Repair of large chest wall defects using pedicle flaps

Three cases of chest wall resection illustrate the use of three different full thickness pedicle flaps which can be used to cover almost any area of the anterior chest wall. The medially based acromiothoracic flap was swung inferiorly to cover a lateral defect. Laterally based abdominal wall and axillary flaps were used to cover more medial defects. In case III bilateral axillary flaps were necessary to cover a huge central defect after resection of the anterior sternum and anterior cartilages of seven ribs for a sebaceous carcinoma.     

Omental transfer for salvage of the moribund lower extremity

Use of omental flaps is well documented in soft tissue reconstruction of the head and neck, chest wall, and abdomen. Three cases of omental transfer for soft tissue reconstruction of the lower extremities are presented. In two patients, free vascularized omental flaps were used to cover deep soft tissue defects over the lower leg and in one patient, a pedicle flap was used to cover a deep groin defect extending into the hip joint. In all patients, use of an omental graft allowed revascularization and subsequent wound healing with good cosmetic results.     

A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor-site selection and technique

Free-tissue transfer has become an important method for reconstructing complex oncologic surgical defects. This study is a retrospective review of a 10-year experience with 716 consecutive free flaps in 698 patients. Regional applications included the head and neck (69 percent), trunk and breast (14 percent), lower extremity (12 percent), and upper extremity (5 percent). Donor sites included the rectus abdominis (195), fibula (193), forearm (133), latissimus dorsi (69),jejunum (55), gluteus (28), scapula (26), and seven others (17). Microvascular anastomoses were performed to large-caliber recipient vessels using a continuous suture technique; end-to-end anastomoses were preferred (75 percent). Flaps were designed to avoid the need for vein grafts. Conventional postoperative flap monitoring methods were used. These included clinical observation supplemented by Doppler ultrasonography, surface temperature probes, and pin prick testing. Buried flaps were either evaluated with Doppler ultrasonography or not monitored. The overall success rate for free-flap reconstruction of oncologic surgical defects was 98 percent. Fifty-seven flaps (8 percent) were reexplored for either anastomotic or infectious problems. Reexplored flaps were salvaged in 40 cases (70 percent). Surviving flaps resulted in a healed wound and did not delay postoperative radiation or chemotherapy. The incidence of major and minor postoperative complications was 34 percent. The mean duration of hospitalization was 20 days, and the average cost was $40,224. The results of this study support the need for only seven donor sites to solve the majority (98 percent) of oncologic problems requiring microsurgical expertise. The evolution of preferred donor sites for specific regional applications is illustrated in this 10-year experience. Technical refinements have simplified performing the microsurgical anastomoses and essentially eliminated the need for vein grafts. Conventional monitoring has led to the rapid identification of vascular compromise and subsequent flap salvage in the majority of non-buried free flaps.     

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.     

The comparative characteristics of methods for breast reconstruction after a mastectomy

Ablation of the breast because of cancer is a damaging operation leading the patients on a heavy psycho trauma. At the background of the main disease--cancer, deformation of the chest wall, caused by mastectomy their depression deteriorates. Therefore the breast reconstruction today is considered as an indivisible part of the complex treatment process. The techniques by means of witch the reconstruction could be achieved are: implantation of breast prosthesis, pedicle or free myocutaneous flaps. We enclose the comparative characteristic of the treatment results of 70 patients using different techniques.     

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.     

Care of patients with leg ulcers: a nursing perspective

Chest wall reconstruction may be required after resection of malignant tumours, radiation injuries, massive trauma or infection. The ideal reconstruction should provide enough stability in the chest wall to allow adequate, spontaneous ventilation, while protecting intrathoracic organs, and be cosmetically acceptable. Recent developments have enabled the reconstruction of defects of almost any size with minimal functional disturbance.     

History of nurse-midwifery in reproductive health care

BACKGROUND: Recently, there have been a few reports recommending use of a 2 mm thick polytetrafluoroethylene soft tissue (Gore-Tex) patch for repair of thoracic wall defects. The potential role of these Gore-Tex patches was examined. METHODS: Five patients underwent chest wall tumor resection with thoracic wall reconstruction using a Gore-Tex patch (2 mm). We present a review of the complications experienced by five patients with Gore-Tex patches, as well as a review of the literature. RESULTS: Functionally and cosmetically, satisfactory results were obtained for 5 patients with Gore-Tex patch. There were no cases of infectious complications. However, we experienced one case of a flail chest postoperatively, in which reconstruction with two Gore-Tex patches of 30 x 15 cm, and 3 days of mechanical ventilation and chest wall support was needed. CONCLUSION: Our experience with Gore-Tex patches has been positive, and we recommend patch closure for thoracic wall defects.     

