Covering extensive soft tissue defects in infected knee endoprostheses by gastrocnemius flap

Total knee arthroplasty has become a routine procedure in surgery. Deep infections have an incidence of 2-5%. Major risk factors are large prostheses, rheumatoid arthritis, diabetes mellitus and postoperative wound-healing complications. In large soft-tissue defects with skin necrosis, local wound care shows poor results, especially if loosening of the prosthesis and necrosis of the patellar ligament are evident. In these cases, no standard surgical therapy has been developed yet. Thus, we consider meticulous débridement with synovialectomy to be mandatory. Exchange of the prosthesis may be necessary. Soft-tissue coverage ought to be performed with a gastrocnemius muscle flap covered with a split-thickness skin graft. In the last three years, 11 patients with large soft-tissue defects and necrosis of the ligament were treated according to this concept. In all cases the muscle flap healed primarily and soft tissue coverage was excellent. Two patients who underwent single-stage removal and reimplantation of the prosthesis showed reinfections of the prosthesis. Reconstruction of the ligament was performed with the flap tendon. The patients with two-stage removal and reimplantation of the prosthesis and those who retained their implants had a good functional outcome. The gastrocnemius muscle flap provides easy and reliable soft-tissue reconstruction in large defects. In our patients a two-stage operation for reimplantation of the prosthesis was superior to a single-stage procedure. The reconstructed ligament should be reinforced with autologous material to prevent a secondary rupture. Early reconstruction with sufficient soft-tissue coverage and reconstruction of the ligament offers the patient the best chances of obtaining a good functional result and prevents arthrodesis or amputation. In addition, reconstructive surgery reduces the length of hospital stay and costs.     

In vitro amphotericin B effects on growth, viability and dimorphism of Paracoccidioides brasiliensis: reversal of the treatment

The reversed dermal graft has been employed in reconstructive plastic surgery for almost 80 years. It is recommended that the dermatologic surgeon use this graft technique whenever a case calls for the combined advantages of the split-thickness skin graft for poorly vascularized areas and the axial pedicle flap appropriate to areas subject to marked mechanical strain. We present cases in which defects on the scalp, sole, palm, and great toe have been covered by reversed dermal graft and split-thickness skin graft in a single operation with excellent results. Our modification of the technique has proved that simultaneous grafting with reversed dermis and split-thickness skin graft produces satisfactory results, reduces postoperative care by 2 weeks, and obviates repeated anesthesia.     

Reconstruction of upper cranial and cranial base defects utilizing the scalping flap

Reconstruction of midfacial defects by means of a scalping flap has been widely practiced and described in the literature. The advantages of the flap are familiar to surgeons who perform extirpations and reconstruction of the head and neck and include contiguous availability, simplicity of application, and a robust and redundant blood supply. Despite these merits, the flap has not been widely used for reconstructions of large anterior cranial defects or defects of the cranial base. A retrospective review of 11 patients who underwent reconstructions between 1990 and 1995 was performed. In each case, a reconstruction of a large anterior cranial or cranial base defect was carried out. The resulting soft-tissue defect was restored via the scalping flap. In six cases, this was carried out in a single procedure. In five cases, flap division and insetting were carried out in a subsequent procedure, following a 1- to 2-week delay. In all cases, the extirpation and reconstruction were well tolerated, and the average time of hospitalization was 5.9 days and ranged from 3 to 11 days. No major surgical complications occurred. One of 11 patients had a minor complication not requiring surgical intervention. There was one recurrence of a cranial base tumor approximately 2 years following the initial resection and reconstruction. In all cases, the final aesthetic and functional results were acceptable to excellent. Follow-up ranged from 11 months to 5 years. In conclusion, the scalping flap can be effectively utilized for soft-tissue coverage in the reconstruction of anterior cranial and cranial base defects. Use of this simple and versatile flap in craniofacial reconstruction is well tolerated and is associated with a low morbidity, a good aesthetic result, and a short hospital stay.     

Transposition of a skin flap from the nasal dorsum for repair of skin loss on the nasal wing. Apropos of 9 clinical cases

The authors use a transposition island skin flap from the nasal dorsum for repair of the ala nasi. It is a modification of the stalk-flap advocated by Edgerton in 1967 to augment the columella. The flap is vascularized by branches of the anterior ethmoidal artery. The main modifications are;-the size of the flap which is 50 mm long and 15 mm wide;-the vascular pedicle is not dissected; this makes the flap very reliable;-the outstanding vascularization of this flap is corroborated by the fact that, in the same stage, it may be lined with a partially composite chondrocutaneous graft. The composite graft is taken from the concha and repaired with the Masson procedure. This flap is a very easy procedure for alar cutaneous repair for partial alar reconstruction, it is possible to fold the flap onto itself after resecting a 2 mm transverse skin strip, making the distal extremity a secondary skin island flap which ensures the lining of the proximal part. For total alar reconstruction and hemi-rhinoplasty; the flap is lined with a composite graft, which allows a one-stage thin reconstruction. The flap was used in 9 patients. In one case, there was a total skin necrosis, while half of the fasciomuscle layer survived.     

