Management of sternal and abdominal wounds in a pediatric heart transplant patient

A 14-year-old girl with congenital heart disease underwent ventricular assist device placement before cardiac transplantation. The inability to close her abdominal fascia necessitated the placement of Prolene mesh, which subsequently became exposed and contaminated when her incision dehisced. Stable closure was obtained with Vicryl mesh and a rectus abdominis turnover flap. Her posttransplant course was notable for compression of the donor heart, necessitating prolonged open sternotomy. She failed an attempt at delayed sternal closure due to compression of the right ventricle by the sternum. In addition to standard pectoralis advancement flaps, a pedicled osseous sternal flap based on her left internal mammary artery was developed to avoid ventricular compression yet still provide some protection to the mediastinum. Alternative uses of this vascularized bone flap to assist with chest wall reconstruction are discussed.     

Antibiotic resistance pattern of enterotoxigenic Escherichia coli isolated from infants and young adults in Israel

BACKGROUND: The usual methods of closure of major chest and abdominal wall defects have significant disadvantages. Skin grafts provide no structural support and result in incisional hernias. Synthetic mesh requires skin cover and is prone to infection and wound breakdown. The tensor fasciae latae (TFL) myocutaneous flap offers skin cover and a semi-rigid fascial layer. We document our unit's experience in pedicled and free TFL flaps. METHODS: The TFL flap closure of trunk defects was undertaken in 10 patients between August 1989 and April 1997. All cases were not amenable to primary closure and repair with synthetic mesh or skin grafts. RESULTS: The defect was satisfactorily repaired in all cases without subsequent herniation. The closure techniques using a pedicled TFL flap and a TFL flap for a free-tissue transfer are described. CONCLUSIONS: We conclude that the TFL flap is the method of choice for repairs of major truncal defects.     

The double dermal keyhole pattern for breast reduction

A small contribution is made to the dependable keyhole pattern in breast reduction. A double dermal modified keyhole closure is described. It is a simple, versatile, and adaptable method of closure regardless of the pedicle technique used for reduction mammaplasty. A triangular flap (skin and dermis) is incorporated on the medial keyhole flap. A deepithelialized dermal flap is created on the lateral keyhole flap. In the final closure of the wound, the medial triangular flap is sutured over the lateral deepithelialized dermal flap. A double dermal closure at the inverted T region is thereby created. The frequency of occurrence of wound spread and early postoperative wound dehiscence is decreased by this closure, which provides cosmetic improvement and wound support where it is needed the most.     

Chronic osteomyelitis of the spine managed with a free flap of latissimus dorsi. A case report

STUDY DESIGN: A patient with intractable spinal osteomyelitis who underwent surgery 12 times with persistent exposed bone is presented. OBJECTIVES: To demonstrate the effectiveness of free-flap grafting for managing difficult spinal osteomyelitis wounds. SUMMARY OF BACKGROUND DATA: Conventional procedures can usually achieve wound closure, but they may not work for advanced cases. METHODS: A free latissimus dorsi flap was transferred for reconstruction. The muscle component was used to obliterate the dead space and cover the exposed bone, and the skin component was used for tension-free closure of the wound. RESULTS: The wound healed dramatically. There was no recurrence of infection at 2-year follow-up evaluation. CONCLUSIONS: For an intractable spinal osteomyelitis wound, a free flap should be considered, although the surgery is difficult. Technical precautions in performing this operation are given.     

The management of unsalvageable free flaps

The loss of vascular flow in the early postoperative period will generally lead to free flap failure. When attempts at flap salvage are unsuccessful, conservative management with delayed flap debridement may be indicated. Seven unsalvageable free flaps were managed with observation and flap debridement 4 to 14 days following loss of vascular signals. At the time of debridement, six of the seven wounds had viable granulation tissue and were successfully closed with skin grafts. The seventh patient had loss of vascular flow to the free flap within 12 hr of surgery and, at the time of delayed debridement, had no evidence of granulation ingrowth. Local revascularization of flaps is known to occur and offers an explanation for these findings. Delayed debridement of unsalvageable free flaps is indicated for noncritical wounds, and may obviate the need for a second free-tissue transfer to obtain wound closure.     