Repair of central upper lip (philtral) surgical defects with island pedicle flaps

BACKGROUND: Surgical defects of the central upper lip (philtrum) are a particularly difficult area to achieve satisfactory cosmetic and functional repair. Reconstruction of the central upper lip has been accomplished primarily through the use of side-to-side closure, bilateral advancement or rotation flap, and full-thickness graft. Repair may be complicated by distortion of the vermilion border, obliteration of the normal contour of the philtrum, eclabium, and trapdooring of the flap. OBJECTIVE: We review the options for reconstruction of this area and describe our experience using an island pedicle flap to complete reconstruction. METHODS: Four patients presented with basal cell carcinomas of the mid upper lip (philtrum). Tumors were cleared by Mohs micrographic surgery. Reconstruction was achieved by island pedicle flaps utilizing donor tissue from the superior philtrum. RESULTS: The patients had excellent cosmetic results with minimal distortion of the vermilion border or obliteration of the philtrum or philtral ridges. Scars healed in a nearly imperceptible fashion, keeping within one cosmetic unit (the philtrum) without extending along the vermilion border as seen in bilateral advancement or rotation flaps. CONCLUSIONS: Island pedicle flaps may be an effective cosmetic and functional repair of selected surgical defects of the central upper lip involving the philtrum.     

Epidural opioids for post-thoracotomy pain

The treatment of abutting fields presents multiple difficulties, including problems of field overlaps or gaps, complexity of simulation, and the difficulties of daily setup and variation. Multiple techniques have been described for the treatment of the breast/chest wall and supraclavicular nodes using tangents and a matched supraclavicular field. The techniques described have used collimator angles, couch angles, and/or corner blocks in an attempt to match these fields with no overlap or gap. Some of these techniques required complex calculations or treatment devices to achieve a geometric match between fields. We describe a technique for treatment of breast and supraclavicular nodes that uses a single isocenter and requires asymmetric collimator jaws to give half-blocked fields. The simulation and setup are done empirically, with no complex calculations required. The daily setup and treatment can be done rapidly and reliably, with no extra equipment required. Custom blocks may be used to conform to the chest wall contour and decrease the amount of lung in the treatment fields.     

A historical review of mental health services in Hong Kong (1841 to 1995)

OBJECTIVE: To review the experience of 1 microvascular surgeon during an 11-year period in performing 210 vascularized bone-containing free flaps for oromandibular reconstruction. DESIGN: Retrospective medical records review of patients who underwent primary and secondary oromandibular reconstruction with the use of vascularized bone free flaps. SETTING: Academic medical center. PATIENTS: A total of 201 patients underwent 210 composite free-flap reconstructions of the mandible for various disorders and with a range of bony and soft tissue defects. INTERVENTION: All patients underwent the microvascular transfer of vascularized bone flaps from the ilium, fibula, or scapula. In selected cases, 2 simultaneous free flaps were transferred to achieve an optimal bone and soft tissue reconstruction. Endosteal dental implants were used in 81 patients, with a total of 360 fixtures placed during these 11 years. MAIN OUTCOME MEASURES: The success of microvascular free tissue transfer, dental implant extrusion, and short- and long-term complications at the recipient and donor sites. RESULTS: Of the 210 mandibular reconstructions that were performed, 202 were successful in reestablishing mandibular continuity. Reexploration for vascular-related complications was done in 16 patients, 8 of whom were successfully treated, yielding an overall success rate of 96%. The overall success rate for endosteal dental implants was 92%. The implant success rate was 86% when the bone in which the fixtures were placed was irradiated postoperatively. The success rate was 64% in the 14 fixtures that were placed into previously irradiated bone. CONCLUSIONS: The success of the use of vascularized bone free flaps in restoring continuity to the mandible is clearly demonstrated in this series. There was an acceptable incidence of donor- and recipient-site complications that resulted in minimal long-term morbidity. The careful selection of a donor site(s) for oromandibular reconstruction allows for an optimal restoration of bony and soft tissue defects. Dental implants can be safely used in oromandibular reconstruction with a high level of success. Placing these implants during the initial surgery shortens the duration for achieving dental rehabilitation and enhances the success of the implants when postoperative radiotherapy is administered.     

The current possibilities for plastic repair with axial skin flaps on the lower extremity

Based on results of complex topographo-anatomical investigations in 187 lower extremities and experiences with performing 220 operations of free and non-free plasty with axial skin flaps formed in the femur, shin and foot, the authors consider the lower extremity as a donor site and a recipient field for such operations. Eight donor zones are selected on the lower extremity and 39 different flaps can be formed within their limits, 27 of them being tested in the clinic. Comparative characteristics of all donor zones are given. The present-day possibilities of the substitution of different wound defects using the axial skin flaps from the femur, shin and foot are shown.     