Functional alveolar ridge reconstruction with prefabricated iliac crest free flap and osseointegrated implants after hemimaxillectomy

We achieved functional alveolar ridge reconstruction after hemimaxillectomy using a prefabricated iliac crest flap. The iliac crest was vascularized secondarily by a long rectus abdominis muscle flap with its inferior epigastric vessels intact to obtain an ideal anatomic location between the maxillary defect and microvascular anastomosis site. The iliac crest was tightly resurfaced with a split-thickness skin graft as well. After a bony surgical delay, the prefabricated iliac crest flap was microsurgically transferred to the face. Three osseointegrated implants were placed in the prefabricated iliac crest, and a dental prosthesis was worn with immobilization and stability. Our procedure enabled recovery of a satisfactory facial appearance and excellent masticatory function.     

Release of oral submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft—a new technique

Long standing oral submucous fibrosis is associated with involvement of the oral submucosa and the muscles of mastication leading to difficulty in mouth opening. Various surgical modalities are mentioned for release but each has its own limitations. This article introduces a new technique of release of submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft. The surgical technique involves a pre-auricular incision extending into the temporal region with dissection carried out in the sub follicular plane to develop the superficial temporal fascia flap to its maximum extent. The masseter muscle origin is released from the zygomatic arch and the temporalis muscle insertion is released from the coronoid process through an external approach. The entire fibrosed mucosa is released intraorally to create a mucomuscular defect thus achieving full mouth opening. The superficial temporal fascia flap is then brought in and sutured to the intraoral defect, which is then covered with a split thickness skin graft. This procedure is performed bilaterally.A total of five patients were treated with this new technique and all of them showed good mouth opening in long term follow up. There was no donor site morbidity. The incision line is well hidden in the hair bearing area. A well vascularised superficial temporal fascia flap brings in good blood supply to the area of affected muscle and mucosa to improve its function.     

Birth after electroejaculation coupled to intracytoplasmic sperm injection in a gun-shot spinal cord-injured man

Cervical reconstruction after postburn scarring remains a challenge for the plastic surgeon. Several well-known procedures are possible: split or full-thickness skin grafts, local flaps, free skin flaps, expanded skin,... In order to evaluate each technique, three procedures are compared with a long-term follow-up (> or = 1 year): skin expansion, free flap surgery and full-thickness skin grafting. Fifteen patients are reviewed, with five patients operated according to each method. In this study, each burn patient was suffering from a severe neck burn contracture, restricting the neck motility to a few degrees. These patients were operated on by different surgeons, according to their personal indications. The full-thickness skin graft is usually harvested from the abdomen (by means of a miniabdominoplasty) and is applied under a tie-over dressing. This simple procedure has few complications and gives satisfactory results. Skin expansion provides a good texture and color matching but has a higher morbidity and necessitates several procedures. Free flap surgery is time-consuming, gives a good functional result but poor cosmetic aspect (different colour, excessive bulk). Comparing the functional and aesthetic result of the three types of reconstruction in terms of morbidity, neck mobility, skin elasticity, skin sensitivity, matching and scar recurrence, full-thickness skin grafting seems to be the most adequate technique.     

Evaluation of an artificial dermis full-thickness skin defect model in the rat

An artificial dermis product was applied to full-thickness skin defects in rats and cell infiltration into the collagen matrix was investigated. Host fibroblasts and capillaries infiltrated as far as the upper end of the collagen matrix by day 14 after application. Determination of glycosaminoglycan levels in the matrix showed that hyaluronic acid was generated in a similar amount to that seen in the intact skin by day 14. An autologous thin split-thickness skin graft was placed onto the artificial dermis simultaneously or several days after its application to the defect. The take rate was 100% when a split-thickness skin graft was performed on day 14 after application of the artificial dermis. At 6 weeks after the skin defect was created, the wound area was 80% of the original area and the dermis at the grafted site was as thick as that of normal skin. These results suggested that the artificial dermis provides a good matrix for thin split-thickness skin graft and is useful for the reconstruction of full-thickness skin defects. This method is considered to be an alternative to the conventional procedure using thick skin grafts or skin flaps.     