Successful twin pregnancy and delivery following free rectus abdominis muscle flap at 15 weeks gestational age

Although a vertical rectus abdominis flap would not have been selected for reconstruction of the patient's defect had her pregnancy been detected preoperatively, the present case does demonstrate the remarkable resiliency and integrity of the anterior abdominal wall after rectus abdominis muscle flap surgery. Meticulous closure of the abdominal wall is of utmost importance in maintaining abdominal wall competence. Although the merits of muscle splitting techniques and the use of mesh are beyond the scope of this report, there is no evidence that modification of technique should be performed in the patient considering future pregnancy. Our case supports other reports that rectus abdominis flap surgery is not a contraindication to future pregnancy. Intuitively waiting at least 1 year, as recommended by Chen et al., seems reasonable, although the present case demonstrated a successful pregnancy and delivery of twins after a vertical rectus abdominis flap was harvested during pregnancy.     

Use of synthetic mesh for the entire abdominal wall after TRAM flap transfer

Abdominal wall competence is a major concern of all plastic surgeons using the TRAM flap for breast reconstruction. Low hernia rates and adequate abdominal stability are standard expectations in abdominal wall closure. Described here is this institution's experience with the use of a large piece of synthetic mesh as a supplementary reinforcement for the entire abdominal wall in an attempt to stabilize it and achieve a superior abdominal aesthetic result. Twenty-five consecutive patients had routine reinforcement with the extended mesh technique. Mean patient follow-up was 24 months with a minimum of 1 year. No hernia or mesh-related infection were encountered and only one patient had a lower abdominal bulge. We recommend the use of a large synthetic mesh for improved strength and aesthetic quality of the abdominal wall after TRAM flap breast reconstruction.     

Sensitivity of fluorochrome microscopy for detection of Mycobacterium tuberculosis versus nontuberculous mycobacteria

BACKGROUND: Sternal wound infection is a relatively rare but potentially devastating complication of open heart operations. The most common treatments after debridement are rewiring with antibiotic irrigation and muscle flaps. Here we present the results of a prospective trial to determine the appropriate roles of closed-chest catheter irrigation and muscle flap closure for sternotomy infection and to assess the effect of internal mammary artery bypass grafting on the outcome of each treatment modality. METHODS: Between 1990 and 1994, 5,658 sternotomies were performed at the University of Washington Medical Center. Sternal dehiscence occurred in 43 patients, 25 of whom had infection (overall incidence, 0.44%). Because of the infrequency of this complication, a prospective, randomized trial was developed in which the initial approach to sternal dehiscence was rewiring and catheter irrigation. Muscle flaps were used as the primary treatment if the sternum could not be restabilized or as secondary treatment if catheter irrigation failed. Wound resolution, length of hospital stay, and complications were evaluated. RESULTS: Sterile dehiscences were successfully closed with irrigation in 17 of 18 patients; the other patient required flap closure. Of the 25 patients with infection, 19 had irrigation and 6, closure with flaps primarily. In the group of infected patients, 17 of the 19 who received irrigation also had internal mammary artery bypass grafting. Irrigation failed in 15 (88.2%) of these 17 patients, and salvage was accomplished with muscle flap closure. All 6 patients with infection who were closed primarily with muscle flaps had a successful outcome. Hospitalization averaged 10.2 days when muscle flaps were used primarily and 14.3 additional days for unsuccessful irrigation. When irrigation was successful, the hospital stay averaged 11.2 days. CONCLUSIONS: Catheter irrigation should be reserved for patients without infection or patients with infection but without internal mammary artery bypass grafts in whom dehiscence occurs less than 1 month after sternotomy. All others should have closure with muscle flaps.     

Closure of multiple pressure sores with split total thigh flap

Pressure sores remain a pervasive and recurrent problem in the chronically bedridden and immobilized insensate patient populations, such as those with spinal cord injury. Various musculocutaneous flaps based on muscles of the buttock and thigh are routinely used to close primary, uncomplicated ulcers. The gluteus maximus, tensor fascia lata, and posterior thigh muscles, for example, can be used to close the majority of primary defects. In the case of extensive and recurrent ulceration, however, particularly when the hip joint or proximal femur is infected or marked heterotopic ossification is present, these conventional flaps are inadequate. The total thigh flap offers a solution to some of these problems by providing a large volume of tissue as a unit to cover the defects, particularly in cases in which other reconstructive options have been exhausted. We describe a modification in the total thigh flap procedure by splitting the flap according to its vascularity to achieve closure of multiple pressure ulcers in a one-stage procedure.     

