046 and P=0.002), but not with FFP (P=0.183 and P=0.099) transfusion volumes. Increasing patient weight was associated with lower PRBC (P=0.010 and P=0.020) and FFP (P=0.045 and P=0.016) transfusion volumes. CONCLUSION: TXA decreased blood product transfusion requirements in patients undergoing CVR for sagittal craniosynostosis, and should be a routine part of the strategy to reduce blood loss in these procedures.

HISTORIQUE: L'administration d'acide tranexamique (ATX) intraopératoire vise à limiter la perte de sang dans le cadre de diverses interventions chirurgicales. Plusieurs études récentes en appuient l'efficacité pour réduire les transfusions lors des reconstructions de la voûte crânienne (RVC) en pédiatrie. OBJECTIF: Effectuer une analyse rétrospective des dossiers pour déterminer si l'utilisation d'ATX s'associe à une diminution importante des transfusions de culots globulaires (CG) et de plasma frais congelé (PFC). MÉTHODOLOGIE: Les chercheurs ont réalisé une étude rétrospective de cohorte auprès de 28 patients qui ont subi une RVC pour corriger une craniosystose sagittale. Ils ont comparé les transfusions chez 14 patients qui n'avaient pas reçu d'ATX à celles des 14 patients qui en avaient reçu. Ils ont également étudié les prédicteurs d'une transfusion accrue de produits sanguins. RÉSULTATS: Le volume total de transfusion de CG diminuait de 50 % grâce à l'utilisation d'ATX (P=0,004), y compris une réduction de 34 % des transfusions de CG intraopératoire (P=0,017) et de 67 % des transfusions de CG postopératoire (P<0,001). Le volume total de transfusion de PFC intraopératoire diminuait de 46 % (P=0,002) et celui de transfusion postopératoire, de 100 % (P=0,001). L'utilisation d'ATX s'associait à une diminution du volume total de transfusions de CG (P=0,003) et de PFC (P=0,003). Un âge plus avancé était lié à un volume total de CG transfusé plus faible (P=0,046 et P=0,002), mais pas à celui de PFC (P=0,183 et P=0,099). Un poids plus élevé s'associait à un volume CG (P=0,010 et P=0,020) et de PFC (P=0,045 et P=0,016) plus faible. CONCLUSION: L'ATX réduisait le volume de transfusion de produits sanguins chez les patients subissant une RVC pour corriger une craniosynostose sagittale. Son utilisation devrait être systématique pour réduire la perte de sang lors de ces interventions.

Use of radial artery perforator flap from burn-injured tissues.

The hands and forearms are frequent sites of burn injury, and due to the high concentration of superficial tendons, bones, and joints, flaps are frequently needed to cover defects in these areas. We present a patient who suffered remote electrical injury to the right forearm which later developed into an open wound with exposed tendon. Successful coverage of this defect was accomplished with an islanded fasciocutaneous flap based on perforating arterial branches of the radial artery, which was harvested from an area of burn injury. Surgical treatment of hand and forearm wounds with axial pedicled flaps from areas of burn injury have been reported, but to our knowledge no reports describe the use of perforator flaps.

Surgical anatomy of the dorsal scapular nerve.

OBJECT: There is a paucity of literature regarding the surgical anatomy of the dorsal scapular nerve (DSN). The aim of this study was to elucidate the relationship of this nerve to surrounding anatomical structures. METHODS: Ten formalin-fixed human cadavers (20 sides) were dissected, and measurements made between the DSN and related structures. The nerve pierced the middle scalene muscle at a mean distance of 3 cm from its origin from the cervical spine and was more or less centrally located at this exit site. It lay a mean distance of 1.5 cm medial to the vertebral border of the scapula between the serratus posterior superior, posterior scalene, and levator scapulae muscles. It was found to have a mean distance of 2.5 cm medial to the spinal accessory nerve as it traveled on the anterior border of the trapezius muscle. The nerve intertwined the dorsal scapular artery in all specimens and was found along the anterior border of the rhomboid muscles. On 19 sides the DSN originated solely from the C-5 spinal nerve, and on one side it arose from the C-5 and C-6 spinal nerves. CONCLUSIONS: Knowledge of the anatomy of the DSN will aid the surgeon who wishes to explore and decompress this structure.

Surgical anatomy of the axillary nerve within the quadrangular space.

OBJECT: There is a paucity of literature regarding the surgical anatomy of the quadrangular space (QS), which is a potential site of entrapment for the axillary nerve. Muscle hypertrophy of this geometrical area and fascial bands within it have been implicated in compression of the axillary nerve. METHODS: Fifteen human cadavers (30 sides) were dissected for this study. Measurements of the QS and its contents were made. The mean height of this space was 2.5 cm and the mean width 2.5 cm; its mean depth was 1.5 cm. The axillary nerve was always the most superior structure in the space, and in all cases the nerve and artery hugged the surgical neck of the humerus just superior to the origin of the lateral head of the triceps brachii muscle. This arrangement placed the axillary nerve in the upper lateral portion of the QS in all cadaveric specimens. The nerve branched into its muscular components within this space in 10 sides (33%) and posterior to it in 20 sides (66%). The cutaneous component of the axillary nerve branched from the main trunk of the nerve posterior to the QS in all specimens. Fascial bands were found in this space in 27 (90%) of 30 sides. CONCLUSIONS: Knowledge of the anatomy of the QS may aid the surgeon who wishes to explore and decompress the axillary nerve within this geometrical confine.