Surgical reconstruction of the contracted eye socket and orbitozygomatic hypoplasia in a one-stage operation

To correct the contracted eye socket and orbitozygomatic hypoplasia simultaneously secondary to previous surgery and radiotherapy, we employed a one-stage surgical reconstruction that used a postauricular skin flap and temporal fascial flap, which were rotated for eye socket reconstruction and bone graft coverage. Hydroxyapatite was inserted as an onlay bone graft substitute to enlarge the orbitozygomatic region. In our 12-case experience the results were satisfying and encouraging with minor complications, which are presented.     

Complex injuries of the dorsum of the hand. Therapeutic reflections apropos of 2 cases

We report 2 similar cases of severe injury of the dorsum of the hand, both treated in emergency. FIRST CASE: A 37-year-old right handed male truck driver was admitted with a complex severe injury of the dorsum of his right hand following a traffic accident. He had a combined large defect involving skin, tendons and bone. A complex reconstruction was performed using a massive iliac crest allograft, a tendon graft and a free serratus anterior flap in a one stage procedure, eight hours after the injury. A skin graft was done later. Two years later the functional and esthetic results are good. SECOND CASE: A 37-year-old woman was admitted with a severe injury of the dorsum of her right hand following a traffic accident. She had a large combined defect involving skin, tendon and bone. A complex reconstruction was carried out using a large iliac crest autograft, a multiple tendon graft and a free latissimus dorsi flap, in one stage 6 hours after the trauma. Eight months later the functional result is partial but useful for the daily activities of the patient.     

"Window" laryngoplasty: a new combined laser endoscopic and open technique for conservation surgery

Endoscopic laser resection of early laryngeal carcinoma is an increasingly used treatment modality; however, the limited exposure achieved and the alteration of vocal function are still major problems. A new surgical procedure, "window" laryngoplasty, has been devised and tested in an in vivo study in 6 canines with 50 days' survival. The right vocal cord was incised endoscopically with the carbon dioxide laser, and the en bloc specimen with adjacent thyroid cartilage was removed through a window approach made in the thyroid cartilage. A sternohyoid muscle flap based superiorly was inserted into the cartilaginous window to reconstruct a pseudocord with coverage of either mucosa or fascia. A diode laser soldering technique was used to secure the mucosal graft in place. Epithelial transplantation can be accomplished externally with precise endoscopic guidance for reliable placement of the pseudocord. The results show that the new technique, a combination of endoscopic and open approaches, may be a better treatment choice than standard vertical partial laryngectomy in selected patients. Advantages of this technique include adequate en bloc resection, including adjacent cartilage for pathologic evaluation, preservation of the integrity of most of the laryngeal framework, avoidance of tracheotomy, and better functional results.     

Combined saphenous vein with free flap reconstruction in the treatment of carotid stenosis

Revascularization for arterial stenosis in varied anatomic sites exposed to therapeutic radiation has been well described. In most circumstances, symptomatic end organ ischemia has been the indication for surgical intervention. We report the case of a patient who had symptomatic carotid stenosis 40 years after having ipsilateral neck dissection with radiation therapy. We did a saphenous vein graft interposition and free flap reconstruction of the overlying damaged skin.     

CHILD syndrome with linear eruptions, hypopigmented bands, and verruciform xanthoma

The traditional rhomboid transposition flap has been widely used in reconstructive surgery. The authors have modified the original technique by eliminating the creation of the rhomboid defect and by directly transposing the flap into the original postexcisional defect. These changes allow maximum flexibility in flap design and minimize normal tissue loss. The authors retrospectively reviewed the charts of patients who underwent periocular reconstruction with flaps from 1990 through 1995. The authors selected those patients in whom the modified rhomboid flap was used. Functional and cosmetic results and complications were reviewed. Two hundred thirty-two patients were identified in whom 242 flaps were performed. The modified rhomboid flap was used in 101 patients (41.7%). Complications occurred in 23 patients (23%), 19 of whom (19%) were treated medically and four of whom (4%) required an additional surgical procedure. Cosmetic and functional results were classified as very good or excellent in 96 patients (96%). The use of a modified rhomboid flap in the reconstruction of the periocular area offers ample versatility in flap design and minimal normal tissue loss. Functional and cosmetic results are satisfactory in the vast majority of cases.     

Thumb reconstruction with a free neurovascular wrap-around flap from the big toe: long-term follow-up of thirty cases

From March 1982 to December 1992, 30 cases of thumb reconstruction with a free neurovascular wrap-around flap from the big toe were performed at Korea University Hospital. Twenty-nine of a total of 30 cases were successful and obtained excellent functional and cosmetic results. Postoperative complications included 1 case of graft failure, 6 partial skin necroses, 1 malunion, and 15 cases of resorption of iliac bone graft including 1 case of fatigue fracture of grafted bone. Even for the first metacarpal neck amputations, thumb reconstruction with a free neurovascular wrap-around flap was possible; however, limitation of motion of the reconstructed thumb and resorption of the grafted bone occurred. Thumb reconstruction with a wrap-around free flap from the big toe gives excellent cosmetic and functional results and causes minimal morbidity on the donor site.     