Economic longitudinal lateral posterior thoracothomy. Minimally invasive option in pulmonary resections

BACKGROUND: Pulmonary resections are usually performed through posterolateral thoracotomy. However this approach has been associated largely with early and late incidence of postoperative morbidity. Several lateral chest approaches have been reported in the medical literature with the objective to decrease morbidity due to thoracotomy. The aim of this study was to evaluate the results of pulmonary resection, performed by means of a minor thoracotomy in the posterior axillary region. METHODS: The skin incision was longitudinal and scapular; shoulder and chest wall muscles were not cut, a subperiosteally lateral portion of rib was removed and the thoracic wall was opened in the rib bed. The approach in this place allowed a smaller skin incision, skin flaps were not necessary and the chest wall opening stayed in a better position in relation to the pulmonary hilum, facilitating the exposition of its anterior and posterior faces. From January 1994 to December 1996 seventy-eight consecutively non-selected patients underwent eighty surgical procedures for several kinds of pulmonary resections. RESULTS: All surgical procedures occurred without difficulties and with a lower number of postoperative complications. A very good aesthetic result was reached. CONCLUSIONS: We believe this chest approach may be a good choice for pulmonary resection.     

Myocutaneous flap as reliable defect coverage in high grade pelvic decubitus ulcers. Classification, therapeutic concept and presentation of personal patient sample of 16 years

Infected pelvic pressure sores of Campbell stages IV-VII require soft tissue reconstruction, which means stable, multi-layered filling cover of the defect and reliable prophylaxis of relapse. Myocutaneous flaps meet these conditions well. Depending on the extent and the area of the sore, with predilection for the sacrum, the ischial tuberosity and the femoral trochanter, the gluteus maximus, biceps femoris and tensor fasciae latae muscles are most often used for myocutaneous flaps. Primary sutures, split skin grafts or local fasciocutaneous flaps are often sufficient treatment for smaller, superficial defects. Between 1981 and 1996, 133 patients (average age 50 years) with 212 pelvic pressure sores of all stages were treated in our clinic. After radical decubitus excision with pseudotumor technique and resection of the osseous prominences, one-stage reconstruction of solitary as well as multiple defects was performed with myocutaneous flaps in 135 cases. The postoperative general complication rate for all treatments was about 10-30%. With regard to the muscle flaps, one third healed without any problems, partial flap necrosis occurred in 6% and there was total loss of flap in 2% of all myocutaneous flaps. According to present knowledge, myocutaneous flaps seem to be the most reliable method for definitive covering of deep pelvic pressure sores, independent of the cause of the ulcer.     

Effect of calcium on the energy status of rat brain synaptosomes under acidosis

Defects created after excision of abdominal wall tumors pose a challenge to the reconstructive surgeon. The task is made more difficult by the wide variety of flaps available for this purpose. We present a simple classification of abdominal wall defects and our choice of flaps for reconstruction. The abdomen was divided into six regions for the purpose of reconstruction. The deep inferior epigastric artery flap alone is the flap of choice for central supraumbilical defects. For lateral supraumbilical defects the latissimus dorsi flap fulfills all the requirements. Infraumbilical defects, central or lateral, are ideally suited to reconstruction by unilateral or bilateral tensor fascia lata flaps. Patients representing each scenario are presented.     

Fate of free flap microanastomosis distal to the zone of injury in lower extremity trauma

The decision to perform free flap microanastomosis to clearly uninjured vessels proximal to the zone of injury for lower extremity reconstruction must be weighed against the anatomic and technical difficulties of performing such an anastomosis. Preserved blood flow through vessels traversing the zone of injury has been shown. The records of all patients who underwent lower extremity reconstruction with microvascular free flaps at NYU Medical Center and Bellevue Hospital Center from January 1979 through August 1995 were reviewed. Patients with free flap microanastomoses distal to the zone of injury were compared with those with proximally based anastomoses. The group of patients was subdivided further into acute (1-21 days), subacute (22-60 days), and chronic (greater than 60 days) reconstruction groups. Of 451 microvascular free flaps, 35 were performed with recipient vessels distal to the zone of injury. Time interval from injury to coverage ranged from 24 hours to 57 years. Of 35 distally based flaps, 33 (94 percent) were successful and 5 required reoperation (14 percent). There was a similar incidence of thrombotic complications throughout all after-injury phases. Of 416 free flaps performed with microanastomoses to vessels proximal to the zone of injury, 388 (93 percent) were successful and 62 (15 percent) required reoperation. There was no significant difference (p > 0.05) in outcome between distal and proximal anastomoses and no significant difference (p > 0.05) in rates of reoperation. Timing of operation after injury had no bearing on outcome. Distally based microvascular free flaps anastomoses may be technically less difficult with rates of survival equal to those of proximally based flaps. The consideration and use of microanastomoses distal to the zone of injury are encouraged in selected patients.     