Effects of vitamin E on cadmium-induced locomotor dysfunctions in rats

The posteriorly based tongue flap can be very useful to close difficult palatal fistulas, especially because the palatal sling prevents dehiscence of the tongue flap. However, special techniques may need to be employed with very large palatal fistulas or severely scarred palates. This technique has been used successfully in 5 patients. A detailed case report is presented, for which refinements of the tongue flap technique was required.     

Non ulcer dyspepsia and Helicobacter pylori

A patient with tuberculous infection of the hand and wrist developed a recurrent draining wound of the right forearm. After recurrent failure of surgical debridement and wound closure under antituberculous therapy, wound closure was established by means of a radial forearm fascial flap with an excellent functional and cosmetic result. Extra-pulmonary tuberculosis must be kept in mind in the diagnosis of slowly growing tumours and chronic wounds in the upper extremity.     

The posterior scalping flap

The posterior scalping flap is described. Hopefully, it brings another alternate method of facial reconstruction and obviates some of the problems previously existing. It is capable of resurfacing any part or the whole of the hemiface or forehead. It offers an excellent method for facila resurfacing. Further refinements and sophistications are necessary.     

The dartos flap as an adjunct in preventing urethrocutaneous fistulas in repeat hypospadias surgery

PURPOSE: Vascularized flaps for repeat hypospadias repair are often limited. We report our experience with the dartos flap in children undergoing secondary hypospadias and complex urethral repair. MATERIALS AND METHODS: The dartos flap is fibroadipose tissue between the scrotal skin and tunica vaginalis layers with its vascular pedicle based at the penoscrotal angle. The flap reaches the distal penile shaft without tension. Eight patients 1 to 17 years old (mean age 6) underwent urethral surgery and an interposed dartos flap procedure in 1994 to 1995. RESULTS: Of 6 patients cosmesis was excellent in 84%, erections were straight in 100%, and urinary streams were of good quality and without fistula in 100% after repeat hypospadias surgery. Following staged repair for anterior urethral valves a urethrocutaneous fistula developed in 1 patient and following urethral duplication repair results were excellent in 1. Mean followup was 1 year. CONCLUSIONS: The dartos flap is easy to mobilize and it provides excellent coverage for repeat proximal hypospadias surgery, since the dartos remains undisturbed. We endorse its use for complex urethral surgery and believe that the extra layer of closure helps to prevent urethrocutaneous fistulas.     

Gastric leiomyoblastoma: literature review and report of a case

The extended V-Y flap, a modified V-Y advancement flap, is very useful in closing relatively large defects on the face. Its extension limb is hinged down as a transposition flap on the end of the V-Y advancement flap to close the most distal portion of the defect. We applied this flap in closing a defect following excision of skin tumors on the face with excellent cosmetic results in 11 patients. However, this flap tended to make a distortion at the base of the flap in the primary closure site. By drawing figures, we concluded that the distortion was due to the characteristic of this technique as a V-Y advancement-rotation flap or V-Y advancement flap with rotation.     

Pedicled external spermatic fascia flap for urethroplasty in hypospadias and closure of urethrocutaneous fistula

PURPOSE: To prevent the development of urethrocutaneous fistula after urethroplasty for hypospadias or recurrence after closure of a urethrocutaneous fistula, the authors developed a new simple technique wherein the readily available external spermatic fascia (ESF) surrounding the testis and cord is used as a pedicled blanket flap to cover the neourethra or the site of closure of a urethrocutaneous fistula. RESULTS: In three patients who had urethroplasty for hypospadias incorporating our ESF flap procedure, no urethrocutaneous fistula developed. It was also effective for closure of urethrocutaneous fistula in five patients, some of whom had had recurrent fistula formation.     

Plantar flap reconstruction for acral lentiginous melanoma

BACKGROUND: Acral lentiginous melanoma continues to be difficult to diagnose despite an overall trend toward early identification of smaller and thin lesions. The insidious nature of this lesion often precludes primary closure of the surgical defect once it is excised, adding to the reconstructive complexity. Local flaps on the plantar foot offer an option for reconstruction when the defect is of intermediate size. METHODS: Eight patients (5 men and 3 women, with an average age of 58 years) who underwent plantar flap reconstruction for defects isolated to the weight-bearing heel were retrospectively reviewed. RESULTS: The average depth of the melanoma was 2.82 mm. Surgical margins were 2 cm or less in seven of the eight patients. Partial flap necrosis occurred in one patient, and loss of part or all of the skin grafts was noted in two patients. Currently five patients are alive with no evidence of disease. CONCLUSION: The plantar flap can provide local well-vascularized tissue for weight-bearing areas where skin grafting alone may not be appropriate. Coverage of these areas with well-padded flaps led to ambulation in all of the patients studied. We believe this flap offers durable coverage for medium-sized defects in acral lentiginous melanoma.     