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.     

Auricular reconstruction with a postauricular myocutaneous island flap: flip-flop flap

Surgical defects of the concha-helix part of the ear larger than 2 cm may pose a reconstructive challenge. Split- or full-thickness skin grafts or local flaps may be used, and a number of these have been described. Yet cosmetic results are often unsatisfactory. Our experience with a postauricular myocutaneous island flap is described. Eleven patients (12 ears), aged 48 to 89 years, underwent the procedure under local anesthesia following excision of conchal bowl malignant tumors that included the cartilage underlying the skin. The surgical technique is described in detail. Few complications were encountered, and cosmetic results were excellent. In four ears, resection margins extended into the ear canal, and that portion was allowed to heal satisfactorily by secondary intention. We recommend the use of this flap for practical, safe, and early good cosmetic results.     

The structure of the L3 loop from the hepatitis delta virus ribozyme: a syn cytidine

Insufficiency of tissues and progressive contraction usually restrict the application of prosthetic devices in anophthalmic eye sockets. To achieve a successful reconstruction, the plastic surgeon has to form a socket that has proper dimensions and is completely covered by a well vascularized epithelial surface. Eye socket reconstruction with free skin, mucous membrane, or dermis-fat grafts usually remains unsatisfactory in severe cases. We have used a prefabricated temporal island flap to solve this difficult problem since 1983. In this method, a full-thickness skin graft is applied over the temporal fascia to create a prefabricated island flap based on the superficial temporal vessels. This flap is transposed into the eye socket 3 weeks later. Some modifications in flap design have been done to get better fitting of the prosthesis since that time. Thirty-three patients with constricted eye sockets that could not use prosthetic devices were treated with prefabricated temporal island flaps since 1983. The follow-up period was between 1 and 13 years. Eye sockets with adequate size and volume were created in all patients, and the results were successful. This method prevented secondary graft shrinkage, and the prefabricated island flaps preserved their dome shape during the follow-up period. We believe this method is a useful one in the treatment of the contracted socket.     

Radial forearm flap in maxillo-facial surgery

Thirty consecutive patients treated with a free radial forearm flap are reviewed. The flap was used in the reconstruction of intraoral defect in 24 patients and of extraoral defect in 6 patients. There were no total or partial flap failures. Donor site complication included a partial loss of skin graft in 4 and radial fracture occurred in 1 patient. The authors considered the application of the radial forearm flap a reliable method for resurfacing large skin defects of the face. However, according to their conviction the most important field of the forearm flap is its use in intraoral reconstruction after pull-through operation. Attention is drawn to the limitation of the use of osteocutaneous flap in the replacement of segmental mandibular defect.     

Salvage of femoropedal bypass graft complicated by interval gangrene and vein graft blowout using a flow-through radial forearm fasciocutaneous free flap

We report the case of a 71-year-old man who had interval gangrene of his calf with subsequent vein graft blowout 3 months after undergoing a femoral-to-dorsalis pedis saphenous vein bypass grafting procedure. To provide wound coverage, restore vascular continuity, and preserve functional ambulation, a flow-through radial forearm fasciocutaneous free flap was interposed between cut ends of the bypass graft. Venous drainage of the flap was from the cephalic vein to the popliteal vein. At 1 month after the operation, the patient had complete wound healing and began to ambulate. At 11 months an asymptomatic high-grade stenosis in the distal radial artery segment of the reconstruction was successfully treated with percutaneous angioplasty. After 22 months of follow-up there have been no further complications, and the patient continues to have full, functional ambulation. The radial forearm flow-through free flap allows single-stage restoration of bypass graft continuity and coverage of extensive, complex tissue defects. This technique represents a novel approach to this difficult problem and provides a viable alternative to major limb amputation.     

3-dimensional computed tomography with model preparation before mandibular reconstruction

Extended mandibular defects resulting from cancer resection are amenable to reconstruction with a free vascularized bone graft transplantation. Between 1992 and 1995, 12 patients were enrolled in a protocol including a preoperative 3D-CT used to develop a custom-made acrylic model of the mandible. Besides contributing to the assessment of tumor extension, 3D-CT helps determine the adequate limits of mandibular resection. 3D-CT has the advantage of providing the surgeon with a more familiar image of the mandible and the mandibular model, allowing better and quicker conformation of the bone flap. The graft can be shaped at the donor site before cutting its vascular pedicle, resulting in a shorter period of ischemia. This series demonstrated that preoperative mandibular modeling with 3D-CT helps improve functional and cosmetic results in mandibular reconstruction.