A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps

A series of 178 immediate reconstructions with regional or distant tissue for repair of oropharyngeal defects caused by treatment of head and neck cancer was reviewed to determine whether reconstruction with free flaps was more or less expensive than reconstruction with regional myocutaneous flaps. In this series, three types of flaps were used: the radial forearm free flap (n = 89), the rectus abdominis free flap (n = 56), and the pectoralis major myocutaneous flap (n = 33). Resource costs were determined by adding all costs to the institution of providing each service studied using salaried employees (including physicians). The two free-flap groups were combined to compare free flaps with the pectoralis major myocutaneous flap, a regional myocutaneous flap. Failure rates in the two groups were similar (3.0 percent for pectoralis major myocutaneous flap, 3.4 percent for free flaps). The mean costs of surgery were slightly higher for the free flaps, but the subsequent hospital stay costs were lower. Therefore, the total mean resource cost for the free-flap group ($28,460) was lower than the cost for the myocutaneous flap group ($40,992). The pectoralis major myocutaneous flap may have been selected for more patients with advanced disease and systemic medical problems, contributing to longer hospitalization and added cost. Nevertheless, this study suggests that free flaps are not more expensive than other methods and may provide cost savings for selected patients.     

Digestive flaps and facial microsurgery

Abdominal wall and contents can be used out of the coeliac cavity, as tissues donors site, for filling up or covering defects. Microsurgical technology mastery can extend their use in all the human body parts, especially in the craniofacial area. More than 110 digestive free transplants have been used during a 8 year period in head and neck surgical repairs. The report shows how to exploit at their best the anatomical and physiological properties of diverse abdominal tissues. Beyond this, the possible association of these transplants with other repair techniques opens new therapeutical perspectives, such as chimerical flaps whose pedicle distributes to heterogenous (or heteroclite) components, double flaps with a single or a double pedicle, replacing, at one single operative time, each missing tissue by the most adequate transplant. In consideration of this, abdominal tissues are an inexhaustible source of transplants, even through some imperfections must be managed.     

Second free flaps in head and neck reconstruction

Over the past decade, free-tissue transfer has greatly improved the quality of oncology-related head and neck reconstruction. As this technique has developed, second free flaps have been performed for aesthetic improvement of the reconstructed site. This study evaluated the indications for and the success of second free flaps. Medical files for patients who underwent second free flaps for head and neck reconstruction at the University of Texas M.D. Anderson Cancer Center, from May 1, 1988 to November 30, 1996, were reviewed. The flaps were classified as being either immediate (done within 72 hr) or delayed (done within 2 years) reconstructions. Indications, risk factors, recipient vessels, outcome, and complications were analyzed. Of the 28 patients included in this study, 12 had immediate (nine as salvage after primary free flap failure, and three for reconstruction of a soft-tissue defect), and 16 had delayed second free flaps (two for reconstruction of a defect resulting from excision of recurrent tumors, and 14 for aesthetic improvement). Reconstruction sites included the oral cavity in 18 patients; the midface in six; the skull base in two; and the scalp in two. The success rate for the second free flaps was 96 percent. Five patients had significant wound complications. In a substantial number of cases, identical recipient vessels were used for both the first and second free flaps. The authors conclude that second free flaps can play an important role in salvaging or improving head and neck reconstruction in selected patients. In many cases, the same recipient vessels can be used for both the first and second flaps.     

Alloplastic sternal replacement in malignant sternal tumors. Case report and review of the literature

Although not seldom as a palliative procedure, the preferred treatment of locally recurrent breast cancer or chest wall involvement by metastases is full-thickness chest wall resection. For closure and coverage of the defect various techniques are described. Autoplastic reconstruction is indicated for smaller defects, while larger defects usually require alloplastic materials, especially in case of chest instability after resection. We report the case of a 55-year-old female who developed a locally recurrent breast cancer with infiltration of the sternum 4 years after left sided ablation. En bloc resection of the chest wall including the complete sternum was followed by replacement with a computer-aided custom made polyethylene sternal prosthesis. With this procedure we stabilized the chest wall with protection of the underlying organs, avoided prolonged postoperative ventilation and achieved a satisfying cosmetic result.