Dermal autografts for fascial repair after TRAM flap harvest

To find an alternative to synthetic mesh closure of abdominal fascial defects after transverse rectus abdominis musculocutaneous (TRAM) flap harvest, dermal autografts were removed from tissue to be discarded and used for fascial closure. Dermal grafts have been used for herniorrhaphy and fascial repair after TRAM harvest previously, but have never been systematically studied. The dermal autograft technique was used in 24 patients to repair or reinforce anterior rectus sheath or external oblique fascia after TRAM harvest for breast reconstruction. During the same period, 25 other patients underwent TRAM breast reconstruction with abdominal wall closure by other methods. All patients were followed by serial physical examinations given by the operating surgeon. Average follow-up in the dermal autograft group was 12.6 versus 12.0 months in the second group. In the dermal autograft group, two patients complained of bulging of the anterior abdominal wall; one developed a true hernia, away from the location of the dermal autograft. In the second group, two patients experienced bulging. Wounds and infectious complications were similar in both groups. Dermal autografts are a useful alternative to mesh repair or direct closure of fascial defects after TRAM flap harvest.     

Left ventricular cavity obliteration during dobutamine stress echocardiography is associated with female sex and left ventricular size and function

After a left pneumonectomy, thoracoscopic closure with fibrin glue was performed for a fistula on the bronchial stump and the postoperative state progressed favorably thereafter. In this paper, we report on this successful case. Case: A 61 year-old male, who underwent a left pneumonectomy on January 17, 1996 for pulmonary carcinoma (T 3 N 1M 0 stage III A). The bronchial stump was covered with anterior serratus muscle flap. On April 1 (the 76th postoperative day), after two courses of Carboplatin and Vindesine treatment, the patient suddenly developed a fistula on the bronchial stump. Bronchofiberscopic closure with fibrin glue was attempted, but failed to close the fistula. Thoracoscopic surgery was then performed on May 15 (the 45th day after the onset of the fistula). After the intrathoracic opening of the fistula was found with a contrast medium, fibrin glue was injected to fill up to the bronchial stump, and communication with the thoracic cavity was blocked. Owing to coverage with a myocutaneous flap, the patient's general postoperative state remained relatively stable. Thoracoscopic surgery is useful as a treatment for some cases of bronchial stump fistula after pneumonectomy.     

Surgical management of pressure ulcers

Surgical management of pressure ulcers ranges from office or bedside debridement to formal debridement in the operating room for the more extensive necrosis. Closure of these wounds may be by advancement flap closure for the simple ulcers and by local muscle or myocutaneous flap closure for the more complex ulcers and defects. Some pressure ulcers recur following previous surgery or following conservative treatment. The simple recurrences can be managed by the use of simple techniques while the surgical options for the management of the more difficult recurrent ulcers are limited involving more complex surgery like sensate flaps, expanded flaps, free tissue transfers and fillet flaps.     

Vertical double flap design for repair of wide defects of the lower limb, using combined ascending scapular and latissimus dorsi flaps

Two cases are presented in which a scapular osteocutaneous flap and a latissimus dorsi musculocutaneous flap were applied as combined flaps with a single pedicle, to repair massive soft-tissue defects resulting from tibial hemisection in the lower limb. In each case, the oval-shaped donor site was divided into two parts (an ascending scapular flap and a latissimus dorsi flap, respectively) to repair the resected area, using a vertically designed, combined flap from the dorsolateral region. Consequently, after flap elevation, the donor site could be closed primarily and functions of the affected limb could be completely reconstructed. For reconstruction of defects too large to be covered with a single flap, the vertical double flap design of a combined ascending scapular and latissimus dorsi flap is a good alternative. It has the merits of easy dissection, broad area skin coverage and it also provides a composite flap that contains a scapular bone graft. Moreover, it allows a simple microsurgical anastomosis, as well as direct closure of the donor site. In addition, when the recipient site is on the lower leg, flap elevation can be carried out simultaneously with surgery at the recipient site. This means that the operative time can be shortened.